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med surg Unit 7 Neuro
CVA
36
Nursing
Undergraduate 1
03/14/2011

Additional Nursing Flashcards

 


 

Cards

Term

CEREBRAL VASCULAR ACCIDENT (CVA) [STROKE]

Definition

INTERRUPTION OF THE BLOOD FLOW TO THE BRAIN RESULTING IN DYSFUNCTION IN MOTOR, SENSORY, PERCEPTUAL, EMOTIONAL OR COGNITIVE ABILITIES

Term
CVA affect
Definition

n   SOME MAY BE PREVENTABLE

n   S/S VARY DEPENDING ON AREA OF THE BRAIN AFFECTED    

Term

CVA 

ETIOLOGY 

Definition

HEMORRHAGIC

ISCHEMICn  EMBOLUSn  THROMBUS    

Term
CVA- HEMORRHAGIC
Definition
occur when a cerebral blood vessel ruptures and blood is released in brain tissue
Term

CVA-

ISCHEMIC

Definition
occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety.
Term

HEMORRHAGIC CVA

Definition

n   VERY HIGH MORTALITY RATE

n   CAN REBLEED IN TWO WEEKS

Term

HEMORRHAGIC CVA

are R/T

Definition

n   ARE R/T HTN, AV MALFORMATION, CEREBRAL ANEURYSM, DISEASES THAT CAUSE COAGULOPATHIES, OVER USE OF ANTICOAGULANTS

n  INTRACEREBRAL BLEED

n  SUBARACHNOID BLEED   

Term

HEMORRHAGIC CVA

CLASSIC SYMPTOM

Definition

   "THIS IS THE WORST HA OF MY LIFE”

Term

 

HEMORRHAGIC CVA

other SYMPTOM

 

Definition

n   DEPENDS ON SEVERITY & LOCATION OF DAMAGE

n  LOC CHANGES, NUCHAL RIGIDITY, PHOTOPHOBIA, RESTLESSNESS, IRRITABLE, N/V, FOCAL S/S IE HEMIPARESIS, PUPIL CHANGES, COMA, RESP. PATTERNS, EYE DEVIATIONS    

Term

HEMORRHAGIC CVA

DX

Definition

n   CT, MRI, LP (BLOODY FLUID), MAYBE ANGIOGRAM

Term

HEMORRHAGIC CVA

MANAGEMENT

Definition

n   SURGERY FOR AV MALFORMATION OR ANEURYSM

n   NEW  -- PERCUTANEOUS BEAD INSERTION  

n   CONTROL BP, CORRECT COAGS

n   CA++ CHANNEL BLOCKERS TO RELIEVE VASOSPASMS

Term

 

HEMORRHAGIC CVA

NURSING

 

Definition

 

MONITOR FOR ­ICP, WORSENING HA, LOC CHANGES

n   MONITOR VITAL SIGNS ESP. BP

n   MAINTAIN QUIET CALM ENVIRONMENT

KEEP LIGHTS DIM

n   SEIZURE PRECAUTIONS

n   BR WITH HOB UP 30 DEGREES


n   NO STRAINING

n  DON’T LET PT. SCOOT SELF UP IN BED

 

n  STOOL SOFTENERS, HIGH FIBER DIET, ADEQUATE FLUIDS   

 

 

 

Term

EMBOLIC CVA

Definition

n   OCCURS WHEN A SUBSTANCE IS CARRIED FROM ANOTHER LOCATION TO THE BRAIN VIA AN ARTERY CAUSING OCCLUSION OF THE ARTERY

n   BACTERIAL ENDOCARDITIS, AIR, PLAQUE DURING MANIPULATION OF AN ARTERY OR ANGIOGRAMS, BLOOD CLOT R/T A-FIB,  LV ANEURYSM, OR CAROTIDS  

Term

THROMBOTIC CVA -- BRAIN  ATTACK

Definition

n   MOST COMMON

n   ATHEROSCLEROTIC PROCESS USU. IN CAROTIDS – SAME AS MI (PLAQUE ® PLATELETS ® CLOT  OCCLUSION)

n   INTERRUPTED BLOOD FLOW TO BRAIN ®  O2 TO CEREBRUM  ANAEROBIC GLYCOLYSIS &  FUNCTION  ISCHEMIA, INFARCTION, CEREBRAL EDEMA

OFTEN PRECEDED BY TIA 

Term
TIA
Definition

n   NEURO DEFICIT LASTING < 24H (USU. LASTS MINUTES TO 3 H)

n   TEACH PT. TO SEEK HELP STAT R/T WILL HAVE CVA SOON – CAN PREVENT CVA

Term

THROMBOTIC CVA 

RISK FACTORS

Definition

n   HX. HTN n   HEART DISEASEn   ATHEROSCLEROSISn   STRESSn   SMOKINGn   HIGH CHOLESTEROL

n   COAGULOPATHIES (HIGH OR LOW)n   POLYCYTHEMIA

DM    

Term

THROMBOTIC CVA  

CLINICAL MANIFESTATIONS

Definition

n   DEPEND ON SEVERITY & LOCATION OF DAMAGE

Term

L CVA = DAMAGE ON L SIDE OF BRAIN

Definition

R HEMIPARESIS

n  DYSFUNCTION OF SPEECH & LANGUAGE IN 95% PT.

n  SLOW & CAUTIOUS

n  MEMORY DEFICITS

Term

R CVA = DAMAGE ON R SIDE OF BRAIN

S/S

Definition

n   L HEMIPARESIS

n   L SIDED NEGLECT

n   FALL RISK R/T QUICK, IMPULSIVE BEHAVIOR, POOR JUDGMENT

n   MEMORY DEFICIT

Term

CEREBRAL VASCULAR ACCIDENT (CVA)

DX.

Definition

CT, MRI, ? LP & ANGIOGRAMS TO R/O HEAD BLEEDING, CAROTID DOPPLER

CBC, CHEMISTRIES, COAGS 

Term

CEREBRAL VASCULAR ACCIDENT (CVA)

MANAGEMENT 

Definition

 

n   ACUTE CARE IN ICU

n   REHAB BEGINS ON ADMISSION

n   MOST SIGNIFICANT RECOVERY OCCURS WITHIN 1ST SIX WEEKS

n   TREAT CONCURRENT CONDITIONS: HEART DISEASE,  HT,   DM, COAGULOPATHY

 

Term

FOR EMBOLIC OR THROMBOTIC R/T CLOT

Definition

TPA TO DISSOLVE CLOTS IF CRITERIA MET

n   HEPARIN GTT THEN COUMADIN

n   ASA QD (81 MG)

n   PLAVIX

n   CAROTID ENDARTERECTOMY   

Term

 NURSING CARE

VITAL SIGNS 

Definition

  VITAL SIGNS & NEURO CHECKS AS INDICATEd

Term

 NURSING CARE

CVA

HOB

Definition

   HOB UP AT LEAST 30 DEGREES TO DECREASE ICP & RISK OF ASPIRATION

Term

n   NURSING CARE

CVA

WHEN EATING 

Definition
PLACE PT. UPRIGHT & USE CHIN TUCK IF DYSPHAGIC
Term

NURSING CARE

CVA

DYSPHAGIA DIET 

Definition

n   THICK LIQUIDS & SEMI SOLID SOFT IE MASHED POTATOES, CUSTARD, PUDDING, EGGS

n  NO THIN LIQUIDS, PEANUT BUTTER, DRY FOODS IE CRACKERS, CHUNKS IE GRAPES, ORANGES, HOT DOGS

Term

CVA

PREVENT HAZARDS OF IMMOBILITY

Definition

n   MAINTAIN PT. DIGNITY DURING CARES

n   MONITOR FOR BLADDER DISTENTION  & CONSTIPATION

n   BOWEL & BLADDER TRAINING

BEDSIDE ULTRASOUND

Term

 

CVA

 APHASIC

EXPRESSIVE – BROCA’S – L. FRONTAL LOBE

 

Definition

 


n   CAN UNDERSTAND BUT CAN’T EXPRESS

n   MAY OR MAY NOT BE ABLE TO WRITE

n   SPEECH SLOW, LABORED, PT. AWARE OF DIFFICULTY SO FRUSTRATED & DEPRESSED

 

Term

CVA

RECEPTIVE – WERNICKE’S – L. TEMPORAL LOBE

Definition

n   CAN’T UNDERSTAND VERBAL OR WRITTEN

n   SPEECH NORMAL EXCEPT MISUSE WORDS

n   PT. OFTEN UNAWARE OF DIFFICULTY SO NOT FRUSTRATED

Term

CVA

GLOBAL 

Definition

COMBINATION OF BOTH R/T MASSIVE INJURY

n   PROGNOSIS TO REGAIN SPEECH POOR

Term

CVA

AFFECTED JOINTS 

Definition

n   HANDLE AFFECTED JOINTS CAREFULLY R/T NO MUSCLE TONE ® EASY DISLOCATION

n   ARM SLING

n   SUPPORT AFFECTED ARM WITH PILLOWS WHEN IN BED

n   DON’T USE WEAK ARM TO SCOOT UP IN BED

Term

CVA

MOBILIZE 

Definition
AS SOON AS MEDICALLY ALLOWED
Term

CVA

 

HOW TO COMPENSATE FOR HEMIANOPSIA 

Definition

n   TURN HEAD TO SCAN ROOM & LOOK AT WEAK SIDE TO DECREASE NEGLECT

MIRROR

Term

CVA

  PICTURE

Definition
Term

CVA

TRANSFERRING

Definition

n   BEAR WT. & PIVOT ON STRONG SIDE WHEN TRANSFERRING

LEAD WITH STRONG SIDE

Term

CVA

WALKING 

Definition
WHEN WALKING ASSIST PT. ON WEAK SIDE SO THEY CAN USE CANE ETC WITH STRONG SIDE
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