Join our Nursing Review Community! Subscribe below. Its Free!

Join NurseReview.Org Community!

Get Connected With Other Nurses All Over The World! Its Free!! Enter your email to receive the Nursing Board Exam NLE Quick Result!


         Nursing Board Exam Result Subscribers PRC December NLE Quick Results Subscription

NurseReview.Org helps nurses all over the world keep in touch with each other. We provide an interactive environment where nurses can share their experience, ask questions regarding issues, provide assistance, etc.

If you want to be informed through email regarding NLE RESULTS, Nursing News, Retrogression Updates, New Nursing Board Exam Question & Answer, Latest Updates Regarding Nclex, please subscribe to us by filling in your email address above.

NOTE: You email address will be kept private and will not be distributed to spammers.
com/albums/dd234/jben501/philippinenurses/need_help_nursing.jpg" border="0" width="400" height="400" />

Saturday, September 1, 2007

Cardio Vascular Accident CVA

If you're new here, you may want to subscribe to our RSS feed. One advantage of subscribing to RSS feeds is that you don't have to constantly re-visit this site to check for updates within specific sections you might be interested in because your browser or Feed reader will do this for you automatically on a regular basis plus you can even get email notification. Thank you so much. Enjoy!

Contemporary Medicines Slideshow Transcript

Slide 1: Critical Care Situations in Neurological Nursing Increased Intracranial Pressure Delirium CVA

Slide 2: Increased Intracranial Pressure: Skull as a “closed box” Brain tissue is 78%  Intravascular blood is 12%  Cerebrospinal fluid is 10 %  About 1900 mL in adults  Normally volume in = volume out 

Slide 3: Normal ICP is 5-15 mmHg in pt. With HOB at 30 degrees. If sustained pressure above 20 mmHg  herniation of the brain is likely, compressing the brainstem Body compensates for minor increases  in ICP by increasing CSF absorption, decreased CSF production, as well as changing intracranial blood volume through increased venous outflow

Slide 4: Cerebral Perfusion Pressure: CPP This is the pressure of the blood flow  into the cerebrum, which must be above 30 CPP = MAP - ICP  Note the pressure-volume curve: 

Slide 5: What are the factors that raise the ICP? Increased arterial blood pressure (note: MAP  is the mean arterial pressure) Maximal constriction of vessels occurs at MAP  of 150, maximal dilation at 50 Increased intra-abdominal and intrathoracic  pressure (eg valsalva, cardiac) Posture (how high head is in relation to  heart)

Slide 6: More factors that influence ICP Hyper and hypothermia  Brain injury = swelling  Low oxygen tension = cerebral vessel dilation  Increased PaCO2 = cerebral vessel dilation  Infection  Masses  Toxic substances in blood/brain tissue 

Slide 7: Signs and Symptoms of Increased ICP Change in LOC: orientation, restlessness,  clouded sensorium. Subtle or dramatic Change in Vital Signs: most important is  watching for pattern. Cushing’s Triad (late sign): widening pulse  pressure, bradycardia with full bounding pulse, and irregular respirations

Slide 8: More Signs and Symptoms Changes in pupil size, vision, symmetry,  reactivity, as well as ocular and lid movement. Hemiparesis, or other changes in motor  function Review decerebrate and decorticate  posturing. Both serious, decerebrate is more ominous. Vomiting, headache. 

Slide 9: Brief overview of treatment of Increased ICP Frequent assessment, with attention to subtle  changes in LOC and neuro exam Very important to ACT EARLY when  symptoms emerge, by the time symptoms are overt, pressure may be hitting the dangerous part of the curve. Maintain calm and non-stimulating  environment (think: similar to “aneurysm precautions”) PaO2 at 100%, some physicians will aim for  hyperventilatory state, some not. Do avoid

Slide 10: Increased ICP Care, continued Team will want to address the cause, and  treat it whenever possible (discuss) Debate about use of sedation (discuss pros  and cons, situational considerations) Diuresis: osmotic and loop diuretics, watch I  & O, note SIADH as serious problem Corticosteroids 

Slide 11: Even More ICP care Maintain normothermia  Avoid skin breakdown  Maintain nutrition (discuss why)  Maintain adequate CPP with BP stable  and fairly normo-tensive (physician may have specific boundaries in mind) Maintain ICP as near normal as  possible, moniter it.

Slide 12: CVA: Epidemiology CVA affects over 730,000 people in US yearly  One of the top 3 causes of death in US  Costs us (in indirect and direct cost) about 41  billion yearly Incidence doubles after age 55, CVA affects  more men than women, and African Americans are at a higher risk as well.

Slide 13: More Epidemiology About 50% Stroke victims in US die  About ½ Strokes in US are associated  with hypertension 85% strokes occur at home  About 50% stroke victims travel to ED  by ambulance

Slide 14: Risk Factors for CVA~Mostly Modifiable Use of Oral Hypertension   Contraceptives Heart disease  History of Migraine  Diabetes  Headache High cholesterol  Elevated  homocysteine Smoking  Obesity and physical Alcohol and other   inactivity drug use, esp Diet cocaine 

Slide 15: Cerebrovascular Disease that Predisposes to Stroke Cerebral Vessel Abnormalities:  arteriosclerosis, aneurysms, arteritis, hypertension*, vasoconstriction Blood Flow Abnormalities: Stenosis,  thrombi, emboli Blood Property Abnormalities:  coagulation problems, viscosity

Slide 16: CVA Symptoms Sudden onset of focal neurological  deficits, the deficits relate directly to the area of the brain that is affected: visual, motor, sensory, speech most common Talk about stroke scales and their  usefulness: NIH full and short scale, the LAPSS—why it matters

Slide 17: Mini NIHSS Facial assessment: able to smile,  grimace, show teeth equal bilaterally? Extremity assessment: can hold  affected arm up at 45 degrees for 10 seconds? Can hold affected leg up at 30 degrees for 5 seconds? Language: Speak clearly and  appropriately?

Slide 18: Pathophysiology of Stroke Brain requires nearly constant supply of  Oxygen and Glucose to function. Brain is about 2% of body mass, but  uses about 20% of the blood pumped by your heart. Brain has little reserve Oxygen/glucose-  therefore TIME IS BRAIN.

Slide 19: Ischemic Stroke (about 85%): Thrombus and Embolus (pictures) Densely ischemic central core: neuronal  tissue undergoes rapid infarction Ischemic prenumbra: larger  surrounding area that is compromised re circulation, but because of collateral circulation, tissue remains viable for a variable period of time (several hours)

Slide 20: Hemorrhagic Stroke: about 15% Hypertension, Aneurysm, malformed  vessel, drug use are implicated Assessment findings alone are not  definitive to differentiate. May find “worst HA ever, blood in CSF 

Slide 21: Parts of the Brain and Deficits in CVA (oversimplified) Frontal Lobe: judgment, foresight,  voluntary movement Parietal Lobe: Language comprehension  Temporal Lobe: Hearing  Occipital Lobe: Primary visual area  Cerebellum: Coordination  Brain Stem: Swallowing, breathing,  heart rate, wakefulness

Slide 22: A Few More Broca’s Area: speech  Wernicke’s Area: speech comprehension  Sensory Cortex: pain, heat, and other  sensations Motor Cortex : movement 

Slide 23: Diagnosis in Stroke: Essential to be correct~treatment differs Physical Assessment CT scan is important  Labs: may see elevated Evaluation needs to  Hgb and Hct if stroke is be rapid. severe, EKG NURSE should be  Blood sugar and patient advocate electrolytes and make sure Stroke mimics things are going on hypoglycemia, migraine, seizure time:Because time is brain.

Slide 24: Guidelines for Emergency Stroke Management On arrival: EKG, blood sugar, Vital signs  Physician evaluation: 10 minutes  Stroke team notification: 15 minutes  CT scan : 25 minutes  CT interpreted: 45 minutes  Drug administration: 60 minutes  Monitored bed: 3 hours 

Slide 25: Most Common Nursing Diagnoses (not all) Self care deficits – all  Immobility  Situational Low Self Esteem  Injury, risk for  Aspiration, risk for & Impaired swallow  Body temp, risk for imbalanced  Communication, impaired  Unilateral Neglect 

Slide 26: Thrombotic or Embolic Stroke tPA Activase to dissolve Manage BP Goal:   clot. 3 hour time window 140/80 to 150/90 and not for hemorrhagic If hypertensive  stroke. 0.9 mg/kg up to labetrol used (20-40 90 mg. First 10% as mg over 2 min), or bolus, rest given over 60 minutes. sodium nitroprusside No ASA or heparin right  now (discuss controversy)

Slide 27: Other Medications: ASA, heparin, anticonvulsants ASA, persantine: Heparin and low   molecular weight Some studies find that  heparin ASA given early prevents early recurrence of Some controversy in  th/emb. research findings: the little decrease in Should be given if no  thrombus or embolus clear diagnosis is may be canceled out by possible (even at home the increased risk of before coming in) intracranial bleeding. Anticonvulsants to  Review the use of these prevent seizure (which  drugs, including would compound injury appropriate lab values to monitor

Slide 28: Nursing Care Issues in Acute Treatment Keep temperature Assess for depression   normal (discuss why) (common) Prevent aspiration and Keep patient calm-avoid   choking while not abrupt increases in ICP starving the patient Aim for good CPP and  Prevent and assess for ICP as close to normal  thromboembolism as possible (discuss) Prevent seizures, seizure Neuro assessment,   precautions report changes

Slide 29: Hemorrhagic Stroke Care Once this type of stroke is diagnosed, there are a few  key differences in medical care. First, tPA, ASA, heparin, etc. are contraindicated (a  main issue). Later, since 50% of hemorrhagic stroke victims go on to have a thrombotic or embolic stroke, they may be used with caution. Second, depending on the case, surgery may be  indicated Third: a medication such as Amicar (an antifibrinolytic)  may be used to facilitate a good clot at site of ruptured aneurysm

Slide 30: Nursing Care Consider many of the same issues as for  thrombotic or embolic stroke—temperature, aspiration, blood pressure, preventing DVT (but without heparin!), maintaining blood glucose. Add aneurysm precautions  Research suggests that organized stroke  teams/units do a better job with some of these nursing care issues, and have better patient outcomes.

Slide 31: Aneurysm precautions Limit TV HOB up   No very hot or cold Bedrest   liquids Quiet  No Valsalva  Dark  maneuver No caffeine Patient may be   sedated with Limit visitors  medication Rationale: 

Slide 32: Prevention Issues Primary Prevention: work with public to  facilitate limiting the modifiable risk factors prior to any illness developing Secondary Prevention: (early detection)  Teach public that time is brain and symptoms of stroke to seek treatment for right away. Talk about ASA.

Slide 33: Tertiary Prevention ASA up to 300 mg/day, Carotid endarterectomy   or persantine. (discuss especially useful if over research) 70% blockage Coumadin therapy esp if  ACE inhibition  person has A fib. (not Pravastatin or good if hemorrhagic  Simvastatin to decrease stroke) hypercholesterol states Antihypertensive therapy  Stop smoking Improve diet and   exercise

Slide 34: Delirium: Basic Characteristics Disturbance of consciousness or  cognition Usually reversible, with acute onset  Usually secondary to some other  condition or problem, such as intoxication, withdrawl, medical condition, severe stressors

Slide 35: Delirium: Assessment concerns Review MMS exam. In Ability to converse   text. Level of Consciousness  Scrutinize for underlying (alert, drowsy,  causes stuporous, etc) Orientation to time (1st Illusions, hallucinations   to go) (type, specific, timing) Orientation to place Awareness of own   deficits Orientation to person  (last to go) Distractability 

Slide 36: Nursing Intervention: Delirium Do what is appropriate to eliminate cause,  includes careful assessment Safety: falls, wandering, Ivs/ NGs pulled out  easily, may strike out in fear Meet physiologic needs: nutrition, hydration,  sleep, appropriate level of stimulation, pain relief Judicious use of antipsychotic,antianxiety  meds

Slide 37: Communication with Confused Person Short questions, instructions, with no  “big” words. Be patient. Check for comprehension, give  instructions more than once, not in condescending manner Face to face, normal tone, good light  No “honey” “dearie” etc 

Slide 38: Reality Orientation with Confused Person Clocks, calendars, cues placed  prominently. Talk about it. Names on doors, big.  Familiar routine, structure, staff  Verbal reorientation to PPT as a natural  part of conversation Read text for more interventions!! 

Article copyright - #1 source of information to update nurses all over the world. All rights reserved. No part of an article may be reproduced without the prior permission.


Philippine Nurses in Action

Search for Nursing Jobs Abroad!

Quick Nursing Facts:

NLE Results December 2011 Results

December 2011 Nursing Board Exam Successful Examinees for the December NLE 2011

Nursing Board Exam July 2010 NLE PRC

July 2011 Nursing Board Exam Successful Examinee PRC

List of Successful Examinees for Nursing Licensure Examination July 2011 Conducted by the PRC

We are one of the few websites to post results right after the Philippine Regulatory Board have release the list of successful examinees

Results for July 2011 NLE Board Exam

July 2011 NLE Nursing Licensure Examination Results List Of Passers

Recommended Books

Filipino Nurse Tag Rolls

NursingReview.Org Disclaimer

© 2008-2009 NurseReview.Org This site contains links to other Web sites. The owner of this blog has no control over the content or privacy practices of those sites. The information provided here is for general information purpose only. Comments are moderated. If in any case the owner approves a comment, it should not be taken as an endorsement of that comment. The owner doesn't claim full ownership of all photos or articles posted on this site. If the respective copyright owners wish for their photos or articles to be taken down, feel free to e-mail me and it will be taken down immediately.