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Neurological Interventions – Stroke Nursing Care in Med-Surg

by Rhonda Lawes

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    00:01 Okay. In case that felt overwhelming, don't worry, because we're going to dive deeper into each section.

    00:07 See, we do want you to learn about a stroke patient. But we also want you to know, how do you manage patient care as a nurse? And that can be so overwhelming.

    00:16 Time management is the biggest challenge when you first start as a nurse, and pretty much the rest of your career. So, ready? Let's dive deeper. We're going to start with neurologic.

    00:28 Okay. So, let's look at some specific neurological interventions.

    00:32 These are the types of things you're going to be doing as a nurse taking care of someone who's had a stroke.

    00:37 So, we're looking for early identification. How do we do that? Well, remember the NIHSS assessment tool? We're going to keep repeating that. They did it at baseline in ER.

    00:49 They did it 24 hours after treatment was received.

    00:52 And then we've got set periods of time where you repeat that assessment.

    00:57 Now, it's a very simple assessment when it appears, and it takes you less than 10 minutes to do it, remember, but I just wanted to remind you, you have to be certified to do this correctly.

    01:06 Now, most nurses who take care of stroke patients who already have this certification, but know that you need to have certification to do it correctly.

    01:14 Now we're going to be watching for that stroke to be extending.

    01:17 Now that might seem kind of bizarre like, "Well, I know he had the stroke, but we've given him the medication." Anytime you've had a stroke, you're at an increased risk for having another stroke.

    01:28 So it might be in the same spot, might be in a different spot, but we're on high alert to watch and see if he's had any changes.

    01:34 So we're going to watch his level of consciousness.

    01:37 That's going to tell us that intracranial pressure is elevating and that's not a good sign for a neuro patient.

    01:43 So we're going to closely and regularly assess his mental status, how his pupils respond, and his extremity movement in strength, making sure they're not asymmetrical and that they're equal.

    01:55 Remember, if Mr. Johnson, he didn't come to us equal because of the stroke.

    01:59 So we're going to watch for any changes that we see from side to side.

    02:03 So, every interaction you have with Mr. Johnson is an opportunity for informal patient assessment.

    02:10 You'll get better information if you don't make him feel weird, right? If he feels really -- very self-conscious to be the patient and have people looking at you, so the more you can just make it casual conversation, make good eye contact with him, sit down and just talk to him, you'll get better information.

    02:31 Now, I just want to show about that NIH Stroke Scale. Here's something really fun.

    02:35 I'd like for you to pause the video and just Google "Stroke Scale Calculator." Now, you'll find lots of calculators out there available on the internet.

    02:44 Practice scoring Mr. Johnson from what you know.

    02:47 Don't obsess over it, if you don't know the answer.

    02:50 I just want you to click through anyway. Make it up, so you can just kind of see how a nurse who was certified would perform that Stroke Scale.

    02:59 Okay. Welcome back.

    03:01 Now, a certified nurse, remember, we've already decided, takes less than 10 minutes for them to do it a certified nurse or a physician.

    03:08 And we're going to do this repeatedly throughout Mr. Johnson's stay, and even in outpatient just to monitor his progress and document it in a consistent and standardized way.

    03:18 So we want to improve his cognitive and functional abilities.

    03:22 I haven't had a stroke, and I would like that, but you're going to carefully assess his ability to speak and to understand conversation.

    03:30 I think this is one of the worst effects of a stroke, to have a thought and not be able to articulate, to have a question, not be able to ask it effectively.

    03:40 This is really frustrating.

    03:42 And I watched my father go through this. He was a very bright and articulate man.

    03:46 But after his stroke initially, this was a big struggle for him.

    03:50 He had those communication difficulties that stroke patients can have, and it made him very anxious and it can be very overwhelming for a stroke patient, particularly in this acute phase.

    04:01 They're not used to it.

    04:03 They're very overwhelmed with the thought that this might be the best they can ever communicate, so be patient with them.

    04:09 Use calm, slow, and natural speech.

    04:14 Think about talking to someone who didn't speak the same language as you.

    04:18 They need extra time to process just as you would if you're hearing something in a language that wasn't your own.

    04:24 So just act unhurried. You want to have frequent, shorter conversations.

    04:30 Those are usually the most beneficial because if you could understand the amount of work that patient has to do to keep up with you, and to follow the conversation, it is exhausting for them after a stroke.

    04:43 So you always want to appear unhurried.

    04:46 Maintain eye contact, smile.

    04:49 Never ever look impatient with him trying to find the words.

    04:55 So, sit down, calm down, make eye conversation, and smile.

    05:01 You'll be amazed at the relationship you can build with your patient.

    05:05 Do not appear rushed or impatient.

    05:08 Reassure them without patronizing, particularly elderly patients, that is degrading when you call them, "Honey, sweetie." That might mean a term of endearment to you, but it's not perceived by all patients to be that way.

    05:22 So, reassure them like, "Oh, yes, thank you.

    05:26 I understand what you were trying to tell me." Use feedback. "Is this what you were saying?" So simplify your sentences without patronizing them.

    05:35 Give them plenty of time to process and respond.

    05:39 Don't look away while they're responding or start charting or doing something else.

    05:43 Just make calm and casual eye contact.

    05:46 Now, you can work or collaborate, is what we call it, collaborate with the speech therapist.

    05:51 You can create a plan that'll help support communication and some possible communication aides.

    05:56 Some patients, if they have very severe communication impairment, we can use things like picture boards and key words.

    06:04 But if it's just a matter of them taking a difficult time finding the right word, or processing things, then that's all on us to be patient.

    06:12 Also, we can role model that for their family.

    06:16 Hey, it has been extremely stressful for Mr. Johnson's family to walk through this, so you can role model for them, "Listen, if you can just stay calm and wait for him, he'll be able to tell you what he's trying to tell you." And remember, gets real complicated in family relationships and marriage, so we don't have all that emotional baggage with a patient.

    06:39 So we're the best person to teach the family members how you can do it and get the most effective communication.

    06:45 So let's practice a little bit with Mr. Johnson.

    06:48 I want you to work through just some simple conversational phrases.

    06:54 Let me give you some ideas and you pause the video and add those in.

    06:58 Okay. So, I want you to practice, all along wherever you're studying, as you walk into the room, what are the things you would do and say when you first met Mr. Johnson? Okay. I know that feels a little weird, but promise you, practicing it now will make it much easier with a patient.

    07:19 Now you're trying to communicate with Mr. Johnson and he's stu-, stu-, stu-, stu-, stu-.

    07:25 He can't tell you what he wants. He starts making a noise like Okay. You have a patient that's waiting for you in the next room.

    07:34 You got a full day's list and he can't come up with a word. What do you do? You tell yourself to take a deep breath before you ever walk in the room of a patient that you know has communication problems.

    07:48 So you take one breath for you one breath for your patient.

    07:59 Then you walk into the room when you know that this is a challenge for Mr. Johnson, because you reset your brain and your mindset, so he has no idea how rushed and how hurried you are.

    08:11 When he's having trouble finding that word -- which is what patients have done, it's what my father did after his stroke, you just say, "Hey, it's okay. It'll come to you. We will figure this out together." So, pause the video, picture in your mind a patient being extremely frustrated using weird mouth sounds to try and communicate to you.

    08:33 Practice some responses that you would say to that patient like Mr. Johnson.

    08:42 Okay. I know you feel pretty ridiculous, but I can tell you, this is the kind of stuff, as a nurse, if you will practice it, it will come naturally.

    08:51 And you will make an impact on people that they will never forget for the rest of your life.

    08:57 They may not remember you exactly, but they're going to remember how they were treated with respect, how they were valued, and what it meant to them at the time.

    09:07 That's the kind of nurse you want to be. That's why we go into nursing.

    09:12 Okay. So, remember, we've talked about speech problems. They also have these sensory perceptual alterations as part of their cognitive and their functional abilities.

    09:22 Vision is a big one.

    09:24 It could range everything from diplopia, which is double vision, that would be so bizarre, or it could be like even a loss of the corneal reflex, and I have a drooping eyelid or they might have -- wait for it -- homonymous hemianopsia. I love that word.

    09:41 That's fun to say to friends that aren't medical because they're just like, "You're weird." It's true.

    09:46 Okay, so, homonymous hemianopsia. That's a big one.

    09:50 I would hate to have to spell that one myself. We'll talk about that in a little more.

    09:54 We'll give you kind of a feel for what it might feel like for your patients.

    09:58 But vision problems are a huge factor in safety and the patient's ability to be independent.

    10:04 Can you imagine if you're trying to feed yourself and you saw two bites of food, and you're trying to find your mouth? That's kind of weird.

    10:11 If somebody has diplopia or double vision, they usually put an eye patch on it, which you might as well just take that with a grain of salt, right? If you get to be in an eye patch, you're going to get a lot of pirate jokes, but there you go. It will help with the double vision.

    10:24 Now, if the corneal reflex is absent, a patient's really at risk for a corneal abrasion.

    10:30 So we got to watch them closely and protect against eye injuries, if that's really the case.


    About the Lecture

    The lecture Neurological Interventions – 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:

    • Neurologic Interventions
    • Sensory-perceptual alterations

    Included Quiz Questions

    1. National Institutes of Health Stroke Scale (NIHSS)
    2. Intracranial pressure monitor
    3. Magnetic resonance imaging (MRI)
    4. Glasgow Coma Scale
    1. Assess the client's ability to speak and understand conversation.
    2. Use calm and slow, but natural, speech.
    3. Maintain eye contact.
    4. Yell loudly to get close to the client's face.
    5. Speak quickly and keep conversations short.
    1. Speech therapist
    2. Occupational therapist
    3. Respiratory therapist
    4. Psychological therapist
    1. Sensory-perceptual alterations
    2. Motor-reflex alterations
    3. Cognitive alterations
    4. Sensory-motor alterations
    1. Maintaining safety
    2. Ensuring caloric intake is met
    3. Providing communication tools
    4. Encouraging participation in physical and occupational therapy

    Author of lecture Neurological Interventions – Stroke Nursing Care in Med-Surg

     Rhonda Lawes

    Rhonda Lawes


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