Stroke & Dysphagia
This screening must be completed before a patient with an acute stroke receives food, fluids, or medications by mouth.
What is a swallowing evaluation?
A decrease in Glasgow Coma Scale score indicates worsening of this neurologic parameter.
What is level of consciousness?
Increased confusion and restlessness occurring in the evening in Alzheimer's disease is called this.
What is sundowning?
During a tonic-clonic seizure, the patient should be turned into this position.
What is side-lying position?
Severe headache, hypertension, flushing, and diaphoresis in a spinal cord injury patient indicate this emergency.
What is autonomic dysreflexia?
A wet, gurgling voice after a stroke suggests this complication.
What is aspiration?
One dilated, nonreactive pupil may indicate this life-threatening complication.
What is increased intracranial pressure or brain herniation?
Rather than arguing with a confused patient, caregivers should use this communication approach.
What is redirection?
Severe headache, fever, photophobia, and nuchal rigidity are classic findings of this disorder.
What is meningitis?
The most common trigger that should be assessed first during autonomic dysreflexia.
What is a blocked or kinked urinary catheter?
Patients with left-hemisphere strokes commonly experience this communication deficit.
What is aphasia (especially expressive aphasia)?
Decerebrate posturing is characterized by extension of the arms and legs and indicates damage above or below this structure.
What is the brainstem?
Clear picture signs on doors and rooms help improve this aspect of patient function.
What is safety and orientation?
Increasing restlessness, vomiting, and rising blood pressure in meningitis suggest worsening of this condition.
What is increased intracranial pressure?
Hypotension, bradycardia, warm dry skin, and loss of sympathetic tone are signs of this type of shock.
What is neurogenic shock?
When caring for a patient with a right visual field deficit, frequently used items should be placed on this side.
What is the left side?
The first priority when a TBI patient develops worsening neurologic signs and oxygen saturation falls.
What is airway support and ventilation?
A Parkinson's patient who "freezes" while walking should be encouraged to do this.
What is consciously lift the feet and take deliberate steps?
In multiple sclerosis, worsening neurologic symptoms during an infection are often due to this trigger.
What is infection?
The most serious complication of Guillain-Barré syndrome requiring immediate reporting.
What is respiratory compromise?
The safest action when a family member wants to give water to a newly admitted stroke patient.
What is keeping the patient NPO until swallowing is evaluated?
This emergency system should be activated when severe neurologic deterioration occurs.
What is the Rapid Response Team (RRT) or Emergency Response System?
he nursing intervention that best helps reduce evening agitation in Alzheimer's disease.
What is maintaining a consistent routine?
Patients with multiple sclerosis should avoid this because it can worsen neurologic symptoms.
What is excessive heat or increased body temperature?
Facial weakness, difficulty speaking, shallow respirations, and decreased breath sounds indicate progression toward this complication.
What is respiratory failure?