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Med II > Ch 62 > Flashcards

Ch 62 Flashcards

1
Q

When do cerebrovascular disorders occur

A

when the blood supply to the brain is disrupted

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2
Q

what is the primary cerebrovascular disorder, 5th leading cause of death in the US, and the leading cause of serious long-term disability

A

stroke

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3
Q

what are the nonmodifiable risk factors for stroke

A

age (greater than 55), gender (men > women), ethnicity (AA and Hispanic/Latino > caucasian)

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4
Q

what are the modifiable risk factors for stroke?

A
  • hypertension is the primary risk factor
  • Cardiovascular disease
  • Elevated cholesterol or elevated hematocrit
  • Obesity
  • Diabetes
  • Oral contraceptive use
  • Smoking and drug and alcohol abuse
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5
Q

Disruption of the blood supply caused by an obstruction, usually a thrombus or embolism that causes infarction of brain tissue is aka ?

A

ischemic stroke

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6
Q

what are the types of ischemic stroke

A
  • Large artery thrombosis
  • Small penetrating artery thrombosis
  • Cardiogenic embolism
  • Cryptogenic
  • Other
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7
Q

if a patient has a large artery thrombosis this means the stroke was caused by?

A

atherosclerotic plaques in the large vessels (accounts 20% of all ischemic stroke)

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8
Q

what is a cardiogenic embolism?

A

ischemic stroke related to cardiac arrythmias; primarily afib (accounts for 20% of all strokes)

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9
Q

what is cryptogenic strokes

A

cause of stroke is unknown (30%)

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10
Q

what is a small penetrating artery thrombosis

A

affect one or more small vessels in the brain
- normally more diffuse and localized
- accounts 25% of all strokes
- aka lacunar strokes

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11
Q

what is lacuna?

A

cavity created after death of infarcted tissue

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12
Q

5% of strokes result from?

A

things such as illicit drug use, coagulopathies, migraines/vasospasm, dissection of carotid or vertebral arteries

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13
Q

symptoms of stroke depend on?

A

the location and size of the affected area called penumbra

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14
Q

what are some of the symptoms of stroke

A
  • numbness or weakness of face, arm, leg mainly on one side
  • confusion/change in mental status
  • trouble understanding or producing speech
  • difficulty walking, dizzy, loss of coordination or balance
  • sudden, severe headache
  • perceptual disturbances
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15
Q

what is the difference between receptive and expressive aphasia

A

receptive aphasia= difficulty understanding speech; usually due to damage to temporal lobe (wernicke)
- can hear what you are saying but cannot understand spoken words

Expressive aphasia: inability to express onself through speech; often due to damage in left side of frontal lobe (Broca area)
- cannot find the words they need or string words together correctly aka word salad

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16
Q

the nurse finds the patient experiencing difficulty speaking due to weak speech muscles. The nurse would document this as?

A

dysarthria

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17
Q

the nurse would document a patient experiencing difficulty and impairment producing speech as?

A

dysphasia

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18
Q

what is apraxia

A

difficulty in skilled voluntary movement

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19
Q

hemiplegia

A

paralysis of one side of the body, or part of it, due to damage to motor area of the brain

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20
Q

hemianopsia

A

blindness of half of thefield of vision in one or both eyes

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21
Q

agnosia

A

not being able to recall the name of common objects

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22
Q

a patient in the ED had a temporary neurologic deficit caused by a temporary impairment of blood flow. Symptoms resolved after about an hour. This is known as

A

TIA

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23
Q

TIA is a warning for? how are permanent deficits prevented?

A

impending stroke
diagnostic workup and evaluation

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24
Q

what are the treatment options both preventative and to prevent secondary prevention

A
  • Carotid endarterectomy for carotid stenosis
  • ANTICOAG for afib (pradaxa or eliquis)
  • antiplatelet therapy
  • statins to control cholesterol
  • BP meds
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25
Q

what must we use to determine the dosage window for tPA?

A

last known well time

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26
Q

what are the components of LKWT?

A

date and time

27
Q

what exam can be used in the “field” to assess potential stroke patient

A

FAST
face, arm, speech, time

28
Q

after arrival to EC how long does care team have to get CT scan

A

20 min

29
Q

how long does care team have to interpret CT results once arrival to EC

A

45 min from the time of arrival (25 min after CT scan done)

30
Q

if a patient is eligible for tPA and arrived to the EC at 0800, what is the latest time tPA can be given according to standard protocol?

A

0845

31
Q

what is the timeframe for the administration of tPA from the last known well time (LKWT)?

A

3 hours

32
Q

if the patients LKWT was 0700 and the patient arrived at the EC at 1030. can the nurse still give tPA?

A

only by physican orders
tPA 3 hr window can be extended by MD especially if pt is younger and healthier

33
Q

what is the maximum amount of time that an MD can decide to perform a thrombectomy

A

24 hours
it is usually between 4.5-24 hrs

34
Q

what screening tool is normally used for stroke patients?

A

NIH stroke scale

35
Q

what is the criteria for extended tPA window?

A

< 80 years old
- no hx of previous stroke in combo with diabetes
- NIH stroke scale score < 25
- no oral anticoags were being taken at time of stroke

36
Q

true or false: a CT scan can diagnose ischemic stroke?

A

False- ischemic strokes do not show up on CT scans and take up to 24 hrs to bloom

37
Q

if CT scan can not dx an ischemic stroke, why is it still done?

A

it is used to rule out hemorrhagic stroke because hemorrhagic strokes will show up on CT

38
Q

what immediate medical interventions need to be done in the acute phase of stroke?

A
  • prompt dx & tx
  • NIH stroke scale
  • thrombolytic therapy
  • elevate HOB unless contraindicated
  • maintain airway & ventilation
  • continuous hemodynamic monitoring & neurologic assessment
39
Q

what is the criteria for tPA

A
  • age > 18
  • dx of ischemic stroke
  • SBP </= 185; DBP </= 110
  • no minor stroke
  • prothrombin time </= 15 secs; INR </= 1.7
  • no low molecular weight heparin given w/in 24 hrs
  • platelets >/= 100,000
  • no symptoms of infective endocarditis
  • no prior intracranial hemorrhage
  • no subarachnoid hemorrhage
  • no stroke, intra cranial surgery, or serious head trauma w/in 3 months
  • no GI bleed w/in 21 days or GI malignancy
40
Q

what is the tPA dosage protocol

A
  • 0.9 mg/kg
  • 90 mg is MAX!
  • 10% given as bolus over 1 min
  • 90% given IV infusion over 1 hr
41
Q

True or False: the nurse is administering tPA through a patient’s IV. The nurse can give other medications through the same IV

A

False- one dedicated line for tPA!!!

42
Q

what is a carotid endarterectomy

A

plaque is removed from the carotid artery to reduce risk of TIA or stroke
- removes innermost layer of artery as well

43
Q

who is eligible for carotid endarterectomy

A

TIA patients and those w/ mild stroke for secondary prevention
- 70-99% stenosis of carotid artery (definite)
- 50-69% (usually)

44
Q

what should the nurse assess during the acute phase of ischemic stroke

A
  • Ongoing, frequent monitoring of all systems, including vital signs and neurologic assessment
    -LOC
  • Motor symptoms
  • Speech
  • Pupil changes
  • I & O
  • Maintain BP
  • Bleeding
  • Oxygen saturation
45
Q

what are the 2 most important assessments during the first 24 hrs of ischemic stroke?

A

bleeding & BP!

46
Q

Assessment of the nurse after the acute phase of stroke and into recovery phase

A
  • mental status
  • Sensation/perception
  • Motor control
  • Swallowing ability
  • Nutritional and hydration status
  • Skin integrity
  • Activity tolerance
  • Bowel and bladder function
47
Q

After a stroke, how long does pt need to remain NPO after ischemic stroke?

A

until gag/swallow reflex returns

48
Q

problems assoicated with ischemic stroke recovery

A
  • Decreased cerebral blood flow
  • Inadequate oxygen delivery to brain
  • Pneumonia
49
Q

nursing interventions for pts recovering from ischemic stroke (#1)

A
  • Improving mobility and preventing joint deformities
  • Prevent shoulder abduction
  • Position the hands and fingers
  • Change positions—every 2 hours
  • Establish an exercise program
  • Passive or active ROM four- or five-times/day
  • Prepare for ambulation
  • Assist patient out of bed as soon as possible
  • Preventing shoulder pain- associated with shoulder subluxation and motor weakness of the rotator cuff muscles
50
Q

nursing interventions for pts recovering from ischemic stroke (#2)

A
  • Enhancing self-care
  • Use of assistive devices and modification of clothing
  • Adjusting to physical changes
  • Assisting with nutrition
    • Consult with speech therapy or nutritional services
    • Have patient sit upright, preferably out of bed, to eat
    • Chin tuck for swallowing method (prevent aspiration)
    • Use of thickened liquids or pureed diet
51
Q

nursing interventions for pts recovering from ischemic stroke (#3)

A
  • Attaining bowel and bladder control
  • Assessment of voiding and scheduled voiding
  • Measures to prevent constipation: fiber, fluid, toileting schedule
  • Improving thought processes
  • Strategies to enhance communication
  • Maintaining skin integrity
  • Improving family coping
  • Coping with sexual dysfunction
  • Monitoring and managing potential complications
52
Q

what is hemorrhagic stroke

A

bleeding into brain tissue, subarachnoid space, or ventricles

53
Q

causes of hemorrhagic stroke

A
  • spontaneous rupture of small vessels primarily related to hypertension; - subarachnoid hemorrhage caused by a ruptured aneurysm;
  • or intracerebral hemorrhage related to amyloid angiopathy, arteriovenous malformations (AVMs) (congenital anomalies), intracranial aneurysms, or medications such as anticoagulants
54
Q

what happens to the brain during hemorrhagic stroke

A
  • Brain metabolism is disrupted by exposure to blood
  • ICP increases, caused by blood in the subarachnoid space
  • Compression or secondary ischemia from reduced perfusion and vasoconstriction causes injury to brain tissue
55
Q

manifestations of hemorrhagic stroke

A

Similar to ischemic stroke
Severe headache
Early and sudden changes in LOC
Vomiting
Bleeding
Sudden Death

56
Q

medical management of hemorrhagic stroke

A
  • Diagnosis: CT scan, cerebral angiography, lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage
  • Care is primarily supportive .
  • Bed rest with sedation.
  • Oxygen
  • Treatment of vasospasm, increased ICP, hypertension, potential seizures (need prophylaxis), and prevention of further bleeding
57
Q

complications associated with hemorrhagic stroke

A

Vasospasm
Seizures
Hydrocephalus
Rebleeding
Hyponatremia

58
Q

what causes hyponatremia in pts after hemorrhagic stroke?

A

SIADH– worst outcome

59
Q

Assessment findings in pts with hemorrhagic stroke

A

Complete and ongoing neurologic assessment; use neurologic flow chart
Altered LOC
Sluggish pupillary reaction
Motor and sensory dysfunction
Cranial nerve deficits
Speech difficulties and visual disturbances
Headache and nuchal rigidity.
Other neurologic deficits

60
Q

which one has higher risk of complications and mortality, hemorrhagic or ischemic stroke?

A

hemorrhagic

61
Q

goals for pts with hemorrhagic strokes

A

Improved cerebral tissue perfusion
Relief of anxiety
The absence of complications

62
Q

how can the nurse optimize cerebral perfusion and implement aneurysm precautions after hemorrhagic strokes?

A
  • Provide a nonstimulating environment, prevent increases in ICP, prevent further bleeding
  • Absolute bed rest with HOB 30 degrees
  • Avoid all activity that may increase ICP or BP; such Valsalva maneuver, acute flexion or rotation of neck or head
  • Stool softener and mild laxatives
  • Nonstimulating, nonstressful environment; dim lighting, no reading, no TV, no radio
  • visitors are restricted
63
Q

what are important precautions and patient education after hemorrhagic stroke

A
  • Relieving anxiety
  • Keep sensory stimulation to a minimum for aneurysm precautions
  • Reality orientation
  • Monitoring and managing potential complications
  • seizure precautions
  • Patient and family education
  • strategies to regain and promote self-care and rehabilitation
64
Q

home care and pt educations during stroke recovery

A
  • Prevention of subsequent strokes, health promotion, and follow-up care
  • Prevention of and signs and symptoms of complications
  • Medication education
  • safety measures
  • Adaptive strategies and use of assistive devices for ADLs
  • Nutrition: diet, swallowing techniques, tube feeding administration
  • Elimination: bowel and bladder programs, catheter use
  • Exercise and activities, recreation and diversion
  • Socialization, support groups, and community resources

Med II (4 decks)

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