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Assessment
- When did symptoms start?
- what the symptoms?
- one side weakness, slurred speech, visual chx, difficulty walking, face droop etc, H/a, BP high, cognition (memory, attention), PMH, FHx,
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Initial Assessment
- Alert Stroke team
- - md- 10 mins
- - neurologist
- - ct scan- 20 mins
- - TPA withing 1hr
- Assess Airway, VS
- - supplemental oxygen, O2 stat, LS: > 95 (hypoxia worsen injury) less than 8 u intubate
- - HOB elev- prevent aspiration (pneumonia- reason for non neurological death)
- - cardiac monitor- rythym
- - NPO status
- IV access
- - two lines: TPA and NS (may have central line)
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more initial assessment
- Hx of symptoms, meds, allergies, PMH (smoking, HTN, DM, Afib)
- Neuro assessment
- - NIH stroke scale- the higher the number the more severe the problem (based on what u see)
- Labs: CBC. platelets, PT, PTT, INR, glucose, chem, type and drug screen
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Neurological Assessment
- Glascow Coma Scale- know this (3 compotents of glascow scale)
- Cranial Nerves- know
- Motor
- - facial
- - upper/lower extremity
- sensory
- - vision
- Psychosocial
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other things you would do
- ECG
- CT scan (non constrast)- to r/o hemarrahagic
- foley cath- if unable to void, or make sure pt can empty bladder, use scan)
- weigh pt- for meds
- start screening for TPA- not able to get tubes or drains bc of bleed once u get tpa...
- antiplatelet therapy, benzodiazepine AED (anxiety), calcium channel (vasodilate, neuro protective affect, to dilate collateral vessels, to improve cerebral, low dose, se: muscle weakness, hypotension, dizzy)
- support pt and family
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Acute Management
- Assess breathing
- - oxygen, intubation
- - oxygen sat, ABG, LS
- - Airway: prevent aspiration, hypoxia,
- Neuro assessment
- BP management
- - lower: hemorrhagic- to take pressure off
- - Ischemic: slightly hypertensive (150/100) it will perfuse cerebral- don't want to drop too fast
- - IV Labetalol- beta blocker
- - oral ace inhi- cough hypotensive
- Temp
- less than 99 give tylenol
- Blood Sugar
- - normal limits: too low/high can have negative affects (too low brain needs glu, too high decr perfusion)
- -
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Tissue Plasminogen Activator
TPA
- Converts plasminogen to plasmin which dissolves the clot
- dissolves the cerebral artery occlusion to re-establish blood flow
- - minimize size of infarct
- - improves outcomes
- - incre perfusion to pneumbra
- must be given w/in three hours of onset of symptoms
- high risk bleeding
- - 1st 36 hrs after TPA
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are you in or out for TPA
- confirmed dx of ischemic stroke
- onset of symptoms w/in 3 hrs
- measurable neurological deficits- speech, motor, cognition
- neuro consult
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Exclusion of TPA
- present/hx intracranial hemorrhage (any risk for bleeding)
- bp > 185 systolic or > 110 diastolic at time of tpa
- hx of GI/GU hemorrhage in the past 3 weeks
- acute MI
- head trauma within past 3 months
- heparin within 48 hours of stroke and elevated PTT
- plat count less 100,000
- oral anti coag and INR > 1.7
- if BS out of wack <50 or > 400
- risk for bleeding
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TPA cont
- dosage is calculated by weight
- -obtain weight
- administer 10% within 1 min and the remaining dose over 1 hour
- - verify by 2nd RN
- assess neuro v bleeding (once on TPA)
- avoid any insertion of any new IV's, tubes for at least 30 mins after infusion ends- bc of risk for bleeding
- f/u up CT, CBC, PT, PTT, plat, fibrogen R/O bleed
- no anti-coag, antiplat for 24 hours post TPA
- f/u CT after 24 hours before starting anti plat tx
- any signs of bleeding stop immediately
- word didnt know hemachisias- bright red blood
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If pt does not meet criteria for TPA
- Antiplatelet therapy
- - aspirin- start within 48 hrs (cheapest option)
- - Plavix
- other: control BP, DM, Chol, AED (hx seizure), stool softners
- Heparin/lovenox
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Tx for hemorrhagic CVA
- Neurosurgical consult
- transfer to Tertiary hospital for surgery
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Impaired Cerebral Perfusion
- Assess Neuro
- assess VS
- Assess respiratory status
- - Oxygen, O2 stat- inc CO2 (cause vasodilation, cap perm, edema)
- assess glucose- brain uses glucose cant store
- assess pain
- HOB elevated, avoid neck and knee/hip flexion (dec venous return- so the brain will be perfused)
- - quiet environment
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Impaired swallowing
- NPO- need to pass test first
- dysphagia screen tool
- - screen done by nurse
- - refer to handout
- (read thru handouts)
- speech and swallowing eval by SLP (speech and language)
- modified barium swallow- if fail assessment
- if fail: options
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Speech and swallow test
- are they alert
- can they follow commands
- - no they fail
- manage secretion
- speech clear- motor function
- swallow 30 ml then can clear throat
- respiration rate
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Impaired swallowing
assessment
- assess s/s of dysphagia
- - coughing, pooling of secretions or food, food retained for long period period of time. nasal regurg. c/o food caught in throat
- assess s/s of aspiration
- - coughing, chx in lung sounds, O2 stat, temperature, incre wbc
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initial diet for impaired swallowing
- thick liquid/puree diet to start and advance as tolerate start w/little
- OOB in chair, HOB elev
- - reduced distractions, take time
- chin tuck swallow
- education family- so they can know what they have to do for the pt
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Impaired Verbal Communication
- Dysarthria- problem w/mouth jaw- not able to formulate word- mouth not working
- expressive (motor) asphasia- not able to say it (slow) Broca's
- receptive (sensory) asphasia- Wernicke's temporal lobe, do not understand verbal/written word (makes no sense)
- Global aphasia- both no speech/understand
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Impaired Verbal communication
- face pt at eye level, eye contact
- simple one step commands
- - eliminate distractions
- - be consistent, normal tone
- present one thought per sentence
- use alternative forms of communication- hands, posters
- avoid yes/no- short ans
- allow time to process and answer
- assess frustration, depression
- assess impact on writing, reading, vision
- SLP referral early
- - early intervention
- - practice, exercises, mirror
- review intervention for receptive and expressive
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Impaired Sensory Perception
- chx in vision, position and spatial/perceptual deficits (at risk for fall)
- diplopia
- loss of peripheral vision
- hemianopsia- loss of half a visual field
- homonymous hemianopsia- loss of half visual field on the same side
- apraxia- loss ability to do ADL- ie combing hair, getting dress
- Ptosisias- at risk for fall, infection, invasive
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Impaired sensory perception
intervention
- approach from unaffected side
- place objects in field of vision
- - adl, tray, call bell
- frequent verbal and tactile cues- tell pt where things are. they may neglect the said they don't see.
- - step by step approach
- remind to turn head/vision to side of defect
- good lighting, eye glasses if needed, removed clutter
- diplopia: patch over affected eye
- patience, consistency wit apraxia
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impaired sensory perception
homonymous Hemiopsia
- loss of 1/2 of visual field in same area
- pts tend to turn away this side
- Intervention
- - teach pt to SCAN the room
- - cues to pt
- - call bell within vision
- - assess safety vision
- - call bell within vision
- - assess safety needs
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impaired sensory perception
unilateral neglect
- Neglect Syndrome (extinction/inattention)
- - usually with right infarct
- - often with visual deficits and or hemiopsia
- - does not use or aware of side of body
- - don't feel side and forgets it is there
- Intervention:
- - encourage pt to touch both sides of body
- - verbal cues- like telling them what u are doing which side you are touching
- - scanning
- - approach from unaffected side, objects in view
- with time, may approach from affected side and objects on affected side- so they can start using this
- safety needs
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Impaired mobility
- assess muscle weakness
- proper body alignment
- preventing joint deformities
- - correct position, asst devices
- - ROM
- sometimes they are not aware pt
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Impaired mobility
- change position q2h/prn
- - HOB elev
- PT and OT consult
- OOB to chair early, ambulation
- - balance, posture, muscle weakness
- - splints, walkers, cane
- - safety: OOB
- Stroke chair- lays flat like a recliner
- - looks like a stretcher, once they are in u can sit them up
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Impaired mobility
subluxation
- incomplete dislocation
- - upper are drops out of socket
- - cause: muscle weakness, early flaccidity
- - after stroke: muscle weak, hand hangs down with little/no movement
- occurs early after stroke event
- this can occur due to neglect- gravity
- support arm
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Subluxation
treatment
- early identification and treatment
- proper position, support, alignment
- utilize asst device, pillows
- slings, straps
- NMES (neuromuscular electrical stimulation)
- mild pain meds
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impaired mobility
prevent complication
- atelectasis, pneumonia
- DVT
- pressure ulcers
- contractures
- pulmonary emobli
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pain
- cause: muscle weakness, paralysis spasticity
- - assess pain and comfort using appropr scale
- - reposition, support, proper alignment
- --- never lift/pull on affected shoulder
- --- asst devices, slings
- ROM
- Alternative pain relief methods
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Intervention by
for impaired mobility
- excerises
- PTmedications: mild pain relief meds
- - other options
- - lamictal AED
- - lyrica (GABA related)
- - valium (benzo)
- - dantrolene (skeletal muscle relaxant)
- NMES
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other nursing dx
- impaired bowel/bladder elimination
- impaired coping (depression)
- impaired self care
- alter thought process
- impaired skin integrity
- high risk for injury (falls, seizure)
- infection
- caregiver burnout
- knowledge deficit (pt/family)
- - prevention/health promotion
- - community resources
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Improving stroke outcomes
- rehab starts as soon as possible day 1
- inc time each day in rehab therapy
- early encouragement of self care
- consistency and encouragement
- know stroke
- - know the signs act in time
- f/u with physician bc of risk
- stroke- plavix/aspirin
- a fib- coag
- teach: chol control, BS control, excercise, no smoking
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improving stroke outcome
- follow up with MD
- - preventing another stroke
- - control a fib, bp, bs, lipids, stop smoking
- - aspirin/plavix therapy
- d/c needs teaching
- - compliance
- - diet/excerise
- - teach: community/family s/s stroke
- resources
- - AHA/ASA
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