Clinical reasoning cycle holistically focus on individual care plan to ensure that nursing intervention are tailored to the highest standard with accurate diagnosis.
Assessment is a deliberate, systematic, and interactive process which allow nurses to make judgement to determine care and treatment needs of a patient. The initial assessment and management of stroke patient is a challenging task and requires methodical approach to undertake the primary survey (Cox 2009). A generic way to assess stroke patients is using the ABCDE mnemonic whereby each letter depicts a step in the assessment process; A stands for airway, B for breathing , C for circulation, D for disability and E for exposure (Fulge 2009). Airway management is paramount in preventing hypoxia which can further lead to aggravation of brain injury. Nurses can use simple statement requiring a response from the patient to assess if he can speak. But however with stroke patient even with clear airway, engaging a conversation may pose a problem. So physically checking is required and measures should be taken to relieve any obstruction. Efficiency of breathing should be established by observing for the rate and depth, use of assessor muscle and inspect the thoracic wall for symmetry. If there is any inadequacy in the breathing, mechanical ventilation such as endotracheal tube should be initiated. At that point, oxygen saturation can measured by a pulse oximeter according to National Institute For Health and Care Excellence(NICE) (2008 a) patient should receive high flow oxygen if oxygen level is below 95%. Once the airway and breathing has been assessed, the next intervention will focus on circulation status. Restoration of adequate circulating blood volume and oxygen carrying capacity is essential. Capillary refill time and pulse rate can be assessed. While primary survey is underway, reassure the patient and keep him informed about the ongoing treatment and other update.