Ischaemic stroke

Question 1

Signs and symptoms

Answer 1

Trouble walking, speaking, one sided weakness

Question 2

Aetiology

Answer 2

Hypertension
Age
Obesity
Diabetes
High Cholesterol

Question 3

Nursing Diagnoes

Answer 3

Impaired verbal communication r/t brain damage
Risk of PI r/t impaired mobility
Risk of constipation due to decreased mobility

Question 4

Assessments

Answer 4

Braden score - risk of PI
BGL - Access for hyperglycaemia due to SNS activation
PERRLA - Pupils, equal, round, reactive, light, accommodating

Question 5

Interventions

Answer 5

Maintain head at 30 degrees
Ensure pt is NBM until assessed by SLT
Low stimulus environment

Question 6

What are the two types of strokes

Answer 6

Haemorrhagic stoke
Ischemic stroke

Question 7

Rational for:
Maintain head at 30 degrees
Ensure pt is NBM until assessed by SLT
Low stimulus environment
TED stocking

Answer 7

To facilitate jugular venous drainage and help reduce cranial pressure
To prevent aspiration of food and oral liquid
To reduce anxiety
Reduce risk of DVT