Stroke (CVA) Brain Attack - NUR 211 Health Care Concepts - Module 4C - PDF

Stroke (CVA) Brain Attack NUR 211: Health Care Concepts Unit Four - Module 4C Part 2 Learning Outcomes 1) Collaborate with the interprofessional team to coordinate high -quality care for patients experiencing a stroke (brain attack) 2) Implement nursing interventions to help the patient and...

Stroke (CVA) Brain Attack NUR 211: Health Care Concepts Unit Four - Module 4C Part 2 Learning Outcomes 1) Collaborate with the interprofessional team to coordinate high -quality care for patients experiencing a stroke (brain attack) 2) Implement nursing interventions to help the patient and family cope with the psychosocial impact caused by a stroke (brain attack) 3) Apply knowledge of anatomy, physiology, and pathophysiology to assess patients experiencing a stroke (brain attack) 4) Use clinical judgment to plan care for patients experiencing a stroke 5) 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 patient is transported to 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 swallowing/gag reflex ● Dysphagia ● Interventions ○ Upright ○ Chin tucked forward ○ Suction available ○ Unaffected side ○ Distraction free ○ Calories met Immobility ● Increased risk ● Range of motion q2 hrs ○ Active: unaffected ○ Passive: affected ● Elevate affected extremities ● Prevention of complications ● Protection of extremity ● Balance impairment ● Safe environment Client Education ● Unaffected side to affected side for eating/ambulating ● Affected side first (when dressing) ● Support affected side ● Adaptive aids: ○ Plate guard ○ Utensils with built up handles ○ Reaching tool ○ Velcro shoes ● Monitor for decreased endurance ● Emotional support Interdisciplinary Care ● Neurology ● Radiology ● Speech and language therapists ● Physical therapy ● Occupational therapy ● Social services/ case management Intracranial Pressure ● Highest risk in first 72 hrs after stroke onset ● Decreased LOC (earliest sign) ● Prevention: ○ HOB 30 degrees ○ O2 between 95 -99 ○ Midline, neutral head position ○ Avoid sudden hip/ neck flexion ○ Avoid clustering procedures ○ Hyperoxygenate before/after suctioning ○ Avoid unnecessary suctioning ○ Quiet, dimly lit environment ○ BP, HR, Oxygen, blood glucose and temperature monitoring