NUR 2790 Exam_Final_ Best Series

Final Exam Content Guide 1. Stroke – CVA – Brain attack disruption of cerebral blood flow secondary to ischemia, hemorrhage, brain attack, or embolism 1) Hemorrhagic – ruptured artery or aneur y sm = ischemia and ↑ICP caused by expanding collection of blood. Prognosis poor. 2) Thrombotic – d/t development of blood clot on an atherosclerotic plaque in a cerebral artery. The clot gradually shuts off the artery causing ischemia distal to the occlusion. Symptoms evolve over several hours to days. 3) Embolic – d/t embolus traveling from another part of the body to the cerebral artery. Blood to brain distal to occlusion immediately shuts off causing neuro deficits, or a loss of consciousness can instantly occur. --- This type of stroke may be reversed with rtPA if given within 4.5hrs of initial symptoms. Risk Factors: HTN, DM, smoking == PREVENTION == Early treatment of HTN, maintain BGL, quit smoking. Right vs Left: Right = visual and spatial awareness and propriception. Left = language, math, and analytic thinking (agnosia – inability to recognize familiar objects). Interventions: Have suction equipment avail. Vitals 1-2hrs – Notify MD if BP >180/110. Temp (↑ can cause ↑ICP). O2 and maintain > 92%. Cardiac monitor. Monitor LOC (↑ICP). Elevate HOB >30 to reduce ICP and promote venous drainage. Maintain midline neutral position. SEIZURE Percautions. Assist with communication. Assist with safe feeding. Intervene for complications r/t immobility. Active ROM to unaffected exteemities, and Passive ROM to affected extremities. Vision deficits = instruct scanning techinique (turning head). Prevent DVT. Assist with ADL’s. Provide frequent rest.