e. Medical and Nursing Management during the Acute Phase of Cerebral
Objectives of care during the acute phase:
(a) Keep the patient alive.
(b) Minimize cerebral damage by providing adequately oxygenated
blood to the brain.
Support airway, breathing, and circulation.
Maintain neurological flow sheet with frequent observations of the
Level of consciousness.
Pupil size and reaction to light.
Patient's response to commands.
(d) Movement and strength.
(e) Patient's vital signs--BP, pulse, respirations, and temperature.
(f) Be particularly aware of changes in any of the above. Deterioration
could indicate progression of the CVA.
(4) Continually reorient patient to person, place, and time (day, month) even
if patient remains in a coma. Confusion may be a result of simply regaining
consciousness, or may be due to a neurological deficit.
Maintain proper positioning/body alignment.
(a) Prevent complications of bed rest.
(b) Apply foot board, sand bags, trochanter rolls, and splints as
(c) Keep head of bed elevated 30, or as ordered, to reduce increased
(d) Place air mattress or alternating pressure mattress on bed and turn
patient every two hours to maintain skin integrity.