The University of Alabama Huntsville

Nursing Concept Map

Stroke

Assessment
Risk Factors (Signs & Symptoms) Complications
Facial drooping
Previous stroke A-fib Death
HTN Dysarthria
Loss of function
Atherosclerosis Left/right side paralysis
Arterial clots Dysphagia
Diabetes Ataxia Loss of speech
Obesity Altered LOC Cognitive impairment
DVT
Genetic factors Constricted pupils Loss of physical mobility
Increased cholesterol Risk for injury/falls
Trauma
80% of strokes are ischemic
Unilateral neglect (Spatial neglect)
Nursing DX Health Promotion
Dysphagia
Medication adherence
Impaired perfusion Confusion Smoking cessation
Risk for aspiration Fatigue Controlled diabetes
Risk for falls Healthy weight
Interventions/Safety Family teaching of s/s- “FAST”
Impaired cognition Physical/Occupational therapy
Assess swallowing ability
Impaired mobility Neuro assessment Speech therapy
Risk for death Orientation to surroundings Counseling
Impaired swallowing Collaborate with OT and PT Home checks for safety
Safe environment
ABCs Meds
Diagnostics Provide oxygen
Monitor pulsoximeter TPA
MRI/CT Cardiac monitoring Anticoagulants
Blood test (disease?) Get to CT ASAP (within 25 mins; determine if ischemic vs Beta-blockers
Clotting times (PT, ppt) hemorrhagic) Steroids (w/insulin)
Monitor O2 sats Clot buster must be given within 3-4 1/2 hours
Antihypertensive (males ED)
Cardiac monitoring Surgical thrombectomy/embolectomy
Limb alert (for spatial neglect)
May have widened high BP
Aspirin (if not hemorrhagic)
Swallow evaluation (thickening agents needed?)**