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LSC Ch 47 CVA
Nursing
| Question | Answer |
|---|---|
| TIA's | Silent Stroke, reversible neurologic deficit, warning sign of cva, symptoms last <24hrs, seek medical attention if occurring, unaware it is happening, "can stick out your tongue/smile?" |
| CVA | disruption in normal blood supply to brain, brain unable to store O2 or glucose, brain death occurs in min, affects both hemispheres of brain, thrombotic, Embolic, Hemorrhagic |
| Risk Factors CVA | Arterial Fib/Heart Murmur, Arteriosclerosis/Atherosclerosis, Previous Stroke or TIA, Manage HTN, Wt control, low fat/sodium/cholesterol diet, no smoking, limit ETOH consumption |
| CVA Assessment | Time of onset is crucial Ischemic strokes often occur during sleep, hemorrhagic stroke during activity, etc |
| Emergency Assessment | ABC's within 10min, Neuro Checks, Specific to location in brain, cognitive changes: unaware of illness, spatial perception, impaired memory, judgment or problemsolving, decreased ability to concentrate |
| Left Hemisphere Strokes | Aphasia, Agraphia, Alexia, Acalculia, domininant, language, math skills, analytical thinking |
| Right Hemisphere Strokes | Visual & Spatial Awareness, Personality Changes, Poor Impulse Control, Poor Judgment |
| Motor Assessment for CVA | Motor Changes are contralateral stroke on one side, motor deficits on other side, |
| Hemiplegia | Paralysis on one side |
| Hemiparesis | weakness one side |
| Flacid Paralysis | hypotonia - can't overcome gravity |
| Spastic Paralysis | hypertonia - contractures joint ROM restricted |
| Proprioception | head and trunk control, balance coordination gait |
| Agnosia | unable to use an OBJECT correctly |
| Apraxia | unable to carry out purposeful motor activity |
| Sensory Assessment | Touch, Painful Stimuli, Decreased sensation on same side as motor |
| Neglect Syndrome | Right Hemisphere Stroke: Unaware of Left Side, won't dress or wash it doesn't sit straight |
| Visual Symptom | Pupil Constriction or dilation, Ptosis, Visual Field Defiits, Pallor or Petechiae of Conjunctiva |
| Amaurosis Fugax | brief blindness |
| hemianopsia | blindness 1/2 visual field |
| homonymous hemianopsia | blindness same side of both eyes, only sees half of visual field |
| Cranial Nerve Assessment: Aspiration Risk | V: Chew, IX & X: Swallow, VII: Facial Paralysis, IX: Absent Gag Reflex, XII: Impaired tongue movement |
| Cardiovascular Assessment Stroke | Think HEART, w/embolic CVA may have heart murmur, dysrhythmias, HTN (180-200/110-120) May need BP at 150/100 to perfuse brain |
| Imaging for CVA | With Ischemic CVA, CT initially negative, changes present after 24hrs, CT: cerebral hemorrhage, aneurysm, ischemia, infarction, cerebral edema, MRI shows: edema, ischemia, tissue necrosis, earlier than CT |
| Common Nursing Diagnosis for CVA | Ineffective tissue perfusion(cerebral), Impaired swallowing, Imparied Physical Mobility, Impaired Verbal communication, Total Urinary Incontinence, Disturbed Sensory Perception, Unilateral Neglect |
| Collaborative Problems for CVA | Potential for: DVT, PE, Increased ICP, Seizures, Hypoxemia, Atelectasis & Pneumonia |
| Interventions for Cerebral Tissue Perfusion | Ischemic Stroke: Thrombolytic Therapy IV or intra arterial thrombolysis |
| Nursing Interventions after administration of rtPA | After infusion, monitor neurovasc checks and VS q 30min for at least 6hrs. monitor hourly for 24hrs after. If Systolic >150 D >105 give hypertension med as prescribed, discontinue infusion if pt reports HA, severe HTN, N&V, and notify physician immediatly |
| Interventions for ICP | HOB Flat or slight elevation (30Degrees), Straight alignment, Avoid stimulation, quiet environment, low lights, suction trach only as need, hyperoxygenate 1st, avoid extreme hip/neck flexion, space out cares, VS prefer slight hypertension, |
| Temp for ICP | Fever Increases ICP Low temp decreases cerepral Perfusion |
| Other Drug Therapy for CVA | Seizures: Ativan LT Seizures: Dilantin, Neurontin, TOpomax, Neuroprotective Drugs: Caclium Channel Blockers prevent vasospasm 4-14 days after stroke, Stool Softners, Analgesics, antianxiety |
| Anticoagulant Therapy After CVA | oral or SQ: Heparin, Lovenox, Coumadin - not for ischemic/hmorrhagic strokes - controversial, Thrombolytics-asprin 1st 24-48hrs, not w/in 24hrs of thrombolytic therapy, NO PLAVIX |
| Monitor Complications | Hydrocephalus & Vasospasm, Blood in CSF-interferes w/CSF absorption, ventricles become enlarged |
| Monitor for Signs of increased ICP | Decreased LOC, HA, Pupil dilation, seizures, poor coordination, gait disturbance, behavior changes |
| Rebleed after aneurysm or AVM | 24hrs to 7-10days after 1st bleed, assess severe HA, N&V, Decreased LOC, Decreased Neuro function (glascow), 50%die first bleed, 40%rebleeds die |
| Carotid Artery Angioplasty w/stent | Radiological procedure, embolic protection device: catch debris, placed beyond stenosis, Angioplasty: sim to other angiogram stents to open carotid arteries, remember groin site care & Nuerovasc checks Endoarterectomy |
| Impaired Swallowing Intervention | Screen for ability to swallow, check gag & cough reflex, SLP eval, feeding usually done by LPN, RN to avoid aspiration, remove distractions when eating, monitor fatigue, position straight up in bed, thickened liquids |
| Interventions Impaired Mobility | Legs recover quicker than UE, Rehab by OT, PT, SLP, DVT Prevention- compression stockings, boots, pneumatic devices, change positions, ambulate, adaptive equip as needed |
| Interventions Impaired Communication | Dusarthria- SLP, one idea per sentence, one step commands, speak slow, not loud, use cues or gestures, avoid yes/no questions, computer picture board, flash cards |
| Expressive Aphasia | Frontal Lobe- difficulty speaking/writing |
| Receptive | Temporo/Parietal area: Difficulty understanding spoken/writen words |
| Mixed Aphasia | Some degree of both |
| Global | Profound problems |
| B/B Interventions | Assess reason for incontinence, Impaired LOC, Impaired innervation, inability to communicate need |
| Bladder Training Program | Fluids 2000ml/day, bladder scanner, indwelling cath: remove ASAP, prevent UTI, better to deal w/incontinence rather than infection |
| Bowel Training Program | Routine time, routine measures pt used to, place on commode/toilet same time, high fiber diet, apple/prune juice, stool softner, suppositories |
| Intervention for impaired sensory Right Hemisphere | Place objects in field of vision, mirror to visualize more of environment, diplopia, patch one eye, remove clutter: ward order |
| Interventions for Impaired Sensory Left Hemisphere | Memory Deficits, Reorient to Month/Year/Day why in hospital, Routine schedule, repititous, Step by step approach, Pictures, familiar objects |
| Unilateral Neglect Interventions | Right Hemisphere-Left Side, Teach use of both sides of body w/ADL's, dress affected side 1st, scanning, turn head side to side to see all visual field, turn meal tray or plate |
Created by:
ginabeana
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