Nursing care of patient who had a stroke Flashcards
what is the cause of a hemmoragic stroke?
aneurysm in cerebral artery breaks and there is actual bleeding into the brain
Ischemic stroke
embolous and blockage of blood flow to a part of the brain. associated with carotid artery.
What is a TIA
a small occlusion of a small artery that resolves within 24 hours. usually no permanent damage, considered a forewarning. the attack itself resolves in a manner of minutes.
What is the surgical response for a TIA
Carotid endarectomy, removal of arthroscerotic plaque, reopens the carotid vessel. `
What are the indications for a carotid endarterectomy?
70-99% occlusion, and a TIA or mild CVA. there are sinigifant risks.
What are the indications for carotid stenting?
less invasive, used for TIA candidates that are high surgical risk.
Post op care for carotid endarterectomy?
Monitor Vitals and neuro status for cranial nerve impairment.
WHat pulses need to be gotten post surgery for carotid endarterectomy?
facial pulses
How do you check for adequate oxegenation and circulation post carotid endarterectomy?
O2 sat and polse ox
What do you asses for at site os incision?
neck edema, hematoma, tracheal deviation.
How should a post op carotid endarterectomy patient be positions?
HOB elevated, off of side of incision to promote drainage of would site.
What can reduce the risk of a CVA by 50%?
A healthy lifestyle.
What are warning signs of a CVA?
trouble walking, talking, comprehension, paralysis or numbness in face and extremities, vision problems, headache.
What are the human responces in the acute phase of a stroke?
change in LOC, presence or absence of voluntary movements, change in quality of RR and pulse, change in ability to speak, visual changes
What are the human responses in post acute phase following a CVA?
mental status change (judgement and behavior), loss of motor control, swallowing ability, self care compromise, sensation and perception, changes in nutritional and hydration status, skin.
What do the S&S of a CVA depend on?
Size of lesion, amount of collateral blood flow, location of lesion.
What is affected with a stroke in the Frontal portion of the brain
movement and personality
What is affected with a stroke in the parietal portion of the brain
Sensation, awareness of body parts
What is affected with a stroke in the Temporal portion of the brain
Senses, hearing taste and smell, also interpretation of sound.
What is affected with a stroke in the occipital portion of the brain
vision
What is affected with a stroke in the left hemisphere portion of the brain ?
Paralysis/weakness on right side, right visual field affected, aphasia, altered intellectual ability, slow cautious behavior (LEFT BEHIND).
What is affected with a stroke in the right hemisphere of the brain ?
Paralysis/weakness on left side, left field visual affected, Spatial and perceptual deficits, increased distractibility, impulsive behavior, poor judgement, lack of awareness of ones own deficits. Always RIGHT.
What is a CT scan used for
gives detailed bone and tissue images, can detect tumors, hemorrhages, fractures, abscesses, hydrocephalus, edema, ventricular and vascular anomalies.
what is a cerebral angiogram used for
assesses blood vessels of brain, uses contrast dye into artery, series of images, must obtain WRITTEN CONSENT, NPO prior to test.
Electroencephalogram EEG
Used to check electrical function of brain, seizures, sleep issues, brain waves, brain death.
Why do a lumbar puncture on a CVA patient?
checking for blood.
What is an ischemic clot retrieval?
microcatheter sent in and screws into clot to remove it, uses a balloon to prevent blood flow while catching thrombus.
What are nursing interventions after a Clot retrieval?
KEEP PATIENT FLAT for 4-6 hours to prevent dislodging of clot. TPA, monitor pulse distal to collection site, movement, and temperature of distal portion.
What are some prevention options?
Clipping of aneurysm.
Acute medical care options for CA
prevent or minimize risk of bleeding/rebleeding, remove blood clot, re-vascularize brain tissue, assess initial injury
Comlications of CVA to be treatedin acute phase of medical care.
Seizured, bleeding, bradycardia, respiratory compromise.
What is a embollus a result from
Fat cellular clumps
What is a thrombolic
result of vascular atherosclerosis and narrowing of the artery.
Management of CVA
sedation, reduce ICP with diuretics, maintain CO2 30-35%, position to avoid hypoxia, intubation to maintain airway.
When is there a surgical interventio for a CVA?
When the hematoma exceeds 3cm and glasgow coma scale score decreases.Clot retrieval, and TPA administration.
What does Tissue plasminogen activator do?
dissolves blood clot, MUST BE USED within 3-6 hours of stroke.
What must be deterimined before usign TPA?
nature of stroke, ischemic vs hemmoragic, thrombolitic vs embolitic, assess severity with NIH stroke scale.
what are the contraindications for TPA
BP>185/110, surgery, cancer, GI bleed, GU bleed.
How often is a post stroke patient monitored
Q 15 minutes for VS and neuro staus. continuous cardiac monitoring, cerial labs and CT Scan.
Nursing care following CVA involves what?
Education, primary compromise, collateral compromise, ancillary concerns, compromise prevention.
Neuro checks
Glasgow coma scale: Eyes, verbal, motor the lower the number the worse it is.
