10/16/24, 2:02 Stroke - Lecture notes Lecture
PM notes
MEDICAL SURGICAL NURSING: NEURO 1.9.6 NURSE ANGIE 2018
STroKe
Sudden loss of neurological function caused by cerebrovascular disease.
CAUSES Assessment
‣ Thrombosis hered field of vision
A stroke can be caused by an embolus in the peripheral ‣ Embolism piratory changes
vasculature that breaks off and makes its way into the ce ‣ Hemorrhage: Intracranial or nosia
ant LOC changes
vessels causing a blockage. This blockage causes cerebra able to speak clearly
ischemia which leads to the death of cerebral cells and ti
causing paralysis, weakness, impaired speech and ooping of the face
ra high BP
possib death.
axia
sarthria
RISK
sessment of cranial
FACTORS nerves
‣ Smoking ficulty chewing.
‣ Advanced age acial paralysis or paresis
‣ Hypertension, Stress sent gag reflex
‣ TIA’s X: Dysphagia
‣ Diabetes, Obesity mpaired tongue movement
‣ High Cholesterol
‣ Oral contraceptives eria for t-PA admin
‣ Atherosclerosis
old
‣ Anticoagulant therapy
al diagnoses of ischemic
f onset of stroke under 3
La bo r ato r y Fin d in gs: s than 185/110 mmHg
‣ CT scan minor or rapid resolving
‣ Electroencephalography
‣ Cerebral arteriography ‣ No seizure at onset of
‣ MRI. ‣ Maintain a patent airway stroke
‣ Administer TpA within 6 hrs of ‣ Not on warfarin
symptom onset, and not for ‣ Prothrombin < 15
NURSING INTERVENTIONS EDUCATION
hemorrhagic stroke if indicated to seconds
break up a thrombus. ‣ Not on heparin
‣ Administer 02 as prescribed within the past 48 hrs.
‣ Platelet count >
10,000/mm3
No prior aneurysm, hemorrhage,
POST ACUTE PHASE
‣
‣
Remind the patient about the ‣
Monitor Vitals
importance of keeping ‣
Maintain BP of 150/100 mmHg to or neoplasm
‣
Maintain a patent airway. appointments and screening. maintain cerebral perfusion.
‣
No major surgery in the last 14
‣
Suction secretions as ordered. No days.
‣
Position.
‣
Educate the client on the
disease process and how it's longer than 10 seconds to prevent
‣
No stroke within 3 months
‣
Monitor elimination patterns
transmitted. ICP.
‣
No GI or GU bleeding within 3
‣
Provide skin care. ‣
Monitor for increased ICP the months.
‣
Perform passive/Active ROM.
‣
Educate the client on
treatments and the importance highest risk for ICP is within the
‣
Dosage : 0.9mg/ kg not to
Move extremities that have been
of adhering to the first 72 hours. exceed 90mg. Given IV 10% as a
affected slowly.
recommended treatment
‣
Position the client on the side with bolus over 1 min. The
‣
Teach the use of supportive
device ( cane, walker, regimens the head of the bed elevated 15-30 remaining IV over 1 hour pump.
commode) ‣
Finish all antibiotics. degrees.
‣
Address communication needs. ‣
Educate the patient of asepsis Monitor LOC, PERRLA.
‣
Orient client to person, place and preventing the spread of
‣
Insert foley
and time. meningitis.
‣
Administer IV fluid.
1
about:bl 1
PM notes
MEDICAL SURGICAL NURSING: NEURO 1.9.6 NURSE ANGIE 2018
STroKe
Sudden loss of neurological function caused by cerebrovascular disease.
CAUSES Assessment
‣ Thrombosis hered field of vision
A stroke can be caused by an embolus in the peripheral ‣ Embolism piratory changes
vasculature that breaks off and makes its way into the ce ‣ Hemorrhage: Intracranial or nosia
ant LOC changes
vessels causing a blockage. This blockage causes cerebra able to speak clearly
ischemia which leads to the death of cerebral cells and ti
causing paralysis, weakness, impaired speech and ooping of the face
ra high BP
possib death.
axia
sarthria
RISK
sessment of cranial
FACTORS nerves
‣ Smoking ficulty chewing.
‣ Advanced age acial paralysis or paresis
‣ Hypertension, Stress sent gag reflex
‣ TIA’s X: Dysphagia
‣ Diabetes, Obesity mpaired tongue movement
‣ High Cholesterol
‣ Oral contraceptives eria for t-PA admin
‣ Atherosclerosis
old
‣ Anticoagulant therapy
al diagnoses of ischemic
f onset of stroke under 3
La bo r ato r y Fin d in gs: s than 185/110 mmHg
‣ CT scan minor or rapid resolving
‣ Electroencephalography
‣ Cerebral arteriography ‣ No seizure at onset of
‣ MRI. ‣ Maintain a patent airway stroke
‣ Administer TpA within 6 hrs of ‣ Not on warfarin
symptom onset, and not for ‣ Prothrombin < 15
NURSING INTERVENTIONS EDUCATION
hemorrhagic stroke if indicated to seconds
break up a thrombus. ‣ Not on heparin
‣ Administer 02 as prescribed within the past 48 hrs.
‣ Platelet count >
10,000/mm3
No prior aneurysm, hemorrhage,
POST ACUTE PHASE
‣
‣
Remind the patient about the ‣
Monitor Vitals
importance of keeping ‣
Maintain BP of 150/100 mmHg to or neoplasm
‣
Maintain a patent airway. appointments and screening. maintain cerebral perfusion.
‣
No major surgery in the last 14
‣
Suction secretions as ordered. No days.
‣
Position.
‣
Educate the client on the
disease process and how it's longer than 10 seconds to prevent
‣
No stroke within 3 months
‣
Monitor elimination patterns
transmitted. ICP.
‣
No GI or GU bleeding within 3
‣
Provide skin care. ‣
Monitor for increased ICP the months.
‣
Perform passive/Active ROM.
‣
Educate the client on
treatments and the importance highest risk for ICP is within the
‣
Dosage : 0.9mg/ kg not to
Move extremities that have been
of adhering to the first 72 hours. exceed 90mg. Given IV 10% as a
affected slowly.
recommended treatment
‣
Position the client on the side with bolus over 1 min. The
‣
Teach the use of supportive
device ( cane, walker, regimens the head of the bed elevated 15-30 remaining IV over 1 hour pump.
commode) ‣
Finish all antibiotics. degrees.
‣
Address communication needs. ‣
Educate the patient of asepsis Monitor LOC, PERRLA.
‣
Orient client to person, place and preventing the spread of
‣
Insert foley
and time. meningitis.
‣
Administer IV fluid.
1
about:bl 1
