It is important to measure the following in ALL stroke patients.
Go through the slides below for more information.
Not only is it important to recognise the abnormal readings, you must be aware of the importance of recognising the sudden changes in parameters. Now let’s look at each of these in a little more detail.
Temperature: This is normally measured using non-invasive digital thermometer via the tympanic (ear) or temporal artery sites. The normal range is 36 – 37.5, but may vary depending on the site used. For more information see references in Additional Information.
Respiratory Rate: Record for a minute by direct observation of chest movements. The normal values are 14-20 breaths per minute.
Oxygen Saturation: Record using an electronic finger probe. The normal values are usually 95% and above.
Glucose: Measured using a BM Stix. The normal ranges are approximately 4 – 7 mmols per litre.
Conscious Level: Use the Glasgow Coma Scale. This scale measures 3 responses:
- Eyes (max score of 4)
- Motor (max score of 6)
- Verbal (max score of 5)
Each response should be scored and recorded separately.
Heart Rate: Measured using a heart rate monitor. All patients should have an ECG on admission. When monitoring a patient’s vital signs the pulse rate is usually taken – the difference between heart rate and pulse rate is covered later in the module. The normal range is 50-80 beats per minute.
Blood Pressure: Measured using a blood pressure monitor. From 2 weeks after the stroke, a target systolic BP of about 130 mmhg is currently recommended, however, for BP targets during acute stroke please see the BP case 1: Jean.
You are the nurse on duty and are assigned four stroke patients; each of these patients have different problems. We will explore physiological monitoring through these four cases.
Page last reviewed: 12 Oct 2020
