Report CVA

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Prepared by:

Bautista, Jovy Rose RN (soon2be)

Gorgonio, Jeraldine RN (soon2be)

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DESCRIPTION:

-CAN BE DIVIDED INTO TWO MAJOR CATEGORIES:

ISCHEMIC

HEMORRHAGIC

- BOTH CONDITION SHOULD HAVE SERIOUS MEDICAL

EMERGENCY WHICH NECESSITATES IMMEDIATE

INTERVENTION TO PREVENT PERMANENT DISABILITY

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THROMBUS

EMBOLUS

HEMORRHAGE

RUPTURED ANEURYSM

ARTERIOVENOUS MALFORMATION

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MODIFIABLE RISK FACTORS:

1.) Smoking

2.) Alcohol

3.) Substance Abuse

4.) Sedentary Lifestyle

5.) Diabetes Mellitus

6.) Hypertension

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NONMODIFIABLE RISK FACTORS:

1.) Race

2.) Gender

3.) Older Adult

4.) Family History

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A.) ISCHEMIC

1.)Transient Ischemic Attacks

2.) Reversible Ischemic Neurologic

Deficit

B.) HEMORRHAGIC

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A.) ISCHEMIC

- Result from occlusion of a

cerebral artery by a thrombus or

embolus

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1.) TRANSIENT ISCHEMIC ATTACKS

- temporary loss of neurological functionoften lasting less than 15 minutes and no more than

24hours.

2.) REVERSIBLE ISCHEMICNEUROLOGIC DEFICIT

- is a temporary loss of neurological function

lasting more than 24hrs but less than 1 week

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B.) HEMORRHAGIC

-Interruption in thevessel wall integrity

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a. Altered level of consciousness

b. Denial of disorder

c. Failure to make appropriate

decisions

d. Inappropriate judgment

e. Poor memory

f. Emotional stability

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g. Proprioceptive or spatial difficulty

decreased awareness of the body in space

h. Hemiplegia- one sided paralysis

i. Hemiparesis

weakness in one side of the

body

j. Dysarthria- difficulty in speech articulation

k. Alexia- difficulty reading

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l. Agraphia difficulty writing

m. Agnosia

loss of recognition ability

n. Hemianopsia- blindness in one side of visual

fieldo. Amaurosis fugax temporary blindness in one

eye

p. Dysphagia

difficulty swallowing

q. Ptosis drooping eyelids

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r. Aphasia Impaired Communication

1.) Expressive aphasia inability to

express oneself (frontal lobe)

2.) Receptive aphasia

inability to

understand what someone

else is saying (temporal lobe)

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a. Complete history and

physical assessment

b. CBC

c. Thrombin and

prothrombin timesd. CSF Analysis

e. CT scan

f. MRI Scan

g. Angiography

h. ECG

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a. Primary prevention

- instruct client and

family on reducingmodifiable risk factors

b. Acute stroke mgnt

- maintain ABC

- assess LOC

- perform cranial nerve

assessment

- administer prescribed

antihypertensive

- monitor fluid and

electrolytes

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- elevate head of bed

30

- monitor for ICP- administer prescribed

analgesics


diuretics (mannitol orfurosemide)

- insert FC


anticoagulants (heparinor warfarin)

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c. Intermediate stroke

mgnt

-Maintain patent airway- maintain upright position

for 30min after eating

-Initiate bladder training

-Increase fiber and fluids

- implement aphasia

interventions

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d. Rehabilitative nsg.

Interventions

-encourage pt. to participate inoccupational therapy

- encourage pt. to participate

in speech therapy

- instruct the client aboutmedications

- encourage importance of

scheduled follow-up with

health care provider- instruct client about

importance of frequent BP

checks

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Theend

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Report CVA

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