Signs & Symptoms
The stroke symptom I am assessing for when asking the patient to touch their nose and then touch my finger.
Ataxia
Impaired balance or coordination.
This is the neurological assessment you will complete if you feel your patient is exhibiting stroke symptoms.
The comprehensive neurological assessment
NIH
A condition that may mimic stroke symptoms and warrants checking the patient's blood sugar.
Hypoglycemia
This is the teaching method we should always include when educating our patients and family.
Teach Back Method
This is the CCF Primary resource for our standard of practice when caring for stroke patients.
Cleveland Clinic Policy and Procedure Manager (PPM)
The stroke symptom I am assessing for when listening to the patient's speech.
Slurred and/or garbled speech
Expressive and/or global aphasia
Word finding issues
Two interventions I want to do if I notice my patient drooling.
Have suction available
Monitor/maintain airway
Raise the HOB
Dysphagia screen
Make patient NPO
An assessment that must be done prior to administering anything PO.
A dysphagia screen
This is a list that is important to reconcile and review with the patient and family prior to discharge.
The home medication list
These are two RN personnel I can consult for assistance and guidance pertaining to caring for my stroke patient.
Charge Nurse
ANM
NOM
Rapid Response Nurse
Stroke Care Coordinator
NPDS (Nursing Education)
Nurse Manager
The stroke symptom I am assessing for when asking the patient to smile.
Facial droop
Change in facial symmetry
You have called a rapid response. The critical care team has arrived and they feel the patient is having a stroke. This is what will be called overhead to get the stroke team at bedside.
Stroke Care
My patient failed the bedside dysphagia screen. These are my next steps.
Make patient NPO
Alert LIP
Obtain order for speech therapy consult
This is an acronym to teach the patient and family prior to discharge so they can recognize something is wrong.
BE FAST
(Balance, Eyes, Face, Arms, Speech, Time)
She is our Stroke Program Coordinator here at Cleveland Clinic Mercy Hospital.
Maria Griffin MSN, APRN-CNP
griffim23@ccf.org
Phone: 330.489.1111 ext 3573
Fax: 330-580-4720
I checked his pupils and documented them as PERRL.
What does PERRL stand for?
Pupils Equal Round Reactive to Light
You're waiting for the stroke team to arrive and one of your other patients requests pain medication. What is your response?
Delegate to another nurse for help. DO NOT leave the stroke patient alone.
Along with our Stroke Program Coordinator, this is the virtual team involved during the stroke care who can see the CT scan results in an immediate/timely manner.
TeleStroke Team
You are administering Eliquis to your patient and they are requesting written education they can read over. This is the resource you can use to find patient education materials pertaining to stroke.
Lexicomp
Lippincott Drug guide
Lippincott Advisor: Stroke
Up to Date
CCF PPM if applicable
Resource Pharmacy
CCF today --> Mercy Departmental Pages --> Stroke resources
You are viewing the Acute Stroke Nursing Care Protocol in PPM. While in the database, this is another policy you might reference when caring for a stroke patient.
Swallow Screening for Adult Patients as Risk for Dysphagia Protocol
Aspiration Precautions, Adult Protocol
Seizure Precautions Protocol
Falls Minimization and Post Fall Care, Adult Protocol
Bleeding Precautions, Adult Protocol
The cranial nerve I am assessing for when I do the visual field test.
Cranial nerve II - Optic Nerve
One piece of important assessment data to know prior to administering any medications during the stroke care.
Last Known Well (LKW)
Tenecteplase
This is the section of our EMR where I will document the discussion I had with my patient and family on at home management after having a stroke.
The Patient Education tab
The National Organization and/or website to obtain education information and stroke guidelines.
The American Heart Association (AHA)
The American Stroke Association (ASA)
National Institutes of Health (NIH)