The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed
Which actions are most important to include in the patient's plan of care? (Select all that apply.) a. Make frequent neurological assessments.
b. Maintain CO2 level at 50 mm Hg.
c. Maintain MAP less than 130 mm Hg.
d. Prepare for thrombolytic administration.
e. Restrain affected limb to prevent injury.
A, C
The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.
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