Nursing Homework


Adult Health Nursing II

Neuro Simulation 

Ticket to Entry

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

· Vision

· Extraoccular movements

· Facial Palsy

· Limb strength

· Ataxia

· Sensation

· Speech and language

5) Which nursing assessments are most important to perform to evaluate potential symptoms of a stroke?

Neuro assessment:

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?

· Corticosteroids

· hyperosmotic agents

· anticoagulants

· thrombolytics

· 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

Healthy diet

Weight control

Regular exercise

No smoking

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.