Front Panel Painting “LIFE” By William T Chua MD

Stroke Unit
Nurse-Rehab
GENERAL
OBJECTIVES
1. Nurses will
promptly identify and
prioritize patient’s
needs by utilizing and
performing proper
health assessment
with emphasis on
neurological
assessment technique
2. Nurses will provide
quality nursing care
based on the
identified patient’s
needs in collaboration
with other members
of the health team
utilizing holistic
approach
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SPECIFIC
OBJECTIVE
Promptly identify
and prioritize
patient’s needs
Utilize and
perform proper
neurologic
assessment
technique
Plan and manage
nursing care
according to
patient’s
condition, needs
and priorities
a. Physiological Care
b. Safe measures
c. Comfort measures
d. Therapeutic
environment
e. Prevention of
complications and
infection
f. Spiritual and
psychosocial care
To be able to
provide specific
nursing care in
collaboration with
other members of
the health team
CURATIVE ASPECT
PROCESS STANDARDS
Nurses will assess patient
comprehensively with the
use of current and
acceptable neurologic
assessment tools
a. Glasgow Coma Scale
b. Diaz Stroke Scale
c. FIM/Barthel Index
Scale
Nurses will correlate
patient’s history with
present signs and
symptoms
Nurses will identify priority
needs of patient based on
assessment
Nurses prioritize and
facilitate
series of diagnostic
examinations per stroke
guidelines
Nurses will implement
Emergency nursing
measures if needed
Nurses will closely monitor
neurologic vital signs with
proper documentation and
reporting of findings:
a. Every 15 mins. for the first
hour
b. Every 30 mins. For the
second hour then every
hour for the next 4 hours
until patient is stable
c. Continue reassessment of
the patient’s condition with
regards to the monitoring
of neurologic vital signs
d. Watch out for increased
ICP, deterioration in
sensorium and progression
of motor deficits
Nurses will provide safety
measures accordingly such
as:
a. Aspiration precautions
b. Fall prevention
c. Use restraints based on
proper protocol
d. Seizure precautions
OUTCOME STANTARDS
Early identification and
prioritization of needs
Immediate initiation of
management
Early transfer/admission to
hospital with stroke or
intensive care unit
Early identification and
assessment of disease
progression
No incidence of falls and
aspirations
No bedsores contractures
and muscle atrophy