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Immediate Nursing Priorities – Stroke Nursing Care in Med-Surg

by Rhonda Lawes

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    00:01 Now it's time. The ICU nurse has arrived with Mr. Johnson.

    00:05 So, let's talk about our immediate nursing priorities. He's rolling into the door. So the first thing we're going to do is get Mr. Johnson from the ICU gurney and the monitors, and get him on the Med-Surg telemetry monitors and back up to his oxygen, because ABC is still a top priority and we want to get his vitals. So, it can sometimes feel chaotic when a patient first comes in the room.

    00:30 But remember, you'll usually have other people there to help you get Mr.

    00:34 Johnson settled. So, you want to get him transferred from the ICU bed into the Med-Surg/telemetry bed, get the monitors transferred over, and make sure you're making contact with Mr. Johnson the whole time during the transfer. So you don't want to talk in third person around him. Be very intentional about greeting him, introducing yourself, and explaining to him what you're going to do. Don't just pick a patient up and slam them over to the bed. You always want him to be very aware, because all hospital patients feel out of control. And the more that you start your relationships like that with patients, you're going to have a much more therapeutic relationship throughout their stay. So, you've got continuity of care, right? You're going to get report with the ICU nurse right there, verify his neuro assessment, like what you received in report, and what he's doing now.

    01:27 Check his rate of oxygen, his IV rates, and any orders that the ICU nurse may have completed before he came to your unit. Then you're going to do your own head to toe assessment, look at his NIHSS, review the healthcare provider orders. That's your next step.

    01:45 Then you're going to figure out what has to be done this shift? What are your top priorities to do? And when you're looking through the orders thinking about what we had, obviously, you're going to get him on the oxygen and get him on the monitors. Those are number 1 priorities, right? Then you're going to work through his other orders. You're going to make sure that those consult orders get into that interdisciplinary part, so we can have those professionals see him as quickly as possible.

    02:13 So that's how we're going to practice with Mr. Johnson, thinking through him system by system. You've done your assessment.

    02:21 Now as the Med-Surg/telemetry nurse, what you want to do is think about what really are the priorities, specifically, for Mr. Johnson? Well, when you think through neurological system, okay, we know that he's had a stroke.

    02:34 We know that he has right-sided weakness. It was a left-sided stroke.

    02:37 We know he's having a little bit of problems with speech, and so, that is going to be one of our main priorities that we watch. You're going to look and see if there's any exams, any diagnostic testing, any lab work that applies to that, and work your way through each system. We know cardiovascular, his blood pressure's up a little bit, but we're okay with that because he was a stroke.

    03:00 We know respiratory-wise, he's on oxygen.

    03:03 We also know the sat that we want to maintain. But you're going to make a mental note.

    03:08 Anything that a patient's on that's not natural, like oxygen or IV, I say, like, anything they didn't come out of the womb with, always think about, why do we have it on, are we going up, are we going down, or can we take this off? Because if Mr. Johnson, we see that he doesn't need that oxygen, then we should look at weaning it off, titrating it off, so we can get that off of him and he can live a more normal life.

    03:34 We're going to look at his musculoskeletal mobility. So, how does he do getting up from the bed? Can he dangle his legs on the side of the bed? Is he safe to stand up? Can he move to the chair? So, we're going to look at those issues with him and set his priorities. You'll work your way through the rest of the system. Don't overlook skin.

    03:53 Skin is really important because if he's starting to have some breakdown somewhere from being in bed so long, that's going to be a huge issue.

    04:02 When we talk about GI, it isn't the most glamorous part of nursing, but it's vitally important that you know when his last bowel movement was, because if he gets constipated, this could be a really big issue. Plus, it's just going to mess everything up. So, you want to know how bowel and bladder are also doing.

    04:21 Now, this system right here is a great way to think about all of your patients.

    04:26 If you want to be prepared when a physician, he or she runs onto your unit and has to see a patient, if you've taken the time to think through your patient, take him system by system by system. Think about any assessment information you have in each one of these systems. Think about any lab work that applies to these systems. Think about any meds the patient is taking that applies to that system. You can set a priority list of problems to talk to the physician. So when they come in, you just pull your paper out of your pocket say, "Yes, I want to talk to -- about Mr. Johnson's --" Boom, boom, boom, boom, boom.

    04:59 That way, you can stay organized and you're ready before the healthcare provider comes for report.


    About the Lecture

    The lecture Immediate Nursing Priorities – Stroke Nursing Care in Med-Surg by Rhonda Lawes is from the course Neurology Case Study: Nursing Care of Stroke Patient. It contains the following chapters:

    • Nursing Priorities by System

    Included Quiz Questions

    1. Bedside report with the ICU nurse
    2. Including the client in bedside report by speaking directly to the client
    3. Performing a National Institutes of Health Stroke Scale (NIHSS) with the ICU nurse to validate deficits
    4. Ensuring that the health care provider is present for bedside report
    5. Receiving report over the phone and accepting the client from a member of the transfer team
    1. To assess deficits and set nursing priorities
    2. To establish a baseline level of care
    3. To be prepared for communication with the physician
    4. To validate that the report received at handoff is correct

    Author of lecture Immediate Nursing Priorities – Stroke Nursing Care in Med-Surg

     Rhonda Lawes

    Rhonda Lawes


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