CVA Flashcards
What is a stroke
Interruption of blood flow for an extended period of time that does not resolve within 24 hours
Most common type of stroke
Ischemic Stroke (85-87%)
True or false stroke is a chronic disease
True
Transient Ischemic attack (TIA)
Brief episode of stroke like symptoms, however it resolves completely
-Can Last a few minutes to a few hours
-Symptoms completely resolve
-Main idea is that it works as a warning sign
How much more likely are you to have a stroke after a TIA
9 times
TIA treatment
-Typically stay for 24-28 hours for observation
-Dual anti-platelets
-Statins
-Tele unit
-Carotid doppler
-Echocardiogram
-Recommend lifestyle changes
-Neuro follow up (even if there are no symptoms)
-Treat it like a stroke with aggressive treatment
Carotid Doppler
Checking for stenosis for TIA or a stroke
How would a TIA differ a stroke on imaging (MRI/CT)
A stroke would be visible occlusion while a TIA would not
A patient came into the clinic with facial drooping and weakness on one side of the body, Through CT and MRI the DO concluded that that this was a TIA however after 24 hours, symptoms do not disappear. How would this affect the diagnosis the patient has
This would be considered a stroke instead of a TIA
What drugs are given for a TIA
anti-plt: Aspirin, Plavix
Statin: Atorvastatin
Echocardiogram TIA
Non-invasive
-Looking for a clotting and PFO
Ischemic stroke
Blood in brain becomes blocked and cuts off blood supply in the brain resulting in death of brain cells
Embolic stroke
Ischemic stroke that a clot from another place in the body becomes dislodged and travels to the brain where it gets stuck preventing blood flow to surrounding tissue
Thrombotic stroke
Ischemic stroke that forms as a result of a narrowing of the blood vessel within the brain itself which leads to occlusion
Left brain
Logic
-Skills like writing, speaking, math, analysis, planning
-Controls the opposite side of the body (Right)
Those with a left brain injury would have issues with
Right side hemiparesis
-Aphasia (Issues regarding speaking)
-Would be aware of their limits (Can become angry or frustrated as they are experiencing a loss)
-Would have trouble with written text (Analysis)
-Issues with writing, math
-Memory is intact , remember their skills pre stroke and can be frustrated at this loss of independence
-Recognizing objects
Right brain
Creativity
-Their attention span
-Emotions
-Problem solving
-Reasoning (jokes and such)
-Making judgment calls
-Memory recall
-Music and art awareness
-Controls left side of the body
Right brain injury would have
Left side hemiparesis
-Impairment in creativity
-Confusion of date time and place
-Struggles with recognition of faces or names
-Loss of depth perception
-Trouble staying on topic (attention span)
-Not being able to interpret non-verbal language (Reasoning)
-Lack of awareness or deficits
-Impulsive and poor judgment
A nurse is caring for a patient who recently experienced a stroke in the right hemisphere. which of the following alterations in functioning would be expected in this patient
A.) Difficulty reading
B.) Inability to recognize family members
C.) Right Hemiparesis
D.) Aphasia
B.) Inability to recognize family members
Left brain is responsible for the logical components of function which A,,D fall into. C is incorrect as the weakness in the body is opposite that of where the injury occurred in the brain
BE FAST (stroke)
B: Balance (Loss of balance, headache, confusion, dizziness)
E: Eyes (Blurry vision, loss of vision)
F: Facial (Face uneven( Drooping), tongue deviating from midline)
A: Arms are weak, or numb
S: Speech difficulties, slurred speech
T: Timing, call 911 the sooner treatment occurs the better the chances of recovery
B (BE FAST)
Balance
E (BE FAST)
Eyes
F (BE FAST)
Facial
A (BE FAST)
Arms
S (BE FAST)
Speech
T (BE FAST)
Time
Arm drift
Hold out arm in front of patient and have them close their eyes , if one drops and the other stays up its a positive identifier
Stroke Diagnosis
-CAREFUL history, rule out other issues and a physical
-Blood draw (CBC, BMP, Cardiac biomarkers, coagulation studies)
-EKG (Dont delay CT/MRI for it tho)
-CT of head to rule out hemorrhage
-MRI to determine ischemic zone
-Cardiac doppler (Stenosis)
-Echocardiogram
-Cerebral angiography
-Need to differentiate Ischemic and hemorrhagic stroke
CT purpose: stroke
Rule out bleeding
MRI purpose: stroke
Determine the ischemic zone
Doctor to needle time, stroke
1 hour from seeing a doctor to getting TPA
Code Stroke
-Get to er within 1 hour of symptoms
-Vitals/EKG 5 min after arriving
-Within 10 min see doctor for neuro eval
-25 min CT scan
-Diagnosis within 45 min after arrival to er
Treatment; Ischemic stroke
-Early intervention is key to prevent infarction of the tissue which is within 1-3 hours
-Pharm treatment
-Thrombectomy: Not everyone is a candidate
-Airway protection
-Blood pressure control (Allow elevated bp)
-Tight diabetic control
-Control of arrhythmias
Pharmacological treatment: Ischemic stroke
t-PA: Dissolves the clot and increases blood flow
-Dual anti-plt therapy (Aspirin, Plavix)
-Statin
-Anticoagulants
-Anti-epileptic medications as needed
TIA is more similar to a hemorrhagic stroke, True or false
False
Thrombectomy
Physical removal of the clot, placement of catheter and then it is used to grab the clot from the blocked artery
-Done after patient has received t-PA and within six hours of acute stroke symptoms
Ischemic stroke treatment: Airway control
Supplemental O2
-Prevent partial airway obstruction, aspiration pneumonia
-May need intubation for airway control
Number one cause of death besides neurologic for those with ischemic strokes
Aspiration pneumonia
Why allow for hypertension for those experiencing a stroke
Hypertension is an increase in blood pressure which may allow for better oxygenation status to areas of the brain that would be affected by the stroke,
-To achieve this they may discontinue the blood pressure medication the patient is on when admitted
t-PA major concern
Risk of bleeding
-Within the 3 hour window
Eligibility criteria t-PA
-18+
-No deficits in pre-stroke status
-SBP <185 and diastolic <110
-Not a minor stroke or rapidly resolving symptoms
-No prior intracerebral hemorrhage, AVM aneurysm or tumor
-No GI, GU bleeding in the past 21 days
-No stroke or head trauma in the past 3 months
A patient who was diagnosed ischemic stroke, however their symptoms spontaneously resolve are they eligible to t-PA
No the symptoms resolved
Tissue Plasminogen Activator (t-PA)
-Only given for ischemic strokes
-Goal is to be given within 60 min of getting to ED
-Contraindicated for hemorrhagic stroke or more than 3 hours (RISK OF BLEEDING)
Nursing interventions t-PA
-Monitor for bleeding
-Neuro checks around the clock
-Vitals
-Labs
-Glucose monitoring
-Bed rest to prevent injury
-Avoid unnecessary trauma to the body (Needles, ivs, foley)
-Blood pressure meds needed for those with hypertension
-Most go to icu
Why are stroke patients with t-PA on bed rest
Threat of falls inducing trauma causing bleeding
Hemorrhagic stroke
-Weakened blood vessel burst and bleeds into the brain
-Cuts off O2 rich blood supply to the area
-Blood increases pressure in the brain leading to even more dmg
Intracerebral hemorrhage
Bleed that occurs within the brain itself, usually caused by htn
Subarachnoid hemorrhage
Bleeding between the brain and the meninges in the subarachnoid space
S+S hemorrhagic stroke
-Presents similar to ischemic stroke, need CT and MRI to differentiate
- Sudden terrible headache (Thunderclap)
-Immediate loss of consciousness (In severe cases)
-Seizures (more common)
-N+V (Can be both projectile and non projectile)
-Visual disturbances
Which stroke has a higher mortality rate ischemic or hemorrhagic
Hemorrhagic, it has an initial mortality as high as 50%
Survivability is dependent on the patient
Hemorrhagic stroke treatment
Goals are to manage the current bleed, allow the brain to recover, minimize future bleeds and prevent complications
-Administer O2
- Bed rest (Avoid even more bleeding)
-Fresh frozen plasma and vitamin K if on blood thinners like warfarin
-Anti-epileptics if seizures occur
-Intermittent pneumatic compression stockings
-Analgesics for head and neck pain
-NEURO EXAM
-If patient is showing worsening neuro exam they might need surgical intervention with craniotomy for aneurism clipping
Risk factors for strokes
-Htn
-Hyperlip
-Diabetes
-Heavy alc use
-Age
-race
-A-fib
-Carotid stenosis
-Cardiac disease
-TIA history
-Obesity
-Sedentary lifestyle
-Smoking
-AV malformation
Nursing assessment, stroke
-Careful history, very thorough
-ABC
- Give O2
-Aspiration pneumonia risk
-Neuro checks
-Eye opening and pupil size
-Ability to speak
-I+O
-Seizure precautions
-Bleeding
-Keep BP in parameters, allow permissive hypertension
Rehab of a stroke
Restore as much function as possible and attain the best quality of life
-Rehab doesn’t cure brain dmg from the stroke but it allows the patient to improve what they have and improve long term outcomes
-Its catered to the patient and their situation, and can vary based on what they need to become independent
Major goals of Rehab
Prevention of aspiration pneumonia
-Improve mobility
-Relive pressire
-Avoidance of shoulder pain
-SELF CARE
-Confidence
-Continence
-Some form of communication
-Prevent joint deformities (Contractures)
Forms of rehab
PT
OT
Speech language
T/F rehab has to be done by a specialist
False the nurse should contribute to start early interventions with the patient
Hemiplegia
Paralysis on one side of the body (In strokes its the opposite to the side of the brain affected)
Hemiparesis
One side of the body is weaker than the other
Dysphagia
Trouble swallowing
Paresthesias
Pain, tingling or prickling sensation that can occur after a stroke in the weakened or paralyzed limbs
Disabilities post stroke: Sensory disturbances
Loss of ability to feel touch, pain, temp, or position
-Paresthesias
- Urinary Incontinence
Disabilities post stroke: Aphasia
-Expressive
-Receptive
-Global aphasia
Expressive aphasia
Can cant form words, however they can understand what you are saying
Allow them time to speak
Receptive aphasia
Have issues receiving information, have trouble understanding words as a result
Use short direct phrases
Global Aphasia
Both receptive and expressive aphasia, most severe form
-Cannot understand language or use it to convey thoughts
Disabilities post stroke: memory and thinking
-Learning
-Planning
-Comprehension of meaning
-Engage in complex mental activities
-Deficits in short term memory affecting ability to follow long instructions
Disabilities post stroke: Emotional disturbances
-Fear
-Anxiety
-Sadness
-Frustration
-Anger
-Feel a sense of grief to physical and mental losses
Most common mental illness for stroke survivors
Depression
Dysphagia mgmt:
-Swallow studies
-Thickened liquids
-Mechanical soft diets
-Assist with feed
-Tuck chin
-Remove distractions ( have them focus on eating)
-Be patient
Aphasia mgmt
-Remove distractions
-Be patient
-Repeat and rephrase
-Speak clearly and unhurried
Receptive aphasia mgmt
-They dont understand what we are saying
-Use shot phrases and simple details
-Use gestures
Expressive Aphasia mgmt
-They know what we are saying but are having trouble responding with their own words
-Be patient
-Ask one question ask a time
-Communication board
-Ask questions that proct a short response
Hemianospia
Half of vision is gone, they can see other part
Hemianopsia mgmt
-Place objects within vision
-Injury prevention
-Approach patient from within vision
-Instruct and remind them to turn head to compensate for loss of vision
-Have someone evaluate driving ability
Long term stroke complications
–Aspiration pneumonia
-Skin breakdown
-UTI
-Complications of immobility
-Deconditioning
-Bowel and bladder dysfunction
T/F once you have a stroke you wont have another for the rest of your life
False you are more likely to have one now
A nurse is caring for a client who has experienced a right hemispheric stroke. Which of the following are expected findings? (Select all that apply):
A.) Impulse control difficulty
B.) Left hemiplegia
C.) Loss of depth perception
D.)Aphasia
E.) Lack of situational awareness
A
B
C
E
A nurse is caring for a patient with left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
A.)Teach the patient to scan to the right to see objects on the right side of her body.
B.)Place the bedside table on the right side of the bed.
C.)Orient the patient to the food on her plate using the clock method
D.)Place the wheelchair on the patient’s left side
B.)Place the bedside table on the right side of the bed.
A nurse is planning care for a patient who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? Select all that apply:
A.)Have suction equipment available
B.) Feed the client thickened liquids
C.) Place food on the unaffected side of the client’s mouth
D.) Assign an assistive personnel to feed the patient slowly
E.) Teach the patient to swallow with the neck flexed
A
B
C
E
A nurse is caring for a patient who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the patient’s plan of care? Select all that apply:
A.) Speak to the patient at a slower rate
B.) Assist the patient to use flash cards with pictures
C.) Speak to the patient in a loud voice
D.) Complete sentences that the patient can not finish
E.) Give instructions one step at a time
A
B
E
A nurse is assessing a patient who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
A.) Impulse control difficulty
B.) Poor judgement
C.) Inability to recognize familiar objects
D.) Loss of depth perception
C
