Signs & Symptoms
The stroke symptom I look for when assessing drift
What is:
Hemiplegia
Weakness on one side
What you call when you suspect your patient is having a stroke
What is:
Stroke Alert
An assessment that must be done prior to administering PO
What is:
A swallow eval
What teaching method should we always include when educating patients and family?
What is:
Teach Back Method
A CCF resource to find information on a medication
What is:
Lexicomp
Pharmacy
Lippincott Drug Guide
CCF PPM if applicable
A stroke symptom I assess for when listening to the patient's speech
What is:
Slurred and/or garbled speech
Expressive and/or global aphasia
Word finding issues
What you do if you're waiting for additional help to arrive and one of your other patients requests pain medication.
What is:
Ask another nurse for help
Do not leave stroke patient alone
Imaging needed to determine immediate best plan of care for a stroke patient
What is:
Brain attack CT scan
A list that's important to reconcile and review with the patient and family prior to discharge
What is:
The medication list
Two nursing personnel I can consult for assistance and guidance
What is:
Charge nurse
ANM
Nurse manager
NOM
Stroke Nurse
NPDS (Nursing Education)
The stroke symptom I assess for when asking the patient to smile
What is:
Facial droop
Change in facial symmetry
Three nursing interventions to perform when your patient is having a stroke
What is:
Vital signs
Complete comprehensive neuro assessment
Make patient NPO
Suction PRN
Place patient on cardiac monitor (Zoll)
Establish large bore IV (18g if possible)
Obtain accurate weight if none in past 24hrs
Maintain O2 SATs >94%
Telestroke if appropriate for your area
Consider notifying family
Two lab tests I anticipate being ordered for a stroke patient
What is:
PT/PTT
INR
CBC
BMP
An acronym to teach the patient and family prior to discharge so they can recognize something is wrong
What is:
BEFAST (Balance, Eyes, Face, Arms, Speech, Time)
The CCF primary resource for our policies when caring for stroke patients
What is:
Cleveland Clinic Policy and Procedure Manager (PPM)
Two interventions I want to do if I notice my patient drooling
What is:
Make patient NPO
Have suction available
Monitor airway
Swallow screening
Raise the HOB
A condition that may mimic stroke symptoms and warrants checking the patient's blood sugar
What is:
Hypoglycemia
A bedside cardiac diagnostic tool that may be ordered
What is:
EKG
A site provided by Cleveland Clinic where I can find patient education materials on stroke
What is:
-Lippincott Advisor: Stroke
-Patient Education Handouts (Your Guide to Managing Stroke, Dysphagia Levels 1-3, Thickened Liquids)
-Lexicomp for medications
A document in the CCF PPM to reference when caring for stroke patients other than the Acute Stroke Nursing Care Protocol
What is:
Swallow Screening for Adult Patients at Risk for Dysphagia Protocol
Aspirations Precautions, Adult Protocol
Seizure Precautions Protocol
Falls Minimization and Post Fall Care, Adult Protocol
A stroke symptom I assess for with my penlight
What is:
Pupil changes and reactivity
One piece of important assessment data to know prior to administering tenecteplase per CCF PPM
What is:
Last Known Well (LKW)
Baseline vital signs and neuro status
Ensure BP < 185/110
Verify actual weight of patient
A medication I anticipate being ordered for an ischemic stroke patient if there are no contraindications
What is:
Tenecteplase
Where I document the discussion, I had with my patient on the booklet "Your Guide to Managing Stroke"?
What is:
Patient education section in Epic
A national organization and/or website to obtain educational information and stroke guidelines
What is:
The American Heart Association (AHA)
The American Stroke Association (ASA)
National Institutes of Health (NIH)