management of patients with cerebrovascular disorders Flashcards
terminology
agnosia
loss of ability to recognize obhects through a particular sensory system; may be visual, auditory, or tactile
terminology
aphasia
inability to express oneself or to understand language
terminology
apraxia
inability to perform previously learned purposeful motor acts on a voluntary basis
terminology
dysarthria
defects of articulationdue to neurologic causes
terminology
dysphagia
difficulty swallowing
terminology
expressive aphasia
inability to express oneself; often associated with damage to the left frontal lobe area
terminology
hemianopsia
blindness of half of the field of vision in one or both eyes
terminology
hemiparesis
weakness of one side of the body, or part of it, due to an injury in the motor area of the brain
terminology
hemiplegia
paralysis of one side of the body, or part of it, due to an injury in the motor area of the brain
terminology
receptive aphasia
inability to understand what someone else is saying; often associated with damage to the temproal lobe area
describe ischemic stroke
- approximately 87%
- occurs over minutes to hours to days
- caused by thrombosis/emoblism
- clot deposits in large vessels or small vessels (small vessles r/t diabetes, called lacunar)
- incidence and mortalities have declined
describe hemorrhagic stroke
- approximately 13%
- rapid
- occurs over minutes to hours
- bleeding
describe thrombolytic therapy for ischemic strokes
- prevents or limits the extent of brain tissue
- must be administered ASAP after onset
- treatment window 3-4.5hrs
- referred to as “brain attack”
name the 5 types of ischemic strokes
- large artery thrombotic
- small penetrating artery thrombotic
- cardiogenic embolic
- cryptogenic
- others: coagulotherapies, cocaine use, migraines/vasospasms, spontaneous dissection
describe large artery thrombotic strokes
atherosclerotic plaques
occur in carotid
describe small penetrating artery thrombotic strokes
lacunar - r/t diabetes
describe cardiogenic embolic strokes
r/t arrhythmias (afib)
emobolic r/t valvular diseases leads to left middle cerebral artery
describe cryptogenic strokes
idiopathic/no known cause
what are some thrombotic causes of ischemic strokes
- atherosclerosis
- bifurcation of common carotid
- most common in diabetics
- lacunar infarct from small vessels d/t HTN and diabetes
what are some embolic causes of ischemic strokes
- travels from outside of brain and occludes cerebral artery
- plaque
- clot from afib
- mechanical valves
what are some covid-19 considerations for strokes
- covid causes abnormal clotting
- high d-dimer
- less than 50 years of age
- occurs in large blood vessels (carotid/midcerebral)
- severe neurological deficits
describe the pathophysiology of ischemic strokes
disruption of cerebral blood flow due to obstruction of blood vessel
cascade of events:
Decreased blood flow → loss of aerobic respiration → switch to anaerobic → creates lactic acid → change in pH → neurons cannot produce sufficient ATP for depolarization → failure of membrane to maintain electrolyte balance → loss of cellular function
what kind of BP do you want for an ischemic stroke?
higher BP to get more blood to the brain
what kind of BP do you want for hemorrhagic stroke?
low BP bc blood to getting out everywhere
what are some symptoms of a stroke
Motor loss – Upper motor neuron lesion; disturbance of voluntary control on one side of body; hemiplegia, hemiparesis; decrease in deep tendon reflexes, flaccid paralysis, spasticity
Communication Loss – aphasia, dysarthria, expressive aphasia, receptive aphasia, apraxia
Perceptual disturbances – hemianopsia, loss of visual-spatial relations
Sensory loss – loss of proprioception, difficulty in interpreting tactile, visual, auditory stimuli, agnosia
Cognitive Impairment and psychological effects – limited attention span, difficulties in comprehension, forgetfulness, lack of motivation. Psych: frustration, depression, emotional ability, hostility, resentment, lack of cooperation, and others.
what are some generalized findings of a stroke
- HTN
- headache
- vomiting
- seizures
- change in mental status
- fever
- changes in EKG
what are some early warning signs of a stroke
- TIA
- transient hemiparesis
- loss of speech
- hemisensory loss
- severe occipital/nuchal HA
- vertigo/syncope
- transient paralysis
- retinal hemorrhage
describe what happens with left hemispheric stroke
- paralysis or weakness of right side of body
- right visual field deficit
- aphasia (expressive, receptive, or global)
- altered intellectual ability
- slow, cautious behavior
describe what happens with a right hemispheric stroke
- paralysis or weakness on left side of body
- left visual field deficit
- spatial-perceptual deficits
- increased distractibility
- impulsive behavior and poor judgements, lack of awareness of deficits
whats included in the assessment of a stroke
- careful history
- neuro exam
- airway patency
- CV status
- neurologic deficits
descrieb the careful history taken for stroke assessment
- warning signs include TIA (loss oc circulation for a brief moment, resolves within 24hrs)
- BP maintenance
- sx of afib and management of afib
describe the neuro exam for stroke assessment
- cranial nerves, muscle strength, drift
- facial droop, drooling, reflexes
when talking about airway patency, whats a person having a stroke at risk for?
aspiration
what are some neurological deficits found upon stroke assessment
drooping, paralysis, weakness
what are some diagnostic tests for stroke assessment
- CT wihtouf contrast (then with if not hemorrhagic)
- MRI (changes not apparent until 8-12hrs after onset)
- ECG (loof for afib)
- transcranial doppler (see what blood flow is like)
- carotid duplex (US -> look for blockage)
- echo (clots in atria or vegetation or valves)
whats the drug given for strokes and what are the guidelines for it
TPA
be sure to ask when the patient was last known to be normal, has to be given in a 3-4hr window
whats included in the primary prevention of stroke
- healthy diet - DASH (dietary approaches to stop hypertension)
- engaging in physical activity
- maintain ideal body weight
- maintain safe cholesterol levels
- smoking cessation
- low dose estrogen birth control
- reduce heavy alcohol intake
- eliminate illicit drug use (cocaine = bad)
whats included in secondary prevention of stroke
- adequate BP control
- check cholesterol
- care of DM
- treatment of CV disease, TIA, and afib
what are some modifiable stroke risk factors
- hyperlipidemia
- cigarette smoking
- heavy alcohol consumption
- cocaine use
- obesity
- women of chilbearing years (pregnancy/birth control)
- unhealthy diet
- physical activity
what are some non-modifiable stroke risk factors
- genetics/family history
- advancing age
- women > men
- sickle cell
- race ethnicity (african americans, american natives)
- carotid stenosis
what are some major stroke risk factors
- hypertension (leading cause)
- CV disease
- diabetes
- prior strokes/TIA
- high cholesterol
- sickle cell disease
whats included in the medical management of strokes
treatment of afib
- warfarin (INR 2-3)
- other anticoagulants (dabigatran, apixaban, edoxaban, rivaroxaban, aspirin, aspirin/clopidogrel)
- platlet inhibitors (aspirin, dipyridomole, clopidogrel)
statins
antihypertensives
- ACEs
- diuretics
thrombolytic therapy
- tPA
endovascular therapy
surgical prevention
- carotid endarterectomy (scrape out the carotid)
describe nursing management of strokes
- maintain a patent airway (elevate HOB, monitor for aspiration, swallow eval)
- improving mobility/preventing joint deformity
- preventing complications
- preventing surgical complications
- med administration
- monitoring VS (monitor and maintain BP)
- monitoring NIH stroke scale (score <5/42 is indicative of a minor stroke, want a low score)
- enhancing self care
- assisting with nutrition
- maintain skin integrity (turn Q2)
- assess with patient and family coping
- maintain glucose control
post giving tPA, whatre you gonna watch for
bleeding
whats super important for stroke management
early recognition and intervention
describe FAST
Face - ask the person to smile to look for facial droop
Arms - ask the person to raise both arms and look for drifiting
Speech - ask the person to repeat a simple phrase and assess for slurred or strange speech
Time - everything has to be taken care of speedy quick
describe hemorrhagic stroke
- rupture of ateriosclerotic and hypertensive vessels
- often secondary to hypertension after age 50
- reuptured aneurysms (2-6mm in diameter)
- produces spasms of cerebral vessels and cerebral ischemia
- extensive residual functional loss
- slow recovery
- 25-60% mortality
other causes include:
- cerebral arterial spasm
- hypercoagulable states - protein C&S deficiencies and disorders of clotting cascade
describe rehab after a stroke
relearning can take place - need early rehab
interdisciplinary management:
- physical therapy
- occupational therapy
- speech therapy
- case management
