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Questions and Answers
What is the first priority in assessing a patient with a stroke?
What is the first priority in assessing a patient with a stroke?
- Performing a physical assessment
- Ensuring the patient is transported to a stroke center (correct)
- Taking a complete medical history
- Administering medications to manage symptoms
What is the first priority in the assessment of a patient experiencing a stroke?
What is the first priority in the assessment of a patient experiencing a stroke?
- Ensure the patient is transported to a stroke center (correct)
- Conduct a psychosocial assessment
- Obtain a detailed medical history
- Perform a physical assessment
What is the first priority in assessing a patient experiencing a stroke?
What is the first priority in assessing a patient experiencing a stroke?
- Conducting a psychosocial assessment
- Transporting the patient to a stroke center (correct)
- Performing a physical assessment
- Taking a detailed medical history
What is the purpose of a neurologic examination in a patient with a stroke?
What is the purpose of a neurologic examination in a patient with a stroke?
Which laboratory assessment can help identify a stroke?
Which laboratory assessment can help identify a stroke?
What laboratory assessment can help diagnose a stroke?
What laboratory assessment can help diagnose a stroke?
Which laboratory assessment is important in assessing a patient with a stroke?
Which laboratory assessment is important in assessing a patient with a stroke?
Which assessment tool is used to evaluate the severity of a stroke?
Which assessment tool is used to evaluate the severity of a stroke?
Which imaging assessment is typically used to diagnose a stroke?
Which imaging assessment is typically used to diagnose a stroke?
What is the purpose of a CT or CTA in a patient with a stroke?
What is the purpose of a CT or CTA in a patient with a stroke?
What is the purpose of the NIHSS in the neurologic examination of a patient experiencing a stroke?
What is the purpose of the NIHSS in the neurologic examination of a patient experiencing a stroke?
What is the possible cause of aphasia and/or dysarthria in a patient experiencing a stroke?
What is the possible cause of aphasia and/or dysarthria in a patient experiencing a stroke?
What is the purpose of the GCS in the neurologic examination of a patient experiencing a stroke?
What is the purpose of the GCS in the neurologic examination of a patient experiencing a stroke?
What is the primary expected outcome for a patient experiencing a stroke?
What is the primary expected outcome for a patient experiencing a stroke?
Which nursing intervention is important in promoting mobility and ADL ability in a patient with a stroke?
Which nursing intervention is important in promoting mobility and ADL ability in a patient with a stroke?
What is the expected outcome for a patient with a stroke in terms of communication?
What is the expected outcome for a patient with a stroke in terms of communication?
What is the possible cause of aphasia and/or dysarthria in a patient experiencing a stroke?
What is the possible cause of aphasia and/or dysarthria in a patient experiencing a stroke?
What is the primary nursing intervention for improving cerebral perfusion in a patient experiencing a stroke?
What is the primary nursing intervention for improving cerebral perfusion in a patient experiencing a stroke?
What is the purpose of monitoring blood glucose in a patient experiencing a stroke?
What is the purpose of monitoring blood glucose in a patient experiencing a stroke?
What is the priority nursing intervention in the planning and implementation phase for a patient experiencing a stroke?
What is the priority nursing intervention in the planning and implementation phase for a patient experiencing a stroke?
Which nursing intervention is important in assessing safe feeding in a patient with a stroke?
Which nursing intervention is important in assessing safe feeding in a patient with a stroke?
Which imaging assessment is preferred for identifying a stroke?
Which imaging assessment is preferred for identifying a stroke?
What is the purpose of monitoring blood glucose in a patient with a stroke?
What is the purpose of monitoring blood glucose in a patient with a stroke?
Which expected outcome is not included in the evaluation phase of nursing care for a patient experiencing a stroke?
Which expected outcome is not included in the evaluation phase of nursing care for a patient experiencing a stroke?
What is the primary nursing intervention for managing changes in sensory perception in a patient experiencing a stroke?
What is the primary nursing intervention for managing changes in sensory perception in a patient experiencing a stroke?
What is the purpose of assessing safe feeding in a patient experiencing a stroke?
What is the purpose of assessing safe feeding in a patient experiencing a stroke?
Which assessment tool is used to evaluate the patient's level of consciousness in a patient with a stroke?
Which assessment tool is used to evaluate the patient's level of consciousness in a patient with a stroke?
What is the purpose of seizure precautions in a patient with a stroke?
What is the purpose of seizure precautions in a patient with a stroke?
What is the purpose of seizure precautions in the nursing care of a patient experiencing a stroke?
What is the purpose of seizure precautions in the nursing care of a patient experiencing a stroke?
What is the primary nursing intervention for promoting mobility and ADL ability in a patient experiencing a stroke?
What is the primary nursing intervention for promoting mobility and ADL ability in a patient experiencing a stroke?
What is the purpose of monitoring blood glucose in the nursing care of a patient experiencing a stroke?
What is the purpose of monitoring blood glucose in the nursing care of a patient experiencing a stroke?
Which nursing intervention is important in managing changes in sensory perception in a patient with a stroke?
Which nursing intervention is important in managing changes in sensory perception in a patient with a stroke?
What is the purpose of seizure precautions in a patient experiencing a stroke?
What is the purpose of seizure precautions in a patient experiencing a stroke?
What is the purpose of monitoring for increased intracranial pressure in a patient with a stroke?
What is the purpose of monitoring for increased intracranial pressure in a patient with a stroke?
What is the purpose of assessing sensory perception in the nursing care of a patient experiencing a stroke?
What is the purpose of assessing sensory perception in the nursing care of a patient experiencing a stroke?
What is the primary nursing intervention for assessing safe feeding in a patient experiencing a stroke?
What is the primary nursing intervention for assessing safe feeding in a patient experiencing a stroke?
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Study Notes
Stroke (CVA) Brain Attack NUR 211: Health Care Concepts Unit Four - Module 4C Part 2
Learning Outcomes
- Collaborate with the interprofessional team to coordinate high-quality care for patients experiencing a stroke (brain attack)
- Implement nursing interventions to help the patient and family cope with the psychosocial impact caused by a stroke (brain attack)
- Apply knowledge of anatomy, physiology, and pathophysiology to assess patients experiencing a stroke (brain attack)
- Use clinical judgment to plan care for patients experiencing a stroke
- Teach the patient and caregiver(s) about common drugs for a patient experiencing a stroke (brain attack)
Learning Resources ● Ignatavicius, D. (2021). pp 898-912 ● Ignatavicius, D. (20221). Study guide, Chapter 41 (questions 1-17) ● Silvestri, L (2023). pp 864-865 ● ATI RN Adult Medical Surgical Nursing 11.0 - Chapter 15 ● ATI RN Pharmacology for Nursing 8.0 - Chapter 25
Stroke: Assessment: Recognize Cues (1 of 2) ● History ○ First priority is to ensure the patient is transported to a stroke center ○ Other history can be taken after this ● Physical Assessment/Signs & Symptoms ○ Neurologic Examination ■ NIHSS ■ GCS ● Psychosocial Assessment
Stroke: Assessment: Recognize Cues (2 of 2) ● Laboratory assessment ○ Elevated H&H, WBC ○ Blood Glucose ○ Hemoglobin A1C ○ PT, INR, aPTT ● Imaging Assessment ○ CT or CTA ○ MRI
Stroke: Analysis: Analyze Cues & Prioritize Hypotheses ● Inadequate perfusion to the brain due to interruption of arterial blood flow and a possible increase in ICP ● Decreased mobility and possible need for assistance to perform ADLs due to neuromuscular or impaired cognition ● Aphasia and/or dysarthria due to decreased circulation in the brain (aphasia) or facial muscle weakness (dysarthria) ● Sensory perception deficits due to altered neurologic reception and transmission
Stroke: Planning and Implementation: Generate Solutions & Take Action ˜Improving cerebral perfusion ˜Monitoring for increased intracranial pressure ˜Promoting mobility and ADL ability ˜Managing changes in sensory perception
Stroke: Evaluation: Evaluate Outcomes ● The expected outcomes are that the patient: ○ Has adequate cerebral perfusion to avoid long-term disability ○ Maintains blood pressure and blood glucose within a safe, prescribed range ○ Performs self-care and mobility activities independently, with or without assistive devices ○ Learns to adapt to sensory perception changes, if present ○ Communicates effectively or develops strategies for effective communication as needed ○ Has adequate nutrition and avoids aspiration
Nursing Care ● Vital signs ● LOC ● Head of bed 30 degrees ● Cardiac monitor/assessment ● Monitor blood glucose ● Seizure precautions ● Speech and communication ● Assess safe feeding ● Decrease aspiration risk
Safe Feeding ● Decrease aspiration risk ● Assess
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