NLE Neurosensory Nursing — Cerebrovascular Disorders and Increased Intracranial PressureRevision Notes

Exam Tips

• NLE questions will often present a clinical vignette — identify stroke type from the scenario clues before selecting the intervention.
• If the question says 'emergent action,' the answer is almost always non-contrast CT scan first.
• Remember: Ischemic = thrombus/embolus = tPA eligible (if no contraindications, within time window). Hemorrhagic = bleeding = NO tPA.
• For SAH, 'worst headache of my life' + neck stiffness = suspect ruptured aneurysm.
• FAST mnemonic is commonly tested in community health/health education contexts in the NLE.

Key Points

• A stroke is a sudden loss of brain function due to disrupted cerebral blood flow, causing irreversible neuronal death within minutes.
• Strokes are classified as ISCHEMIC (80–85%) or HEMORRHAGIC (15–20%) — treatment is OPPOSITE, so type must be identified first.
• EMERGENCY: Non-contrast CT scan of the head is the FIRST and MOST IMPORTANT diagnostic test — it rules out hemorrhage before any treatment.
• Modifiable risk factors: Hypertension (single most important), atrial fibrillation, diabetes, dyslipidemia, smoking, obesity, carotid stenosis.
• Non-modifiable risk factors: Advancing age, male sex, family history.
• Ischemic stroke subtypes: THROMBOTIC (clot forms on atherosclerotic plaque in a cerebral artery) and EMBOLIC (clot travels from elsewhere, classically from left atrium in atrial fibrillation).
• Hemorrhagic stroke: Rupture of a cerebral vessel — most often from uncontrolled hypertension, cerebral aneurysm, or AVM.
• Ruptured cerebral aneurysm → Subarachnoid hemorrhage (SAH): Classic presentation is sudden 'worst headache of my life' + neck stiffness + rapid neurologic decline.
• The penumbra is the zone of ischemic but still salvageable tissue surrounding the infarct core — target of urgent reperfusion therapy.
• Warning signs mnemonic: FAST — Face drooping, Arm weakness, Speech difficulty, Time to call for emergency help.

Definitions

Section Title

Stroke (Cerebrovascular Accident) — Overview and Classification

Common Mistakes

• Giving tPA before confirming stroke type with CT — this is a fatal error; always CT first.
• Confusing contralateral deficits: stroke deficits appear on the OPPOSITE side of the brain lesion, not the same side.
• Thinking hemorrhagic stroke can be treated with tPA or anticoagulants — these are absolute contraindications.
• Forgetting that HYPERTENSION is the single most important modifiable risk factor for stroke in the Philippine context.
• Mistaking subarachnoid hemorrhage for a tension headache — the sudden severe 'worst headache of my life' must always prompt urgent CT.

Exam Tips

• NLE key fact: TIA resolves within 24 hours with NO permanent deficit — if deficit persists beyond 24 hours, it is a stroke.
• TIA management priority: Start antiplatelet therapy, control blood pressure, evaluate for AF and carotid stenosis.
• Patient teaching: 'Do not ignore even brief neurologic symptoms — seek emergency care immediately.'

Key Points

• TIA is a brief neurologic dysfunction from TEMPORARY cerebral ischemia — symptoms resolve COMPLETELY, usually within 1 hour and by definition within 24 hours, with NO permanent infarction.
• TIA is a critical 'warning stroke' — a significant number of patients will have a full stroke within days if untreated.
• TIA requires URGENT evaluation and workup even though symptoms have resolved.
• Management: Antiplatelet therapy (aspirin), risk factor control, carotid evaluation (Doppler ultrasound), cardiac workup (ECG, echocardiography for AF).
• Key distinction: TIA resolves fully (no permanent damage); stroke leaves permanent deficits.
• Teaching priority: ANY episode of neurologic symptoms — even if it resolved — must be reported and evaluated immediately.

Definitions

Section Title

Transient Ischemic Attack (TIA)

Common Mistakes

• Dismissing TIA because symptoms resolved — TIA is a medical emergency requiring urgent workup.
• Confusing TIA with stroke: TIA = complete resolution within 24 hours; stroke = persistent deficits beyond 24 hours or with infarction on imaging.
• Not including TIA as a risk factor for subsequent stroke in patient teaching.

Exam Tips

• Memory trick: Left brain = Language (both start with L). Right brain = spatial, impulsive, neglect.
• NLE question pattern: 'A patient with left hemisphere stroke would MOST likely exhibit...' → Answer: aphasia + right-sided weakness.
• For a patient with dysphagia: PRIORITY nursing diagnosis is Risk for Aspiration — keep NPO, elevate HOB, consult speech therapist.
• Unilateral neglect teaching: Always approach from the unaffected side; teach patient to scan environment; place call bell on unaffected side.

Key Points

• Stroke deficits are CONTRALATERAL — weakness/sensory loss appears on the OPPOSITE side of the brain lesion.
• LEFT hemisphere stroke (dominant in most people): Aphasia (language impairment), analytical thinking deficits, RIGHT-sided hemiparesis/hemiplegia, slow/cautious behavior.
• RIGHT hemisphere stroke: Spatial-perceptual deficits, poor judgment, impulsiveness, LEFT-sided hemiparesis/hemiplegia, unilateral neglect (ignoring the affected side).
• Aphasia types: Expressive/Broca's (knows what to say but cannot say it), Receptive/Wernicke's (cannot understand speech), Global (both).
• Dysphagia (difficulty swallowing) is a major aspiration risk — always assess before oral feeding.
• Hemianopia: Loss of half of the visual field in BOTH eyes on the affected side.
• Unilateral neglect: Patient ignores or is unaware of the affected side — common in right hemisphere strokes.
• FAST mnemonic: Face drooping, Arm weakness, Speech difficulty, Time to call emergency services.
• Other manifestations: Sudden severe headache (hemorrhagic), sudden vision changes, sudden loss of balance/coordination.
• NANDA priority nursing diagnoses: Ineffective Cerebral Tissue Perfusion, Impaired Physical Mobility, Impaired Swallowing, Impaired Verbal Communication, Risk for Aspiration.

Definitions

Section Title

Clinical Manifestations of Stroke and Hemispheric Differences

Common Mistakes

• Expecting deficits to be on the SAME side as the lesion — they are ALWAYS on the OPPOSITE (contralateral) side.
• Forgetting that right hemisphere stroke causes LEFT-sided deficits and spatial/neglect issues (not aphasia — that's left hemisphere).
• Allowing oral intake without a swallowing assessment first — dysphagia and aspiration risk must be addressed immediately.
• Approaching a patient with unilateral neglect from the affected/neglected side — approach from the UNAFFECTED side to ensure awareness.

Exam Tips

• NLE pattern: 'What is the PRIORITY diagnostic test for a patient with acute onset of sudden facial drooping and arm weakness?' → Non-contrast CT scan of the head.
• If glucose is low → treat hypoglycemia first before pursuing stroke workup.
• LP is not routine in stroke — only if CT is negative and SAH is still suspected.

Key Points

• NON-CONTRAST CT SCAN of the head is the FIRST priority diagnostic test — distinguishes ischemic from hemorrhagic before ANY treatment.
• MRI (especially diffusion-weighted imaging/DWI) detects early ischemia more sensitively than CT but takes longer.
• CT angiography or MR angiography: Visualizes cerebral blood vessels and identifies occlusion or aneurysm.
• Carotid Doppler ultrasound: Evaluates for carotid stenosis (embolic source).
• ECG and echocardiography: Identifies atrial fibrillation or intracardiac thrombus as embolic source.
• Blood glucose: MUST be checked — hypoglycemia mimics stroke symptoms and is easily reversible.
• CBC, coagulation studies (PT, PTT, INR), electrolytes: Baseline before tPA.
• Lumbar puncture (LP): If CT is negative but SAH is still suspected (xanthochromia in CSF confirms SAH).

Definitions

Section Title

Diagnostics for Stroke

Common Mistakes

• Ordering MRI before CT in acute stroke — CT is faster and sufficient to rule out hemorrhage for tPA eligibility.
• Forgetting to check blood glucose — hypoglycemia is a stroke mimic that is easily treated and must be excluded.
• Giving contrast for the initial CT — the FIRST scan must be NON-CONTRAST to detect acute blood.

Formulas

Exam Tips

• NLE question clue words: 'ischemic stroke,' 'within 3 hours,' 'last known well' → tPA is the answer.
• NLE contraindication questions: 'bleeding on CT' or 'history of ICH' → tPA is CONTRAINDICATED.
• Priority nursing action DURING tPA: Avoid invasive procedures + monitor for bleeding (especially intracranial hemorrhage).
• After tPA: Do not give aspirin or anticoagulants for at least 24 hours to reduce bleeding risk.
• STOP infusion signs: Sudden severe headache, vomiting, rapid BP rise, or sudden neurologic decline.

Key Points

• tPA (alteplase, tissue plasminogen activator) is the standard IV thrombolytic for ISCHEMIC STROKE ONLY.
• Time window: Within 3 hours of symptom onset; extended to 4.5 hours in selected eligible patients.
• KEY PHRASE: 'Time is brain' — every minute without treatment = approximately 1.9 million neurons lost.
• Establish LAST KNOWN WELL time (not when symptoms were discovered; unknown onset = NOT eligible for standard tPA).
• Blood pressure must be controlled to BELOW 185/110 mmHg BEFORE tPA administration.
• Dose: 0.9 mg/kg IV (maximum 90 mg); 10% given as IV bolus over 1 minute, remaining 90% infused over 60 minutes.
• ABSOLUTE CONTRAINDICATIONS: Any hemorrhage on CT, active internal bleeding, recent intracranial surgery/trauma, history of intracranial hemorrhage, uncontrolled severe hypertension.
• MOST DANGEROUS COMPLICATION: Intracranial hemorrhage (ICH) — monitor closely during and after infusion.
• Nursing: Avoid ALL invasive procedures during/after tPA (no arterial punctures, IM injections, Foley insertion unless necessary); monitor neuro status and VS frequently.
• STOP infusion immediately and notify physician if: sudden severe headache, vomiting, hypertension, or neurologic deterioration occurs.
• Endovascular mechanical thrombectomy: Option for large-vessel occlusions, extends treatment window beyond tPA in selected patients at capable centers.
• For HEMORRHAGIC stroke: NO tPA, NO anticoagulants, surgical evaluation, manage ICP, control blood pressure.

Definitions

Section Title

Thrombolytic Therapy — tPA (Alteplase) for Ischemic Stroke

Common Mistakes

• Giving tPA without CT confirmation of ischemic type — must always confirm no hemorrhage first.
• Using discovery time instead of last known well time — time is calculated from LAST KNOWN WELL.
• Performing arterial punctures or IM injections during tPA infusion — any invasive procedure risks serious bleeding.
• Not monitoring blood pressure before tPA — BP must be BELOW 185/110 mmHg before administration.
• Continuing tPA infusion when patient develops sudden severe headache or neurologic worsening — STOP immediately; suspect ICH.

Formulas

Exam Tips

• NLE HIGH YIELD: Earliest sign = decreasing LOC. Latest/most ominous sign = Cushing's Triad.
• Cushing's Triad memory: 'BBC' — Blood pressure Up (Broad pulse pressure), Bradycardia, Cheyne-Stokes/irregular respirations.
• Blown pupil (fixed, dilated, unilateral) = CN III compression = herniation is starting — EMERGENCY.
• CPP formula is commonly asked in NLE critical care questions: CPP = MAP − ICP, target 60–70 mmHg.
• ICP management priority order: Airway first → oxygenation → positioning (HOB 30°, neutral head) → reduce stimulation → medications.

Key Points

• Normal ICP: 5–15 mmHg. Sustained ICP above 20 mmHg requires treatment.
• Monro-Kellie Doctrine: The skull is a rigid, fixed-volume container; if volume of one component (brain, blood, CSF) increases, another must decrease to maintain normal ICP. When compensation fails, ICP rises.
• Causes of increased ICP: Cerebral edema (stroke, trauma, tumor), intracranial hemorrhage, hydrocephalus, brain tumor, abscess.
• EARLIEST sign of increased ICP: DECREASING LEVEL OF CONSCIOUSNESS (LOC) — always assess this first.
• Other signs: Headache, projectile vomiting (without nausea), papilledema (optic disc swelling seen on fundoscopy).
• Pupillary change: Unilateral FIXED and DILATED pupil (blown pupil) = CN III (oculomotor nerve) compression — URGENT sign of herniation.
• Abnormal posturing: Decorticate (arms flexed, legs extended) → Decerebrate (all extremities extended, poor prognosis) as ICP worsens.
• CUSHING'S TRIAD (LATE and OMINOUS sign): Rising systolic BP with WIDENING PULSE PRESSURE + BRADYCARDIA + IRREGULAR RESPIRATIONS — impending herniation.
• Herniation = life-threatening brain shift; requires emergency intervention.
• Cerebral Perfusion Pressure (CPP) = Mean Arterial Pressure (MAP) - ICP. Target CPP: 60–70 mmHg. Avoid both hypo and hypertension.
• NANDA nursing diagnoses: Ineffective Cerebral Tissue Perfusion, Risk for Decreased Intracranial Adaptive Capacity, Impaired Airway Clearance.
• Maslow: Priority is physiologic safety — airway and oxygenation first, then ICP management.

Definitions

Section Title

Increased Intracranial Pressure (ICP)

Common Mistakes

• Calling Cushing's Triad an EARLY sign — it is a LATE and ominous sign. The EARLIEST sign is decreasing LOC.
• Forgetting that a unilateral fixed, dilated pupil (blown pupil) signals CN III compression and impending herniation — this is a neurological emergency.
• Confusing decorticate (arms FLEXED) and decerebrate (all extremities EXTENDED) — decerebrate has a worse prognosis.
• Elevating the head of bed more than 30 degrees — exactly 30° is the standard; over-elevation can reduce CPP.
• Allowing neck and hip flexion — these obstruct venous drainage and raise ICP.

Formulas

Exam Tips

• NLE drug-of-choice question: 'Which drug reduces ICP in a patient with cerebral edema?' → Mannitol (osmotic diuretic).
• NLE scenario: 'Patient with brain tumor has edema.' → Dexamethasone is appropriate.
• NLE scenario: 'Patient with ischemic stroke has edema.' → Dexamethasone is NOT indicated.
• Positioning question: 'Correct position for increased ICP patient?' → HOB 30°, head neutral/midline, avoid neck and hip flexion.
• Hyperventilation: Only used as a SHORT-TERM emergency measure; not routine management.

Key Points

• PRIORITY 1 (Maslow — Physiological): Maintain PATENT AIRWAY and ADEQUATE OXYGENATION — hypoxia and hypercapnia dilate cerebral vessels and worsen ICP.
• Suction cautiously: Limit suctioning to 10–15 seconds per pass; pre-oxygenate; avoid prolonged stimulation.
• POSITIONING: Elevate head of bed (HOB) to EXACTLY 30 DEGREES. Keep head and neck in NEUTRAL, MIDLINE ALIGNMENT — prevents venous outflow obstruction.
• AVOID: Extreme neck flexion, extreme hip flexion (raises intra-abdominal pressure), Valsalva maneuver, straining, coughing.
• Give stool softeners (e.g., bisacodyl, docusate) to prevent straining during bowel movements.
• Cluster nursing care — group all activities to allow extended rest periods and minimize ICP-raising stimulation.
• Environment: Maintain calm, quiet, dimly lit room; control pain and agitation; manage fever aggressively (fever raises cerebral metabolic rate).
• Monitor CPP: Target 60–70 mmHg; avoid both hypotension (reduces cerebral perfusion) and severe hypertension.
• PHARMACOLOGY — Mannitol: Osmotic diuretic; dose 0.25–1 g/kg IV; draws fluid from brain into vasculature to reduce cerebral edema; give via filter; monitor serum osmolality (keep below ~320 mOsm/kg), urine output, electrolytes; risk of dehydration and rebound edema.
• PHARMACOLOGY — Hypertonic Saline (3%): Alternative osmotic agent for cerebral edema reduction.
• PHARMACOLOGY — Dexamethasone (corticosteroid): Reduces VASOGENIC edema around BRAIN TUMORS; NOT effective for cytotoxic edema of ischemic stroke or traumatic brain injury.
• PHARMACOLOGY — Antiseizure medications (levetiracetam, phenytoin): Seizure prophylaxis when seizure risk is high.
• PHARMACOLOGY — Sedation/analgesia: Reduces cerebral metabolic demand; facilitates ICP management in mechanically ventilated patients.
• Controlled hyperventilation (PaCO2 target ~30–35 mmHg): Briefly used in acute ICP crisis; induces cerebral vasoconstriction, temporarily reduces ICP — NOT for sustained use (causes ischemia).
• Surgical options: Ventriculostomy (external ventricular drain/EVD) for CSF drainage; decompressive craniectomy for refractory ICP.

Definitions

Section Title

Nursing Management of Increased ICP — Interventions and Pharmacology

Common Mistakes

• Using dexamethasone for ischemic stroke edema — it is ONLY effective for vasogenic edema around brain TUMORS.
• Forgetting to filter mannitol — crystalline particles can cause embolic complications.
• Not monitoring serum osmolality during mannitol therapy — osmolality above 320 mOsm/kg risks renal failure.
• Placing the patient supine or with neck flexed — always HOB 30°, head neutral and midline.
• Performing vigorous suctioning without time limits — limit to 10–15 seconds per pass to avoid ICP spikes from hypoxia/stimulation.

Formulas

Exam Tips

• Classic NLE pattern for epidural hematoma: Trauma → brief LOC → walks and talks (lucid interval) → sudden rapid decline → SURGICAL EMERGENCY.
• Basilar skull fracture triad: Raccoon eyes + Battle's sign + CSF rhinorrhea/otorrhea — NEVER pack, NEVER NGT nasally.
• GCS ≤8 = severe TBI; intubation threshold.
• Chronic subdural hematoma: Think elderly patient on anticoagulants with insidious cognitive decline and history of even minor head bump.
• Halo/ring sign is a NURSING assessment — bedside test with gauze for CSF leak.

Key Points

• Head injury ranges from mild concussion to severe TBI; all share risk of secondary injury from hypoxia and raised ICP.
• EPIDURAL HEMATOMA: Bleeding between SKULL and DURA; usually ARTERIAL (middle meningeal artery); classic pattern = brief LOC → LUCID INTERVAL → rapid deterioration; SURGICAL EMERGENCY.
• SUBDURAL HEMATOMA: Venous bleeding beneath the dura; can be ACUTE (rapid onset, severe) or CHRONIC (develops over weeks, subtle — especially in elderly and anticoagulated patients).
• BASILAR SKULL FRACTURE signs: CSF RHINORRHEA (CSF from nose), CSF OTORRHEA (CSF from ears), RACCOON EYES (bilateral periorbital ecchymosis), BATTLE'S SIGN (mastoid/behind-ear ecchymosis).
• Test suspicious drainage for CSF: HALO/RING SIGN — drop fluid on gauze; if CSF is present, a clear halo forms around the bloody center.
• NEVER PACK the nose or ears in basilar skull fracture — packing blocks CSF drainage and can introduce infection.
• NEVER insert an NG tube nasally in basilar skull fracture — risk of entering the cranium; use orogastric (OG) tube instead.
• NEVER perform nasal suctioning in basilar skull fracture.
• Concussion: Mild TBI with temporary neurologic dysfunction, no structural damage on imaging.
• Management: Prevent secondary injury — maintain airway, oxygenation, normotension; manage ICP; assess neuro status frequently using GCS.
• Glasgow Coma Scale (GCS): Scores eye opening (1–4), verbal response (1–5), motor response (1–6); total 3–15. GCS ≤8 = severe TBI, intubation usually required.

Definitions

Section Title

Traumatic Brain Injury (TBI) and Head Injury

Common Mistakes

• Packing the nose or ears in basilar skull fracture — NEVER pack; allow free drainage.
• Inserting an NG tube nasally in basilar skull fracture — NEVER nasally; use orogastric (OG) tube.
• Thinking the lucid interval means the patient is improving and safe — it is a WARNING SIGN of impending deterioration in epidural hematoma.
• Confusing epidural (arterial, lucid interval, rapid) with subdural (venous, slower, especially chronic in elderly).
• Using total GCS score alone without documenting individual component scores — each component provides different clinical information.

Exam Tips

• NLE clue: Headache WORSE in the MORNING that eases after getting up → think increased ICP/brain tumor.
• Drug for brain tumor edema: Dexamethasone (corticosteroid for vasogenic edema).
• Metastatic brain tumors: Ask about primary cancer history — lung and breast cancer most common sources.
• Post-craniotomy: Priority assessment = neurologic status (GCS, pupils, motor) + hemorrhage signs.

Key Points

• Brain tumors may be PRIMARY (originating in brain tissue) or METASTATIC (spreading from another primary site — lung, breast, colorectal cancers most common sources in Philippines).
• Even BENIGN tumors are dangerous because they raise ICP in the fixed skull.
• Manifestations depend on LOCATION: headache (classically worse in the MORNING, aggravated by bending/coughing), seizures, focal neurologic deficits, personality/behavioral changes, signs of raised ICP.
• Morning headache: Worse upon waking because ICP is higher when lying flat overnight — a classic NLE clue.
• Diagnosis: MRI with contrast (gold standard); CT scan; tissue biopsy for definitive classification.
• Treatment: Surgical resection (craniotomy), radiation therapy, chemotherapy; combination depends on tumor type, grade, and location.
• Dexamethasone: Reduces peritumoral (vasogenic) edema surrounding brain tumors — a major symptomatic treatment.
• POSTOPERATIVE CRANIOTOMY CARE: Strict frequent neuro checks (GCS, pupils, motor strength), ICP precautions, positioning per surgical approach (e.g., avoid operative side if bone flap removed), hemorrhage and CSF leak monitoring.
• Seizure prophylaxis: Commonly initiated postoperatively and for tumors with high seizure risk.
• NANDA nursing diagnoses: Ineffective Cerebral Tissue Perfusion, Anxiety, Deficient Knowledge, Risk for Injury (seizures).

Definitions

Section Title

Brain Tumors

Common Mistakes

• Thinking benign brain tumors are not dangerous — even benign tumors cause death if they raise ICP beyond compensation.
• Missing the morning headache clue — headache worse in the morning that improves after getting up is a classic brain tumor symptom.
• Using dexamethasone for all types of cerebral edema — it is SPECIFIC to vasogenic edema around tumors, NOT for TBI or ischemic stroke.
• Not positioning the craniotomy patient correctly — positioning depends on the surgical approach; check specific orders.

Exam Tips

• NLE community health/patient teaching question: Emphasize blood pressure control, FAST recognition, antiplatelet adherence, and no smoking.
• Unilateral neglect: Approach from UNAFFECTED side; place items on UNAFFECTED side; teach compensatory scanning.
• DVT prevention priority: Early ambulation/mobilization + compression stockings + anticoagulants as ordered.
• Under RA 9173, the nurse has a legal and ethical obligation to provide health education — stroke prevention teaching is a nursing responsibility.

Key Points

• MAJOR COMPLICATIONS of stroke and ICP disorders: Herniation and death, aspiration pneumonia (from dysphagia), DVT/PE (from immobility), contractures, pressure injuries, UTI (from catheter use), depression.
• ASPIRATION PNEUMONIA: Primary prevention — NPO until swallowing evaluated; upright positioning for meals; swallowing therapy; thickened liquids as prescribed.
• DVT PREVENTION: Early mobilization, passive/active ROM exercises, compression stockings, sequential compression devices (SCD), anticoagulants as ordered.
• PRESSURE INJURY PREVENTION: Frequent repositioning (every 2 hours), pressure-relieving mattress, skin assessment, adequate nutrition.
• PATIENT TEACHING — FAST: Teach family to recognize Face drooping, Arm weakness, Speech difficulty — Time to call emergency services; do not drive the patient; call 911 or equivalent.
• For HEMIANOPIA/NEGLECT: Place objects, food, and call bell on the UNAFFECTED side; approach from unaffected side; teach scanning techniques.
• SWALLOWING: Use prescribed diet consistency (thickened liquids, pureed solids); sit upright at 90° for meals; check for residue in mouth; avoid distractions.
• SECONDARY PREVENTION of stroke: Strict blood pressure control (most important), antiplatelet therapy (aspirin, clopidogrel), anticoagulation for AF (warfarin, DOACs), lipid management (statins), smoking cessation, weight management, exercise.
• Medication adherence: Emphasize importance of NOT stopping antihypertensives or antiplatelets without physician advice.
• Rehabilitation: Early PT, OT, speech therapy; Filipino cultural sensitivity — involve family/significant others in care and discharge planning.
• Under RA 9173: Nurse is responsible for health education, advocacy, and safe, accountable professional practice including proper documentation of neuro assessments.

Definitions

Section Title

Complications, Patient Teaching, and Secondary Prevention

Common Mistakes

• Approaching a patient with left-sided neglect from the left (affected) side — always approach from the RIGHT (unaffected) side.
• Allowing oral feeding before swallowing assessment — always assess swallowing first; aspiration can be silent.
• Not emphasizing medication adherence for antihypertensives — uncontrolled BP is the top cause of recurrent stroke in the Philippines.
• Forgetting DVT prophylaxis in immobile stroke patients — hemiplegia + immobility = high DVT risk.