Care of the Patient Exam Review Solution 2024 A+
stoke - ANSWER-Most effective way to decrease the burden of stroke is prevention.
Risk factors can be
... [Show More] divided into nonmodifiable (age, gender, race) and modifiable risks (bp).
Our biggest role is prevention
types of stroke - ANSWER-Ischemic
-Thrombotic
-Embolic
Hemorrhagic
-Intracerebral
-Subarachnoid
ischemic stroke - ANSWER-Thrombotic stroke
-Thrombosis occurs in relation to injury to a -blood vessel wall and formation of a blood clot.
-Result of thrombosis or narrowing of the blood vessel
-Most common cause of stroke
-Lacunar strokes are typically asymptomatic:A lacunar stroke refers to a stroke from occlusion of a small
penetrating artery with development of a cavity in the place of the infarcted brain tissue. This most
commonly occurs in the basal ganglia, thalamus, internal capsule, or pons.
ischemic stroke - ANSWER-Embolic stroke:
-Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms.
-Onset of embolic stroke is usually sudden and may or may not be related to activity.
-Patient usually remains conscious, although he may have a headache.
*Warning signs are less common with embolic than with thrombotic stroke.
hemorrhagic stroke - ANSWER-Intracerebral hemorrhage
-Bleeding within the brain caused by rupture of a vessel
-Hypertension is the most important cause.
-Hemorrhage commonly occurs during periods of activity.
pre-hospital assmesnt - ANSWER-Face
Arm
Speech
Time
transient ischemic attack - ANSWER-Temporary focal loss of function d/t ischemia secondary to
microemboli
Manifestions < 24 hours:
-Onset considered time from when last seen symptom-free or asks when it started, you have to say
exactly when sypmtoms started
-Symptoms typically last < 1 hour without visual evidence of infarction with diagnostic imaging (CT scan
or MRI)
-Brain attack: 911! Treat within 60 minutes
-Inpatient treatment is controversial: treat in outpatient
-What is the cause: brain injury, overdose, ischemia
*Changes in pupil reaction is NOT a manifestation of a stroke
Nursing Assessment
of Stable Patient: primary assessment - ANSWER-Primary assessment:
-History of current illness (symptoms, onset, duration, nature, changes in S/S)
Past medical illnesses, particularly
-Previous stroke
-Hypertension
-Atrial fibrillation
Family history of stroke
Nursing Assessment
of Stable Patient: secondary assessment - ANSWER--Level of consciousness
-Cognition (orientation person place time)
-Motor function
-Cranial nerve function
-Sensation-qtip cotton ball don't let them watch where your touching, sharp vs. dull
-Proprioception-pt eyes closed, ask her to tell you the position of her toes/fingers in space
(towards/away from head).
-Cerebellar function: balance, heal to toe, walk a line.
-DTRs (deep tendon reflex)
-Stroke Scale (NIHSS)
National Institutes of Health Stroke Scale (NIHSS): 0-42 - ANSWER--Level of consciousness (alert-reflex
only-unresponsive)... [Show Less]