Chapter 49 Nursing Care of Patients with Cerebrovascular Disorders

Answers CHAPTER 49 NURSING CARE OF PATIENTS WITH CEREBROVASCULAR DISORDERS AUDIO CASE STUDY Grandpa Max Has a Stroke 1. Max exhibited right-sided weakness and difficulty speaking; additional symptoms might include dizziness, head pain, confusion, and vision changes. In women, nausea, face or limb pain, chest pain, shortness of breath, hiccups, or palpitations can occur. 2. Face, Arms, Speech, Time. 3. The onset of his symptoms was unknown, so it could not be confirmed that he was within the 4.5-hour window. After 4.5 hours, the risks of tPA outweigh the potential benefits. 4. Amanda and her grandfather were at the center of the team. In the hospital, a stroke team was involved as well as physicians, nurses, a nursing assistant, and speech, occupational, and physical therapists. VOCABULARY 1. (7) 2. (3) 3. (1) 4. (4) 5. (5) 6. (6) 7. (9) 8. (10) 9. (8) 10. (2) DRUGS USED FOR CEREBROVASCULAR DISORDERS 1. (1) 2. (3) 3. (4) 4. (2) CRITICAL THINKING: STROKE 1. A stroke is the infarction of brain tissue due to the disruption of blood flow to the brain. Considering Mrs. Saunders’s history, the cause of her attack was most likely ischemic, the result of atherosclerosis. 2. Hemiplegia. 3. Left, because her right side is paralyzed. 4. She was a smoker, she has a history of atherosclerosis and hypertension, and she is overweight. 5. Expressive aphasia. 6. Her score on the Glasgow Coma Scale is 11. 7. Early symptoms of rising intracranial pressure include restlessness, irritability, and decreased level of consciousness. Later signs include dilated pupils, increasing systolic blood pressure and respiratory rate, and increasing and then decreasing pulse rate. 8. A thrombolytic medication may have been used in the emergency department if Mrs. Saunders arrived within 3 to 4.5 hours of onset of her symptoms. The nurse would continue to monitor for side effects. Heparin may be ordered as an anticoagulant; antiplatelet drugs may be ordered for long-term prevention of recurrent stroke; antihypertensives may be ordered to control blood pressure; statins may be ordered to lower cholesterol if needed. 9. Many diagnoses fit Mrs. Saunders’s situation. An example is Impaired Physical Mobility related to her flaccid right side. Measures to prevent complications related to immobility include repositioning every 1 to 2 hours, maintaining good body alignment with pillows, consulting physical therapy for exercise recommendations, range-of-motion exercises, constraint therapy, and possibly a sling to prevent harm to her weakened shoulder muscles. 10. Reposition every 1 to 2 hours, maintain good nutrition and fluid intake, apply a pressure-reducing mattress to the bed, use a lift sheet, keep skin clean and dry, and check frequently for incontinence. 11. Because Mrs. Saunders understands spoken words, ask her if she has to go to the bathroom. Usually if a patient is attempting to get out of bed, there is a reason for it. See if she can nod yes or no in response. She may be able to point to the bedside commode or bathroom. A picture board might also be helpful. 1 2 Chapter 49 Answers 12. Check swallowing. Ask for a consultation with the speech therapy department or other swallowing expert for recommendations specific to Mrs. Saunders. 13. Many patients do better with pureed foods and thickened liquids. Be sure she is sitting straight up, preferably in a chair, to eat. Have her tilt her head forward while swallowing. Have her swallow each bite twice. After each bite, remind her to check the right side of her mouth for food that is not noticed. Avoid straws. Check swallowing study recommendations for specific instructions for each patient. 14. Involve her family in her care. Give them small tasks to do for her. Encourage them to attend physical and other therapies with her. Explain what will happen at the rehabilitation facility. Assist the family to identify resources that can help when she is discharged to home. Consult with the social worker or discharge planner to provide them with additional information. 15. Antiplatelet drugs such as aspirin or clopidogrel (Plavix). REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (1) is correct. A temporary impairment of cerebral circulation that causes symptoms lasting minutes to hours is a transient ischemic attack, or TIA. (2, 3, 4) are incorrect. A cerebrovascular accident, stroke, or subarachnoid hemorrhage cause permanent deficits. 2. (2) is correct. In atrial fibrillation, the blood is not ejected normally, and small clots may develop in the atria. If these clots are ejected into the circulation as emboli and travel to the brain, an embolic stroke occurs. (1) is incorrect. A hemorrhagic stroke is caused by a rupture of a blood vessel that, in turn, deprives the brain tissue beyond that vessel of needed oxygen and nutrients. (3) is incorrect. A thrombotic stroke is caused by a blood clot occluding an artery, causing decreased perfusion to brain tissue; the bifurcation of the carotid artery is the most common site of this type of stroke. (4) is incorrect. A cerebral aneurysm places patients at risk for hemorrhagic stroke. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 3. (1) is correct. The patient may be exhibiting unilateral neglect or homonymous hemianopia. (2) is incorrect. There is no evidence that the patient is hard of hearing. (3) is incorrect. Waving the hand is rude and unnecessary in this case. (4) is incorrect. Using a picture board will not help if the patient cannot perceive the left side. 4. (2) is correct. A stroke can reduce inhibitions. (1) is incorrect. Punishment is inappropriate; his actions are not on purpose. (3, 4) may be true but do not address the problem. 5. (4, 5, 6) are correct. These can help prevent aspiration. (1) is incorrect. Sitting upright is recommended. (2) is incorrect. Straws should be avoided. (3) is incorrect. Thin liquids are more easily aspirated. 6. (3) is correct. Allowing the patient to defecate on his usual schedule can help prevent incontinence. (1) is incorrect. If the patient is unable to detect the need to have a bowel movement, asking him will not be helpful. (2, 4) are incorrect. Incontinence pads may be useful and avoiding embarrassing the patient is essential, but neither will help reduce incontinence. 7. 62 mg 1 grain 1 tablet 60 mg 1 grain = 1 tablet 8. (2) is correct. The stroke may be extending. (1, 3, 4) all delay treatment if the stroke is extending. 9. (2) is correct. Patients with stroke are prone to aspiration, and reducing the risk of aspiration is the highest priority; patients should be turned to the side to reduce this risk with vomiting. (1, 3) are incorrect. Setting up suction and giving medication will take too long; they are not priorities. (4) is incorrect. Performing a test for blood is not indicated with the information provided. 10. (2, 4, 6) are correct. All increase risk of bleeding. (1, 3, 5) do not increase risk of bleeding. 11. (2, 4) are correct. Before giving a patient with a suspected stroke anything to eat or drink, including medications, the patient should pass a swallow, or dysphagia, screen. If there is any apparent facial weakness or asymmetry, do not give the patient anything by mouth. If everything appears normal, have the patient swallow about 30 ounces of water. If the patient coughs, has difficulty swallowing, or has a wet/gurgly voice afterward, the patient should still not be given anything by mouth. (1, 5) are incorrect. Grip and blood pressure are not related to ability to swallow. (3) is incorrect. A positive gag reflex would indicate that swallowing may be intact. (6) is incorrect. Aspirin and clopidogrel are not related.