Strokes
Name types of strokes
Ischemic Stroke Embolic Cryptogenic Hemorrhagic Stroke TIA'S
What happens if the patient is left with untreated increase ICP.
Displacement of brain tissue
Your patient is diagnosed with an ischemic stroke and is being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy?
Has a serious head injury 4 weeks ago
Patient with MVA head injury found on floor right side turned away from body and RT foot extended what part of brain is impacted
Abnormal posture is brain stem decerebrate and rigid
What IV fluid would be utilized with a patient with increased intracranial pressure (ICP) sensitive to fluid-volume shifts to reduce this patient’s cerebral edema?
3% sodium chloride
High-concentration sodium chloride solutions pull water from the interstitial spaces into the vascular space without the dramatic fluid shifts caused when osmotic diuretics are utilized.
Hemorrhagic Stroke is bleeding in brain caused by
Break in a blood vessel, aneurysm burst uncontrol hypertension old vessels are not as resilient
What are assessment findings indicative of increased ICP?
Headache
Abnormal posturing
Unequal pupils
The nurse is administering mannitol IV to decrease the client’s ICP following a craniotomy. What laboratory test result should the nurse monitor during the client’s treatment with mannitol?
Serum osmolality
A client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document?
.
Paralysis of the right side of the body and ataxia
What potential problems will the nurse monitor for if patient is on anticoagulant/antiplatelet therapy?
Bruising
Hematuria
Hypotension
Tachycardia
Ischemic stroke
What is a disruption in blood flow to brain
What instructions would you include to parents of child with a post ventriculoperitoneal shunt to notify upon discharge.
Call the physician if the infant has a high-pitched cry
A patient is being discharged after treatment for an ischemic stroke. Which medications would you expect to be included in the management of this neurological disorder?
Anticoagulants
Antihypertensive
Antiplatelet therapy
Lipid-lowering agent
A patient had a stroke affecting the right hemisphere of the brain. The nurse should initially assess for which problem?
Poor impulse control
(Coumadin). this drug works by which mechanism?
Blocking of vitamin K-dependent factors
What would you do if a patient under your care diagnosed with atrial fibrillation reports numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first?
.
Call a Rapid Response Team/code STROKE
What activities do you try to avoid performing with a patient that has ICP.
Coughing
Sharp hip flexion
Valsalva maneuver
Vomiting
Ischemic stroke is being considered for recombinant tissue plasminogen activator (rt-PA). The nurse recognizes which factors as contraindications to this treatment?
Age greater than 80
history of diabetes mellitus
Takes anticoagulants example warfarin for atrial fibrillation
Prior history of Stroke
The nurse is caring for a client diagnosed with a thrombotic stroke who received a thrombolytic medication in the ED. Which intervention should be implemented?
Monitor heparin infusion
If patient taking (Plavix) calls the nurse to report black, tarry stools and coffee-ground emesis.
What will the nurse instruct the patient to do ?
Inform the patient to come in to be seen
The patient you are caring for is 85year-old diagnosed with a stroke is reporting a severe headache. Which intervention should the nurse implement first?
Complete a neurological assessment.
You are caring for a patient that has a ventriculostomy. What finding would you report immediately upon assessment to the doctor?
ICP 24 mmHg
Normal ICP is 0 to 15 mm Hg
You are teaching a patient recovering from an ischemic stroke his prescribed verapamil (Calan). The nurse teaches the patient that this medication works by which action
Decreases blood pressure
Verapamil (Calan) is a calcium channel blocker used to reduce blood pressure to prevent long-term damage from excessive shear stress and reduce the chance for complications of hypertension such as intracerebral hemorrhage.
What are signs of cerebral herniation
Increased systolic blood pressure (BP) with decreased diastolic BP (widened pulse pressure), bradycardia, and irregular respiratory pattern, Cushing's Triad
The client is being admitted with warfarin toxicity. Which laboratory data should the nurse monitor?
International normalized ratio (INR)
PT/INR is a test to monitor warfarin (Coumadin), an anticoagulant, action in the body