N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide ©2017 Achieve Test Prep Page 110 of 204 • Does not seem to care about occurrence of CVA/indifference Signs and symptoms of left hemisphere infarction: • Loss of movement • Paralysis on right side of body • Slurred or absent speech (aphasia) • Language memory deficits • Depression in regard to CVA • Cautious behavior Nursing assessment for cerebral vascular accidents: • Full neurological assessment with vital signs: o Hand grips and muscle/leg strength o Sensory pin pricks o Check respiratory status and circulation (ABCs) o Vital signs: temperature, pulse, respiration, blood pressure, and oxygen saturations • Review laboratory and radiology reports: o CT scan: Most commonly used test to show the location infarction in thebrain o MRA: Can show blood flow to the brain, aneurysm, andhemorrhages o EEG: Indicates low voltage in cases of CVA o Lumbar puncture: Blood in the cerebrospinal fluid is indicative ofCVA Nursing diagnosis for cerebral vascular accidents: • Altered tissue perfusion related to decreased blood flow to the brain • Self-care deficit related to immobility, paralysis, and impaired cognition • Impaired physical mobility related to paralysis and weakness • Impaired verbal communication related to speech deficit, secondary to CVA • Altered nutrition related to impaired chewing and swallowing • Risk for ineffective management related to knowledge deficit, secondary to communication deficit One-sided paralysis Numbness to extremities Emotional changes Signs and symptoms of right hemisphere infarction: • Loss of movement • Paralysis on left side of body • Deficits to perception/spatial awareness • • Incontinence Paresthesia Memory deficit Impulsive behavior • • • • •