CVA pt.3 (Exam 4) Flashcards
Stroke: Primary assessment focuses on
Cardiac status
Respiratory status
Neurologic assessment
If a patient is stable, we need to obtain:
Description of current illness
Attention to symptom onset, duration, nature, and changes
Current meds
Family history
History of risk factors and other illnesses
Secondary assessment includes neurologic exam, what does that contain?
LOC
NIH stroke scale
Cognition
Motor abilities
LOOK AT NIHSS STROKE SCALE ON CANVAS
Comprehensive Neurologic Exam includes
-Cranial nerve function
-Sensation
-Proprioception (person is aware of their position and movement)
-Cerebellar function (motor function)
-Deep tendon reflexes
Respiratory Nursing Care
Risk for atelectasis (may be intubated)
Neurologic Nursing Care
Monitor for extension of stroke
Increased ICP
Vasospasm
Recovery from stroke S/S
Cardiovascular Nursing Care
V/S
Cardiac rhythms
I&O’s
Risk for VTE
Monitor accordingly
Musculoskeletal System Nursing Care
Prevent joint contractures / atrophy
Acute phase, ROM and positioning are important
Trochanter roll at hip to prevent external rotation
Hand cones to prevent hand contractures
Avoid pulling patient by arm to avoid shoulder displacement
Prevent foot drop w/ footboards / high top tennis shoes
Integumentary System Nursing Care
Prevent skin breakdown
Regular pressure relief by position changes
DO NOT place longer than 30 minutes on weak side
How do we prevent long term external rotation in stroke patients?
Trochanter Roll
How do we prevent foot drop in a stroke patient?
Foot board
What is the most common bowel problem?
Constipation
Urinary system
Poor bladder control
Avoid use of indwelling catheters
Bladder retraining program
Once swallowing is approved what foods should be started?
Foods that are easy to swallow with enough texture, temp, and flavor to stimulate swallow reflex
Nutrition
IVF’s
Keep NPO until speech therapist performs a swallowing eval
Assistive Devices for Eating
Rounded plate
Special cutlery
Rocking knife
Plate guards
Double handed cup
Communicaiton
Nurses role – Supportive
Speak slowly and calmly use simple words or sentences
Gestures may be used to support verbal cues
Speech comprehension and language deficits are most difficulty problem for patient
Sensory-perceptual problems
Diplopia
Loss of corneal reflex
Ptosis
Homonymous hemianopia
Patient Discharge
To home
Intermediate / long term care
Rehabilitation facility
Rehabilitation
Target physical, mental, and social well-being
Focus on preventing additional loss and balance training
