258 Final Review

all types of shock: manifestations

early:

↓ BP

↑ HR

↑ RR

late:

temp

loc

kidneys: low UO, bun/cr high

no bowel sounds

septic shock

circulating bacteria causes inflammation, vasodilation, and decreased bp

SIRS criteria:

only need 2/4

-temp > 38.3 (101) or < 36 (96.8)

-tachycardia > 90

-tachypnea > 20

-WBC > 12 or < 4, bands >10% or 10% immature bands

septic shock priority

find the cause

-cbc

-ua

-culture and sensitivity

1 hour sepsis bundle

1. lactate, remeasure if greater than 2

2. obtain blood culture before abx

3. broad abx

4. rapid LR for low bp + lactate greater than 4

5. vasopressors if bp is low, or after a fluid bolus to maintain map (nor epi)

hypovolemic shock

shock resulting from blood or fluid loss = low venous return, low stroke volume, low cardiac output and low tissue perfusion

-15-30% in volume (750-1000ml in a 70 kg person)

hypovolemic causes

increased fluid loss (burns, diuresis, vomiting, diarrhea)

blood loss (due to trauma, surgery, NSAIDS)

gynecologic/obstetric causes

hypovolemia shock due to diarrhea consideration

need constant ekg monitoring due to hypokalemia risk

hypovolemic shock labs

blood loss: ↓ H+H

fluid loss: ↑ H+H

hypovolemic shock tx

treat the underlying causes of fluid loss

fluids + blood replacement: isotonic crystalloids (NS, LR, D5W)

medications: after fluids (fill the tank first), vasopressors

PRIO = ABC, FLUIDS

cardiogenic shock causes

decreased ability to contract and to pump blood (low cardiac output) due to a direct cardiac cause

mi

hf

cardiomyopathy

dysrhythmias

valvular rupture/stenosis

cardiogenic shock treatment

client cannot tolerate lots of fluids to increase bp

-inotropes (dobutamine + dopamine + epi + milrinone) to increase hr and contractility

-pressors to increase bp

-nitro

-oxygen and morphine

distributive shock

leaky blood vessels

decreased blood return to the heart = decreased perfusion

distributive shock types

neurogenic, anaphylactic, septic

anaphylactic shock meds

antihistamines: diphenhydramine(urticaria)

Epi before fluids

- Bronchoconstriction

- Angioedema

- Urticaria

- Hypotension

**assess vitals & client

Priority medications is IM epinephrine (vasoconstricts and bronchodilates)

Oxygen

Adjunct therapies:

- Antihistamines

- Corticosteroids

- Bronchodilators

- IV fluids

airway: swelling

breathing: wheezing

circulation: decreased bp, increased hr

skin: urticaria

gi: nv

Obstructive Shock

Blood flow to heart is blocked

Causes:

- PE (blocks pulmonary artery)

- cardiac tamponade, fluid in pericardium compresses heart (ssx: becks triad ↓ bp, jvd, muffled heart sounds. Tx: pericardiocentesis, monitor ecg, O2, bowel sounds, color)

- tension pneumothorax (Tx: needle decompression + chest tube)

stages of shock

-initial: no visible changes, map drops 5-10, mild vasoconstriction, a slight increase in hr

-compensatory (non-progressive): increase co to increase perfusion + oxygenation

-progressive

-refractory (irreversible)

shock priority and management

ABC's

priority: oxygen status (high flow 15L nonrebreather), be prepared to intubate

-then: vs, continuous ecg, hourly uo

-loc

-skin color, temp, moisture, turgor, cap refill

first intervention with low bp

elevate legs 45 degrees (modified trendelenburg): if bp increases fluids will help, if there is no change fluids wont help and you need to do pressors

inotropic agents

increase contraction and cardiac output

decrease afterload

-dobutamine, dopamine, epi, milrinone

vasoactive agents

increase resistance + bp

keeps blood on the arterial side

-dopamine, norepinephrine, epinephrine

dobutamine + dopamine + epi + milrinone AE

arrhythmias and increased hr

-if extravasates into tissues the reversal is phentolamine

dopamine + norepinephrine + epinephrine considerations

low dose: increases kidney perfusion

high dose: decreases kidney perfusion

-phentolamine is the reversal agent

-prolonged use: necrosis

MODS patho

release of toxic metabolites + destructive enzymes in response to low oxygenation

-original organ + 2 additional organs

MODS risk factors

shock/sepsis

severe trauma

burns

acute pancreatitis

major surgery

ards

*any severe illness that decreases BP + organ perfusion

MODS manifestation

lungs are often first to be affected

resp: hypoxia, tachy, low o2 sat

CNS: changes in loc, confusion, psychosis

hepatic: jaundice, increase liver enzymes, low albumin

cardiac: tachy, low bp, increased lactate, changes in ecg

renal: oliguria, increased bun/creatinine

hematological: low plts + protein c, increased d-dimer, petechia, dic

MODS management

early detection + control of initiating event

supportive measures

nutritional support

patient comfort

measures that compensate: dialysis, mechanical vent

Open (wide) angle glaucoma

- most common

- usually bilateral

- decreased outflow of aqueous humor, blockage in drainage, ↑ IOP

- loss of peripheral visions

- "silent thief"

- lifelong treatment to reduce IOP and prevent vision loss

- Timolol ( 5 mins apart)

Open (wide) angle glaucoma manifestations

initially asymptomatic

- mild eye pain

- blurry vision

- halos around lights

- headaches

Angle-closure (narrow-angle) glaucoma

ocular emergency

- sudden closure of angle (often pupil dilation), IOP rapidly ↑ ( ≥ 30 mm Hg)

- loss of central visual acuity & pain

- an ocular emergency, immediate surgery required to lower IOP

- nursing management: nausea and pain

glaucoma surgery and post-op care

- wear glasses in bright areas

- avoid activities that ↑ IOP (bending down, sneezing, lifting >15 lb, straining w/ bowel movement)

- do not lie on operative side

- REPORT: severe pain and nausea (hemorrhage)

glaucoma goal, meds, and management

goal: prevent vision loss and optic damage, maintain IOP <21 mm Hg

medications:

- timolol reduced IOP (used in both)

- pilocarpine causes miosis of the pupil (closed angle)

- analgesics & antiemetics: pain and nausea (closed angle)

nursing management:

- monitor IOP

- med adherence

- monitor vision

cataracts manifestations/management

- painless progressive blurred vision

- reduced night vision

- sensitivity to glare

- reduced visual acuity

- decreased color perception

- color shifts, lens become more brown

- myopic shift

- prescription changes

- diplopia in single eye

- opacity of lens

- check visual acuity with Snellen chart

- determine functional capacity

- ↑ light in room

- adaptive devices: magnifying glass, large print, talking devices

cataracts surgical management and post-op

- surgery needed if vision alters ADL

- outpatient basis, local anesthesia, 1 hr surgery, small incision, lens removed, replacement lens inserted

post-op:

- avoid heavy lifting

- wrap around glasses to protect against UV & glare

- padded, metal eye protector during bedtime to prevent accidental rubbing or pressure

retinal detachment manifestations

Ocular emergency

- "shade" or "curtain" across vision of one eye

- bright flashing lights

- sudden onset of floaters

- NO pain

- "cob web" eye

retinal detachment surgical management

scleral buckle - band compresses

vitrectomy - dissection with substitute

pneumatic retinopexy Post op: Prone positioning - gas bubble w/ pressure

acute otitis media Ssx/tx

common in children,<6 weeks

- causes: viral, bacterial

- s/s: pain when lying down, tugging/pulling ear, irritable, drainage if eardrum ruptures but no pain, muffled hearing (pearly gray healthy color, red bad)

- Tx: analgesics, abx, myringotomy (incision to drain fluid), tympanostomy tubes (to ventilate preventing buildup)

chronic otitis media

- causes: recurrent infection, mastoid air cells w/ TMP

- s/s: hearing loss, "fullness", otalgia, otorrhea, vertigo

- tx: topical antibiotics

**can cause irreversible damage/scarring

Meniere disease

overproduction of inner ear fluid balance in vestibular system

- s/s: vertigo, tinnitus, "fullness", N/V, progressive hearing loss

- tx: low sodium diet (1000-1500 mg/day), NO surgical procedures for vertigo, avoid sudden movements

- meds: antihistamines (meclizine), tranquillizers (diazepam), antiemetics, diuretics

-Fall risk

No sudden manuevors =

No sodium menUVieres

hearing impairment

Face client when speaking

no loud voice

occupations: construction/military

ototoxic meds: lasix/furosemide, NSAIDS, Myocins

Rule of nines

determines TBSA% burned

- anatomic regions of the body

- add all affected burn areas

parkland formula

remember PARKLAND FOURMULA

4 mL x % burn (TBSA) x pt weight in kg = total fluids (mL) for 24 hours

- ½ of the total volume is given over the first 8 hrs​

- remaining fluid given over next 16 hrs

Burns labs

Hyperkalemia

Hyponatremia

High H&H

Burns: Emergent/Resuscitative Phase: In-hospital care

•Airway/breathing

•Fluid resuscitation

•Indwelling urinary catheter insertion

•NG tube insertion

•Client is stabilized and condition is continually monitored

•Continuous telemetry monitoring

•Pain control

•Psychosocial and emotional support

neutropenic precautions

□ Monitor WBC count, neutrophil levels

□ Assess for signs and symptoms of infection, such as fever, chills, or sore throat

□ Strict hygiene

□ Limit visitors

□ Avoid flowers or plants to avoid pathogens

□ Ensure proper ventilation and air filtration

□ Educate on early signs of infection

□ Educate on avoiding raw or uncooked foods

HIV

- chronic infection

- cannot be cured, lifelong therapy

- acquired immunodeficiency syndrome (AIDS) is the disease caused by HIV infection

Transmission: blood, semen, vaginal fluid, breast milk, sharing needles

HIV post-exposure prophylaxis

1. CDC: begin antiretroviral meds ASAP (<72 hours after possible HIV exposure

2. drugs prescribed for 28 days

3. follow-up blood testing

**not 100% effective

AIDS: Stage 3

**All people with AIDS have HIV, but not all people with HIV have AIDS.

○ Defined as a CD4 count <200 CD4 or the occurrence of an AIDS defining illness

○ Not enough CD4 T-lymphocytes present to fight off infection

○ Immune system is severely impaired

○ Characterized by life-threatening opportunistic infections

○ End stage of HIV

○ Without treatment, death often occurs within 5 years

AIDS defining conditions

these typically occur in individuals with significantly weakened immune systems due to advanced HIV infection

- pneumocytes pneumonia

- Kaposi's sarcoma

- candidiasis

- cytomegalovirus

- TB

- HIV wasting syndrome

- malnutrition

- infection in general

etc.

HIV testing

screening: ELISA

confirmation: western blot

viral load: effectiveness of ART

CD4 Count: if western blot positive, checks pt's immune system

HIV medications

- ART (antiretroviral therapy): combination drug therapy

- PrEP (pre-exposure prophylaxis): do not have HIV but at risk

- PEP (post-exposure prophylaxis): exposed to HIV, <72 hours

At least 2-3 medications are used in combination every day to suppress HIV replication

HIV education

Avoid large gatherings

clean toothbrush through dishwasher

avoid digging in garden

hand hygiene regularly

airborne precautions

PPE: gown, gloves, N95

- private negative air pressure/airflow room

- keep door closed

- Measles, TB, Varicella (MTV=airborne)

droplet precautions

PPE: mask, face shield/goggles

- face mask within 3-6 ft to pt

- private room, but door can remain open

- pneumonia, influenza, meningitis, mumps, pertussis (PIMMP = droplet)

flu vaccine - egg allergy, and Guillian barre

flu tx: viral, supportive care, FLUIDS, bedrest

contact precautions

PPE: gown, gloves (mask not needed)

- private room or pt with same infection

- MRSA, VRE, CDIFF

Clostridium difficile

○ causes: antibiotic therapy or immunosuppression, toxins from bacteria are released into the bowel and cause excessive diarrhea, spreads easily

risk: dehydration and fluid and electrolyte imbalance

○ tx: oral vancomycin or metronidazole, fluids

○ management: contact precautions, gowns and gloves, handwashing, clean equipment with a bleach product, dedicated equipment, leave equipment in room, gloves off first(dirtiest piece)

Central line associated blood stream infections (CLABSI) nursing interventions

□ Hand hygiene

□ Sterile technique

□ Skin preparation with antiseptic solution (chlorhexidine)

□ Daily assessment

□ Securement of catheter

□ Cap and line care

□ Change dressing every 7 days

Catheter associated UTI (CAUTI) nursing interventions

- assess need, avoid indwelling catheter whenever possible

- monitor urinary output

- sterile technique with insertion

- securement device

- adequate hydration to promote urine flow and flush bacteria

- timely removal

rheumatoid arthritis & manifestations

○ Chronic systemic inflammatory disease (autoimmune)

○ Destruction of connective tissue and synovial membrane within the joint

○ bilateral and symmetric

Shows up in Small joints of hands and feet. Knees would be more like osteoarthritis.

bilateral/symmetrical, typically begins in hands and feet, morning stiffness, ↓ ROM, tenderness, joint deformities, muscle atrophy, joint spongy on palpation

systemic: fever, fatigue, weakness

rheumatoid arthritis management

○ non-pharm management: education, physiotherapy, rest, exercise

○ NSAIDS

○ DMARDS: Methotrexate (bone marrow suppression, monitor BP and s/s of infections (Disease-Modifying Antirheumatic Drugs))

○ Corticosteroids (long-term risk for immunosuppression)

○ Reconstructive surgery

○ Joint arthroplasty

systemic lupus erythematosus

Chronic, progressive, systemic inflammatory disease (no cure)

○ Exaggerated production of autoantibodies that attack many sites in the body

○ Can cause failure of major organs

Extreme fatigue

Photosensitivity (sensitivity to sun exposure)

Hair loss

Skin rashes

Joint pain or swelling

Chest pain when breathing deeply

Headaches

Lupus nursing management

Pharm: NSAIDS

Corticosteroids (immunosuppression)

-biologic DMARDS

-non-biologic DMARDS

-Antimalarials (hydroxychloroquine)

○ Monitor for medication effectiveness

○ Monitor adverse effects of medications

○ Adequate nutrition

○ Pain relief

○ Routine health screenings

○ Report manifestations that can indicate SLE exacerbation or complications

○ Teach to avoid cold hands/toes, raynauds

○ Protect from sun exposure

○ Treatments for impaired skin integrity

○ psychosocial support

○ monitor body temperature

What can exacerbate this?

sunlight, warm to cold, illness/infection, pregnancy, emotional stress, sleep deprivation, rigorous exercise

gout & ssx

- inflammatory arthritis

- hyperuricemia: uric acid crystals to deposit in joints and body tissues, can lead to breakdown of purines in cells

- s/s: pain with movement or touch, redness, warmth, edema,

- most common in big toe joint

- attacks: 3-10 days with tx

gout tx

- allopurinol: prevention, take every day even w/ feeling well, drink plenty of fluids (renal failure side effects= ↑ fluids)

- tx: NSAIDs, Colchicine(Diarrhea), Corticosteroids

- diet: low in purines, avoid meats, shellfish, alcohol

take allopurinol as prescribed

exercise

limit intake of foods high in purine

increase fluids 2+L a day

avoid citrus juices

Addison's disease

↓ cortisol and aldosterone from adrenal glands

cortisol: metabolism, BP, glucose

aldosterone: fluid balance, reabsorbs NA and secretes potassium

- fatigue, irritability, depression

- skin hyperpigmentation, vitiligo

- weight loss

- N/V/D, constipation, abdominal pain

Sodium ↓

Potassium ↑

Sugar ↓

BP ↓

Remember Opposite of cushings

Addison Disease nursing management

○ ACTH stimulation test (addisons doesnt respond to acth stim)

- IV hydrocortisone 3-4L NS or dextrose

- 0.9 NS bolus

- Hyperkalemia = calcium gluconate/insulin & glucose

- daily weights

- monitor infection/hypoglycemia

Addisonian Crisis manifestations

○ Triggering factors: most common cause is abrupt withdrawal of glucocorticoid therapy

○ Stress on the body

- Dehydration

- ↓ BP Severe

○ ↓ NA

○ ↑ Potassium

○ ↑ BUN/Creatinine

- Profound fatigue

- Confusion and restlessness

Addisonian Crisis nursing management

○ Administer IV fluids (1st, secondary is meds)

○ Position: recumbent, legs elevated

○ IV hydrocortisone

○ Vasopressors to ↑ BP

○ Treat underlying cause (did we stop steroids abruptly? Tumor?)

Cushing disease/syndrome & ssx

Syndrome: ↑ cortisol usually from steroids

Disease: ↑ cortisol, inside harm from pituitary/adrenal/tumor

manifestations:

○ Personality changes

○ Weight gain

○ Fluid retention

○ Paper thin skin

○ Buffalo hump

○ Striae

○ Moon face

○ Sick more often

○ Osteoporosis

Sodium ↑

Potassium ↓

Sugar ↑

BP ↑

Think fat + fluids

Cushing disease/syndrome medical management

Dexamethasone Suppression test - before sleep, PO at 11 pm and cortisol lvl taken at 8 am.

○ Corticosteroids (syndrome): taper off

○ Tumor removal

○ Diuretics

○ No salt

hypothyroidism & ssx

Hashimoto's

T3/T4 ↓ TSH ↑

- ↓ metabolism = ↑ weight

- fatigue and lethargic

- cold intolerant

- dry skin, brittle hair

- large tongue (monitor airway)

- ↓ HR

- ↓ BP

hypothyroidism tx

Levothyroxine

- monitor for hyperthyroidism

- take in morning on empty stomach

- lifelong

fluids for ↓ bp

hyperthyroidism & ssx

Graves disease

T3 T4 ↑ TSH ↓

- anxiety, restless, irritable

- heat intolerant

- HTN

- bulging eyes

- diarrhea

- ↓ weight

- ↑ HR

- ↑ BP

hyperthyroidism tx

- thyroidectomy (monitor for hypocalcemia, trach kit nearby)

- Propylthiouracil (PTU) (monitor for infection, thrombocytopenia)

- Methimazole

- Betablockers LOL's

- Radioactive iodine therapy (radioactive precautions)

thyroid storm & ssx

Surge of thyroid hormones by stressful event

↑ temp

↑ HR

↑ BP

chest pain, delirium, psychosis

thyroid storm tx

- O2

- cool patient (blanket, antipyretics, acetaminophen)

- ↓ HR = digoxin

- Dextrose IV fluids

- calm environment

- PTU

- BB

diabetes insipidus & ssx

Dry inside

↓ ADH

- ↑ Urine output > 250 mL/hr

- ↓ gravity = diluted

- polydipsia (thirsty)

- polyuria

- ↓ BP

- ↑ HR

- ↑ NA

- dehydration

- weight loss

- seizures

diabetes insipidus tx

fluid deprivation test: fluids held for 8-12 hrs or until 3-5% body weight lost, stop if dehydration ssx occur.

Desmopressin (at night, prevent nocturia)

- lifelong

- fluids first

Remove tumor

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) & ssx

Soaked Inside

↑ ADH

- ↓ Urine output

- ↑ gravity = concentrated

- ↓ osmolality

- seizures

- ↑ BP

- ↓ HR

- ↓ NA

- fluid overload ssx

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) tx

S -Sodium tabs, 3% saline, NS

I -I&O's strict

A -abx

D -diuretics, daily weights, diet

H -head check

type 1 diabetes mellitus

Autoimmune, insulin dependent

- Insulin-producing beta cells in the pancreas are destroyed

- Result: absence of pancreatic insulin production, unchecked glucose release by the liver, and fasting hyperglycemia, fat breakdown, producing ketoacidosis and a profound reduction in blood pH

- Tx: Insulin

fasting glucose = 126+

2-hour, post meal glucose = 200+

A1C = 6.5+

type 1 diabetes manifestations

Hyperglycemia

3 P's = Polydipsia, Polyuria, Polyphagia

Weight loss (ketones)

Fatigue, weakness

N/V

Abdominal Pain

Kussmaul resp. with acidosis

type 2 diabetes mellitus

Insulin resistance, impaired insulin secretion

- Risks: obesity, >30, slow progressive, hyperosmolar coma

- Tx: diet, exercise, oral hypoglycemic drugs, lifestyle changes, +/- insulin

type 2 diabetes manifestations

slow onset, polyuria, polydipsia, polyphagia, may go undetected for years, obesity, usually after age 35, wounds heal slow, lots of itching, blurred vision, recurring infections, fatigue.

diabetes diet

carbs- 45%

- whole grains, non-starchy veggies

fats- 20-35%

- reduce saturated and trans fats

protein- 15-20%

increase fiber, lowers cholesterol

diabetes and exercise

↓ BG

↓ weight

↓ cardiovascular risk

exercise when BG 80-250

DONT exercise if ketones present

high-intensity workout= snack prior, 15-g carb

HAVE comfortable shoes

sick day rules

○ Monitor BS every 2-4 hrs.

○ Continue taking insulin/oral meds during illness (can lead to hyperglycemia)

○ Consume liquids every hour to prevent dehydration

○ Meet carbohydrate needs through soft food 6-8 times per day

○ Test urine for ketones every 3-4 hrs of if BS is >240 mg/dL

meal coverage insulin

rapid acting, lispro = 10-15 mins before meal

short acting, regular = 30 mins before meal

Hypoglycemia ssx

- cold & clammy needs some candy

- hunger

- lightheaded

- tachycardia

- decreased LOC

- headache

diabetic ketoacidosis ssx

hyperglycemia emergency

T1D

S/S:

- 3 P's

- fruity breath

- Kussmaul breathing

diabetic ketoacidosis tx

Analyze:

- hyperglycemia >330

- glycosuria, positive ketones (acidotic)

- hyperkalemia

Tx:

1. 0.9% NS

2. IV regular insulin

3. Add dextrose to IV fluids once BG decreases to 200-250

- hourly BG monitoring

- monitor potassium, add once BG decreases

- cardiac monitor for arrhythmias

Hyperglycemic Hyperosmolar Syndrome (HHS) & ssx

Lack of insulin

T2D

>600 glucose

↓ BP

↑ HR

dehydration

neuro ssx

HHS management

1. Rehydration with IV fluid (usually 0.9% N/S bolus then 0.45% N/S infusion since hyperosmolar blood needs diluting), 6 liters of fluid replacement in initial 12 hours

2. IV regular insulin infusion

Monitor:

- I&Os, glucose, electrolytes

- educate about not stopping insulin

Neuro diagnostics

Glasgow Coma Scale

15 = Awake and Alert

8 = 8 or Less than 8 Intubate

6 = Coma

3 = Brain dead

ICP Tx & Education

Tx:

- mannitol (working if they have ↑ UO), corticosteroid

- phenytoin (stop or prevent seizures)

- 3% NS

- semi-fowlers, elevate HOB(#1 intervention)

- Quiet environment

Educate:

- avoid: coughing, sneezing, vomiting, rapid IV bolus, suctioning

- constipation: stool softeners

ICP Cause & Early/Late ssx

Cause: increased CSF, blood entering CSF, head trauma/infection, tumors

Early

- Changes in LOC

- Confusion

- Headache

- Vision changes

Late

- ↑ Temp and BP (widened pulse pressure)

- ↓ HR and RR (two rates go down) Cushing's Triad

- vomiting

- dilated pupils

- seizures, coma, posturing

head injury priority

Stabilize/immobilize cervical spine until injury is ruled out

if have to do CPR: modified jaw thrust

Nursing Management of Spinal and Neurogenic Shock

- Vitals (bradycardia)

- MAP >= 85 mm hg

- Isotonic fluids

- Meds to ↑ BP or HR (norepi, dobutamine, atropine)

- I + O's

- VTE (scd's)

- Monitor GI fx

- NG tube gastric decompression

- prevent skin breakdown

Autonomic Dysreflexia

OVERREACTION of a stimulus below SCI.

-Distended bladder = most common cause

-Constipation or bowel impaction

-Stimulation of the skin (pressure injury, pain from ingrown toenail, restrictive clothing)

-Place client in sitting position immediately - this is priority!

-Notify the healthcare provider

-Determine and treat the cause

-Check patency of urinary catheter or insert catheter for distended bladder

-Remove fecal impaction

-Assess for injury (skin, fractures, infection)

-Remove tight clothing

-Adjust room temperature and block drafts

-Vitals

-Antihypertensives (nitrates or hydralazine)

Above injury: ↑ BP, Bradycardia, red, sweaty, ha

Below injury: Cool, clammy, pale

Left and Right brain functions/stroke manifestations

Left hemi manifestations: language, math, analytical thinking, more airway prior

Right hemi manifestations: visual, spatial awareness, proprioception, hemianopsia, more safety prio

Transient Ischemic Attack (TIA)

Temporary blockage of blood flow

-Warning of impending stroke

BE FAST

B=loss of Balance

E=Eyesight changes

F=Facial droop

A=Arm weakness

S=Speech difficulty

T=Terrible headache

911