What is the immediate nursing management for a patient presenting with hypertension and recurrent nausea and vomiting in the context of a potential stroke?

Immediate Nursing Management for Stroke Patient with Hypertension and Recurrent Nausea/Vomiting

For a patient presenting with hypertension and recurrent nausea/vomiting in the context of potential stroke, immediate nursing management must focus on frequent neurological assessment, permissive hypertension (avoiding treatment unless BP >220/120 mmHg), maintaining NPO status until dysphagia screening is completed, and preventing aspiration while monitoring for signs of increased intracranial pressure. 1

Initial Stabilization and Assessment

Airway and Positioning

• Position the patient with head of bed elevated 20-30 degrees with head in neutral alignment to facilitate venous drainage and reduce aspiration risk 1
• Maintain airway patency and assess for signs of respiratory compromise, particularly if vomiting is recurrent 1
• Provide supplemental oxygen only if oxygen saturation falls below 94% (routine oxygen is not recommended for non-hypoxic patients) 1
• Keep patient strictly NPO until dysphagia screening is completed to prevent aspiration pneumonia 1

Neurological Monitoring

• Perform neurological assessment using the National Institutes of Health Stroke Scale (NIHSS) every 15 minutes for the first 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1
• The Glasgow Coma Score is inadequate for stroke monitoring and should not be used 1
• Monitor specifically for signs of increased intracranial pressure: decreased level of consciousness (early sign), pupillary changes (late sign), worsening neurological deficits, or changes in respiratory pattern 1
• Up to 30% of stroke patients deteriorate in the first 24 hours, necessitating intensive monitoring 1

Blood Pressure Management

For Patients NOT Receiving Thrombolysis

• Observe and do NOT treat hypertension unless systolic BP >220 mmHg OR diastolic BP >120 mmHg 1
• This permissive hypertension approach is critical because cerebral autoregulation is impaired and aggressive BP lowering can worsen ischemia 1
• If BP exceeds 220/120 mmHg, administer labetalol 10-20 mg IV over 1-2 minutes, may repeat every 10 minutes (maximum 300 mg) 1
• Target only a 10-15% reduction in BP, not normalization 1

For Patients Eligible for Thrombolysis

• BP must be reduced to <185/110 mmHg BEFORE initiating thrombolysis 1
• After thrombolysis, maintain BP <180/105 mmHg for 24 hours 1
• Use labetalol 10-20 mg IV or nitropaste 1-2 inches for pre-treatment BP control 1

BP Monitoring Frequency

• Use manual sphygmomanometers if atrial fibrillation is present (automatic oscillometric monitors are inaccurate with irregular rhythms) 1
• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1

Management of Nausea and Vomiting

Immediate Interventions

• Treat nausea and vomiting aggressively as these symptoms worsen patient outcomes and increase aspiration risk 1
• Position patient on side if actively vomiting to prevent aspiration 1
• Have suction equipment immediately available at bedside 1
• Assess whether nausea/vomiting represents a sign of increased intracranial pressure (particularly if associated with headache or deteriorating consciousness) 1

Underlying Cause Assessment

• Nausea and vomiting may indicate increased ICP, particularly with posterior circulation strokes or cerebellar involvement 1
• Rule out other causes: hypoxia, hyperglycemia, medication side effects 1
• If signs of increased ICP are present (headache, visual disturbances, decreased consciousness), notify physician immediately for emergency brain imaging 1

Additional Critical Monitoring

Temperature Management

• Monitor temperature every 4 hours 1
• Treat any temperature >37.5°C (99.5°F) with antipyretics 1
• Fever is associated with marked increase in morbidity and mortality after stroke 1

Glucose Monitoring

• Check blood glucose on arrival and every 6 hours for the first 72 hours 1
• Maintain glucose levels between 140-180 mg/dL (7.8-10 mmol/L) 1
• Treat glucose >198 mg/dL (11 mmol/L) with insulin 1

Cardiac Monitoring

• Continuous cardiac telemetry for at least 24 hours to detect atrial fibrillation or other arrhythmias 1
• Cardiac complications account for 2-6% of mortality in first 3 months, with highest risk in first 2 weeks 1

Hydration Status

• Maintain adequate hydration with isotonic fluids (0.9% normal saline preferred) while patient is NPO 1
• Avoid hypoosmolar fluids (5% dextrose in water) as they may worsen cerebral edema 1
• Monitor fluid balance to identify dehydration 1

Dysphagia Screening Protocol

• Complete dysphagia screening using a valid tool within 4-24 hours before administering ANY food, drink, or oral medications 1
• The presence of a gag reflex does NOT constitute adequate dysphagia screening 1
• 40-78% of acute stroke patients have dysphagia, which significantly increases pneumonia risk 1
• If patient fails screening, refer immediately to speech-language pathologist for formal assessment 1
• Maintain IV hydration until swallowing safety is established 1

Nurse-Patient Ratio and Care Setting

• Maintain 1:2 nurse-patient ratio for the first 24 hours 1
• If patient stabilizes, ratio may be adjusted to 1:4 1
• Care should be provided in stroke unit with continuous cardiac telemetry or intensive care unit 1
• Nurses must be specifically trained in acute stroke care, recognition of bleeding complications (if thrombolysis given), and signs of increased ICP 1

Critical Pitfalls to Avoid

• Never aggressively lower BP in acute stroke unless specific thresholds are exceeded or patient is receiving thrombolysis 1
• Never give anything by mouth until dysphagia screening is completed 1
• Never use nitroprusside for BP control as it causes cerebral venodilation and can increase ICP 1
• Never assume nausea/vomiting is benign—it may signal increased ICP requiring emergency intervention 1
• Never rely on Glasgow Coma Score alone for neurological monitoring in stroke patients 1