Adult Health Nursing II
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1) Describe the pathophysiology of Cerebrovascular Accident (CVA). What are the signs and symptoms?
A loss of function due to an interruption of blood flow to the brain. Transient ischemic attack (TIA): can last several minutes, usually last less than 24 hours; may experience several TIAs before a CVA.
S/S: dizziness; loss of vision of one eye; one-sided numbness; weakness of the fingers, arms, legs; periods of aphasia
2) List possible risk factors for CVA.
hypertension; diabetes; cardiac disease; obesity; sedentary lifestyle; smoking; stress; high cholesterol; drug abuse; oral contraceptives
3) What are the appropriate nursing interventions for a patient with a CVA?
Acute phase: ensuring airway, breathing and circulation are PRIORTY focus
*Diet: Check gag reflex: if none tube feedings and IV; if yes: swallow study, thicken liquids, type of diet
--If embolic/thrombotic: keep bed flat increase cerebral perfusion
--Hemorrhagic: keep HOB up to decrease cerebral perfusion
--As tolerated - PT, ST, OT added
4) Describe the National Institutes of Health Stroke Scale (NIHSS).
NIHSS - National Institutes of Health Stroke Scale
· Level of consciousness
· Extraoccular movements
· Facial Palsy
· Limb strength
· Speech and language
5) Which nursing assessments are most important to perform to evaluate potential symptoms of a stroke?
LOC, numbness/weakness, paralysis, difficulty swallowing, N/V, incontinence, increased or decreased HR, BP, respiratory distress, unequal pupils
6) Research the possible medications for CVA. What are some special considerations for these medications, if any?
· hyperosmotic agents
· platelet aggregation inhibitors
· calcium channel blockers
· tPA - CVA thrombolytics used to dissolve clots by breaking down fibrin 3hr window
7) Research the pharmacology of Labetalol. What would be the indicated use of this medication for a stroke patient?
Nonselective beta-adrenergic antagonist
Also clocks alpha 1 adrenergic receptor, inhibits peripheral vasoconstriction, causes peripheral vasodilation.
A potent agent for lowering blood pressure
Indication: Acute management of hypertensive crisis
8) Discuss the collaborative management of CVA.
Goals include management of modifiable risk factors
Limited alcohol consumption
Routine health assessments
Measures to prevent development of a thrombus or embolus are used in patients at risk for stroke.
Antiplatelet drugs are used in patients who have had a TIA related to atherosclerosis.
Aspirin is the most frequently used antiplatelet agent.