acute care of stroke Flashcards
what does better in rehab hemo or ischemic
hemo
a lot of the deficits that are originally seen are due to brain swelling therefore once this swelling goes down the deficits are reduced
what is the main medical treatment for ischemic stroke
TPA - 3 hrs
thromboectomy - greater than 3 hrs
what is the NIHSS
a quantitative assessment that provides a measure of stroke related deficits
used to determine treatment, acuity of the stroke, and predict pt outcomes
NIHSS scoring
0 good
42 very very bad
NIHSS >25
very server neuro impairments
NIHSS 15-25
server impairment
need a second set of hands to work with these patients
NIHSS 5-15
mild to mod impairment
NIHSS <5
mild impairment
can handle this by myself
what NIHSS does well in rehab
middle ranges
up to 20
larger NIHSS and rehab
they may be a able to tolerated this amount of activity
D/C planning and NIHSS scale - <5
12x more likly to go home
D/C planning and NIHSS scale - 6-13
1.9x skilled facility
IPR>SNF
D/C planning and NIHSS scale - >14
3.4x skilled facility
IPR<SNF
ischemic stroke BP
has strict floor and caps
what is the point of monitoring BP in those who have ischemic stroke
prevent hemo conversion
encourage perfusion
do we want to keep the pressure high or low with an ischemic stroke
high
what does CPP stand for
cerebral perfusion pressure
what does CPP mean
net pressure of blood flow to the brain
how do we calculate CPP
MAP - ICP
what does MAP mean
force that pushes blood into the brain
> 60
what does ICP mean
force that pushed blood out of the brain
10-15
what is hemo conversion
Hemorrhagic conversion occurs when blood vessels in the brain rupture after blood flow is restored to the brain after a stroke
has both kind of strokes
ischemic stroke BP allowed with thromolytic agent (TPA/TNK)
180/105
ischemic stroke BP allowed without thromolytic agent
220/120
ischemic SBP floor
130
ischemic SBP cao
220 or 180
what is BP management for with hemo stroke
prevent further bleeding
vaso spasm
what is a vasospasm
after a hemorrhage the blood can irritate the brain and cause the vessels in the brain to narrow and spasm, limiting the blood and cuasing death of the brain tissue
what are the symptoms of vasospasm
lethargy
MS change
NS assessment worsens
what does SAH stand for
Subarachnoid hemorrhage (SAH)
what are the two types of hemo stroke
SAH
intracerebral hemorrhage
where does a intracerebral hemorrhage occur
is bleeding into the brain parenchyma
what is the parenchyma
the functional tissue in the brain that is made up of the two types of brain cell, neurons and glial cells
what is a subarachnoid hemorrhage
is bleeding into the subarachnoid space
what is the subarachnoid space
a space between your arachnoid mater and pia mater. It’s filled with cerebrospinal fluid
surrounds the brain
what is spasm watch
the first 14 day on the ICU/step down
looking for the sypmtoms of spasm
what is the target SBP for SAH
<160
what is the target SBP for ICH
<140
what are the common caps for vasospasm
140-180
what is cerebral edema
accumulation of fluid in the brain
midline shift
what are the symptoms of brain edema
lethargy
MS changes
confusion
when does cerebral edema peak
3-5 days
ischemic cerebral edema tx
BP management
medications
neurosurgical (bone flap removal)
hemo cerebral edema - effects
tissue swelling
increased blood in the ventricles
hemo cerebral edema - tx
EVD/LD (extra ventricular drain and lumbar drain)
bone flap removal
craniotomy
skull is temporarily removed
craniectomy
removing a portion of the skull without replacement
craniectomy vs craniotomy which one needs a helmet
craniectomy
EVD/LD stands for
extra ventricular drain and lumbar drain
what kind of stroke is EVD/LD used for
hemo stroke - SAH
excessive blood in the CSF
clog villi that absorbs CSF causes increase in ICP
what does a EVD/LD do
monitors the ICP
drains CSF
what is a normal ICP
10-15
how is a EVD/LD controlled
height of the chamber relative to the midbrain
raise decrease drainage
lower increase drainage
if you are working with a pt who has this device what do you need to first do
must be clamped it is gravity dependent
goals of a EVD/LD
raise drain above midbrain to safely discharge drain
otherwise may need a shunt for continued drainage
what is a normal CSF color
clear yellow
CSF with infect
yellow
red CSF
lot of blood in the CSF
pink CSF
some blood in the CSF
what is a VP shunt
an internalized drain - stomach
these drains need to clammed when you stand up with a patient
what can lead to a high risk of seizure
any injury to the brain
anti-epileptic drugs (anticonvulsants) used to control seizures
dilantin and keppra
side effects of dilantin and keppra
lethargy
SAH and seizures
blood in the subarachnoid space is a irritant and can cause seizures
what are some common signs of seizures
spaced out
UI - loss of bowl or bladder control
what is duo tube
s a nasal, double lumen tube allowing simultaneous intestinal feeding and gastric drainage
what is a cerebral angiogram
threading a plastic catherter into your vessel and using x-ray to examine the blood vessel of the brain to determine a treatment
femoral angiogram
BR if catheter remain otherwise 4 hr rest
radial angiogram
no strict precuations
mim wrist activity
EVD/LD and OOB
must always be clamped
it is a gravity driven device
what is the first observations that you make with stroke ICU/acute care pts
EO/EC
gaze preference
purposeful/spontaneous movement
tone/synergies
what is arousel
the global state of responsiveness
brainstem
what is awareness
brain’s ability to perceive specific environmental stimuli in different domains, including visual, somatosensory, auditory, and interoceptive (e.g. visceral and body position).
cortex
what is stupor (noxious)
a state of near-unconsciousness or insensibility.
what is a noxious stimuli
noxious stimulus is actually, or potentially, damaging to tissue and liable to cause pain, but does not invariably do so
examples of noxious stimuli
sternal rub
nailbed
what are the types of responses we look for with noxious stim
no response
extends
flexes
withdrawals
localized
how to assess STM
3 words
what did you eat for breakfast
do you remember me from yesterday
LTM questions
how is here visiting with you
mimicking vs demostrative
- We want to do things related to function
- Hand someone a phone and see what they are doing with it
what is the best score for GCS
15
comatosed on the GCS
</= 8
unresponsive on the GCS
3
what does MS stand for
mental status
what is a focal problem
problem with nerve, spinal cord, or brain function.
It affects a specific location, such as the left side of the face, right arm, or even a small area such as the tongue.
Speech, vision, and hearing problems are also considered focal neurological deficits.
what is Generalize (non-focal)
NOT specific to a certain area of the brain, there isn’t a particular area or spot that stands out as abnormal or concerning.
may include a general loss of consciousness or emotional problem.
what info do you want to look at is the pt is presenting with preceptual deficts
VF
general visual acuity
hearing impairment
what is included in the sensation examination
light touch
JPS
sharp vs dull
sensation wise how do you test if cognition is impaired
pinching
do they withdrawl
what is extiniction
- Can see or feel something when one stimulus is present but when both stimulus is present then they do not feel or see it because there is to much for the brain to do
what is a another way to look at JPS
is their arm stuck under them
motor examination - how to test motor strength and ROM
hold up your arm
put something on their face
hand them something
what are Brunnstrom stages
Describe the development of the ability to move and the reorganization of the brain after a stroke
Brunnstrom stages 1-4
- Stage 1: flaccid (hypotoncity)
- Stage 2 – 3: increased spasticity (hyper, movement within syngergies)
- Stage 4: decrease in spasticity
spasticity vs synergy
passive vs active
what is the synergy pattern we often see in the UE
flexion pattern
what is the syngery pattern wee often see in LE
extension pattern
what is a field cut
involve partial blindness where the patient cannot see on the affected side
field cut vs neglect
they can see in neglect but are not attentive to it
neglect vs inattention
inattention - they prefer on side
neglect: pt does not pay attention to one side
what is Unilateral spatial neglect (USN)
is a disorder of contralesional space awareness which often follows unilateral brain lesion
Unilateral spatial neglect is normally due to lesion on what side of the brain
right hemp
what is more common R or L neglect
left sided neglect
personal self space neglect - - Personal neglect
lack of exploration or awareness of the side of the body opposite the brain lesion
o Examples: failure to dress one half of the body or combing only one side of the head.
Peripersonal neglect
refers to neglect behaviors occurring within reaching space (near space).
Example: failure to eat the food on one half of a plate.
Extrapersonal neglect
refers to neglect behaviors occurring in far space.
Example: inadvertently contacting obstacles such as a doorway when walking.
why is R sided neglect rare
there is a redunacy of the processing fo the right space
what is pusher syndrome
inaccurate perception of vertical orientation resulting in postural control deficits
can you push someone with pusher synndrome
no they will just push back harder
pull them towards you
what is pusher syndrome often accompanied with
hemisensory
server inattention - spatial neglect
what side lesion do we often see pusher syndrome
right side
left hemp and pusher syndrome is associated with what
aphasia
do you ever pull on the flaccid side
NO
