Quality Measures
Where can you print / view the quality measures document?
Downtime Forms / Nursing Webpage / Front Nursing Station on 6 South
A patient is being admitted with S&Ss of AMS what should be documented before anything PO
swallow screen
Full NIH
A patient with no history of stroke presents with L-sided numbness and weakness what is your first action you want to take?
Name 3 key risk factors for ischemic stroke ?
increasing age, hypertension and use of antihypertensive treatment, cad, prior stroke, and presence of atrial fibrillation.
When should NIH handoffs be completed on a patient?
When the patient has an order for NIH assessments.
A patient is being admitted with confirmed ischemic stroke, what care plans must be documented?
1. Altered cerebral tissue
2. Ischemic Stroke
You and another nurse are completing bedside handoff, and conducting a Full NIH assessment. Together you notice there is a 4 point difference in assessment scoring from the last done assessment - what actions should you take?
Call the neuro. provider consulted for the patient
You are providing education to your newly admitted stroke patient - where can you find written resources / educational material?
A CT scan reveals R-sided ischemic stroke, list 2 symptoms would you expect this patient display?
1. Left sided weakness/neglect
2. Impulsive
3. Short attention span
4. Speech, language, and comprehension issues
A patient was given an oral pain medication how long after the medication was administered does a re-assessment of pain need to be documented?
1 hour after administration
A patient arrives on the unit post spine related surgery, you conduct your neuro assessment within the hour your patient arrives - you get busy with other patients how should you chart the neuro assessment you conducted earlier?
A 62 year old woman with a history of hypertension and hyperlipidemia presented to a primary stroke center with sudden onset of weakness of the right side. On examination, she had a global aphasia, left gaze preference, right facial droop, dysarthria, and right hemiplegia (NIH Stroke Scale = 22). CT angiography showed a left middle cerebral artery occlusion. This patient has arrived to your floor what care plans / education topics need to be documented for this patient?
1. Altered Cerebral tissue perfusion
2. Ischemic stroke
3. Hypertension / HTN
4. Impaired Speech
Where can you go to view resources for 6 South Stroke, Spine, EMU, etc. on any computer?
Stroke is the _____ leading cause of death and a major contributor to disability worldwide. The prevalence of stroke is highest in developing countries, with ______ stroke being the most common type.
second, ischemic
What two resp. nursing interventions / education items must be documented daily for the patient?
Incentive spirometer use with achieved volume and goal volume AND cough and deep breathe
A stroke patient has BP parameters of systolic 100 - 120 and diastolic of 80 - 90. Your patient had a hypertensive reading, you called the provider and obtained a new order for anti-hypertensive treatment. Where should you document this?
Under Provider Notification in the Flowsheets
You receive in report a patient who had a mild ischemic stroke. They have a neuro consult, and their last NIH documented was a 2. Where do you go to review if the patient has scheduled Modified NIHs and/or Neuro checks ordered?
Who can pain re-assessments be delegated to?
Virtual RN
Stroke is a neurological disorder characterized by blockage of -------------- . Clots form in the brain and interrupt blood flow, clogging arteries and causing blood vessels to break, leading to -------. Rupture of the arteries leading to the brain during stroke results in the sudden death of brain cells owing to a lack of oxygen. Stroke can also lead to depression and dementia.
blood vessels, bleeding,
An IV medication was given to the patient to the patient with post-operative pain, when does the pain need to be re-assessed and documented?
In 30 minutes
You have a spine patient that is having increasing reports of pain and discomfort - you need to call a provider after 5pm - what resource can you use to help you?
On call after 5pm sheet - found on the unit OR on the nursing website
You were assigned a stroke patient who is impulsive and confused. He had avasure in place, and still had a fall. He landed on the fall matt and the bed alarm was on and went off. He is not on any anti-coagulants. Post fall, what items do you need to perform and where can you find a review of these items?
1. Post Fall Note
2. Voice
3. Supper huddle - manager fills out post fall form
4. Nursing Website
Zenworks - in the Oakland directory look up SJMO MSN
The incidence of stroke increases with age, doubling after the age of --- years.
55