CVA Cerebral Vascular Accident (Stroke) 30 Second Review CVA Cerebral Vascular Accident RN, LPN DEF: Neurologic abnormalities caused by ischemia of brain tissue S/S: Motor-sensory deficit; convulsions or coma RX: a) Monitor Airway, Breathing, Circulation, Level of consciousness b) 1) 02 at 8-10 L 2) Start IV 16 gauge catheter Ringers Lactate, TKO 3) Transport to ER SKILL LEVEL: DEFINITION: RN, LPN Cerebral vessels are occluded by an embolus or cerebrovascular hemorrhage, resulting in ischemia of the brain, and thus neurologic abnormalities. Neurologic symptoms may be permanent or of short duration.
DATA BASE: Subjective: Symptoms and complaints will vary dependent upon the area of brain involved and the type of stroke. Objective: 1. Document onset, duration, activity contributing or associated factors, sensorium, neck rigidity, location of cerebral deficit convulsions. Vital Signs, current meds, other illnesses. Assess Neuro status - Facial Motor-Sensory - Upper extremity M/S - Lower extremity M/S - Speech - Vision - Gait - Gross and Fine motor coordination - Balance - Sensorium - Memory - Autonomic vital signs
2. 3.
Page 1 of 2
CVA (Stroke) Plan: 1. 2. 3. 4. Assure airway clearance. Monitor ABC. Continue neurological assessment. a) 02 at 8-10 L b) Start IV 16 gauge catheter Ringers Lactate, TKO c) Transport to ER When patient returns from ER assure standard evaluation was completed. This standard evaluation includes either CT Scan or MRI, EKG, glucose evaluation. All results of the above tests should return with the patient. a) If ischemic thrombosis, patient may have received TPA (anticlot therapy). b) If hemorrhagic bleeding exists, patient needs surgical intervention. If patient returns and continues progressive deterioration which is not expected, return patient to the ER.
5.
6.
APPROVED:
Health Services Manager
Date
Chief Medical Officer
Date
Medical Director Effective Date: Rev: June 2004
Date
Page 2 of 2