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NCM 116 Lecture > Midterms_ CVA > Flashcards

Midterms_ CVA Flashcards

1
Q

an ischemic stroke or“brain attack, ” is a sudden loss of brain function resulting from Cerebral Vascular Accident (Ischemic Stroke) disruption of the blood supply to a part of the brain.

A

cerebrovascular accident (CVA)

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2
Q

FIVE CLASSES OF STROKE BY SEVERITY LEAST TO MOST SEVERE

A

TRANSIENT ISCHEMIC ATTACK (TIA) “ANGINA OF THE BRAIN

REVERSIBLE ISCHEMIC NEUROLOGICAL DEFICIT (RIND)

PARTIAL, NON PROGRESSING STROKE

PROGRESSING STROKE (STROKE IN EVOLUTION)

COMPLETED STROKE

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3
Q

a warning sign of stroke
- localized ischemic event
- produces neurological deficits lasting only
minutes or hours.
- full functional recovery within 24-48 hours.

A

TRANSIENT ISCHEMIC ATTACK (TIA) “ANGINA OF THE BRAIN

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4
Q

similar to TIA
- finding lasts between 24 hours and three weeks
- usual functional recovery within three to four
weeks

A

REVERSIBLE ISCHEMIC NEUROLOGICAL DEFICIT (RIND)

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5
Q

some neurological deficit, but stabilized

A

PARTIAL, NON PROGRESSING STROKE

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6
Q

deterioration of neurological status often with grand mal seizure activity.
- has residual neurological deficits that last indefinitely.

A

PROGRESSING STROKE (STROKE IN EVOLUTION)

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7
Q

results from a stroke in evolution.

A

COMPLETED STROKE

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8
Q

TWO TYPES OF STROKE BY“CAUSE”

A

Ischemic Stroke
Hemorrhagic Stroke

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9
Q

stroke commonly results from occlusion of the lumen of the cerebral vessels by a thromboembolism.
Systemic hemodynamic failure can also result in ischemic stroke as a consequence of a decreased volume of blood flowing through the cerebral vessels.

A

Ischemic

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10
Q

3 Ischemic Etiologies

A

Embolic
Thrombotic
Lacunar

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11
Q

Cardiogenic emboli are a common source of recurrent stroke. They may account for up to 20% of acute strokes and have been reported to have the highest 1-month mortality.

A

Embolic

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12
Q

Large-artery infarctions often involve thrombotic in situ occlusions on atherosclerotic lesions in the carotid, vertebrobasilar, and cerebral arteries, typically proximal to major branches; however, large-artery
Infarctions may also be cardioembolic.

A
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13
Q

Small vessel or lacunar strokes are associated with small focal areas of ischemia due to obstruction of single small vessels, typically in deep penetrating arteries, that generate a specific vascular pathology.

A

Lacunar

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14
Q

MANIFESTATIONS OF ISCHEMIC STROKE

A

Symptoms depend upon the location and the size of the affected area.
● Numbness or weakness of face, arm, or leg, especially on one side.
● Confusion or change in mental status
● Trouble speaking or understanding speech
● Difficulty in walking, dizziness, or loss of balance
or coordination
● Sudden severe headache
● Perceptual disturbances

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15
Q

typically results from the rupture of a cerebral vessel.
● abrupt onset
● occurs most often in hypertensive older adults

A

HEMORRHAGIC STROKE

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16
Q

HEMORRHAGIC STROKE

CLASSIFIED INTO TWO SUBTYPES:

A
  1. Intracerebral
  2. Subarachnoid
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17
Q

hematoma is formed within the brain parenchyma with or without blood extension into the ventricles.

A

● Intracerebral hemorrhage (ICH

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18
Q

life-threatening and result from the accumulation of blood between the arachnoid and the pia mater.

traumatic in nature.

A

Subarachnoid hemorrhages

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19
Q

presenting symptom is the thunderclap headache, which clients may describe as the “worst headache of my life”

A

Subarachnoid hemorrhages

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20
Q

Hemo Stroke May be due to spontaneous rupture of small vessels primarily related to:

A

Hypertension
- subarachnoid hemorrhage due to ruptured
aneurysm
- or intracerebral hemorrhage related to amyloid
angiopathy, arteriovenous malformations
(AVMs), intracranial aneurysms,
- or medications such as anticoagulants or
thrombolytic therapy

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21
Q

most often caused by rupture of saccular intracranial aneurysms.
- more than 90 % are congenital aneurysms

A

SUBARACHNOID HEMORRHAGE (SAH)

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22
Q

cerebral arterial vessels are involved. often loss of consciousness for a short period of time called transient unconsciousness

A

Epidural Bleeds

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23
Q

vein are involved may not be evident until months after an initial trauma

A

Subdural Bleeds

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24
Q

MANIFESTATIONS OF HEMORRHAGIC STROKE

A

● Similar to ischemic stroke
● Severe headache
● Early and sudden changes in LOC
● Vomiting

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25
Q

RISK FACTORS
Modifiable

A

Hypertension
● Atrial fibrillation
● Hyperlipidemia (elevated cholesterl, triglyceride)
● Obesity
● Smoking
● Diabetes
● Asymptomatic carotid stenosis and valvular heart disease (eg, endocarditis, prosthetic heart valves)
● Periodontal disease
● illicit drug use (esp cocaine)

Bleeding Disorder/ anticoagulant use

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26
Q

Nonmodifiable risk factors

A

● Advanced age (older than 55 years)
● Gender (Male)
● Race (African American)

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27
Q

Recognizing Stroke: BE FAST

A

Balance
Eyes
Face
Arms
Soeech
Time

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28
Q

General signs and symptoms include

A

numbness or weakness of face, arm, or leg (especially on one side of the body); confusion or change in mental status; trouble speaking or understanding speech; visual disturbances;loss of balance, dizziness, difficulty walking; or sudden severe headache.

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29
Q

CLINICAL MANIFESTATIONS

A

1.Motor loss
2. Communication Loss
3. Perceptual disturbances and sensory loss
4. Impaired cognitive and psychological effects
5. Localizations

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30
Q

Diagnostic Findings

A

CT scan.
PET scan
Cerebral angiography.
Lumbar puncture.
CSF total protein level
Transcranial Doppler ultrasonography.
EEG
Skull x-ray
ECG
Laboratory studies to rule out systemic causes: CBC, platelet and clotting studies, VDRL/RPR, erythrocyte sedimentation rate (ESR),chemistries (glucose, sodium).

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31
Q

is
one of the most useful tests in
evaluating patients with stroke.
Increasingly, it is being
performed earlier in the
evaluation, not only to define
the cause of the stroke but
also to stratify patients for
either medical management or
carotid intervention if they have
carotid stenoses. Patients with
symptomatic critical stenoses
on carotid duplex scanning
may require anticoagulation
before intervention is
performed. is
one of the most useful tests in
evaluating patients with stroke.
Increasingly, it is being
performed earlier in the
evaluation, not only to define
the cause of the stroke but
also to stratify patients for
either medical management or
carotid intervention if they have
carotid stenoses. Patients with
symptomatic critical stenoses
on carotid duplex scanning
may require anticoagulation
before intervention is
performed.

A

Carotid duplex scanning

32
Q

Medical Management

A
  1. Recombinant tissue plasminogen activator
  2. Increased ICP.
  3. Endotracheal Tube.
  4. Hemodynamic monitoring
  5. Neurologic assessment
33
Q

would be prescribed unless contraindicated, and there should be monitoring for bleeding.

A
34
Q

Management of increased ICP

A

includes osmotic diuretics, maintenance of PaCO2at 30-35mmHg,and positioning to avoid hypoxia through elevation of the head of the bed.

35
Q

There is a possibility of intubation establish patent airway if necessary

A

Endotracheal Tube

36
Q

should be implemented to avoid increasing blood pressure.

A

Hemodynamic monitoring.

37
Q

to determine if the stroke is evolving and if other acute complications are developing

A

Neurologic assessment

38
Q

Stroke: Emergency Treatment
• ischemic stroke

A

emergency treatment focuses on medicine to
restore blood flow.
A clot-busting medication is highly effective at
dissolving clots and minimizing long-term
damage, but it must be given within three hours
of the onset of symptoms.

39
Q

Stroke: Emergency Treatment

Hemorrhagic strokes

A

are more difficult to manage.
Treatment usually involves attempting to
control high blood pressure, bleeding, and brain
swelling.

40
Q

Treatment ICH

A

Pharmacologic
• antihypertensive agents : alpha-blockers and beta-
blockers
• systemic steroids: dexamethasone (Decadron)
• osmotic diuretics: mannitol
• antifibrinolytic agents: aminocaproic acid (Amicar)
• vasodilators
• anticonvulsants
• Recombinant factor VIlla (rFVlla) therapy
• Reverse coagulopathies
• Vitamin K. FFP, Platelets

41
Q

treatment ICH

A

Neurosurgical ICU
• Constant monitoring
• Bedrest
• Pain control
• Reverse coagulopathies
• Vitamin K, FFP, Platelets
• ICP control
• Mannitol, Induced Coma, Hyperventilation

42
Q

Treatment of SAH

A

• Neurosurgical ICU
• Constant monitoring
• Bedrest
• Pain control
• Reverse coagulopathies
• VT Prophylaxis
• Blood Pressure Management
• Management of Aneurysms/AVMs

43
Q

Treatment
Common to both types of stroke
• care based on findings

A

nutritional support
• physical
• speech
• behavioral
• Occupational

44
Q

Benchmarks for Potential Thrombolysis
Candidate.

A

Time interval. Time Target

Door to doctor 10 min
Access to neurologic expertise 15 min
Door to CT scan completion 25 min
Door to CT scan interpretation 45 min
Door to treatment 60 min
Admission to monitored bed 3 h

45
Q

General Management of Patients with Acute Stroke

A

Blood glucose
Blood pressure
Cardiac monitor
Intravenous
fluids
Oral intake
Oxygen
Temperature

46
Q

Management:Blood Glucose

A

Treat hypoglycemia with D50
Treat hyperglycemia with insulin if serum glucose
>200 mg/dL

47
Q

Management: BP

A

See recommendations for thrombolysis candidates
and noncandidates

48
Q

Management: Cardiac Monitor

A

Continuous monitoring for ischemic changes or
atrial fibrillation

49
Q

Management: IV Fluids

A

Avoid D5W and excessive fluid administration
IV isotonic sodium chloride solution at 50 mL/h
unless otherwise indicated

50
Q

Management: Oral Intake

A

NPO initially; aspiration risk is great, avoid oral
intake until swallowing assessed
Supplement if indicated (Sa02 <90%, hypotensive
etc)

51
Q

Management: Oxygen

A

Supplement if indicated (Sa02 <90%, hypotensive
etc)

52
Q

Management: Temperature

A

Avoid hyperthermia, oral or rectal acetaminophen
as needed

53
Q

SURGICAL MANAGEMENT

A

1, Carotid endarterectomy.
2. Hemicraniectomy

54
Q

This is the removal of atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.

A

Carotid endarterectomy

55
Q

may be performed for increased ICP from brain edema in severe cases of stroke.

A

Hemicraniectomy

56
Q

NURSING ASSESSMENT

A

ACUTE PHASE (1-3 DAYS)

POST ACUTE PHASE

57
Q

ACUTE PHASE (1-3 DAYS)

A

Weigh patient (used to determine medication dosages), and maintain a neurologic flowsheet to reflect the following nursing assessment parameters:
● Change in level of consciousness or responsiveness, ability to speak, and orientation
● Presence or absence of voluntary or involuntary
movements of the extremities: muscletone, body
posture, and head position
● Stiffness or flaccidity of the neck
● Eye opening, comparative size of pupils and
pupillary reactions to light, and ocular position
● Color of face and extremities; temperature and
moisture of skin
● Quality and rates of pulse and respiration;
ABGs, body temperature, and arterial pressure
● Volume of fluids ingested or administered and
volume of urine excreted per 24 hours
● Signs of bleeding
● Blood pressure maintained within normal limits

58
Q

POST ACUTE PHASE

A

Assess the following functions:
● Mental status (memory, attention span,
perception, orientation,affect, speech/language)

Sensation and perception (usually the patient has decreased awareness of pain and temperature).
● Motor control (upper and lower extremity movement); swallowing ability, nutritional and hydration status, skin integrity, activity tolerance, and bowel and bladder function.•
● Continue focusing nursing assessment on impairment of function in patient’s daily activities.

59
Q

NURSING DIAGNOSES

A

★ Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
★ Acute pain related to hemiplegia and disuse
★ Deficient selfcare (bathing, hygiene, toileting,
dressing,grooming, and feeding) related to
stroke sequelae
★ Disturbed sensory perception (kinesthetic,
tactile, orvisual) related to altered sensory
reception, transmission,and/or integration
★ Impaired swallowing
★ Impaired urinary elimination related to flaccid
bladder, detrusor instability, confusion, or
difficulty in communicating
★ Disturbed thought processes related to brain
damage
★ Impaired verbal communication related to brain
damage
★ Risk for impaired skin integrity related to
hemiparesis or hemiplegia,decreased mobility
★ Interrupted family processes related to
catastrophic illness and caregiving burdens
★ Sexual dysfunction related to neurologic deficits
or fear of failure

60
Q

NURSING INTERVENTIONS in patients with stroke

A

1, Positioning
2. Prevent flexion
3. Prevent adduction
4.prevent edema
5. Full range of motion
6. Prevent venous stasis
7. regain balance
8. Personal Hygiene
9. Manage Sensory Difficulties
10.Visit a speech therapist
11. Voiding Patterns
12. be consistent in patients activities
13. Assess skin

61
Q

Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions.

A

CT SCAN

62
Q

May not immediately reveal all changes, e.g., ischemic infarcts are not evident on CT for 8–12 hr; however, intracerebral hemorrhage is immediately apparent; therefore,emergency CT is always done before administering ________

A

tissue plasminogen activator (t-PA).

63
Q

patients with TIA commonly have a NORMAL CT scan

(T/F)

A

TRUE

64
Q

Provides data on cerebral metabolism and blood flow changes

A

PET scan

65
Q

Shows areas of infarction, hemorrhage, AV
malformations, and areas of ischemia.

A

MRI

66
Q

Helps determine specific cause of stroke, e.g., hemorrhage or obstructed
artery, pinpoint site of occlusion or rupture. Digital subtraction angiography evaluates patency of cerebral vessels, identifies their position in head and neck, and detects/evaluates lesions and vascular abnormalities.

A

Cerebral angiography.

67
Q

Pressure is usually normal andCSFisclear in cerebral thrombosis, embolism, andTIA.

A

Lumbar puncture

68
Q

suggest subarachnoid and intracerebral hemorrhage.

A

● Pressure elevation and grossly bloody fluid

69
Q

level may be elevated in cases of thrombosis because of the inflammatory process.

A

CSF total protein level

70
Q

Evaluate The Velocity of blood flow through major intracranial vessels;identifies AV disease, e.g., problems with the carotid system(blood flow/presence of atherosclerotic plaques).

A

Transcranial Doppler ultrasonography

71
Q

Identifies problems based on reduced electrical activity in specific areas of infarction; and can differentiate seizure activity fromCVAdamage.

A

EEG

72
Q

May show a shift of pineal gland to the opposite side from an expanding mass; calcifications of the internal carotid may be visible in cerebral thrombosis; partial calcification of walls of an aneurysm may be noted in subarachnoid hemorrhage.

A

Skull x-ray

73
Q

To rule out cardiac original source of embolus (20% of strokes are the result of blood or vegetative emboli associated with valvular disease, dysrhythmias, or endocarditis).

A

ECG and echocardiography.

74
Q

to rule out systemic causes: CBC, platelet and clotting studies, VDRL/RPR, erythrocyte sedimentation rate (ESR),chemistries (glucose, sodium).

A

Laboratory studies

75
Q

Provide a high fiber diet and adequate fluid
intake (2 to 3 L/day), unless contraindicated
(T/F)

A

TRUE

NCM 116 Lecture (11 decks)

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