CVA Flashcards
stroke
occurs when there is ischemia to part of the brain or hemorrhage into the brain
non modifiable stroke risk factors
- age
- sex
- ethnicity and race
- heredity
- arteriovenous malformation
modifiable stroke risk factors
- hypertension
- diabetes
- heart disease
- increased serum cholesterol
- heavy alcohol consumption
- oral contraceptive use
- smoking
- obesity
- substance use
thrombotic stroke
cerebral thrombosis is a narrowing of the artery by plaque. plaque can causes a clot which blocks the passage of blood
embolic stroke
- embolus lodges in an artery and block blood flow
- results in infarction and edema
- pt conscious with headache
- emboli usually originate in endocardial layer
hemorrhagic stroke
burst blood vessel allows blood to seep into damaged brain tissue until clotting shuts of leak
symptoms
- neurological deficits
- headache
- n&v
- decreased LOC
- hypertension
ischemic stroke
- inadequate blood flow to the brain from occlusion of an artery
- thrombotic, embolic
- TIA is precursor
transient ischemic attack (TIA)
transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain
symptoms are <1 hour
lacunar stroke
occlusion of a small, penetrating artery with development of a cavity in the place of the infarcted brain tissue. This most commonly occurs in the basal ganglia, thalamus, internal capsule, or pons.
typically asymptomatic
CM stroke
- motor functions
- elimination
- intellectual function
- spatial perceptual alterations
- personality
- affect
- sensations
- communications
CM of stroke: motor function
impairment of
- mobility
- respiratory function
- swallowing and speech
- gas reflex
- self-care abilities
CM of stroke: motor deficits
- loss of skilled voluntary movement
- impariment of integration of movement
- alterations in muscle tone
- alterations in reflexes
CM of stroke: communications
- aphasia when stroke damages dominant hemisphere of brain
- dysarthia (disturbance in muscular control of speech)
- poor pronunciation, articulation, phonation
CM of stroke: affect
- difficulty controlling emotions
- exaggerated or unpredictable
- depression
- frustration
CM of stroke: intellectual function
- impairment of memory and judgement
- left-brain stroke is more likely to result in memory problems related to language
CM of stroke: spatial-preceptual alterations
- more likely in RS stroke
categories
- deny illness or own body parts (anosognosia)
- erroneous perception of self in space
- inability to recognize object by sight, touch, hearing (agnosia)
- inability to carry out learned sequentual movements (apraxia)
CM of stroke: elimination
- frequency, urgency, incontinence
- constipated
- occur initially and are temporary
dx studies for stroke
- CT (distinguish between ischemic and hemorrhagic stroke)
- MRI
- CTA (visualization of cerebral vasculature)
- MRA
- cerebral or carotid angiography (identify occlusion, plaque)
- Digital subtraction angiography
- Transcranial Doppler ultrasonography (measures velocity of blood)
- Lumbar puncture (for evidence of RBC in cerebrospinal fluid is hemorrhage is suspected)
stroke assessment findings
- altered LOC
- Weakness, numbness, or paralysis
- Speech or visual disturbances
- Severe headache
- ↑ or ↓ heart rate
- Respiratory distress
- Unequal pupils
- Hypertension
- Facial drooping on affected side
- Difficulty swallowing
- Seizures
- Bladder or bowel incontinence
- Nausea and vomiting
- Vertigo
initial interventions for stroke
- Ensure patent airway
- Call stroke code/team
- Remove dentures
- Perform pulse oximetry
- Maintain adequate oxygenation
- Obtain IV access with NS
- Maintain BP
- remove clothing
- insert catheter
- CT scan
- baseline labs
- position head midline
- elevate bed 30 degrees if no symptoms of shock or injury occur
- seizure precautions
- NPO
acute care of stroke
- hypertension is common after: meds to lower BP
- control fluid and electrolyte balance
ongoing stroke interventions
- LOC
- sensory function
- pupil size and reactivity
- O2 sats
- cardiac rhythm
recombinant tissue plasminogen activator (tPA)
- re establish blood flow through blocked artery to prevent cell death
- administer within 4.5 hours on onset
- IV
- no antiplatelets or anticoagulants with it
stroke rehabilitation
- after stroke has been stabilized for 12-72 hours: attain optimal functioning
comprehensive neuroexamination
- Level of consciousness (using Canadian Neurological Scale)
- Cognition
- Motor abilities
- Cranial nerve function
- Sensation
- Proprioception
- Cerebellar function
- Deep tendon reflexes
respiratory management: nursing considerations and stroke
- Risk for atelectasis
- Risk for aspiration pneumonia
- Risks for airway obstruction
- May require endotracheal intubation and mechanical ventilation
neurological: nursing considerations and stroke
- monitor for stroke extension, increased ICP, vasospasm
- GSC
- NIHSS
- pupillary responses
- extremity movement and strength
cardiovascular: nursing considerations and stroke
- monitor VS
- monitor rhythms and heart sounds
- intake and output
- regulating IV infusions
- monitor lung sounds
- prevent DVT
musculoskeletal: nursing considerations and stroke
- maintain optimal function
- prevent joint contractures and muscular atrophy
- ROM and positioning
- hand splints, slings, rolle to prevent deformities
integumentary: nursing considerations and stroke
- susceptible to breakdown
- compounded by pt age, poor nutrition, dehydration, edema
- pressure relief by changing positions
- emollients to dry skin
- early mobility
- only position on paralyzed side for 30 mins
gastrointestinal/urinary : nursing considerations and stroke
- constipation
- stool softeners
- avoid in-dwelling catheters
- bladder retraining program (adequate fluids, toileting q2h)
nutrition : nursing considerations and stroke
- test swallowing, chewing, gag reflex, pocketing
- follow eating with oral hygiene
communication: nursing considerations and stroke
- speak slow, calm, use simple words and sentences
- gestures to support words
- picture board
stroke prevention
- Antiplatelet (aspirin) meds
- statins
- anticoagulants for tx of TIA in those with AF
