Nursing Fundamentals

Pupillary Response - list the steps

1. Darken the room. 2. Ask the patient to look straight ahead. 3. Bring the penlight in from the side of the patient's face and briefly shine light on pupil. 4. Observe pupil's reaction. 5. Repeat procedure with the same eye, but this time, observe the eye. 6. Repeat the procedure with the other eye. Taylor et al., Fundamentals of Nursing, 8th Edition, p. 644

The nurse is caring for a patient who has experienced a sudden change in level of consciousness and has difficulty speaking. What is the priority action of the nurse?

Assess the patient first then notify the charge nurse and the provider. The nurse would document the findings last. Lippincott Advisor, Stroke

Assessing Level of Awareness

Assess time (What is today's date? What day of the week is it?), place (Where are you now? What is the name of this city?), and person (What is your name? How old are you?) If the patient is oriented to time, place, and person, the nurse would document that the patient is alert and oriented x 3 (or A&O x3) Taylor et al., Fundamentals of Nursing, 8th Edition, p. 666

Potential neurologic compromise assessment findings

Decreasing level of consciousness, unequal pupils Lippincott Procedures, Neurologic assessment

Symptoms of stroke

Dysphagia, mild left-sided weakness, urinary incontinence, communication difficulties, and sensory deficits Lippincott Advisor, Stroke

Patient - stroke with mild dysphagia What would be an appropriate nursing intervention for this patient in order to minimize risk for injury?

Educating the patient about the importance of alternating liquids and stools. (Help minimize the potential risks) Providing 30-minute rest prior to mealtimes. (Decrease the possible risk of choking and/or aspiration) Positioning patient upright in chair if not contraindicated Taylor et al., Fundamentals of Nursing, 8th Edition, p. 1223

Patient is experiencing dysphagia following a stroke. How should the nurse position the patient when administering medications?

High Fowler's The nurse should position the patient at 90 degrees (high Fowler's) or should sit the patient upright in a chair. The nurse should not position the patient supine (on back), semi-Fowler's (45 degrees), or left lateral (on the side) during medication administration, because these positions can impede swallowing and the passage of food/liquids into the stomach. Taylor et al., Fundamentals of Nursing, 8th Edition, p. 1223

Patient positioning

High Fowler's (90 degrees) Semi-Fowler's (45 degrees) Supine (on back) Left lateral (on the side)

Glasgow Coma Scale

Measures Eye Opening, Verbal Response, and Motor Response Typically used with patients who have suffered a brain injury as a result of trauma Taylor et al., Fundamentals of Nursing, 8th Edition, p. 667

Components of neurological examination

Memory, level of consciousness, sensory perception, cranial nerves, patterns of speech, and bilateral hand grips

A patient with dysphagia following a stroke expresses concern about having difficulty eating and drinking. What is the appropriate reply by the nurse?

Muscle weakness frequently occurs after a stroke; we need to make sure that food is not going into your lungs.

Risk factors for stroke

Smoking, hypertension, and diabetes mellitus

The nurse is calling in a report to the provider using the SBAR format. Which statement by the nurse would be the "S" when using this reporting technique? a. The patient's lungs are clear to auscultation. b. The patient was admitted with stroke and mild left hemiplegia. c. The patient began coughing when eating breakfast this morning. d. I recommend the patient be sent for a swallow study.

The patient began coughing when eating breakfast this morning. SBAR stands for situation, background, assessment, and recommendation. The situation (or the "S") statement is: The patient began coughing when eating breakfast this morning. The background statement is: The patient was admitted with stroke and mild left hemiplegia. The assessment is: The patient's lungs are clear to auscultation. The recommendation is: I recommend the patient be sent for a swallow study. Taylor et al., Fundamentals of Nursing, 8th Edition, pp. 169-170 Lippincott Procedures, SBAR communication

Possibilities a patient who has experienced stroke has aspirated

Coughing, hoarseness, and regurgitation into the mouth Taylor et al., Fundamentals of Nursing, 8th Edition, p. 1223

Patient - suspected of having a stroke. First action to ensure patient safety when patient is having difficulty swallowing prescribed medication

Hold dose of medication and make the patient NPO. Notify provider who will probably over a swallow study. Patient safety is the priority. Taylor et al., Fundamentals of Nursing, 8th Edition, p. 1224

Patient is placed on fall precautions. What actions should the nurse take to keep the patient safe?

Maintain bed in low position at all times. Place the call bed within reach. Provide non-skid socks for ambulation. Instruct patient to call for assistance when out of bed.