DEFINITION: rapid occurrence of neurological dysfunction ...



| | |

|DEFINITION: rapid occurrence of neurological dysfunction that results from |RELATED DIAGNOSTIC TESTS: various tests are used to assess the type and size of|

|impeded vascular blood flow to the brain. This incident results from one of two |a stroke: |

|types of stroke: ischemic (arterial occlusion) or hemorrhagic (arterial rupture |- CT scan |

|and bleeding). The part(s) of the brain affected can suffer permanent or |- MRI |

|temporary damage, leading to deficit(s) in associated functions. Impairment can |- EEG |

|be slight to severe, or even fatal. |- radionuclide scan |

| |- angiography |

| |- CSF draw |

| | |

|ETIOLOGY: |MEDICAL MANAGEMENT: |

|Nonmodifiable risk factors: gender (male), age (65+ years), race |Prevention: anticoagulant tx (Heparin, Coumadin, ASA, Persantine, Ticlid) in |

|(African-American) and heredity. |case of potential infarction; carotid endarterectomy, extracranial-intracranial|

|Modifiable risk factors: hypertension, cardiac disease, diabetes mellitus, serum |bypass and transluminal angioplasty are surguries to maintain arterial blood |

|lipid deviations, smoking, diet. |flow. |

| |Acute: maintain a patent airway and breathing (O2, intubation, mechanical |

| |ventilator); hyperosmotic agents to reduce cerebral edema; surgical repair of |

| |cerebral hemorrhage. |

| | |

|PATHOPHYSIOLOGY: Vascular flow of blood to the brain is impeded by either |NURSING MANAGEMENT: |

|ischemic or hemorrhagic stroke. In the former a thrombosis (blood clot) or |- maintain patent airway |

|embolus (usually cardiac plaque or tissue) occludes the lumen of a cerebral |- monitor s/s stroke in evolution or intracranial pressure: change if LOC, eye |

|artery. The latter results from the rupturing of a cerebral vessel and bleeding |response, motor abilities, mental function, VS |

|into brain tissue or ventricles. The stroke can be classified based on |- monitor for fluid overload: edema I&O |

|neurological deficits: |- minimize risk of thrombophlebitis: range-of-motion exercises, compression |

|- transcient ischemic attack (TIA) - deficits are temporary, lasting only minutes|stockings, admin. anticoagulant meds |

|or up to 24 hours. |- prevention of contractures, atrophy: positioning, range-of-motion exercises |

|- reversible ischemic attack - deficits are temporary, but last days to weeks. |- monitor change in integumen, circulation |

|- evolution - progressive deterioration of neurological dysfunction over hours or|- monitor changes in GI / GU function |

|days. |- assist patient in understanding effects of illness and in performing ADL’s; |

|- completed - deficits remain unchanged after 2-3 days. |monitor coping ability |

| |- direct rehabilitation: prevent deformity, maintain & restore function; assist|

| |in family teaching |

| |- incorporate health care team into rehabilitation (eg: PT, OT, D/C nurse, |

| |dietician) |

| | |

| | |

| | |

|SIGNS & SYMPTOMS: symptoms vary greatly as they are dependent on the stroke’s |HEALTH DEVIATION SELF-CARE REQUISITES: |

|site, size and rate, and on the presence of collateral circulation. Listed are |- follow prescibed, preventative medical treatment |

|broad categories: |- adhere to physical, cognitive therapies to improve function |

|- neuromotor: akinesia, hypo- or hyperrefexia, dysphagia, bladder and bowel |- maintain prescribed exercise program |

|dysfunction |- follow strict diet regimen |

|- communication: aphasia |- be alert to impending symptoms of another stroke (eg: headache, vertigo, |

|- affective: loss of control of emotion |numbness, visual problems, emotional lability) |

|- cognitive: impaired judgement and memory | |

|- perception: impaired spatial orientation | |

| | |

| | |

|REFERNCE PAGES: | |

|- Lewis & Collier, Medical-Surgical Nursing, 4th Ed., p. 1723-1748 | |

|- Dirksen, Lewis & Collier, Clinical Companion to Medical-Surgical Nursing, p. | |

|101-112 | |

| | |

| | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download