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NURS4036 - complex health > CVA > Flashcards

CVA Flashcards

1
Q

stroke

A

occurs when there is ischemia to part of the brain or hemorrhage into the brain

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2
Q

non modifiable stroke risk factors

A
  • age
  • sex
  • ethnicity and race
  • heredity
  • arteriovenous malformation
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3
Q

modifiable stroke risk factors

A
  • hypertension
  • diabetes
  • heart disease
  • increased serum cholesterol
  • heavy alcohol consumption
  • oral contraceptive use
  • smoking
  • obesity
  • substance use
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4
Q

thrombotic stroke

A

cerebral thrombosis is a narrowing of the artery by plaque. plaque can causes a clot which blocks the passage of blood

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5
Q

embolic stroke

A
  • embolus lodges in an artery and block blood flow
  • results in infarction and edema
  • pt conscious with headache
  • emboli usually originate in endocardial layer
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6
Q

hemorrhagic stroke

A

burst blood vessel allows blood to seep into damaged brain tissue until clotting shuts of leak

symptoms
- neurological deficits
- headache
- n&v
- decreased LOC
- hypertension

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7
Q

ischemic stroke

A
  • inadequate blood flow to the brain from occlusion of an artery
  • thrombotic, embolic
  • TIA is precursor
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8
Q

transient ischemic attack (TIA)

A

transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain

symptoms are <1 hour

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9
Q

lacunar stroke

A

occlusion of a small, penetrating artery with development of a cavity in the place of the infarcted brain tissue. This most commonly occurs in the basal ganglia, thalamus, internal capsule, or pons.

typically asymptomatic

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10
Q

CM stroke

A
  • motor functions
  • elimination
  • intellectual function
  • spatial perceptual alterations
  • personality
  • affect
  • sensations
  • communications
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11
Q

CM of stroke: motor function

A

impairment of
- mobility
- respiratory function
- swallowing and speech
- gas reflex
- self-care abilities

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12
Q

CM of stroke: motor deficits

A
  • loss of skilled voluntary movement
  • impariment of integration of movement
  • alterations in muscle tone
  • alterations in reflexes
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13
Q

CM of stroke: communications

A
  • aphasia when stroke damages dominant hemisphere of brain
  • dysarthia (disturbance in muscular control of speech)
  • poor pronunciation, articulation, phonation
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14
Q

CM of stroke: affect

A
  • difficulty controlling emotions
  • exaggerated or unpredictable
  • depression
  • frustration
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15
Q

CM of stroke: intellectual function

A
  • impairment of memory and judgement
  • left-brain stroke is more likely to result in memory problems related to language
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16
Q

CM of stroke: spatial-preceptual alterations

A
  • more likely in RS stroke

categories
- deny illness or own body parts (anosognosia)
- erroneous perception of self in space
- inability to recognize object by sight, touch, hearing (agnosia)
- inability to carry out learned sequentual movements (apraxia)

17
Q

CM of stroke: elimination

A
  • frequency, urgency, incontinence
  • constipated
  • occur initially and are temporary
18
Q

dx studies for stroke

A
  • CT (distinguish between ischemic and hemorrhagic stroke)
  • MRI
  • CTA (visualization of cerebral vasculature)
  • MRA
  • cerebral or carotid angiography (identify occlusion, plaque)
  • Digital subtraction angiography
  • Transcranial Doppler ultrasonography (measures velocity of blood)
  • Lumbar puncture (for evidence of RBC in cerebrospinal fluid is hemorrhage is suspected)
19
Q

stroke assessment findings

A
  • altered LOC
  • Weakness, numbness, or paralysis
  • Speech or visual disturbances
  • Severe headache
  • ↑ or ↓ heart rate
  • Respiratory distress
  • Unequal pupils
  • Hypertension
  • Facial drooping on affected side
  • Difficulty swallowing
  • Seizures
  • Bladder or bowel incontinence
  • Nausea and vomiting
  • Vertigo
20
Q

initial interventions for stroke

A
  • Ensure patent airway
  • Call stroke code/team
  • Remove dentures
  • Perform pulse oximetry
  • Maintain adequate oxygenation
  • Obtain IV access with NS
  • Maintain BP
  • remove clothing
  • insert catheter
  • CT scan
  • baseline labs
  • position head midline
  • elevate bed 30 degrees if no symptoms of shock or injury occur
  • seizure precautions
  • NPO
21
Q

acute care of stroke

A
  • hypertension is common after: meds to lower BP
  • control fluid and electrolyte balance
22
Q

ongoing stroke interventions

A
  • LOC
  • sensory function
  • pupil size and reactivity
  • O2 sats
  • cardiac rhythm
23
Q

recombinant tissue plasminogen activator (tPA)

A
  • re establish blood flow through blocked artery to prevent cell death
  • administer within 4.5 hours on onset
  • IV
  • no antiplatelets or anticoagulants with it
24
Q

stroke rehabilitation

A
  • after stroke has been stabilized for 12-72 hours: attain optimal functioning
25
Q

comprehensive neuroexamination

A
  • Level of consciousness (using Canadian Neurological Scale)
  • Cognition
  • Motor abilities
  • Cranial nerve function
  • Sensation
  • Proprioception
  • Cerebellar function
  • Deep tendon reflexes
26
Q

respiratory management: nursing considerations and stroke

A
  • Risk for atelectasis
  • Risk for aspiration pneumonia
  • Risks for airway obstruction
  • May require endotracheal intubation and mechanical ventilation
27
Q

neurological: nursing considerations and stroke

A
  • monitor for stroke extension, increased ICP, vasospasm
  • GSC
  • NIHSS
  • pupillary responses
  • extremity movement and strength
28
Q

cardiovascular: nursing considerations and stroke

A
  • monitor VS
  • monitor rhythms and heart sounds
  • intake and output
  • regulating IV infusions
  • monitor lung sounds
  • prevent DVT
29
Q

musculoskeletal: nursing considerations and stroke

A
  • maintain optimal function
  • prevent joint contractures and muscular atrophy
  • ROM and positioning
  • hand splints, slings, rolle to prevent deformities
30
Q

integumentary: nursing considerations and stroke

A
  • susceptible to breakdown
  • compounded by pt age, poor nutrition, dehydration, edema
  • pressure relief by changing positions
  • emollients to dry skin
  • early mobility
  • only position on paralyzed side for 30 mins
31
Q

gastrointestinal/urinary : nursing considerations and stroke

A
  • constipation
  • stool softeners
  • avoid in-dwelling catheters
  • bladder retraining program (adequate fluids, toileting q2h)
32
Q

nutrition : nursing considerations and stroke

A
  • test swallowing, chewing, gag reflex, pocketing
  • follow eating with oral hygiene
33
Q

communication: nursing considerations and stroke

A
  • speak slow, calm, use simple words and sentences
  • gestures to support words
  • picture board
34
Q

stroke prevention

A
  • Antiplatelet (aspirin) meds
  • statins
  • anticoagulants for tx of TIA in those with AF

NURS4036 - complex health (10 decks)

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