Page 2023 - Saunders Comprehensive Review For NCLEX-RN

d. Allow time for the client to
communicate.
e. Use a picture board, communication
board, or computer technology.

F. Interventions during the acute phase of stroke

1. Maintain a patent airway and administer oxygen as
prescribed.
2. Monitor vital signs.
3. Usually a blood pressure of 150/100 mm Hg is
maintained to ensure cerebral perfusion.
4. Suction secretions to prevent aspiration as prescribed,
but never suction nasally or for longer than 10
seconds to prevent increased ICP.
5. Monitor for increased ICP, because the client is most at
risk during the first 72 hours following the stroke.
6. Position the client on the side to prevent aspiration,
with the head of the bed elevated 15 to 30 degrees as
prescribed.
7. Monitor level of consciousness, pupillary response,
motor and sensory response, cranial nerve function,
and reflexes.
8. Maintain a quiet environment.
9. Insert a urinary catheter as prescribed.
10. Administer intravenous fluids as prescribed.
11. Maintain fluid and electrolyte balance.
12. Prepare to administer anticoagulants, antiplatelets,
diuretics, antihypertensives, and antiseizure
medications as prescribed depending on the type of
stroke that has been diagnosed.
13. Establish a form of communication.
G. Interventions in the postacute phase of a stroke
1. Continue with interventions from the acute phase.
2. Position the client 2 hours on the unaffected side and
20 minutes on the affected side; the prone position
may also be prescribed.
3. Provide skin, mouth, and eye care.
4. Perform passive range-of-motion exercises to prevent
contractures.
5. Place antiembolism stockings on the client; remove
daily to check skin.
6. Monitor the gag reflex and ability to swallow.
7. Provide sips of fluids and slowly advance diet to foods
that are easy to chew and swallow.
8. Provide soft and semisoft foods and flavored, cool or
warm, thickened fluids rather than thin liquids,
because the stroke client can tolerate these types of
food better; speech therapists may do swallow studies

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