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LSC Ch 47 CVA

Nursing

QuestionAnswer
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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