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Nursing 232 > CV Disorders > Flashcards

CV Disorders Flashcards

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1
Q

Cerebrovascular disorders =

A

umbrella term that refers to functional abnormality of the CNS that occurs when the usual blood supply to the brain is disrupted

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2
Q

Stroke/brain attack causes?

A

caused by blockage or rupture and bleeding into brain tissue

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3
Q

How common is stroke as a cause of death in Canada?

What % made up by each of two kinds of stroke?

A

•Stroke is 3rd leading cause of death in Canada
o 80% ischemic
o 20% hemorrhagic

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4
Q

What is stenosis?

A

abnormal narrowing of passage in body

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5
Q

______ is single most importance modifiable risk factor for stroke

A

HTN

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6
Q

Non-modifiable risk factors for CVA?

A

Aging: risk doubles each decade after 55
Gender: male
Race: non-caucasian

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7
Q

Modifiable risk factors for CVA?

A 
HTN
AFib
hyperlipidemia
obesity
smoking
DM
carotid stenosis
valvular disease
periodontal disease
excessive alcohol consumption
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8
Q

Signs and symptoms of CVA?

A

• numbness or weakness (especially on one side of body)
• Confusion or change in mental status
• Trouble speaking or understanding speech
• Visual disturbances
• Difficulty walking, dizziness, or loss of balance and coordination
• Sudden severe headache
- Hemiplegia
- Loss of voluntary control
- Dysarthria
- Aphasia/dysphasia
- Apraxia
- Loss of half of visual field, peripheral vision, diplopia
- paresthesia
- Sensory loss
Etc…

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9
Q

hemiparesis

A

weakness on one side

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10
Q

Hemiplegia

A

Paralysis on one side

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11
Q

Ataxia =

A

unsteady gait

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12
Q

Initial signs of motor loss typically can be:

A

flaccid paralysis + loss of deep tendon reflexes

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13
Q

Dysarthria =

A

difficulty forming words, due to paralysis of muscles

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14
Q

3 kinds of aphasia/dysphasia

A

receptive, expressive, and global [mixed]

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15
Q

Apraxia =

A

difficulty completing previously learned action

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16
Q

homonymous hemianopsia

A

loss of half of visual field

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17
Q

paresthesia =

A

numbness and tingling of extremity

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18
Q

Describe sensory loss in CVA?

A

may be slight impairment of touch or total loss of proprioception (ability to perceieve position and motion of body parts), diffculty interpreting stimuli; agnosias

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19
Q

agnosias =

A

= deficits in ability to recognize previously familiar objects

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20
Q

Damage to frontal lobe leads to?

Other possible cognitive impairment and psychological effects of a stroke?

A

deficits in learning, memory, or other higher intellectual functions

limited attn span, forgetfulness, etc; emotional labiality, frustration + depression

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21
Q

If conscious most hemorrhagic stroke patients report what symptom?

What other symptoms common to some types of hemorrhagic stroke?

A

severe headache

Loss of consciousness of period of time; pain and rigidity in back of neck (nuchal rigidity) and spine; possible visual distubances, tinnitus, dizziness, and hemiparesis

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22
Q

Symptoms associated with subarachnoid hemorrhage

A

atypical headache with rapid onset, vomiting, neck stiffness, photophobia, hypertension, and cardiac arrhythmias

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23
Q

In what situation of hemorrhage from a brain vessel might few neurological signs be seen?

A

Slow bleed…may be stopped by clot

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24
Q

Right sided stroke effects?

A 
Paralysis/weakness of left side 
Left visual field deficit
Spatial-perceptual deficits
Increased distractibility
Impulsive behavior and poor judgement
Lack of awareness of deficits
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25
Q

Left sided stroke effects?

A 
Paralysis/weakness of right side 
Right visual field deficit
Aphasia (expressive, receptive, or global)
Altered intellectual ability
Slow, cautious behavior
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26
Q

What is the best approach to preventing a TIA?

A

Primary prevention!
* Healthy lifestyle prevention of occurrence and reoccurrence → reduces risk by ½

• Diet, nutrition, fitness, monitoring BP, adherence to med regimens, smoking cessation, health sleep hygiene practices, access to medical diagnostics, interventions and education

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27
Q

single most important risk factor for TIA?

A

HTN

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28
Q

Causes of TIA?

A

HTN is #1 cause, Afib, Diabetes, Family hx, cholesterol, Race (African Americans higher incidence)

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29
Q

What is a TIA?

Does it cause tissue damage?

A

A transient ischemic attack (TIA) is when blood flow to a part of the brain stops for a brief period of time.

  • Manifests as sudden loss of motor, sensory, or visual function

A person will have stroke like symptoms from minutes to a few hours
TIA is like a warning sign to a stroke
TIA – does not cause brain tissue to die.

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30
Q

Measures for TIA prevention other than the usual lifestyle factors?

A
  • 100mg Aspirin every other day shown to be effective
  • Treat HTN and manage DM
  • Those with AFib: use anticoagulants
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31
Q

Compare main presenting symptoms for ischemia and hemorrhagic stroke?

A

Ischemic = numbness or weakness of face, arm, or leg, especially on one side of body

Hem: exploding headache, decreased LOC

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32
Q

Ischemic vs hem in terms of recovery?

A

Ischemic: usually plateaus at 6 months

Hem: slower, usually plateaus at ~18months

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33
Q

Why is early thrombolytic tx important for ischemic strokes?

What is the key timelines for intervention?

A

Early thrombolytic tx results in fewer symptoms + less LOF

• Rapid response

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34
Q

5 kinds of ischemic strokes based on cause?

A

1) Large artery thrombotic strokes (plaque and occlusion),
2) small penetrating artery thrombotic strokes (affect more than one vessel, most common type)
3) Cardiogenic embolic strokes: associated with dysrhythmias (usually Afib), valvular heart disease or, or thrombi in left ventricle…start in heart, end up in brain; prevented with use of anticoag tx
4) Cryptogenic strokes – no known cause
5) “other”: illicit drug use, coagulopathies, migraine, etc.

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35
Q

Patho of brain ischemia as result of stroke?

A

obstruction of blood vessel + consequent initiation of “ischemic cascade”- series of cellular metabolic events; brain cells revert to anaerobic resp; acid build up + lack of ATP production; large calcium influx; cell membrane destruction, free radical production

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36
Q

Penumbra region:

A

area of low cerebral blow flow around infracted area → infarction spreads to this region as infarction advances

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37
Q

How quickly does damage to the brain occur?

A

1.9 million neurons lost/minute untreated; brain ages 3.9 years/hour without tx

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38
Q

How does hem stroke differ from ischemic in terms of long term deficits and recovery?

A

Those who survive acute phase of case usually have more severe deficits and longer recover phase than those with ischemic stroke

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39
Q

What are hem strokes due primarily due to?

Where does bleeding occur into?

A

Primarily d/t intracranial or subarachnoid hemorrage

bleeding into brain tissue, ventricles, or subarachnoid space

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40
Q

What is a intracerebral hemmorhage?

A

rupture of small vessels

makes up 80% of hem stroke cases

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41
Q

Subarachnoid hem d/t?

A

caused by tear in cerebral artery

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42
Q

What % of hem cases are d/t burst aneurysm?

A

bleeding is result of burst aneurysm

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43
Q

Common cause of hem stroke in elderly?

A

intracerebal hemorrhage d/t cerebral amyloid angiopathy – protein deposit in small and medium blood vessels

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44
Q

Patho of hem stroke?

Symptoms a result of what here?

A

symptoms produced when hemorrhage, anerysm, or AVM presses on nearby cranial nerves or brain tissue OR when aneurysm or VM ruptures causing subrarachnoid hemorrhage

Secondary ischemia d/t reduced perfusion pressure and vasospasm that accompany subarachnoid hemorrhage

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45
Q

Intracerebral hemorrhage
What is it?
Most common with what conditions?

A

(bleeding into brain tissue) most common with HTN and cerebral atherosclerosis – causing rupture

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46
Q

What is a Intracranial (cerebral) aneurysm?

Common location?

A

dilation of the walls of a cerebral artery that develops as result of weakening of artery walls;

usually occurs at birfucation of larger arteries in circle of Willis

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47
Q

What is the most common cause of stroke in young people?

A

AVM

Arteriovenous Malformations

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48
Q

AVM = ?

A

Arteriovenous Malformations = caused by abnormal embryonal development that leads to tangle in arteries and veins in brain that lacks cap bed

49
Q

Focal neurologic signs and symptoms of stroke (according to pp picture)

A
  • Paralysis
  • Sensory Loss
  • Language disorder
  • Reflex changes
50
Q

S&S of TIA

according to pp picture

A
  • Confusion
  • Vertigo
  • Dysarthria
  • Transient hemiparesis
  • Temporary vision changes
  • Syncope
51
Q

Acute phase of ischemic stroke may last how long?

A

1 to 3 days

52
Q

Medical imaging Interventions with ischemic stroke pt?

A
  • CT scan of head
  • CT angiography of Cerebral and neck vessels
  • ECG & carotid ultrasound standard tests
  • MRI?
  • Transcranial ultrasound?
53
Q

What should the initial focus of assessments be for a patient post stroke?

A

focus on airway patency (may be compromised by loss of gag and cough reflex), cardio status, and gross neurological deficits

54
Q

will a TIA be seen on medical imaging?

A

Won’t see any evidence of ischemia

55
Q

What imaging is typically done first with stroke? Why?

A

CT scan (of head) usually done first – shows if stroke is I or H

56
Q

What does a cerebral angiography show?

A

blood flow through vessels in brain

57
Q

Nursing interventions for ischemic stroke pt?

A
  • careful hx and complete phyical and neurological exam
    • Inc HOB
  • Very regular monitoring of Vitals and neuro vitals
  • Continuous hemodynamic monitoring (BP very important)
    • Continued assessment to determine if stroke evolving or other acute complications: bleeding (dec BP), medication-induced bradycardia, etc

Managing complications

o Maintaining airway patency
o O2 admin to minimize ischemia

58
Q

Pharmacological interventions for ischemic stroke pt?

A
  • Needed for secondary prevention in TIA or stroke
  • Afib treated with Warfarin
  • Aspirin, plavix, etc. depending on patient
  • Statins widely used for prevention
  • tPA if person qualifies
  • After acute phase, antihypertensives used for secondary prevention (aggressive control of HTN important)
  • Thrombolitics if within 3-4.5hrs
59
Q

When is an interdisciplinary approach initiated for stroke patients

A
  • Multidisciplinary approach initiated immediately

* Nurses, OT, PT, and SLP key to keeping independence in survivors

60
Q

How are efforts to reduce ICP made pharmacologically in care of stroke patients?

A

osmotic diuretics

61
Q

Surgical interventions in carotid for stroke patient?

A

carotid endarterectomy = removal of atherosclerotic plaque or thrombi’s from carotid artery to prevent stroke

or carotid stent

62
Q

Important complications to manage in stroke patient?

A

o Risk for aspiration pneumonia → maintaining adequate gas exchange key!
o Maintaining airway patency
o O2 admin to minimize ischemia
o Other complications = UTI’s, dysrhythmias, and complications of immobility

63
Q

Why is important to inc HOB with stroke patients?

A

promote venous drainage (swelling, ICP)

64
Q

When diagnosing stroke in individual under 40, may do what?

A

may take toxicology report to look for illicit drug use

65
Q

Which medical imaging tool is used to confirm diagnosis of intracranial aneurysm or AVM

A

Cerebral angiography – show location and size of lesion, and provide info about adjoining arteries, veins, adjoining vessels

66
Q

Possible complications of hem stroke?

A

rebleeding or hematoma expansion, cerebral vasospasm resulting in ischemia, acute hydrocephalus, and seizures

67
Q

Medical management of hem stroke?

A

Goal: to allow brain to recover from initial insult (bleeding), prevent or minimize risk of rebleeding, and to prevent and treat complications

o O2 + ensuring HCt and Hb are at good levels
o IV fluids for adequate hydration to ensure BP remains high enough to keep cerebral blood flow + keep blood viscous
o CSF drainage might be necessary with ICP (disturbed CSF flow possible)
oMay consist of bed rest with sedation to prevent agitations and stress, management of vasospasm, and surgical + medical intervention to prevent rebleeding
o Antiseizure agents often used prophylactically
o manage hyperglycemia
o Surgery
o Stool softeners used to prevent straining

68
Q

What condition often occurs in early stages of hem stroke?

A

Hyperglycemia in early stage often occurs – should be managed

69
Q

Why might a o Hypertonic saline infusion be used with hem stroke patients?

A

can draw fluids from cerebral tissue by inducing hypernatremic state
→ book seems ambivalent about whether this is effective measure of tx

70
Q

WHy is mannitol used?

What is it?

A

may be administered to reduce ICP – draws water from brain tissue by osmosis and reduces total body water by diuresis → important to assess for dehydration and electrolyte imbalances

71
Q

What sort of neuro assessment abnormalities might you see in a hem stroke patient?

A

may see altered LOC, sluggish PERLA, headache and nuchal rigidity, motor and sensory dysfx, cranial nerve deficits, speech difficulties, etc

72
Q

Nursing interventions for hem stroke pt?

A
  • Neuro assessment
  • Watch for complications (seizure, vasospasm, hydrocephalis, rebleeding)
  • BP, pulse, pupillary response, motor fx checked hourly
  • Regulate aneurysm precautions
  • Inc HOB
  • Low lighting (photophobia common)
  • Nurse feeds and baths to prevent all exertion
  • Seizure precautions
73
Q

From an observer, what are common first signs of a hem stroke?

A

Altered LOC (drowsiness, slurring of speech)

74
Q

What are aneurysm precautions?

A

strict bed rest, nonstimulating environment, limited visitors, no straining, acute flexion or rotation of head (restricts bloodflow), smoking

75
Q

Instruct pt to do what to prevent straining with voiding/defecation?

What other measure might be taken for this?

A

breath out mouth during voiding and defecation

Stool softeners and mild laxatives – no enemas!

76
Q

How much should HOB be elevated for stroke patients? Why? WHen might a patient be instructed to lie flat?

A

HOB elevated 15-30 degrees to promote venous drainage and decrease ICP (or may be told to lie flat to inc cerebral perfusion)

77
Q

If a seizure occurs, what are the nurses primary goals?

A

maintain airway + prevent injury

78
Q

Nursing assessments during the acute phase of a stroke?

A
  • Neurological flow sheet maintained
  • Looking for reduced LOC, loss of orientation, dec response to stimulation
  • Presence or absence of voluntary and involuntary movements
  • Stiffness and flaccidity of neck
  • Eye opening, PERLA, dry eyes (d/t loss of blink reflex)
  • CWMS
  • Quality and rates of resps and pulse, ABG’s, temp
  • Ability to speak
  • I/O
  • Bleeding
  • Maintenance of BP
79
Q

What is recombinant tPA?

When should it be used?

A

genetically engineer from from t-PA (thrombolytic substance in body) – binds fibrin, converts plasminogen to plasmin, which stimulates fibrinolysis of atherosclerotic lesion

•Intervene with these within 3-4.5hrs to significantly reduce long-term recovery

80
Q

Why is there a time limit on the use of thrombolytics in stroke?

A

• Delay in tx means pt no longer elibible for thrombolytic tx b/c revascularization of necrotic tissue (develops at 3-4.5hrs) increase risk of cerebral edema and hemorrhage

81
Q

How is tPA dose determined? Is everyone eligible? What happens if you are?

A
  • T-PA dose determined based on weight

* Must determine if pt is candidate for tPA tx; once this is intiated, no other anticoag given for 24hrs

82
Q

Important considerations for giving tPA?

A

Greatest risk of t-PA is bleeding → delay insertion of nasogastric tubes, urinary catheters, etc

83
Q

What is given to those who are not qualified for tPA?

A

anticoag (heparin and LMWH) used; efforts to reduce increased intracranial pressure (ICP) from brain edema incl osmotic diuretics,

84
Q

What is TPA in body (not recombinant)?

A

Tissue plasminogen activator (TPA) = natural substance that dissolves already formed clots

85
Q

How does warfarin work?

A

works by inhibiting vitamin K syn by bacteria in GI, thus inhibiting production of vitamin-K dependent clottin factors

86
Q

What condition might you confuse a TIA with?

A

you might think its Diabetes as it has similar symptoms

87
Q

What would nursing assessments in recovery of stroke focus on?

Important to know what about pre stroke patient?

A

Assessments focused on decreased fx in daily activities – closely tied to quality of life

•Important to know how patient was before stroke

88
Q

When does rehab of stroke begin?

Goals?

A
  • Rehab begins moment of stroke but intensifies during convalescence period
  • Most important goals around improving quality of life and minimizing dependence
89
Q

Main areas of focus for nurses in rehab of stroke patients?

A
  • Improving mobility and preventing joint deformities
  • Preparing for ambulation
  • Preventing shoulder pain
  • Enhancing self-care
  • Managing sensory-perceptual Difficulties
  • Assisting with nutrition
  • Attaining Bowel and Bladder control
  • Improving Thought Processes and communication
  • Maintaining skin integrity
  • Improving family coping
  • Helping pt cope with sexual dysfunction
90
Q

Important considerations for prevention of joint deformities?

A
  • correct positions important for prevention of contractures, prevent compression neuropathies

o May use splint at night to keep extension

o Preventing should adduction: while in bed, place pillow in axilla, arm placed in slightly flexed position with distal joints higher than proximal – helps to prevent edema and joint fibrosis
o Fingers slightly flexed, hand slightly supinated; botox injections possibility
o Change position q2h
o Put pillow between legs when turning to lateral lying
o Time spend on affected side should be minimized if loss of sensation
o Upper thigh should not be acutely flexed when lateral lying to prevent edema and promote venous return
o If possible, place in prone position 15-30mins several times/day; pillow under pelvis to promote hyperextension of hips → this position helps gait, drains bronchial secretions and prevents contractural deformities in shoulders and knees

91
Q

How do joints tend to contract after stroke?

A

o When control of voluntary muscles lost, flexor muscles exert control over extensors
o Arms tends to adduct and rotate internally, legs rotate internally, flex at knee

92
Q

ROM activities how many times per day for rehab?

Long or short sessions better?

A

o Affected extremities exercised passively through full ROM 4-5 times/day

o Frequent short periods better than prolonged at infrequent intervals

93
Q

Why is repetition important in rehab?

A

forms new CNS pathways, encourages new patterns of movement

94
Q

Why do rehab pt’s need exercise programs?

A

Enhances circ to prevent venous stasis + thrombi, maintain mobility, etc

o Need daily exercise to improve muscle strength + maintain ROM

95
Q

What muscles are some of the most important to mobilize first?

A

Quad + gluteal started first to promote walking – done at least 5 times/day for 10mins

96
Q

What can be a helpful tool for exercise schedule in rehab patients?

A

Written schedule can remind pt

97
Q

General guidelines in helping pt preparing for ambulation

A

o First will work to balance when sitting, then standing
o Can use tilt table if pt has difficulty balancing when standing (esp good for those with orthostatic htn after prolonged bed rest)
o If needs wheelchair, folding type with hand breaks best because pt involved in manipulating
o Training periods short and frequent
o Parallel bars may be helpful, pronged cane as gains confidence

98
Q

What kind of pain is especially prevalent in stroke rehab patients?

A

Shoulder

99
Q

Why does shoulder pain result in rehab patients?

A

o 3 situations possible: painful shoulder, subluxation of the shoulder and should-hand syndrome
o If has flaccid shoulder, can easily be overstretching during positioning – ensure never to lift pt by flaccid shoulder
o Subluxation (dislocation) can occur from overstretching and gravity if arm is paralyzed

100
Q

What is shoulder-hand syndrome?

A

pain in shoulder with swelling in hand; can cause frozen shoulder and atrophy of subcut tissues – when shoulder becomes stiff, is usually painful

101
Q

Measures for should pain prevention/treatment?

A

o Much pain can be prevented with proper positioning and mobility
o When seated, position flaccid arm on table or with pillow
o ROM exercises very important
o May use sling when first mobilizing to prevent dangling of arm
o Avoid overhead pulleys
o Other treatments: analgesia, massage, acupuncture, TENS, should strapping

102
Q

What can nurse do to enhance self care of pt?

A

o Set realistic goals, possible add 1 activity each day
o First step: carry out self-care activities on unaffected side
o Use small towel, boxed toilet paper rather than roll
o Get baseline functional abiltity – FIM = Functional Independence Measure
o Keep space uncluttered and organized
o Place clothes on affected side in order need to be put on
o Be present to help with fatigue and encouragement

103
Q

Nursing considerations for managing sensory-perceptual difficulties (those r/t vision)

A

o Approach on side where visual perception is intact
o Place all visual stimuli on unaffected side (clock, calendar, etc)
o Have turn head toward affected side to compensate
o Inc lighting, possible glasses
o With homonymous hemianopsia tend to move away from and avoid affected half = amorphosynthesis → imp for nurse to remind of other side of body, position limbs correctly and so within visual field

104
Q

How to aid with nutrition after stroke?

A

o Dysphasia possible – risk for pneumonia, dehydration, aspiration, malnutrition
o SLP will evaluate
o Increase HOB, encourage chin tuck to prevent aspiration
o May have feeding tube

105
Q

Why do post stroke patients experience intermittent incontinence?

A

d/t confusion, inability to voice needs, impaired motor and postural control

o Bladder may become spastic as deep tendon reflexes and muscle tone inc

106
Q

What might be used at first after stroke for voiding and why?

Other aids?

A

Response to bladder filling may be diminished at first – intermittent catheterization used

o Voiding pattern analyzed and bed pan offered at this schedule
o Males aided by upright or standing position
o High fibre, adequate fluids encouraged to prevent constipation

107
Q

When working to improve thought processes, what should the approach or attitude of the nurse be?

How should exercises be designed?

A

o Role of nurse = supportive; reviews results of neuropsychological testing, observes performance and progress, gives positive feedback and conveys attitude of confidence and hope
o Exercises designed to capitalize on strengths while improving performance of affected fxs

108
Q

What part of the brain is the cortical area responsible for integrating the pathways required for comprehension and formulation of language

A

Broca’s area

109
Q

Why are speech deficits more likely seen if left hemispheric damage?

A

Broca’s area very close to left motor area – often affected if also see motor deficits → why foten those paralyzed on right side (damage left side) can’t speak, damage to right less likely to affect speech

110
Q

What can aphasia result in (regarding mental health). Role of nurse here?

A

depression → nurse to be supportive of anxiety and frustration

111
Q

What is a common pitfall of nurses in the care of patients with aphasia?

A

completing thoughts or sentences of patient → don’t do this!

112
Q

What simple measure can be helpful for functioning despite deficits?’

Other considerations for those with reduced communication abilities?

A

Consistent schedule, routines, and repetition

o May be aided by copy of daily schedule, audiotaped list, folder of personal info, checklists, communication board with common needs and phrases
o Give one instruction at a time, speak slowly and clearly, keep language consistent
o Communicating with pt with aphasia – see box on pg. 2059
o Remember to speak with pt during care → important to have this social contact

113
Q

Tips for improving family coping with stroke pt.

A

o Encourage to access emotional supports
o Give info about expected outomces
o Teach to not do what pt can do for themself
o Ensure knows recovery from hemiplegia is many months and progress is slow
o Teach to keep interactions positive, focus on remaining abilities
o Prepare family to expect some emotional lability – instruct that crying or laughing may not indicate happiness of sadness, and that lability will improve with time

114
Q

Possible barriers in post-stroke patients regarding sexual functioning?

Nurse to do what?

A

physical limitations, discomfort and/or pain which may limit sexual positions, decreased libido/arousal

o Nurse plays key role in speaking with pt about this- should do in-depth assessments of sexual hx and follow with appropriate interventions r/t physical barriers, promotion of intimacy, pleasure, and self-confidence

115
Q

• Constraint-induced movement therapy =

A

intensive exercises given to affected limb while unaffected limb is restrained

116
Q

What to encourage to prevent depression in stroke survivors?

A

• Encourage to continue hobbies, keep social contact

117
Q

Considerations for care-givers of stroke patients?

A
  • Caregiver burden associated with inc anxiety, depression – assess for signs of this in caregiver
  • Remind caregivers to attend their own needs too – respite care services encouraged
118
Q

Glasgow Coma Scale

A

The Glasgow coma scale (GCS) is a reliable and universally comparable way of recording the conscious state of a person. Three types of response are measured, and added together to give an overall score. The lower the score the lower the patient’s conscious state. The GCS is used to help predict the progression of a person’s condition.

13- 15 Mild TBI (traumatic brain injury) symptoms. Concussion?
9 – 12 Moderate disability – LOC?, physical or cognitive impairments
3 – 8 Coma – unconscious state – no meaningful response, no voluntary response

119
Q

3 categories in GCS?

A

Eye opening
Verbal
Motor

Nursing 232 (12 decks)

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