NUR-140 Moraine Valley Community College Mrs. Jagellaa Final Exam
Decreased cardiac output - ANSWER-EO: patient will demonstrate adequate cardiac
output as evidenced by BP and pulse rate and rhythm within normal limits.
Excess fluid volume - ANSWER-EO: patient will maintain normal blood volume as
evidenced by weight loss and decreases in edema, jugular venous distention, and abdominal distention.
activity intolerance - ANSWER-EO: patient will participate in physical activity as tolerated.
TIA (transient ischemic attack) - ANSWER-Sometimes called a mini-stroke Is a brief period of localized cerebral ischemia that causes neurological deficits lasting for less than 24 hours.Serves as a warning sign of an impending stroke.
Why would a patient have a carotid endarterectomy? - ANSWER-This is a procedure performed on patients who had a TIA or are in danger of having another stroke.
Define carotid endarterectomy - ANSWER-The occluded area is clamped off An incision is made in the artery Plaque is removed from the inner layer of the artery Artery is then sutured or a graft is placed to restore blood flow
What are common symptoms of a CVA? - ANSWER-Symptoms vary according to the location of the lesion.Motor loss Communication loss Perceptual disturbances Sensory loss Cognitive impairment Psychological effects
How is CVA diagnosed? - ANSWER-CT scan (to determine if ischemic or hemorrhagic) Carotid Ultrasound(attempt to find source of thrombi or emboli) MRI of brain and neck vessels Transcranial doppler flow study
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Define CVA (stroke) - ANSWER-An emergency condition in which neurological deficits result from sudden decrease in blood flow localized to an area of the brain. A manjor loss of blood supply to the brain can result in severe disability or death.
ischemic stroke - ANSWER-87% of strokes When the blood supply to a part of the brain is suddenly interrupted by thrombus, embolus, or blood vessel stenosis.
Hemorrhagic stroke - ANSWER-13% of strokes When a blood vessel ruptures spilling blood into spaces surrounding neurons.
The acronym FAST stands for - ANSWER-F- face (ask patient to smile, does one side droop) A- arm (ask patient to raise both arms, does one arm drift downwards) S- speech (ask the patient to repeat a simple sentence, is their speech blurred or strange) T- time (if the patient is showing any of these call 911/ code immediately)
How is CVA treated? - ANSWER-Recombinant t-PA (used to treat ischemic stroke by dissolving clot blocking blood flow to the brain, can cause bleeding to occur in eyes, IVs, catheters, NG tubes, urine and stool) IV heparin Osmotic diuretic to decrease ICP Elevation of head of bed to promote venous drainage and lower ICP Intubation to establish airway Continuous hemodynamics monitoring Neurological assessment to determine if CVA is evolving or if complications are developing
What are the 6 types of CVA? - ANSWER-1. Ischemic
- Hemorrhagic
- Large vessel (thrombotic) stroke
- Small vessel (lunar infarct)
5. TIA
- Cardiogenic embolic stoke
Risk For ineffective tissue perfusion:cerebral - ANSWER-EO: patient will demonstrate appropriate orientation to person, place, time, and situation as indicated. Patients cerebral perfusion will be adequate as evidenced by motor/sensory functions, pupillary size and reaction, and behaviors.
Impaired physical mobility - ANSWER-EO: patients joint ROM will be maintained with progression to transfers and ambulatory as tolerated and appropriate for condition.
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Self-care deficit - ANSWER-EO: patient will be able to complete self-care activities to optimal potential.
Impaired verbal communication - ANSWER-EO: patient will be able to use alternative methods of communication effectively
Impaired urinary elimination and risk for constipation - ANSWER-EO: patient will be able to perceive and recognize cues for toileting and independently conduct toileting activities to their optimal function.
Impaired swallowing - ANSWER-EO: patient will remain free from aspiration as
evidenced by clear lung sounds and temperature within normal range.
What is the nursing care for CVA patient? - ANSWER-Provide referrals to family members or patient Assist patients with passive ROM exercises Assist with ADLs Assist with interpersonal or intimate relationships with others Improved mobility Achievement of self-care Relief of sensory and perceptual deprivation Prevent aspiration Achieve a form of communication Bowel and bladder continence Maintain skin integrity
What are the nursing interventions for CVA patient ? - ANSWER-Improve mobility and prevent joint deformities Prevent shoulder adduction Positioning of hand and fingers Changing positions Establish exercise program Preparing for ambulatory Preventing shoulder pain Enhancing self care Managing sensory perception difficulties Assist with nutrition Attain bowel and bladder control Improve thought process Improve communication Maintain skin integrity Improve family coping Help patient to cope with sexual dysfunction Promote community and home based care
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