Basic Concept ATI Template: Caring for a client who had a stroke
Related Content: ( E.G. Delegation, Levels of Prevention, Advanced Directive)
Underlying Principles
Nursing Interventions: ( Who? When? Why? How?)
The Correct Answer and Explanation is :
Basic Concept ATI Template: Caring for a Client Who Had a Stroke
Related Content
- Delegation: Assign non-complex tasks like vital sign monitoring or assisting with ADLs to unlicensed assistive personnel (UAP), while maintaining responsibility for assessments and complex care.
- Levels of Prevention: Focus on tertiary prevention to maximize rehabilitation efforts and reduce complications.
- Advanced Directives: Ensure the client’s wishes about end-of-life care are documented and respected; advocate for timely discussions with the healthcare team and family.
Underlying Principles
Stroke, or cerebrovascular accident (CVA), results from an interruption of blood supply to the brain, causing cell death in affected areas. This leads to varying neurological deficits, depending on the location and extent of the stroke. Principles of care include promoting neuroplasticity through rehabilitation, preventing complications like aspiration or pressure injuries, and supporting functional recovery. Collaboration among multidisciplinary teams (nursing, physical therapy, occupational therapy, speech therapy) ensures holistic care.
Nursing Interventions
Who?
- Primary RN: Assesses neurological status, manages medications, coordinates care, and monitors for complications.
- UAP: Assists with hygiene, mobility, and routine care under supervision.
- Interdisciplinary Team: Includes therapists for rehabilitation and a dietitian for nutrition optimization.
When?
- Immediate Phase: Prioritize airway, breathing, and circulation (ABCs), manage blood pressure, and assess for ischemic versus hemorrhagic stroke.
- Rehabilitation Phase: Start as soon as the client stabilizes to maximize recovery potential.
Why?
- Early interventions reduce secondary injury and complications (e.g., aspiration, contractures). Long-term interventions aim to improve independence and quality of life.
How?
- Neurological Monitoring: Regular Glasgow Coma Scale (GCS) assessments, monitoring for increased intracranial pressure (ICP).
- Positioning: Elevate the head of the bed (30 degrees) to reduce ICP and aspiration risk.
- Swallowing Safety: Conduct a bedside swallow study; collaborate with speech therapy.
- Prevent Complications: Use sequential compression devices (SCDs) to prevent deep vein thrombosis (DVT); turn the client every 2 hours to prevent pressure injuries.
- Mobility Support: Encourage range-of-motion (ROM) exercises; use assistive devices for ambulation.
- Education: Teach caregivers about stroke prevention and rehabilitation strategies.
Explanation (300 Words)
Stroke care requires a multidisciplinary approach to address the complex needs of the client. Early and accurate assessment of neurological status is critical for identifying changes in condition and guiding interventions. For example, a rapid response to dysphagia (common after stroke) reduces the risk of aspiration pneumonia. Collaborative efforts with speech therapists to assess swallowing and dietary modifications enhance safety and nutrition.
Positioning plays a vital role in both immediate and long-term care. Elevating the head of the bed reduces ICP and promotes effective breathing, while frequent repositioning prevents pressure ulcers. Preventing complications such as DVT is crucial in clients with limited mobility. Nurses play a key role in recognizing signs of thrombosis and implementing preventive measures like SCDs and anticoagulation therapy.
Rehabilitation begins early to maximize neuroplasticity and improve functional recovery. Engaging in ROM exercises and physical therapy helps prevent contractures and promote mobility. Delegating appropriate tasks to UAPs (e.g., assisting with hygiene or ambulation) ensures that the RN can focus on critical aspects of care like assessments and medication administration.
Education and emotional support are integral to nursing care. Stroke survivors and their families must understand the importance of secondary prevention, such as adhering to prescribed medications and lifestyle changes. Advanced directives should be reviewed to ensure care aligns with the client’s wishes.
By combining vigilant monitoring, evidence-based interventions, and compassionate care, nurses significantly improve outcomes and quality of life for stroke clients.