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34 Cards in this Set
- Front
- Back
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Four types of CVA
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1) TIA
2) RIND Reversible Ischemic Neuro-Deficit 3) Stroke in Evolution 4) Completed Stroke |
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TIA manifestations
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Paresis (parital loss of movement)
Paralysis (unilaterally) Speech Disorder Staggering gait Confusion Unequal Pupils Coma Sudden HA + stiff neck = hemorrhage Apraxia (inability to carry out learned movements) |
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TIA residuals
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no leftover
red flag |
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Stroke in Evolution
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Progressive stroke
Deficit occurs in steps Some over 24 hours, some over 72 hours |
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Complete stroke
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stable deficits w/in 1 hour
Can have secondary injury up to 72 hours Most occur during sleep because BP drops while sleep=hypotension=decreased perfusion to area. |
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Hemiplegia
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half paralyzed
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hemiparesis
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half weakened
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Wernicke's
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Receptive Aphasia
auditory association temporal lobe cant understand/follow commands I called my mother on the television and did not understand the door. It was too breakfast, but they came from far to near. My mother is not too old for me to be young. |
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Broca's
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Expressive Aphasia
Understands but cant speak or write motor speech (frontal lobe) Yes... ah... Monday... er... Dad and Peter H... (his own name), and Dad.... er... hospital... and ah... Wednesday... Wednesday, nine o'clock... and oh... Thursday... ten o'clock, ah doctors... two... an' doctors... and er... teeth... yah. They know what they want to say but cant get it out. |
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NIH Stroke Scale assesses these 11 items
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1)LOC
2)Best Gaze 3)Visual 4)Facial Palsy 5)Motor Arm 6)Motor Leg 7) Limb Ataxia 8)Sensory 9)Best Language 10)Dysarthria 11)Extinction and Inattention |
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Stroke collarborative care
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HOB 30 degrees -prevent aspiration
Maintain Airway Admin oxygen Protect affected side Monitor Cardiac Rhythm Accucheck-dextrose prn Low BS and neuro deficits can mimic CVA signs |
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Stroke meds
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ASA
Plavix Ticlid Persantine (antiplatelets) Anticoagulants (coumadin) Thrombolytics (3 hour window) |
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Systolic maintain at this level to maintain brain perfusion
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150
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FAST STROKE
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F: Face
A: Arm and Leg S: Speech T: Time |
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Stroke Nursing Diagnosis
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Ineffective Tissue Perfusion
Stable VS Stable/improving LOC Stable/improving deficits Absence of symptoms |
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Interventions to Maintain Adequate Cerebral Perfusion
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Monitor Neuro Status
Prevent Complications Quiet Environment No coughing, no straining, no lying prone, no isometric contraction, no emotional upset, abrupt headache or flexion ALL THESE INCREASE ICP |
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Risk for disuse Syndrome
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Place things on affected side
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Thrombolytic Therapy TPA Window
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3 hours
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TPa Activase dosing for Stroke
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(Give within first 3 hours): 0.9 mg/kg (max 90mg)-10% of dose given ivpush, followed by a continuous infusion over 1 hour
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Standard of Care for Impaired Swallowing
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No chit chat-quiet environment
HOB elevated Mouthcare before meal Stimulate saliva flow-strong salt Mechanical soft diet better than liquids Thickeners Small bites unaffected side Chew thoroughly Pockets-sweep after each bite Mouth care after meals Position food in visible field Accurate I&O until sufficient intake achieved. Weekly weight |
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Subdural Hematoma
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Under dura mater
between dura and brain |
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Subdural Hematoma
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Under dura mater
between dura and brain |
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Subarachnoid Hemorrhage
Cerebral Aneurysm |
space between arachnoid and pia
Circle of Willis common |
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Subarachnoid Hemm/Aneurysm predisposing factors
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Valsalva maneuver
Sex Physical Exertion |
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Subarachnoid/Aneurysm Manifestations
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Severe Pounding HA
Photophobia Nausea Unequal pupils Gaze Seizures Nuchael Rigidity Hemiparesis Loss of Consciousness Inc ICP Rebleed most likely in 24-48 hrs POOR PROGNOSIS |
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Subarachnoid/Aneurysm
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Blood in CSF/lumbar puncture
Cerebral angiogram CT |
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Subarachnoid/Aneurysm Care
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No cure
Osmotics Anti-HTN to keep BP down Craniotomy to clipaneurysm before rupture Goal: prvent further increase in ICP Immediate strict bed rst Prevent valsava Check swallowing HOB elevated Quiet dim environment |
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Subarachnoid/Aneurysm
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Keep BP down
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Amicar (vasoactive drug)
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hemostatic agent
for UTI, CEREBRAL BLEEDS, DIC Watch for bleeding, neuro checks, signs of clotting. |
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AMICAR (hemostatic agent=stop bleeding)
Subarachnoid Bleeds and Aneurysms |
UTI, CEREBREAL BLEEDS, AND DIC
Watch for bleeding, neuro checks, signs of clotting |
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NIMOTOP (Ca channel blocker)
Subarachnoid Bleeds Aneurysms |
potent vasodilator
decreases vasospasm side effects are CHF and dysrhythmias Neuro checks, I&O, watch for signs of CHF |
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Concussion
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Immediate temporary LOC 5 min or less
Often treated at home DC INSTRUCTIONS r/t LOC |
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Contusion
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bruised brain, may hemmorhage
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Discharge Instructions for Hemmorhage or Concussion or Contusion
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Problems occur AFTER 24 hours
Watch for sleepiness Waken every 2-3 hours Immediately return to MD if: Any change in LOC Unable to arouse Seizures occur Bleeding Clear Drainage from Ear or Nose Loss of sensation in any extremity Blurred Vision, Slurred Speech Vomiting |
