CVA/SAH 2 Flashcards
1
Q
goals of acute phase ischemic stroke
A
- preserve life
- prevent further brain dmg
- reduce disability
2
Q
collaborative care - ischemic stroke
A
- ABCs
- monitor pt 24-48 hours post stroke
- BP may be elevated
- F/E balance
- increased temp increased brain metabolism
- monitor for sz, no ppx meds
- control pain
- hypervolemia
- constipation
- ventriculostomy to drain CSF
3
Q
ICP - ischemic stroke
A
- increased ICP peaks 72 hours
- elevate HOB
- maintain head and neck alignment
- avoid hip flexion
- manage temp
- pain mgmt, stool softeners, diuretics
- CSF drainage
- bone flap
4
Q
drug tx - hemorrhagic stroke
A
- contra: anticoagulants, platelet inhibitors
- BP mgmt: want high, but keep SBP
5
Q
surgical tx - hemorrhagic stroke
A
- resection
- clipping of aneurysm
- evacuation of hematomas
6
Q
hyperdynamic therapy
A
- prevent vasospasm in hemorrhagic stroke:
- hemodilution
- HTN
- hypervolemia
7
Q
nursing mgmt - respiratory
A
- RN priority
- risk for atelectasis, aspiration pneumonia, airway obstruction
8
Q
nursing mgmt - neurologic
A
- monitor closely for neuro changes
- assess for
- extension of stroke
- ICP
- vasospasm
- recovery
9
Q
nursing mgmt - CV
A
- goal is to maintain homeostasis
- may have decreased cardiac reserves
- monitor VS q1h
- monitor cardiac rhythms
- strict I/Os
- heart/lung sounds
- DVT
10
Q
nursing mgmt - musculoskeletal
A
- goal: optimal function
- prevent joint contractors and muscular atrophy
- ROM
11
Q
nursing mgmt - integumentary
A
- skin breakdown
- loss of sensation
- decreased circulation
- immobility
- change positions
- special mattresses
- good skin hygiene
- emollients to dry skin
- early mobility
- position 30 mins on paralyzed side
12
Q
nursing mgmt - GI
A
bowel problems
- stool softeners or fiber
- physical activity
13
Q
nursing mgmt - urinary
A
- acute stage: incontinence
- promote normal bladder function
- no foley: muscle will get weaker
14
Q
nursing mgmt - nutrition
A
- may need IVF or enteral nutritional support
- speech tx needs to do a swallow eval
- place food on unaffected side of mouth
- oral hygeine
15
Q
nursing mgmt - communication
A
- supportive tx
- speak slow, calmly, use simple words
- gestures and word of picture boards may be useful
