Question

Mrs. Nelson is admitted to the nursing home where you work as a nurse. She had a
stroke 2 weeks ago and is not strong enough to go to a rehabilitation facility. She has
left-sided weakness. You collect admitting data to help determine her plan of care.

1. Mrs. Nelson tells you that she needs to get up to go to the bathroom. What are some
things you can do to determine if she is able to ambulate on her own?
2. Mrs. Nelson’s first meal is served. What can you do to determine she is ready to eat
safely?
3. Mrs. Nelson says, “Will you go to the kitchen and get me one of those cookies I like?”
How do you determine whether she is confused?

Answer 1

Ans) 1)While helping a stroke patient, a nurse should stand at the patient's weak side. She should support the weak arm with her hand and grasp the belt at the patient's back. Have patient slide forward to the edge of the bed before attempting to stand.

2) Stick to soft foods. Items like cooked cereal, mashed potatoes, soup, cottage cheese, and applesauce are all easier to eat.
- Thicken your liquids. It's important to drink enough fluid to avoid dehydration.
- See a speech therapist

3) A stroke can cause sudden confusion. For example, if you're typing on your computer or having a conversation, you may suddenly have difficulty speaking, thinking, or understanding speech.

- Here also giving command will put the patient in confusion.

Although delirium can occur at any time after a stroke, and may be part of the presentation of the stroke, often delirium is caused by medications, infection, heart failure or metabolic abnormalities. The researchers stress that it is important to determine the cause of delirium in order to improve patient outcomes.