36 Questions
What is the first priority in assessing a patient with a stroke?
Ensuring the patient is transported to a stroke center
What is the first priority in the assessment of a patient experiencing a stroke?
Ensure the patient is transported to a stroke center
What is the first priority in assessing a patient experiencing a stroke?
Transporting the patient to a stroke center
What is the purpose of a neurologic examination in a patient with a stroke?
To evaluate the patient's motor and sensory function
Which laboratory assessment can help identify a stroke?
Elevated H&H, WBC
What laboratory assessment can help diagnose a stroke?
Elevated hemoglobin A1C levels
Which laboratory assessment is important in assessing a patient with a stroke?
Hemoglobin A1C
Which assessment tool is used to evaluate the severity of a stroke?
NIHSS
Which imaging assessment is typically used to diagnose a stroke?
CT or CTA
What is the purpose of a CT or CTA in a patient with a stroke?
To assess the patient's brain perfusion and rule out hemorrhage
What is the purpose of the NIHSS in the neurologic examination of a patient experiencing a stroke?
To assess the patient's motor function
What is the possible cause of aphasia and/or dysarthria in a patient experiencing a stroke?
Decreased circulation in the brain
What is the purpose of the GCS in the neurologic examination of a patient experiencing a stroke?
To assess the patient's level of consciousness
What is the primary expected outcome for a patient experiencing a stroke?
Adequate cerebral perfusion to avoid long-term disability
Which nursing intervention is important in promoting mobility and ADL ability in a patient with a stroke?
Providing assistive devices as needed
What is the expected outcome for a patient with a stroke in terms of communication?
The patient communicates effectively or develops strategies for effective communication as needed
What is the possible cause of aphasia and/or dysarthria in a patient experiencing a stroke?
Decreased circulation in the brain
What is the primary nursing intervention for improving cerebral perfusion in a patient experiencing a stroke?
Administering thrombolytic therapy
What is the purpose of monitoring blood glucose in a patient experiencing a stroke?
To maintain blood glucose within a safe, prescribed range
What is the priority nursing intervention in the planning and implementation phase for a patient experiencing a stroke?
Improving cerebral perfusion
Which nursing intervention is important in assessing safe feeding in a patient with a stroke?
Monitoring the patient's ability to swallow
Which imaging assessment is preferred for identifying a stroke?
CT
What is the purpose of monitoring blood glucose in a patient with a stroke?
To maintain cerebral perfusion
Which expected outcome is not included in the evaluation phase of nursing care for a patient experiencing a stroke?
Learning to play the piano
What is the primary nursing intervention for managing changes in sensory perception in a patient experiencing a stroke?
Providing sensory stimulation
What is the purpose of assessing safe feeding in a patient experiencing a stroke?
To decrease aspiration risk
Which assessment tool is used to evaluate the patient's level of consciousness in a patient with a stroke?
GCS
What is the purpose of seizure precautions in a patient with a stroke?
To prevent seizures
What is the purpose of seizure precautions in the nursing care of a patient experiencing a stroke?
To prevent seizures
What is the primary nursing intervention for promoting mobility and ADL ability in a patient experiencing a stroke?
Providing physical therapy
What is the purpose of monitoring blood glucose in the nursing care of a patient experiencing a stroke?
To prevent hyperglycemia
Which nursing intervention is important in managing changes in sensory perception in a patient with a stroke?
Encouraging the patient to use assistive devices as needed
What is the purpose of seizure precautions in a patient experiencing a stroke?
To prevent seizures
What is the purpose of monitoring for increased intracranial pressure in a patient with a stroke?
To maintain cerebral perfusion
What is the purpose of assessing sensory perception in the nursing care of a patient experiencing a stroke?
To manage changes in sensory perception
What is the primary nursing intervention for assessing safe feeding in a patient experiencing a stroke?
Decreasing aspiration risk
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
Test your knowledge on stroke (CVA) and nursing interventions for patients experiencing a brain attack in this quiz! Learn about the importance of collaborating with the interprofessional team, assessing cues and prioritizing hypotheses, implementing solutions, and evaluating outcomes. This quiz covers topics such as anatomy, physiology, and pathophysiology of stroke, psychosocial impact, clinical judgment, and common drugs for stroke patients. Sharpen your skills on vital signs, cardiac monitoring, blood glucose monitoring, and speech and communication assessments
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