nursing considerations in neurological care

Question 1

what is pneumbra?

Answer 1

• area that could be affected by stroke
• nurses should try at all costs to save cells around primary injury

Question 2

how do nurses limit pneumbra?

Answer 2

• early stroke consultant assessment: odds of death low at 30 days
• CT scan within 24 hours
• early nurse and therapist assessment
• early swallow assessment and nutrition management
• early IV fluids and aspirin

Question 3

what are essential nursing interventions in acute stroke care?

Answer 3

• positioning: seated upright
• GCS
• BM
• BP: treat if BP >180/100
• sats <95%
• temp
• swallowing screening
• hydration and nutrition

Question 4

how do nurses prevent aspiration?

Answer 4

• positioning of head of bed (at least 30 degrees)
• suction setup
• residual neurological symptoms remain NPO until dysphagia screening

Question 5

why do nurses need to keep the blood glucose controlled?

Answer 5

• risk of diabetics
• acute hyperglycemia at time of stroke
• should monitor on admission

Question 6

why do nurses need to consider temperature?

Answer 6

• fever could have critical effect in first 24hrs after stroke
• goal - afebrile
• 37.5 - treat aggressively physical and pharmacologically
• prevent shivering