Stoke Flashcards

1
Q

How to manage/NI?

A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Monitor signs of respiratory compromise /ABC

A

Decreasing LOC increased for tongue dropping back causing obstructed airway

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

O2 Adminsration

A

tissue oxygen needs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Monitor VS: BP, Pulse, RR, Temp

A

BP may be increased due to a compensatory mechanism to keep cerebral perfusion
treatment indicated if greater thanh 220/120 mm hg
Hyperthermia increase ICP negative outcome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Assess nuero status / neuro checks

A

q15mins to determine progression of treatment
LOC
Glascow coma scale
NIH Scale

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Establish/maintain IV access

A

for medication adminstration
anticipate antihypertensensive meds
thrombolytic (RO hemorrhagic Stroke)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

position head midline/ raise HOB

A

decreases IcP
improves venous drainage
Decreases risk for aspiration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Monitor EcG/ Cardiac montiring

A

to detect any life threatening dysrhythmias

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Monitor for signs of Increased ICP

A

Complication of stroke

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

seizure precaution

A

complication of stroke
pad siderails
have sunction available
oxygen avialable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Monitor for N/V

A

to prevent aspiration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

provide skin care

Assess Bladder/Bowl

A

loss of sensation on half of body;Hemiplegia

incontinence may occur after stroke

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

teach patient to scan surrounding

A

possibility of hemaniopsia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

maintain NPO

A

swallow eval first . increased risk for aspiration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

provide referral for speech, physical, occupation therapies

A

risk for aphasia (receptive, expressive)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Provide ROM activated/ passive

A

increased risk for muscle tone decrease

17
Q

WHAT SHOULD I REPORT?

A

LOC

18
Q

2re

A

BP,Pulse, Temp

19
Q

3re

A

Resp status

20
Q

4re

A

headache

21
Q

5re

A

mobility )Hemiplegia

22
Q

6re

A

speech patterns

23
Q

WHAT SHOULD I ANTICIPATE ?

A

02

24
Q

2AN

A

ECG / CARDIAC MONITORING

25
Q

3AN

A

CBC , PT, PTT

26
Q

4an

A

BUN Creatinine, glucose

27
Q

5an

A

cardiac enzymes if indicated

28
Q

6an

A

transesophagial echocardiography TEE-cardioembolic stroke

29
Q

7an

A

EEG

30
Q

8an

A

CT WO contrast to rule out hemorrhagic stroke

31
Q

9an

A

MRI scan of brain

32
Q

10an

A

seizure precaution

33
Q

11an

A

NPO

34
Q

12an

A

antihypertensive med:
Calcium chanel Blockers -Nimodipine
Labetelol , sodium nitroprusside

35
Q

13an

A

antiemetic

36
Q

14an

A

tPA administration if no contrindication/criteria met

37
Q

15an

A

aspirin,plavix, warfarin , heparin