HAPI Prevention
A patient with left-sided paralysis spends most of the shift lying on their affected side. What complication are you trying to prevent with scheduled repositioning?
What is a pressure injury caused by prolonged pressure over bony prominences?
This side effect of many antihypertensive medications can increase fall risk when a patient stands too quickly.
What is orthostatic hypotension?
Every stroke patient should receive this assessment before oral intake.
What is a dysphagia/swallow screening?
What is the Stroke Activation number
What is 2-2111
NR 1002
This immobile stroke patient has a Braden score of 12 and is frequently incontinent. What intervention should occur immediately?
What is implementing the pressure injury prevention protocol (position change every 1-2 hours, no body contact on hard surfaces, consider offloading boots, moisture management) Policy 1203
This assessment tool is commonly used to identify patients at increased risk for falls.
What is the Morse Fall Scale?
This is the most frequent severe complication of a stroke
What is Pneumonia
What does the acronym BEFAST stand for
What is Balance Eyes Face Arm Speech & Time
A patient is turned every two hours but remains constantly moist from urinary incontinence.
Which pressure injury risk factor is not being adequately addressed?
What is moisture management?
A patient has right-sided weakness and wants to transfer from bed to chair.
Which side should typically lead the transfer?
What is the stronger, unaffected side?
The amount of water required to complete a Dysphagia Screening
What is 30 ml's
Stroke is the number one cause of what
What is Adult Disability
Which stroke deficit places a patient at the highest risk for a HAPI: mild facial droop, expressive aphasia, visual neglect, or complete hemiplegia?
What is complete hemiplegia because it significantly limits independent mobility and repositioning?
A patient repeatedly bumps into objects on the left side and ignores people standing there.
What is visual neglect or inattention?
A nurse notices a stroke patient taking multiple swallows to clear one sip of water and leaving liquid in the mouth after swallowing.
What are findings that indicate the patient may fail a dysphagia screen?
Why are stroke patients at increased risk for DVTs?
What is decreased mobility?
Which stroke patient is at greatest risk for developing a HAPI?
A-NIHSS 2, ambulatory
B-NIHSS 18, incontinent, dysphagic, hemiplegic
C-NIHSS 4, independent with transfers
D-NIHSS 3, eating regular diet
Who is Patient B?
A patient has right-sided weakness, neglect, and urinary urgency. Which risk factor is most likely to cause an immediate fall?
What is attempting to toilet without assistance?
Name a type of Dysphagia
What is Oral Dysphagia, Pharyngeal Dysphagia and Esophageal Dysphagia
A mental state where a patient who has mild weakness but frequently forgets limitations, disconnects equipment, and attempts to walk alone.
What is impaired judgment.