NotesDefinition
Description
Risk FactorsNonmodifable
Pathophysiology Show
Clinical ManifestationsGeneral signs and symptoms include numbness or weakness of face, arm, or leg (especially on one side of body); confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; loss of balance, dizziness, difficulty walking; or sudden severe headache. Motor Loss
Medical Management
Management of Complications
Nursing AssessmentDuring Acute Phase (1 to 3 days)Weigh patient (used to determine medication dosages), and maintain a neurologic flow sheet to reflect the following nursing assessment parameters:
Assess the following functions:
DiagnosisNursing Diagnoses
Collaborative Problems/Potential Complications
Planning and GoalsThe major goals for the patient (and family) may include improved mobility, avoidance of shoulder pain, achievement of selfcare, relief of sensory and perceptual deprivation, prevention of aspiration, continence of bowel and bladder, improved thought processes, achieving a form of communication, maintaining skin integrity, restored family functioning, improved sexual function, and absence of complications. Goals are affected by knowledge of what the patient was like before the stroke. Nursing InterventionsImproving Mobility and Preventing Deformities
Preventing Shoulder Pain
EvaluationExpected Patient Outcomes
ExamChoose the letter of the correct answer. Good luck! Congratulations - you have completed MSN Exam for Cerebro Vascular Accident CVA (PM)
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Nursing Care PlanNursing Diagnosis
May be related to
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Desired Outcomes
Nursing Interventions
Monitor vital signs:
Administer medications as indicated:
Nursing Diagnosis
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Nursing Diagnosis
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Desired Outcomes
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Nursing Diagnosis
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Nursing Diagnosis
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Nursing Diagnosis
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Which of the following is the initial diagnostic in suspected stroke?Everyone with suspected stroke should have a brain scan within 1 hour of arriving at hospital if possible. An early brain scan is especially important for people who: might benefit from medicine to clear blood clots (thrombolysis), such as alteplase or early anticoagulant treatment.
What is the most common cause for a cerebrovascular accident and what is its most common site?Ischemic stroke is caused by a blood clot that blocks or plugs a blood vessel in the brain. This is the most common type; about 80% of strokes are ischemic. Hemorrhagic stroke is caused by a blood vessel that breaks and bleeds into the brain.
What is the most common site for a cerebrovascular accident?Middle Cerebral Artery (MCA) Infarction
The middle cerebral artery (MCA) is the most common artery involved in stroke.
Which of the following is the most common side effect of tissue plasminogen activator TPA?Because TPA is a powerful blood thinner, the main side effect is bleeding. Bleeding is a serious complication that can result in a hemorrhagic stroke, which is often more serious than an ischemic stroke.
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