week 2: CVA Flashcards
what do we do when we suspect a stroke
get a head CT stat
what are modifiable risk factors of CVA
HYPERTENSION***
Diabetes mellitus
Heart disease
Afib
Carotid stenosis
Hyperlipidemia
Obesity
Oral contraceptive use
Heavy alcohol use
Physical inactivity
Smoking
what is the main etiology of strokes
A fib
(irregular, no p wage, tight and narrow QRS)
etiology of hemorrhagic stroke
HTN*
Anticoagulant drug therapy*
Trauma
Arteriovenous malformations
Ruptured aneurysms
treatment of TIA
- medication to prevent platelet aggregation (ASA, Plavix)*
- oral anticoagulants
Diagnostics of stroke
in order
Tests for emergent evaluation of the patient CVA:
History and FOCUSED physical exam - vitals/telemetry
National Institute of Health Stroke Scale (NIHSS) score
CT head without contrast w/i 20 MIN of ARRIVAL
(Can distinguish between ischemic and hemorrhagic, and indicate size and location of stroke)
Start IV and draw labs - chemistry panel, CBC, Coag panel (PT,PTT,INR)
EKG
Carotid ultrasound of warranted
MRI possibly if needed
Ensure LKWT is documented
Nursing action for acute CVA
starred actions only
- ensure patient airway
- aspirattion precautions
- maintain BP/ permissive HTN
- neuro assessment and NIH stroke scale
- CT stat
- position hehad midline with HOHB 30 (if no shock/ injury)
- anticipate thrombolytic therapy for ischemic stroke
stroke code, VS, obtain IV and blood work, seizure precaution
what should you do if you can’t give fibrinolytics
observe pt
when is the most crucial time
first 3 hours
lack of blood flow -> ischemia -> cerebral infarction
when does alteplase (tPA) need to be administer
- must be given within 3-4.5 hrs of onset of ischemic stroke
- before 3 hr: possible benefit of thrombolytic outweighs the possibility of intracranial bleed
- after 3 hr: risk outweigh benefit
what should be done post tPA administration
neuro assessment q15min for 2 hours then q30min for 6 hours
monitor for sxs of intracerebral hemorrhage
what is permissive HTN
allowing HTN patients with ischemic stroke to 200-220mmHg systolic (often by withhholding meds) to protect tissue that would otherwise by hypoxic
tPA patient’s SBP should be
less than 185mmHg
what is the main CVA nursing goals
attain max self care activites and skills
what is aphasia and what is the goal/ intervention?
def: impaired verbal communication
goal: increase communication
intervention: speak in normal tone, allow time for response, use yes/ no Q, use picture and text
what is expressive aphasia
when you know what you want to say. but have trouble saying or EXPRESSING your thoughts
what is receptive aphasia
affects the ability to read and understand speech
you can hear waht people say or see words on a page but hahve trouble making sense of what they mean
main intervention for impaired swallowing
- check for food pockets, especially on affecvted side
- never leave client withh food in mouth
- position upright
- suction readily available
- minimize distraction
what is ischemic stroke
caused by inadequate blood flow tot the brain from partial or complete occulsion of an artery
hemorrhagic stroke
caused by bleeding into the brain tissue itself
what is TIA
- not an actual stroke, but prestroke
- transient episode of neurologic dysfunction caused ischemia without acute infarction
thrombotic stroke
occlusion of cerebral vessel by thrombus
main concern for pt with impaired physical mobility
make sure physical therapist is ordered and visiting
embolic stroke
emoblus become lodges in vessel and cause occulsion
**cause by a fib, recent MI, endocarditis, valvualr disorder, athehrosclerotic lesion, vasculitis
