MedSurg Mod 4: Stroke Flashcards
Most strokes are ___
ischemic (85%)
What are the 2 main types of Ischemic Stroke
Thrombotic
Embolic
Embolic Stroke
Clump of something like a thrombus, fat, or cells move to the brain and block flow
ex: Cells can be anything from infection lodging on valves of the heart, or chunks and pieces of cellular debris, when people inject non sterile materials into their veins, etc
Thrombolic Stroke
Results from vascular sclerosis –> Narrowing of the artery
TIA
transient ischemic attack
type of thrombotic stroke
occlusion of a small artery
resolves quickly within 24 hours and with little residual deficit
Another term for stroke
CVA
CVA occur when …
blood supply to the brain is disrupted
___ is the primary cerebrovascular disorder and the ___ leading cause of death in the US
stroke; 3rd
Non Modifiable risk factors and patient profile for strokes
age (>55)
gender
ethnicity (higher in African American pop. d/t diabetes, vascular disorders, HTN risk)
Modifiable risk factors and patient profile for strokes
lifestyle issues like diet, SMOKING, alcohol, lack of physical activity
drug use - cocaine, amphetamines, OTC cough and cold drugs (SUDDEN VASOCONSTRICTION)
What are some lifestyle related diseases that increase stroke risk
HTN - #1 - risk for both ischemic and especially hemorrhagic stroke
Hyperlipidemia
Obesity
Diabetes
Periodontal Disease because gingivitis can lead to generalized body inflammation
A Fib - quivering causes blood pool stasis and clotting that can move from L ventricle –> aorta –> brain
OC - Oral contraceptives
How does smoking contribute to CVA
it has a role in blood vessel damage
it damages the endothelium lining in particular causing inflammation and increasing the chance for plaque and blood clots to form
A healthy lifestyle can reduce CVA risk by ___%
50% (to even 80%)
An ounce of ___ is worth a pound of cure
prevention
Transient Ischemic Attack
form of thrombotic stroke that occludes a very small artery or arteriole
affects only a small portion of the brain tissue meaning there usually is no permanent neurological compromise
lasts <5 minutes and symptoms must resolve within 24 hours
Despite minor issues, do not ignore this
Why should TIA not just be ignored for being not very serious itself?
because TIA is considered a forewarning for further stroke issues
What is the Approach to Care after a TIA
Same as Stroke Prevention
- Lifestyle - focus on modifiable areas intensively
- Medications - aspirin and other antiplatelet; anticoagulants if A Fib
- Surgical/Catheter Interventions - endarterectomy, stenting, etc
Carotid Endarectomy
Removal of plaque from the lining of carotid arteries thus reopening the blood vessels
Indicated as a surgical response to TIA or Mild CVA with 70-99% carotid blockage and significant risk for stroke
It is reserved for significant occlusion though since there is a chance to damage the vessel wall
Carotid Stenting
Less invasive surgical procedure indicated for TIA or mild CVA
Used for those with high surgical risk - must less invasive than an endarectomy
Mesh tubes are inserted in the vessel allowing trapping of clots and allowing blood to get through - the tube prevents collapse and the filter will grab and break the clots
What is involved in the post op nursing care for stroke surgeries and for what reason?
Monitor VS/neuro status (cranial nerve impairment?)
Facial Pulses (Adequate circulation?)
Assess incision for edema, hematoma, tracheal deviation (Airway compromise?; Neck edema –> tracheal deviation –> airway obstruction?)
Elevate HOB and position off operative side (promote drainage and wound visibility)
Notify MD if VS are not within parameters
Worry about cranial nerves
Warning signs and symptoms of CVA`
trouble walking
trouble speaking and understanding
paralysis or numbness of the face, arm, or leg
trouble with seeing in one or both eyes
HA
FAST`
signs of stroke
Face - does it look uneven
Arm - does one arm drift down
Speech - does their speech sound strange
Time - if you notice F A or S then call 911
What are the human responses to the acute phase of CVA
change in LOC or responsiveness
presence or absence of voluntary or involuntary movements
change in quality/rates of pulse and respiration
change in ability to speak
presence of bleeding
vital signs / O2 saturation
visual changes
abnormal movements that may mimic a seizure even
What are the human responses to the post acute phase for CVA
mental status changes - judgment and behavior in general changed
loss of motor control – uni or bilateral
swallowing ability impairment - do not feed until evaluated
self care compromises
sensation and perception changes
changes in nutritional and hydration status
skin - because of immobility
S/S of CVA
RELATIVELY INDEPENDENT OF CAUSE
It depends on the size of the lesion, amount of pre existing collateral blood flow, and the location of the lesion (is it a lobe of the brain or an entire hemisphere?)
Frontal Lobe
movement and personality!!!
motor area for speech, emotional behavior and complex intellectual abilities
Parietal Lobe
Sensations!!!
pain, cold, pressure, size, shape, texture, location and intensity of stimuli, awareness of body parts
Temporal Lobe
Senses!
hearing, taste, smell, interpretations of sound
Occipital
Vision!
visual stimuli
Do s/s of stroke depend on whether it is ischemic or hemorrhagic?
no it depends on the size of the lesion, how much is affected, and what parts of the brain is blocked off
Hemiplegia
Hemi - Half
Plegia - paralysis
Cannot move half the body
Hemiparesis
paresis - weakness
Half weak but it can move still
Dysarthria
difficulty expressing language due to issues neurologically which effect the muscles of the jaw, tongue, etc
trouble with speech
Aphasia
“without understanding”
Expressive Aphasia
trouble expressing oneself
speaking non sense but it makes sense in their head
Receptive Aphasia
cannot understand the incoming words
Global Aphasia
elements of both expressive and receptive aphasia
Hemianopsia
loss of vision in half of the visual field
ex: cannot see out the right side of both eyes
What may damage to the left hemisphere look like
paralysis and weakness on the Right side
Right visual field deficit
Aphasia - expressive, receptive, or global
Altered intellectual ability
Slow cautious behavior
What may damage to the right hemisphere look like
paralysis and weakness on the left side
left visual field deficit
spatial perceptual deficits
increased distractibility
impulsive behavior
poor judgment
lack of awareness of deficits
Why do we say left hemisphere CVA patients are LEFT BEHIND
because these lesions tend to cause more slow, cautious, and behaviorally slow to perform s/s
Why do we say right hemisphere CVA patients are ALWAYS RIGHT
because they are distractible, have spatial perceptual issues, and are unaware of their deficits so they always feel like they are right without issue
What is the first test done if stroke s/s appear
CT Scan
CT Scan for CVA
Done with or without contrast
Details tissue and bone images
Can detect hemorrhage, tumor, fracture, abscesses hydrocephalus, edema, ventricular or vascular anomalies
The standard of care for CVA CT scans means it must be done within what time period
within 30 minutes of a suspected stroke
Cerebral Angiogram
Angio = Blood vessels ; Gram = picture
Used to assess vasculature in the brain
A contrast dye is injected into an artery and a series of images is obtained from perfusion through the entire brain
a blockage will be seen as an area without vessels
What 2 things are required prior to a cerebral angiogram?
- Written consent
- NPO prior to test
What is preferred, cerebral angiogram or CT for CVA patients?
CT Scan
What are some other diagnostic procedures that can be done for CVA/neurological issues
lumbar puncture
CT scan
PET scan
MRI
Angiography
EEG
When is a lumbar puncture done
if there is suspicion something is wrong with the CSF
When is a PET done and why?
It is more specific but it can give an idea of metabolic activity in regions of the brain including blood flow and other metabolic activities
Why use an MRI
it is more detailed than a CT - but it may not be needed for a stroke assessment
it can show size and location of a lesion
Why use an EEG
more so for seizure activity not so much stroke
assesses localized damage
so if local damage is affecting electric signals this may be done
What diagnostic test always supercedes others for CVA?
CT Scan looking for edema, lesions, and structure
What are the goals of acute medical care of a CVA patient
prevent/minimize the risk of re-bleeding OR remove blood clot AND re-vascularize affected brain tissue
assess initial injury
prevent and treat complications
What sort of complications can occur from a CVA that we must monitor for
seizures
bleeding
bradycardia
respiratory compromise
What sort of ways can we manage acute medical care for a CVA patient
sedation
reduce intracranial edema and pressure
intubation to preserve the airway
surgical intervention if indicated
t=PA administration
clot retrieval
Why do we sedate CVA patients
to lower the metabolic demand of the brain
Why do we worry about respiratory compromise in CVA
because if the respiratory centers were affected in the brain if can have dire impacts
In what ways do we reduce intracranial edema and pressure for CVA
osmotic diuretics
maintain CO2 range of 30-35
position to avoid hypoxia
elevate the HOB
Why give osmotic diuretics to a CVA patient
because it can rid of extra fluid in the brain that is contributing to pressure
Why is it important to manage CO2 levels between 30-35 in CVA patients
because if the brain is sensing there is less O2, it will naturally attempt to compensate via vasodilation which will bring blood flow in while increasing pressure
What is the indication for surgical intervention with a CVA
- Hematoma exceeding 3 centimeters
AND
- Glasgow Come Scale score decreases
may need to surgically remove clot to fix this
What is a classic thrombolytic agent the body makes that is also given to break up clots
t-PA
t-PA - Tissue Plasminogen Activator
Thrombolytic agent that dissolves the BLOOD clot - not other clots like fat or cells
Given via IV within 3 hours of symptom onset
Requires accurate identification of CVA pathology
What is the window of opportunity for t-PA
within 3 hours (to 6) of the onset of symptoms
Risk though is that revascularizing necrotic tissue can increase the risk of cerebral edema and hemorrhage so we give early to minimize dead cell perfusion
Why is it so important to know CVA pathology before giving t-PA?
It should only be given for ischemic strokes (with blood clots) and not hemorrhagic strokes
stroke scale can determine severity as well to allow us to know direness of the situation
What are some contraindications for giving t-PA
recent trauma
recent surgery
cancer
CVA
GI/GU Bleed
INR > 1/7
BP >185/110
This is all due to risk of causing vessels to burst due to perfusion occurring from clot breakdown
Before giving t-PA do a …
CT scan
Once admitted to the ICU/CCU and given t-PA, what must be done?
Frequent monitoring of VS/neuro status (Q15 min to start)
Continuous cardiac monitoring
serial labs
serial CT scans
seizure precautions
Why do we not give t-PA after CPR
because some ribs may be broken and there is bleeding occurring and we do not want continued bleeding after
What are some Nursing Interventions after t-PA is given
Monitor all invasive lines for bleeding - IV, catheter, NG tube etc - anything we put in and can bleed
Monitor all output for signs of bleeding
Delay any invasive treatment for 24 hours (injections, lab draws, IV restarts)
Monitor for s/s of intracranial bleeding like HA, LOC change, loss of function, etc
monitor VS and labs
monitor medications for interactions that can cause bleeding and prevent clotting
____ is something you should not give to someone on t-PA
aspirin
Clot Retrieval
Approach for ischemic CVA where a micro catheter is guided beyond a thrombus, proximal loops are deployed through the thrombus, and a balloon is inflated to prevent blood flow while the thrombus is retracted into a catheter with aspiration
Basically a catheter will vac suction the clot out of the blood stream
Fast. no bleeding problems or med issues
Nursing Interventions after Clot Retrieval
t-PA interventions AND…
Keep flat for 4-6 hours to prevent dislodging of a clot at the femoral access site
monitor pulse distal to the access site (pulse, movement, temperature)
The access site for a clot retrieval is ___, so we should watch for pulses in the ___
femoral; feet
How to prevent CVA
diet, exercise, and attention to periodontal disease
carotid endarectomy
anticoagulant therapy (w/ something like A Fib)
antiplatelet therapy like aspirin, Plavix, and others
“Statins”
antihypertensive medications (prevent hemorrhagic stroke and long term HTN damage to vessels)
Clipping of Aneurysm
Purpose of Statins
often thought regarding cholesterol plaque in the heart but it also prevents plaque in the brain vessels (and other peripheral vessels) too - and vessels are never isolated from each other throughout the body so this can be beneficial at preventing an embolus
Aneurysm
When a person has weakness in the vessel wall and blood flows into there it makes the vessel bulge like a balloon and if it bursts it becomes a hemorrhage
Aneurysm Clipping
a procedure where a clip is placed at the base of an aneurysm vessels so blood continues to go through the vessel normally instead of getting caught up in the out pouch
Aneurysms are a source for ___ stroke
hemorrhagic
Who tends to have aneurysms?
No one in particular we know of - even younger people get them
Sometimes they are found incidentally as we cannot do angiograms and CT scans for everyone
Aneurysm Coiling
a procedure where an aneurysm is spotted as a large black balloon looking out pouch on CT scan so the surgeon will fill the aneurysm with soft metals like platinum
It is a silly string like metal material that goes into the out pouch and prevents blood from going in because it is full - so no blood going in now causes a clear and non dark area on CT scan
clipping alternative
If a man’s left side has something wrong with it and is drooping….
then there must be a right hemisphere problem
Garbled speech means ___
dysarthria
Glasgow Coma Scale
a scale for neurological checks that has some issues but is a great quick screening tool (used in other areas while more intensive neuro settings have better scales)
Has 3 Areas: Eyes, Verbal, Motor with Eyes being scored 1 to 4, Verbal 1 to 5, and Motor 1 to 6
Higher scores mean more function while 1-2 means no function at all
What are some major considerations to make when a CVA patient is recovering
potential for aspiration
Aphasia - expressive, receptive, global
Coping
Dysphagia - speech therapy and pneumonia potential
Mobility - PT
enhancing self care - occupational therapy
sensory or cognitive impairment
bowel and bladder control - and retraining
skin care
Dysphagia and CVA
one must consider if the patient can eat and swallow safely
What is one of the first complications considered by the CVA patient
mobility issues
Ways to improve Mobility for the CVA pt
encourage pt to exercise unaffected side
establish a regular exercise routine
muscle exercises recommended by PT
assist the patient OOB ASAP; assess balance; move slowly
Functional Independence Measure (FIM)
instrument which provides information about current mobility, social, and cognitive function
It is used to evaluate a person holistically and let you know how independent and functional they are on their own
May indicate if they need intensive or gentle rehabilitation and where a person goes and what insurance coverage they get via the score
What is the importance of the wall suction unit for CVA patients
The CVA patient is at high risk for aspiration so this can allow suctioning to prevent issues of aspiration
The color determines how high the pressure is of suction but we usually do not leave green as high pressure damages mucosa
Yellow and slightly higher may be ok for sticky secretions but orange and red are too high for mucous secretion normally
What is the importance of the suction canister for CVA patients
it attaches to the bottom of the wall suction unit via small tubing and the long tubing has a suction catheter which actually does the suctioning and goes into the patient
the material will enter the canister and when you swing it the cap will cap off and it can be disposed of
What is the importance of the suction catheter for CVA patients
it connects to the blue port of the long tubing of the suction canister
it is soft and can suction the mouth, airway in the lungs, and the nose
if there is aspiration, trouble swallowing or choking this will help get things out
Yankauer Suction
“Tonsil Tip Suction”
A rigid plastic larger opening catheter
It can suction up the secretions in the mouth or back of the throat
What is the issue with the Yankauer suction
it is rigid so it should only go as far as the back of the throat an now down into the airway like a soft catheter
suctioning beyond the back of the throat can damage tissue in the airways
Issue with FAST
It can miss posterior circulation issues involving the vertebrobasilar arterial system
Strokes from this area have an 85% mortality rate or higher
BE-FAST
A newer updated version of fast that can detect the posterior circulation strokes FAST cannot
What does BE FAST stand for
Balance (Are they suddenly losing balance?)
Eyes (loss of vision in any eye?)
Face (drooping? uneven?)
Arms (Is one weak or numb?)
Speech (Slurred? confused?)
Time (Call 911!)
What are the losses seen for BEFAST like?
they are sudden losses NOT gradual ones
