Monday, October 15, 2007

205: Stroke and Health assessment book and class notes

References: wikipedia probably, although I don't remember. Also Lemone/Burk

HEALTH ASSESSMENT

At the completion of this class, the student will be able to:

1. Discuss the pathology of strokes;

2. Describe key risk factors of strokes;

3. Discuss nursing and medical management of stroke patients;

4. Discuss the key elements obtained from a health history;

5.Explain the significance of certain physical findings;

6.Identify expected outcomes of health assessments;

7.Describe sequencing to conduct a physical health exam in an orderly fashion;

8.Discuss key assessment techniques with specific systems;

9. Given a specific case scenario, discuss health assessment activities.

Aspiration of food, usually goes into the right lung b/c of bronchi angles

I. STROKE

Brain becomes ischemic, usually due to embolus [traveling thrombus.]

A. Pathology: CVA, brain attack, sudden decrease in blood supply to part of the

brain, most ischemic—and then neurons die and you don’t get around so well. Brain receives 20% of cardiac output, therefore 20% of the O2 supply.

Types of strokes:

TIA: transient ischemic attack: mini stroke—injury symptoms last a few minutes or a few hours. These victims are likely to have a big stroke in the future.

Thrombotic Stroke: blood clot occludes a vessel. Usually occurs in geri’s when their BP is low, at rest, and it cannot force the clot through the vessel. Clots often form in atherosclerotic vessels, esp the major arteries to the brain.

Embolic Stroke: blood clot or clump of something [embolus] lodges in a vessel too small to get through. Has several etiologies. The embolus might stay lodged or it might break up or dissolve.

Hemorrhagic stroke: cerebral blood vessel pops. Happens with high BP patients: HTN. Most fatal type of stroke. Pressure from excess blood in the brain causes high pressures and further damage. Two kinds--intracerebral and subarachnoid—subarachnoid means bleeding into the area surrounding the brain, under the arachnoid layer of the pia mater.

B. Risk factors:

1. HTN: Biggest factor. High BP means all blood vessels are slowly damaged.

2. heart disease: Atrial fibrillation [irregularly irregular heart rhythms—little heart muscles are just twitching around] is second biggest factor. Can create emboli in the left chambers of the heart and cause cardiogenic embolic strokes.

3. diabetes mellitus: increases HTN. Diabetes is both sugar and fat metabolism

4. sleep apnea: increases BP, lack of O2 and CO2 txfr in the brain.

5. smoking: responsible for more strokes in young adults.

6. sickle cell: funky shaped cells means funky shaped clots

Notes on sleep; they’re linking sleep apnea to obesity, and underslept kids to obese kids. Your body rejuvenates by eating and sleeping, if it can’t do one, it does the other.

If your pt didn’t sleep well, assess their need for more rest and schedule treatments together so the pt can have a rest period.

When there is not enough O2 perfusion, it may cause one of those TIAs.

C. Manifestations: depend on part of brain affected

1. contralateral weakness or paralysis: no motor on the opposite side of the body

2. dysphagia: trouble swallowing “difficult or painful eating.” Research says that until speech therapist comes in and/or swallow therapy initiated, stroke pts need to be NPO b/c at risk for aspiration. There are 3 -4 cranial nerves involved in swallowing.

3. facial droop: flaccidity on contralateral side of face

4. sudden severe HA:

5. nursing diagnosis: ‘ineffective tissue perfusion: cerebral’ breathing may be impaired, O2 may need to be applied, monitor airway patency

6. aphasia/dysphasia: inability to speak or understand language [due to injury in left brain language centers]

If you have a stroke pt and he has 3 meds PO, what do you do? Figure out why that’s the picture—what the pt is cleared for by speech therapist. Or if they have a gastro tube to crush pills into.

D. Interdisciplinary Care

1. diagnosis: time of onset, history, PE, CT. Start w/ health history, than full phys assessment, including neurologic exam. NIH stroke scale assesses degree of damage and recovery. CT scanner [cat scan] identifies what kind of stroke, where, and what foreign bodies are present, need to rule out hemorrhagic—other scans work too; MRI, MRA, Doppler, PET, SPECT.

2. Medications: anticoagulants, fibrinolytics, antihypertensives; are used to prevent stroke in clients who have had TIAs [mini strokes], some treat during the peak of the stroke. Asprins and anticoags prevent clots. Anti-fibrin and anti-platelet drugs also work well. HTN needs to be managed.

3. Rehabilitation: physical therapy, occupational therapy [eating, drinking, bathing, toileting, reading writing, ADLs’], speech therapy to relearn language skills.

4. Health promotion; prophylactic: weight maintenance, smoking cessation, regular lipid panels, education about signs of TIA.

Time is so important for stroke pts b/c we have good interventions now—you have to figure out exactly when that pt was normal. If it’s been an ischemic stroke w/I 3 hrs, there’s a possibility of TPA. The risk of intracerebral bleed w/ TPA [clot dissolving drug] is 1%...there are a lot of contraindications for that drug, but it’s successful. Community Ed: people need to call 911 immediately after stroke occurs. Faster arrival to med svcs the better the chances.

Penumbra; area around ischemic area that can be saved by TPA, these cells can be rehabbed.

II. HEALTH HISTORY

We’ll be assessing people forever and ever. You can’t be too good at it. Infinite subtlety. We’ll get faster and faster at noticing problems [shade of lavender noticed way before purple.] As a beginner you’ll not know what you’re observing, just that there’s a change, which is good data to report.

FNP/MD do full assessment breast, ear etc exams. We do “shift” or “focused” assessments; VS and whatever brought them in there; which can be a lot of body systems.

My education and my instructor’s orders are always second to pt. safety.

Admission assessments are long long long

Anyone who takes dig and or has Hx of Atrial Fibrillation, you need to do apical and atrial pulse

“HTN is considered 140+/90+” If you have a pt on meds for HTN and his BP is 150/97 in the AM, check operator error, check that they rec’vd meds, get someone else, etc. Might need higher dose.

Labile; unstable—changing of VS because of their physiology.

A. Purpose

B. Therapeutic communication: non judgmental, professional

C. Subjective and objective data collection:

Subjective: their complaints. The complaint isn’t the surgical procedure done to fix it, but what it was they had that needed the surgery.

Objective: VS,

D. Elements: what are they?

Your opinion isn’t part of this chart, it might be worth communication to the MD

1. biographic information

2. chief complaint

3. present health status

4. health history: allergies, diet, medications: priority thing. An allergy is considered anything the patients say they don’t like. Even if ‘codeine makes me feel crappy.’

5. family history

6. psychosocial, lifestyle: coping skills, cultural, addictive behaviors: TOB, don’t throw the pamphlets at them first off. We really want correct accurate ETOH intake [therapeutic]—are they going to have withdrawal and stuff, rxns to anaethesia, sedation is helpful with ETOH withdrawal. Coping skills- what are the pts coping skills normally outside the hospital [music, etc—things we can provide to help them cope with hosp stay and pain and loneliness, etc. Family can be helpful with this.]

7. nutrition: dietary habits, restrictions: do they have a special diet that can be accommodated, can fam bring food [MD order for OK]

8. domestic violence: JCAHO requirement: have to assess for violence: “Do you feel safe at home?” This is a big big hot potato. Get your charge RN to come down and check out your suspicions—charge RN is the one to make the calls. If you don’t report it you’re bad bad. Esp important in ER. Report it if something doesn’t seem right.

Animal therapy research is highly linked to pts getting better. It can happen—it’s a procedure but sometimes they can get a pet into the hosp room.

III. PHYSICAL HEALTH ASSESSMENT WITH ACUTELY ILL ADULT

CLIENTS

Health assessment:

Step 1:

  • introduce self and role
  • eval LOC and responsiveness
  • survey of enviro [is he still on O2? You’d better notice. What tubes are in him?]
  • establish relationship- eye contact, etc. What do they want to be called? RNs are getting sued for unprofessional treatment.

Step 2:

  • Assess VS
  • Check pulses, skin [pedal and radial, not cardiac] Skin temp, moisture, swelling.
  • Individulize assessment; whatever got sliced should be checked.

Step 3: thorax

  • Skin
  • Symmetry of chest
  • APETM: assessing heart sounds at each valve, can help to roll client onto their left side.
  • breath sounds: under clavicle
  • you can assess a lot from the door; resp rate, labored or unlabored, check head of bed—if it’s flat they’re not in resp distress.

Step 4:

  • Head south; bowel sounds; 4 quadrants, push firmly. Don’t go under dressings. Glove if body fluids. Listen before you palpate—palpation stimulates bowels and you’ll get more noise
  • Check to make sure the foley tape is intact etc, foley hooked to bed

Step 5:

  • Southward; pedal pulses [don’t do it with gloves, don’t count it] Check that they are equal. Temp, color too.
  • Check ankle swelling and breakdown from laying in bed on heels.

Step 6:

  • Sit them up if they can to check back; lower lobes do most of the work, check if they’re similar sounds bil. Listening in front ain’t good.
  • Rhonchi: coarse wet sounds [lung butter sounds, like we have when we have colds] Ronchi are in the bronchi
  • Wheezes—little whistles [athsmatics, COPD, etc] these are narrowing of the airways
  • Crackles or rales: fluid in alveoli. Like rice krispies.
  • If you can’t hear it, it’s not because they’re dead. Get them to breathe loudly, lean forward.
  • If they can’t get up or roll over, you can check their sides for sound in the bases
  • You have to be tough w/ your postop pts about moving around

Always always checking skin at pressure points to prevent tissue breakdown. Tissue breakdown is always always preventable.

Document document document!

A. Purposes:

1. obtain baseline data

2. compare to data obtained in health history

3. obtain data to determine nursing diagnoses and plan of care

4. evaluate physiologic outcomes of care

5. identify areas for health promotion and disease prevention

B. Preparation:

1. prepare the client: how?

2. prepare the environment: how?

C. Head to Toe Framework: key points

1. general survey

2. vital signs

3. head

4. neck

5. upper extremities

6. chest and back

7. abdomen

8. perineum

9. lower extremities

D. Systems Framework: key points

1. neurological: LOC,GCS, pupils, sensation, reflexes, movement

2. respiratory: quantity, quality, adventitious breath sounds, chest excursion, O2,

SaO2

3. cardiovascular: BP, HR, apical pulse, skin temperature, peripheral pulses, heart

sounds

4. gastrointestinal: size, bowel sounds, bowel activity

5. renal: urine output, I & O

6. musculoskeletal: ROM, gait, balance, equality

7. integumentary: color, pigmentation, edema, turgor, temperature, sensation, lesions

8. psychosocial: fear, anxiety, education, grooming, thought process, orientation,

memory, judgment

E. Methods of Examination

1. Inspection: what do you look for?

2. Palpation: what?

3. Percussion

4. Auscultation: what and when?

IV. NEWBORN AND PEDIATRIC ASSESSMENT

V. GERONTOLOGIC CONSIDERATIONS

A. Physiologic changes with aging: nerve conduction, sensory, dentition

B. Assessment

1. neuron: LOC, sensory, motor

2. skin: fragility, dryness, hair loss, bruises

3. lungs: respiratory muscle strength, alveoli, gas exchange, cough

4. heart: cardiac output, clotting, hypotension, edema, dyspnea

5. GI: appetite, peristalsis, glucose

6. renal: blood flow, bladder, urine

7. musculoskeletal: contractures, ROM, gait

VI. CASE SCENARIOS

A. 84 yo female admitted with sudden onset left-sided weakness, slurred speech, and

difficulty swallowing. Discuss key aspects of health history obtained from her

husband. Discuss key aspects of a physical assessment with this patient.

Demonstrate on your partner.

Think stroke. Ask when she was normal, has it happened before?

Assess neurological system, make her smile, grip your fingers, check aspiration.

B. 76 yo male patient admitted yesterday with COPD with pneumonia. He is your

patient today on Med-Surg. Discuss key health history assessment. Discuss key

physical assessment. Demonstrate on your partner.

Hx: smoking, on O2 and how much, diet, activity level baseline

Assess respiratory; esp breath sounds, which lobes you can hear [if COPD has smushed one lung]

C. 24 yo female admitted last night with severe abdominal pain. Discuss key health

history and key physical assessment.

Check safe sex, sexual activity, pregnancy,

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