Synopsis
Deliver coordinated stroke-unit care that prevents aspiration, venous thrombosis, pressure injury and physiological deterioration while detecting cerebral oedema, haemorrhage and other early complications promptly.
- Admission to a specialist stroke unit improves outcomes through coordinated nursing, medical, therapy, nutrition and discharge care rather than through one isolated intervention.
- Screen swallowing with a validated process by a trained professional before oral food, fluid or medication; a patient who talks clearly can still aspirate silently.
- Give aspirin 300 mg after haemorrhage is excluded in acute ischaemic stroke, but wait at least 24 hours after thrombolysis and obtain the required follow-up imaging first.
- Maintain oxygenation, hydration, normoglycaemia and temperature while avoiding routine oxygen in a non-hypoxic patient, excessive intravenous fluid and intensive insulin that causes hypoglycaemia.
- Use intermittent pneumatic compression for an immobile acute-stroke patient when appropriate; routine graduated compression stockings are not an effective substitute.
- Mobilisation and rehabilitation should be individualised and started by the multidisciplinary team when clinically stable; very early high-dose mobilisation is not a universal target.
- Neurological deterioration requires immediate reassessment for haemorrhagic transformation, recurrent or extending ischaemia, cerebral oedema, seizure, infection, metabolic disturbance and medication effects.
- Large middle cerebral artery or cerebellar infarction can produce life-threatening swelling and needs early neurosurgical discussion before irreversible herniation or brainstem compression develops.
Key red flags
Any new neurological deficit, fall in consciousness, severe headache or vomiting requires immediate senior stroke review and urgent repeat brain imaging.
Stridor, inability to handle secretions, repeated aspiration or worsening hypoxia requires airway and critical-care assessment rather than repeated bedside oral trials.
Painful swollen leg, sudden hypoxia, pleuritic pain or haemodynamic collapse raises venous thromboembolism and needs urgent diagnostic and treatment review.
A large infarct with evolving oedema or cerebellar mass effect requires early neurosurgical contact; waiting for fixed pupils loses the opportunity for benefit.
Fever with hypotension, rising oxygen need or reduced urine output suggests sepsis or another systemic emergency and should not be attributed automatically to stroke.
Investigation priorities
Identify patients who need restriction of oral intake and formal swallowing assessment before food, fluid or medicines.
Management branches
A new stroke patient has not passed a trained swallowing screen or shows clinical dysphagia.
- Keep the patient nil by mouth, including routine tablets and water, while providing mouth care and an alternative safe route for essential hydration and medicines.
- Arrange prompt specialist swallowing assessment and communicate posture, texture and supervision recommendations to every staff member and carer.
- If oral intake will remain inadequate, discuss nasogastric feeding, medicine formulations, nutrition targets and refeeding risk with the multidisciplinary team.
- Review swallowing serially because recovery and fatigue alter safety; do not leave restrictions or tubes in place without reassessment.
The patient is medically and neurologically stable enough for active assessment and goal setting.
- Assess mobility, upper-limb function, speech, language, swallowing, cognition, vision, continence, mood and activities of daily living with the relevant disciplines.
- Agree goals that are specific to the person's priorities and deliver therapy at an intensity they can tolerate, rather than imposing one uniform dose.
- Identify equipment, carer training, communication support, work and driving implications and likely discharge environment early.