Stroke/ nursing care Exam Questions and answers
Nursing Assessment - first for Stroke
Stablize - ABC's
ABC's for stroke
cardiac status, respiratory status, neurologic assessments
what are we monitoring closely for
signs of increasing neurologic deficit or increased ICP
Common immediately following stroke
elevated BP - may reflect attempt to maintain cerebreal perfusion
Treatment of BP in ischemic stroke
treat is SBP>220/120, Map >130
Treatment of BP in hemorrhagic Stroke
treat if SBP >160
Signs/Symptoms of Stroke
1. sudden severe headache with no known cause
2. sudden trouble seeing in one or both eyes
3. sudden confusion, trouble speaking, or understanding
4. sudden numbness or weakness of face, arm or leg, esp on one side of the body
5. sudden trouble walking, dizziness, loss of balance, or coordination
what is important for an accurate history
time of onset - determines which meds can be used
Comprehensive Neurologic Assessment
LOC, cognition, motor abilities, NIH Stroke Scale
NIH Stroke Scale
higher number, poorer prognosis - range from 0-42
Symptoms occurring abruptly
embolic/hemorhagic
symptoms occurring gradually
thrombotic
, Severity of symptoms
with or withour improvement
Nursing Actions - Acute Care
control fluid and electrolyte balance, manage ICP
Control of fluid and electrolyte balance
adequate hydration promotes perfusion and decreases further brain injury
when does ICP peak
72 hours
Interventions for ICP to improve venous draninage
HOB up, head/neck alignment, treat fever, pain, prevent seizures, constipation
Stroke Assessment Cues
related to location of stroke - neural tissue destruction is basis for neurologic dysfunction
Frontal Lobe Function
problem solving/thinking/personality/mood
Occipital Lobe Function
visual/perceptual ability
Temporal Lobe Function
hearing/language
Cerebellum Function
balance/coordination
Broca's Area Function
speech control
Wernkicke's Area
language comprehension
Characteristics of Left Sided CVA
paralyzed right side, impaired speech/language aphasias, slow performace, cautious, aware of deficits:
depression, anxiety, impaired comprehension related to language, math
Characteristics of Right Sided CVA
Nursing Assessment - first for Stroke
Stablize - ABC's
ABC's for stroke
cardiac status, respiratory status, neurologic assessments
what are we monitoring closely for
signs of increasing neurologic deficit or increased ICP
Common immediately following stroke
elevated BP - may reflect attempt to maintain cerebreal perfusion
Treatment of BP in ischemic stroke
treat is SBP>220/120, Map >130
Treatment of BP in hemorrhagic Stroke
treat if SBP >160
Signs/Symptoms of Stroke
1. sudden severe headache with no known cause
2. sudden trouble seeing in one or both eyes
3. sudden confusion, trouble speaking, or understanding
4. sudden numbness or weakness of face, arm or leg, esp on one side of the body
5. sudden trouble walking, dizziness, loss of balance, or coordination
what is important for an accurate history
time of onset - determines which meds can be used
Comprehensive Neurologic Assessment
LOC, cognition, motor abilities, NIH Stroke Scale
NIH Stroke Scale
higher number, poorer prognosis - range from 0-42
Symptoms occurring abruptly
embolic/hemorhagic
symptoms occurring gradually
thrombotic
, Severity of symptoms
with or withour improvement
Nursing Actions - Acute Care
control fluid and electrolyte balance, manage ICP
Control of fluid and electrolyte balance
adequate hydration promotes perfusion and decreases further brain injury
when does ICP peak
72 hours
Interventions for ICP to improve venous draninage
HOB up, head/neck alignment, treat fever, pain, prevent seizures, constipation
Stroke Assessment Cues
related to location of stroke - neural tissue destruction is basis for neurologic dysfunction
Frontal Lobe Function
problem solving/thinking/personality/mood
Occipital Lobe Function
visual/perceptual ability
Temporal Lobe Function
hearing/language
Cerebellum Function
balance/coordination
Broca's Area Function
speech control
Wernkicke's Area
language comprehension
Characteristics of Left Sided CVA
paralyzed right side, impaired speech/language aphasias, slow performace, cautious, aware of deficits:
depression, anxiety, impaired comprehension related to language, math
Characteristics of Right Sided CVA
