Cerebrovascular Accident (short for exam)
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- Created by: evepoag
- Created on: 23-05-23 15:56
Explain each nursing assessment of a suspected CVA and rationale for each (pt.1)
ABCDE assessment
- Airway = airway blocage, airway noises, can the patient talk? = this is important if patient has a facial droop
- Breathing = respiratory rate, bilateral chest expansion, deviated trachea, spo2, use of accessory muscles, auscultation fo
- Airway = airway blocage, airway noises, can the patient talk? = this is important if patient has a facial droop
- Breathing = respiratory rate, bilateral chest expansion, deviated trachea, spo2, use of accessory muscles, auscultation fo
1 of 14
Explain each nursing assessment of a suspected CVA and rationale for each (pt.2)
- Circulation = manual pulse (irregular = indicates AF), blood pressure (usually high post-stroke), CRT (<2 seconds = indicates hypovolaemia in haemorrhagic stroke patients), ECG (no P wave = indicates AF), get IV access and take bloods, temperature
- Dis
- Dis
2 of 14
Explain each nursing assessment of a suspected CVA and rationale for each (pt.3)
Exposure = any bleeding/wounds/rashes, head-to-toe assessment = rules out anaphylaxis or external bleeding
3 of 14
Explain each nursing assessment of a suspected CVA and rationale for each (pt.4)
FAST = Face, Arms, Speech, Time
Face = is there a facial droop? is it one-sided? can they smile?
Arms = can they obey commands? can they lift their arms? is there a one-sided weakness?
Speech = can they speak? is there speech clear or are there disturbanc
Face = is there a facial droop? is it one-sided? can they smile?
Arms = can they obey commands? can they lift their arms? is there a one-sided weakness?
Speech = can they speak? is there speech clear or are there disturbanc
4 of 14
Explain each nursing assessment of a suspected CVA and rationale for each (pt.5)
CT brain scan = identifies any intracranial haemorrhage or haemahorragic stroke. Ischaemic stroke will not show yet.
This is important as haemorrhagic patients would not be suitable for. thrombolysis treatment and wouldn't require a thrombectomy
This is important as haemorrhagic patients would not be suitable for. thrombolysis treatment and wouldn't require a thrombectomy
5 of 14
Explain each nursing assessment of a suspected CVA and rationale for each (pt.6)
Glasgow Coma Scale - 3 aspects:
- Eye opening response (spontaneous, sound, pain, none)
- Verbal response (orientated, confused, inappropriate words, incoherent speech, none)
- Motor response (obeys commands, localises to pain, withdraws from pain, abnorm
- Eye opening response (spontaneous, sound, pain, none)
- Verbal response (orientated, confused, inappropriate words, incoherent speech, none)
- Motor response (obeys commands, localises to pain, withdraws from pain, abnorm
6 of 14
Explain each nursing assessment of a suspected CVA and rationale for each (pt.7)
PEARL = pupils equal, round, reactive to light = shows neurological status
7 of 14
Explain each nursing assessment of a suspected CVA and rationale for each (pt.8)
Blood tests:
- FBC and CRP = shows underlying infections causing delirium which may mimic stroke
- U&E = shows renal impairment, which affects drug dosage
- LFTs = can affect clotting in ischaemic stroke
- Coagulation screen = checks for risk of bleeding
- FBC and CRP = shows underlying infections causing delirium which may mimic stroke
- U&E = shows renal impairment, which affects drug dosage
- LFTs = can affect clotting in ischaemic stroke
- Coagulation screen = checks for risk of bleeding
8 of 14
Explain each nursing assessment of a suspected CVA and rationale for each (pt.9)
ROSIER = Recognition Of Stroke In the Emergency Room = identifies acute stroke or stroke mimics
NIHSS = completed by the medical team or specialist stroke nurse to rate the severity of ischaemic strokes
NIHSS = completed by the medical team or specialist stroke nurse to rate the severity of ischaemic strokes
9 of 14
Explain each nursing assessment of a suspected CVA and rationale for each (pt.10)
History taking =
- onset of symptoms (very important for thrombolysis treatment)
- what treatment has been given by paramedics
- drug history
- biological information = name, DOB, NOK, comorbidities, etc.
- presenting complaints = what happened? what are
- onset of symptoms (very important for thrombolysis treatment)
- what treatment has been given by paramedics
- drug history
- biological information = name, DOB, NOK, comorbidities, etc.
- presenting complaints = what happened? what are
10 of 14
Explain each nursing assessment of a suspected CVA and rationale for each (pt.11)
Pain assessment = PQRST
- Provoking factors
- Quality
- Radiation and location
- Severity
- Time
= important as haemorrhagic strokes can be ruled out (ie: excruciating headaches), and pain is common post-stroke, especially if thalamus (controls pain) has
- Provoking factors
- Quality
- Radiation and location
- Severity
- Time
= important as haemorrhagic strokes can be ruled out (ie: excruciating headaches), and pain is common post-stroke, especially if thalamus (controls pain) has
11 of 14
Describe the signs and symptoms of ischaemic stroke and the related pathophysiology(need to add pathophysiology)
- Hemiplegia
- Speech distrubances
- Visual disturbances
- Numbness and tingling
- Facial droop
- Speech distrubances
- Visual disturbances
- Numbness and tingling
- Facial droop
12 of 14
Describe the complications of CVA
- paralysis or loss of muscle movement = can be on one side (hemiplegia), "locked in syndrome"
- difficulty talking or swallowing = stroke affects muscles of mouth and throat, making it difficult to eat, talk, swallow. May also have trouble understanding
- difficulty talking or swallowing = stroke affects muscles of mouth and throat, making it difficult to eat, talk, swallow. May also have trouble understanding
13 of 14
Describe the complications of CVA
- emotional problems = "emotional lability" when the front lobe blood flow is occluded, may have difficulty controlling emotions
- pain = these may occur in the parts of the body affected by the stroke, others experience numbness or unusual sensations
-
- pain = these may occur in the parts of the body affected by the stroke, others experience numbness or unusual sensations
-
14 of 14
Other cards in this set
Card 2
Front
Explain each nursing assessment of a suspected CVA and rationale for each (pt.2)
Back
- Circulation = manual pulse (irregular = indicates AF), blood pressure (usually high post-stroke), CRT (<2 seconds = indicates hypovolaemia in haemorrhagic stroke patients), ECG (no P wave = indicates AF), get IV access and take bloods, temperature
- Dis
- Dis
Card 3
Front
Explain each nursing assessment of a suspected CVA and rationale for each (pt.3)
Back

Card 4
Front
Explain each nursing assessment of a suspected CVA and rationale for each (pt.4)
Back

Card 5
Front
Explain each nursing assessment of a suspected CVA and rationale for each (pt.5)
Back

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