Neurological: TIA/CVA/Stroke Flashcards
1
Q
Symptoms resolve typically within 24 hours.
Temporary blockage of blood flow to brain
Lasting 30-60 minutes
Warning sign of impending stroke - know and treat
Damage may occur after multiple TIAs could cause damage
Impossible to differentiate - manifestations impossible to differentiate between TIA/CIA/stroke
Symptoms usually resolve completely within 24 hours
Visual
Mobility - issues with mobility
Sensory
Speech
Assessments
Nursing Diagnosis
Nursing Interventions
Nursing Education
A
TIA
2
Q
Blurred vision
Diplopia (double vision)
Blindness in one eye
Tunnel vision
A
Visual
3
Q
Weakness (facial droop, arm or leg drift, hand grasp)
Ataxia (gait disturbance)
A
Mobility - issues with mobility
4
Q
Numbness (face, hand, arm, or leg) - inability to differentiate between sharp and dull senses
Vertigo
A
Sensory
5
Q
Aphasia
Dysarthria (slurred speech)
A
Speech
6
Q
Carotid Endarterectomy (CEA) surgical procedure that restores blood flow to the brain. Usually to treat build up in the arteries.
Complete neurologic exam
Laboratory test
Radiologic exam
EKG
A
Assessments
7
Q
NIHSS certification have get
Assure complete recovery from TIA - differentiation process - something lagging behind probably a stroke
A
Complete neurologic exam
8
Q
CBC - Hgb: 12-18; Hct- 37-52%; platelet - 150-400000
Coagulation times - pT - 30-40, PTT - 11-12.5, INR - 0.8-1.1
Electrolytes - K: 3.5-5, Na - 135-145
A
Laboratory test
9
Q
CT head without contrast
CT angiography head and neck
MRI of the Head
A
Radiologic exam
10
Q
Atrial Fibrillation - looking for this specifically; when turns back into sinus rhythm or other rhythm where atria contract clots move causing stroke
A
EKG
11
Q
Acute Confusion r/t hypoxia - most common; lack air getting to brain
Readiness for enhanced Health management
A
Nursing Diagnosis
12
Q
Medication
Diet
Surgery
Wellness diagnosis
A
Readiness for enhanced Health management
13
Q
After TIA resolved - make sure TIA not stroke
Reduction of blood pressure
Antiplatelet medication
Diabetes control
Promotion of health lifestyle
Surgical interventions
A
Nursing Interventions
14
Q
Antihypertensives - ACE inhibitors; diuretics; combo
A
Reduction of blood pressure
15
Q
ASA - aspirin/plavix
Clopidogrel
A
Antiplatelet medication
16
Q
100-180 mg/dL
Medications - insulin
A
Diabetes control
17
Q
Smoking cessation
Heart healthy diet
Increased activity
A
Promotion of health lifestyle
18
Q
Carotid Endarterectomy (CEA) surgical procedure that restores blood flow to the brain. Usually to treat build up in the arteries.
A
Surgical interventions
19
Q
TIA is a precursor to an ischemic stroke - know experienced could be real stroke: understand s&s - fam, friends, pt; so can get hospital quickly
Heart Healthy diet
Medications
A
Nursing Education
20
Q
Antihypertensives - ACE Inhibitors, diuretors
Antiplatelet - aspirin, plavix
Anticoagulants - heparin, warfarin (used in combo with stroke due to afib)
Smoking cessation
A
Medications
21
Q
2 types of stroke/brain attack
Ischemic
Hemorrhagic
A
Types of strokes
22
Q
Thrombotic
Embolic
A
Ischemic
23
Q
Aneurysm
HTN
Arteriovenous malformation
A
Hemorrhagic
24
Q
Thrombotic - stationary - thrombosis not move; Clots forms in vessels of brain
Embolic - mobile - embolism moves; lodges somewhere; quicker
Interruption of perfusion to brain - causing symps
Medical emergency - short period of time to take care of them
Usually due to Atherosclerosis
Time is brain tissue - get quickly to treatment
Can cause permanent disability - stroke can and often does unless treatment
Termed infarction caused by lack of perfusion for few minutes
Contralateral injury (occurs on right side of brain = left side of body is paralyzed or weak)
Brain edema and increased intracranial edema may cause secondary injury within stroke
Thrombotic Stroke
Embolic Stroke
A
Ischemic stroke
25
Intracranial arteries (Carotid)
Extracranial arteries (Carotid)
Usually due to Atherosclerosis
26
Half of all strokes
Atherosclerosis
Arterial Spasm - very rare; happen lot within intracranial or subarachnoid hemorrhages
Ruptured plaque - part build-up thrombotic stroke
Moves - ruptured plaque within this - stays in place and not move
Gradual in nature - Minutes to hours
Progression
Thrombotic Stroke
27
Intracranial arteries
Extracranial arteries (Carotid)
Atherosclerosis
28
Suitcases - moves quickly
Very fast - jams up vessel quickly
Originate from
Blockage may be permanent and/or temporary - does try to lyse clot - difference between TIA and stroke
Rapid in nature
Embolic Stroke
29
Heart (Atrial Fibrillation)
Foreign heart valve if not anticoagulated properly
Endocarditis (Septic emboli from vegetation on heart valve)
Originate from
30
Interruption of vessel integrity - usually rupture or false pocket
Bleeding into the brain tissue or the subarachnoid space - most common
Types
Hemorrhagic stroke
31
Intracerebral Hemorrhage (ICH)
Subarachnoid Hemorrhage (SAH)
Arteriovenous Malformation (AVM) - A collection of thin walled blood vessels that has no capillary bed. Rupture easily and very quickly - Cause big vasospasm in head
Types
32
For lot diff types strokes
Risk factors modifiable
Risk factors non-modifiable
Risk Factors Medically Managed - IMP
CVA
33
Smoking
Substance use (specifically Cocaine)
Obesity
Sedentary lifestyle
Use Oral contraceptives
Heavy ETOH use
Phenylpropanolamine (PPA) (found in antihistamines)
Risk factors modifiable
34
American Indian
Alaskan Native
African American
Risk factors non-modifiable
35
Hypertension
Diabetes
Atherosclerosis
Aneurysm
Risk Factors Medically Managed - IMP
36
Stop smoking
Stop drug use
Take prescribed aspirin everyday (only for ischemic stroke - not for bleeding stroke as worsens symptoms)
Exercise
Reduce ETOH use
Decrease salt intake
Take prescribed blood pressure medication
Incidence and Prevalence
CVA - health promotion and maintenance
37
Increased risk of risk of stroke volume and severity in SE states (stroke belt)
Disparities in income, health edu, diet, use of street drugs
CVA/Stroke is the fifth leading cause of death in the United States and is considered a major cause of disability worldwide. According to the U.S. Centers for Disease Control and Prevention (CDC), approximately 795,000 people experience new or recurrent stroke; about 130,000 Americans die each year from stroke. About 13,000 Canadians die each year from stroke
Eight southeastern states in the United States are known as the “stroke belt” because they have a mortality rate that is 20% higher than the rest of the nation. The coastal plains of North Carolina, South Carolina, and Georgia have a 40% higher mortality rate. Possible factors influencing these differences include income, education, dietary habits, and access to health care
It is estimated that there are more than 4.7 million stroke survivors in the United States and 400,000 stroke survivors in Canada living with long-term disability. Deaths from stroke have declined over the past 15 years as a result of advances in prompt and effective medical treatment. However, the number of strokes occurring in the younger-adult population is increasing. In this group, strokes are associated with illicit drug use because many street drugs cause hypercoagulability, vasospasm, or hypertensive crisis.
Incidence and Prevalence
38
Assessment
National institute of health stroke scale
Assessment
Stroke syndromes
Manifestations of CVA
CVA
39
Full history
Medications
Cognition
Sensory Perception
Assessment - CVA
40
Although an accurate history is important in the diagnosis of a stroke, the first priority is to ensure that the patient is transported to a stroke center. A stroke center is designated by The Joint Commission (TJC) for its ability to rapidly recognize and effectively treat strokes. TJC designates two distinct levels of stroke-center certification.
Fam hx
Full history
41
Forgot take meds and then had change in mental status
Medications
42
Lot have trouble with sensory perception - including not feeling like half of their body exists
Sensory Perception
43
The primary certified stroke center is required to provide diagnostic testing (CT) and stroke therapy with IV fibrolytic therapy and a stroke team; the comprehensive stroke center provides timely and advanced diagnostics and life-saving measures such as endovascular interventions that can prevent long-term disability. Obtaining a history should not delay the patient's arrival to either the stroke center or interventional radiology within the comprehensive stroke center. A focused history to determine if the patient has had a recent bleeding event or is taking an anticoagulant is an important part of the rapid stroke-assessment protocol.
Primary - CT, IV fibronolytic therapy, stroke team
Comprehensive - CT, IV fibronolytic therapy, stroke team, clot evac, higher level issues handled
Availability to get to Stroke center
44
NIHSS
Higher number = more chance of stroke
Very high number = large vessel stroke - large vessel occluded
Small number off and not explain why - treat as a stroke; big numbers = large vessel - better response to intervention when do clot extration with pranumba device
Score 0-40
National institute of health stroke scale - CVA
45
FAST
Glasgow Coma Scale - hospital - be careful; score 3 and be dead
Stroke Mimics
Assessment - CVA
46
Face drooping
Arm weakness
Speech difficulty
Time to call 911
Very much Used more for laymen than experienced health care provider
FAST
47
Low blood glucose - BIG
Low blood pressure
Arteriospasm - if left long enough will cause a stroke
Look like having stroke
Stroke Mimics
48
Equates where stroke may be occurring, manifestations with what type of vessel being blocked
Middle Cerebral Artery Strokes
Posterior Cerebral Artery Strokes
Internal Carotid Artery Strokes
Anterior Cerebral Artery Strokes
Vertebrobasilar Artery Strokes
Stroke syndromes - CVA
49
Sudden trouble speaking or understanding
Sudden weakness or numbness of arms or legs
Memory impairment
Aphasia: Inability to speak or comprehend language; difficulty speaking
Alexia or dyslexia: Difficulty reading
Agraphia: Difficulty writing
Acalculia: Difficulty with mathematic calculation
Motor
Sensory
Cranial nerve
Cardiovascular
Manifestations of CVA - CVA
50
Hypotonia, or flaccid paralysis: Inability to overcome the forces of gravity, and the extremities tend to fall to the side when lifted
Hypertonia (spastic paralysis): Increased muscle activity causing fixed positions or increased tone of the involved extremities; paralyzed - either could have no tone or super hypertone - super spasticity - hypertonia
Agnosia: Inability to use an object correctly - should know object but cannot use it
Apraxia: Inability to perform previously learned motor skills or commands (may be verbal or motor); past skills cannot do
The MOBILITY assessment provides information about which part of the brain is involved. A right hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body) indicates a stroke involving the left cerebral hemisphere because the motor nerve fibers cross in the medulla before entering the spinal cord and periphery. On the other hand, a left hemiplegia or hemiparesis indicates a stroke in the right cerebral hemisphere. If the brainstem or cerebellum is affected, the patient may experience hemiparesis or quadriparesis (weakness in all extremities), ataxia (gait disturbance), and cranial nerve deficits.
In collaboration with the physical therapist (PT) and occupational therapist (OT), assess the patient's muscle tone.
Motor
51
Neglect: Unilateral inattention (body neglect) syndrome: Being unaware of the existence of his or her paralyzed side (particularly common with strokes in the right cerebral hemisphere); part body not understand is there
Ptosis: Eyelid drooping
Hemianopsia: Blindness in half of the visual field, resulting from damage to the optic tract or occipital lobe
Homonymous hemiaopsia: Blindness in the same side of both/each eye
Nystagmus: Involuntary movements of the eyes (can be vertical or horizontal); eye bounces back and found
Paresthesia: Numbness, tingling, or unusual sensations; cannot tell difference between sharp and dull pain
The SENSORY PERCEPTION assessment focuses on the patient's response to touch and painful stimuli. In addition to diminished motor function, decreased sensation typically occurs on the affected side of the body.
Evaluate for sensory changes
Sensory
52
Gag reflex - check this
Swallowing - check ability
Chewing - check ability
Cough - check ability
If not know about these functions, pt needs put at NPO until have speech patho test for swallow
Assess the patient's ability to chew, which reflects the function of cranial nerve (CN) V. Assessment of the patient's ability to swallow reflects the function of CNs IX and X. In addition, note any facial paralysis or paresis (CN VII), diminished or absent gag reflex (CN IX), or impaired tongue movement (CN XII). The patient who has difficulty chewing or swallowing foods and liquids (dysphagia) is at risk for aspiration pneumonia and may become constipated or dehydrated from inadequate fluid intake. Assess for pocketing of food under the tongue or buccal mucosa caused by diminished ability to propel food with the tongue. Also assess the patient's ability to cough, which reflects the function of CN X. If the cough reflex is minimal or absent, the patient is at risk for aspiration
Cranial nerve
53
Atrial Fibrillation
Hypertension
Both are predisposing factors for a stroke
Patients with embolic strokes may have a heart murmur, dysrhythmias (most often atrial fibrillation), or hypertension. It is not unusual for the patient to be admitted to the hospital with a blood pressure greater than 180 to 200/110 to 120 mm Hg, especially if he or she has a hypertensive bleed. Although a somewhat higher blood pressure of 150/100 mm Hg is needed to maintain cerebral PERFUSION after an acute ischemic stroke, pressures above this reading may lead to extension of the stroke.
Cardiovascular
54
Left side - cannot see since directly behind the eye
Optic chasm - takes out peripheral vision
Heminopsis heminopsia - left side both eyes - cannot see since on right side
Eyes
55
Psychosocial
Laboratory
Diagnosis
Acute treatment
CVA
56
Depending on type brain attacked - trouble composing self
Assess for:
Psychosocial - CVA
57
Changes in body image
Self concept
Coping ability
Emotional lability
Assess for: - Psychosocial
58
The typical patient with a stroke is older than 65 years, is hypertensive, and has varying degrees of impaired MOBILITY and level of consciousness. Speech, language, and COGNITION deficits, as well as behavior and memory problems, may also occur.
Changes in body image
59
Assess the patient's reaction to the illness, especially in relation to changes in body image, self-concept, and ability to perform ADLs. In collaboration with the patient's family and friends, identify any problems with coping or personality changes.
Self concept
60
Ask about the patient's financial status and occupation, because they may be affected by the residual neurologic deficits of the stroke and the potential long recovery. Patients who do not have disability or health insurance may worry about how their family will cope financially with the disruption in their lives. Early involvement of social services, certified hospital chaplain, or psychological counseling may enhance coping skills.
Coping ability
61
Assess for emotional lability (uncontrollable emotional state) especially if the frontal lobe or right side of the brain has been affected. In such cases, the patient often laughs and then cries unexpectedly for no apparent reason. Explain the cause of uncontrollable emotions to the family or significant others so they do not feel responsible for these reactions.
Emotional lability
62
CBC
WBC
Coagulation values
Laboratory - CVA
63
Elevated H and H (ischemic)
CBC
64
Infection - do with cognitive ability - trying fight that; types infection: hypercoagable state - cause stroke; specifically from septic heart valve
WBC
65
Prothrombin time (PT)
International normalized ratio (INR)
Partial thromboplastin time (PTT)
Decreased if not treated with anticoag; are - high; see norm INR on warfarin to treat for stroke and having changes in mental status/weakness - warfarin not working appropriately - redosing and calling PCP
Coagulation values
66
Fast rule out hemorrhage - CT w/o hemorrhage - first - then okay start TPA to thin out and bust out clot
CT head without contrast
CT head and neck with contrast
MRI of the head and neck
Imaging Assessment.
Diagnosis
67
Only used to R/O hemorrhage
Show hemorrhage - no ischemic CVA until after tissue necrotic - if TPA have necrotic tissue - bleed out into brain and secondary injury and brain - hemorrhage
Only view ischemic CVA after brain tissue is neurotic
CT head without contrast
68
CT head/neck angio
Evaluated blockage in large vessels - big stroke, high NIH - have clot removed - clot extraction device
CT head and neck with contrast
69
Can picture an evolving CVA - contrast fast and read almost immediately
MRI of the head and neck
70
For definitive evaluation of a suspected stroke, CT perfusion scan is used to assess ischemia of brain tissue (or areas of decreased PERFUSION to or in brain tissue). Cerebral aneurysms or AVM may also be identified. Magnetic resonance angiography (MRA) and multimodal techniques such as perfusion-weighted imaging enhance the sensitivity of the MRI to detect early changes in the brain, including confirming blood flow. Ultrasonography (carotid duplex scanning) may also be performed.
Imaging Assessment.
71
Fibrinolytic Therapy.
For select patients with ischemic strokes, early intervention with IV fibrinolytic therapy (“clot-busting drug”) is the standard of practice to improve blood flow to viable tissue around the infarct or through the brain. The success of fibrinolytic therapy for a stroke depends on the interval between the time that symptoms begin and treatment is available. IV (systemic) fibrinolytic therapy (also called thrombolytic therapy) for an acute ischemic stroke dissolves the cerebral artery occlusion to re-establish blood flow and prevent cerebral infarction. Alteplase (tPA [tissue plasminogen activator], Activase) is the only drug approved at this point for the treatment of acute ischemic stroke. The most important factor in determining whether or not to give alteplase is the time between symptom onset and time seen in the stroke center. Currently, the U.S. Food and Drug Administration (FDA) approves administration of alteplase within 3 hours of stroke onset. The American Stroke Association endorses extension of that time frame to 4.5 hours to administer this fibrinolytic for patients unless they fall into one or more of these categories:
Age older than 80 years
Anticoagulation regardless of international normalized ratio (INR)
Imaging evidence of ischemic injury involving more than one third of the brain tissue supplied by the middle cerebral artery
Baseline National Institutes of Health Stroke Scale score greater than 25
History of both stroke and diabetes
Ischemic Stroke
Fibrinolytic (TPA)
Clot evacuation
Carotid artery endarterectomy
Acute treatment
72
Treatment in CVA - specifically ischemic CVA
Dose for TPA - 0.9 mg/kg in IV infusion - cannot exceed 90 milligrams - given over 1 min; IV bolus can be IV pushed by critical care nurse by then remaining amount given over 60 minutes
d/c if pretreatment greater than 1.7 or aptt or ptt elevated - want check coag values before admin TPA for really high risk bleeding
Admin: not IV push - entire dose
IV push bolus - moved to critical care immediately
Unit where competent care for pt where TPA drip
TPA admin
CVA - fibrinolytic
73
DO NOT IV push
Critical Care
Frequent neuro checks - q15min to 1hr
DC TPA for decrease in neuro status - if not; if improve - leave on for entire hour; if start to worsen - turn off TPA - conversion from ischemic to bleeding stroke
Antihypertensive greater than 180 - before start TPA - BP greater than 180 give antihypertensive; give close eye on BP
No invasive lines for 24 hours after drip started
TPA admin
74
Clot retrieval and destruction - Aka Embolectomy
Carotid artery angioplasty with stenting
Carotid artery endarterectomy
CVA - treatment (ischemic)
75
Stent placement
Intra-arterial thrombolysis
Penumbra device - special device go in - drill hole into clot and suck back out
Clot retrieval and destruction - Aka Embolectomy
76
Femoral (Groin) approach - same protective measures as cardiac cath - neuro status checked, groin - large catheter in it - pulled and make sure not develop hematoma - pulses in feet
Same protective measures as cardiac catheterization
Carotid artery angioplasty with stenting
77
Blood pressure under control
Monitor for Hematoma formation in neck - push carotid artery and reduce blood flow to the brain
ICU
Carotid artery endarterectomy
78
Fluid trapped and swelling; causing stress on brain
Decreased LOC (First sign)
Restlessness, irritability, and confusion
Headache
Nausea and Vomiting
Changes in speech pattern
Change in sensorimotor status
Seizures - if bad enough
Cushing Triad
Posturing
Medical emergency
Widened pulse pressure
Bradycardia
Activate rapid response - need as much help as possible
CVA - increased ICP
79
BP control
Other complications
CVA
80
Want Blood pressure slightly elevated to promote circulation - get blood around clot area
HOB flat - heart not work as hard to push blood around clot
May use pressor (Neosynephrine) - help raise BP
Ischemic - CVA
81
Lower blood pressure to prevent further bleeding
HOB elevated at least 30 degrees to promote drainage
Nicardipine - reduces BP
Hemorrhagic - CVA
82
Hydrocephalus - increased ICP
Vaso or arterio spasms - stroke mimic
Increased ICP
Seizure - could cause this
Rebleeding or rupture is a common complication for the patient with an aneurysm or AVM. Recurrent hemorrhage may occur within 24 hours of the initial bleed or rupture and up to 7 to 10 days later. Assess for severe headache, nausea and vomiting, a decreased LOC, and additional neurologic deficits. Potential consequences of a second cerebral hemorrhagic event may be catastrophic.
Other complications - CVA
83
Monitor the patient with an aneurysm or arteriovenous malformation (AVM) and patients following repair of these vessel malformations for signs and symptoms of hydrocephalus and vasospasm. Hydrocephalus (increased cerebrospinal fluid [CSF] within the ventricular and subarachnoid spaces) may occur as a result of blood in the CSF. This prevents CSF from being reabsorbed properly by the arachnoid villi because of obstruction by small clots. Cerebral edema, which interferes with the flow of CSF out from the ventricular system, may also develop. Eventually the ventricles become enlarged. If hydrocephalus is left untreated, increased intracranial pressure (ICP) results. Observe for signs and symptoms of hydrocephalus, which are similar to those of ICP elevation, including a change in the LOC. Clinical findings may also include headache, pupil changes, seizures, poor coordination, gait disturbances (if ambulatory), and behavior changes.
Hydrocephalus - increased ICP
84
If blood is in the subarachnoid space, the patient is at risk for cerebral vasospasm. Signs and symptoms of vasospasm may include decreased LOC, motor and reflex changes, and increased neurologic deficits (e.g., cranial nerve dysfunction, motor weakness, and aphasia). The symptoms may fluctuate with the occurrence and degree of vasospasm present. Hemorrhage-related cerebral vasospasm can result in permanent vascular changes and irreversible neurologic impairment.
Vaso or arterio spasms - stroke mimic
85
Ischemic
Hemorrhagic
Ongoing Drug Therapy.
CVA- ongoing therapy
86
Antithrombotic/anticoagulant med
Aspirin
Antiplatelet
warfarin (Atrial Fibrillation) - blood thinner to go through brain
Antihypertensive
Stool Softeners - not have to push and cause ICP
Ischemic - CVA- ongoing therapy
87
clopidogrel/plavix
Antiplatelet
88
ACE inhibitors
Diuretics (hydrochlorithiazide)
Antihypertensive
89
Calcium Channel Blocker
Stool Softeners - not have to push and cause ICP
Hemorrhagic - CVA- ongoing therapy
90
CVA- ongoing therapy
Calcium Channel Blocker
91
Ongoing drug therapy depends on the type of stroke and the resulting neurologic dysfunction. In general, the purposes of drug therapy are to prevent further thrombotic or embolic episodes (with antithrombotics and anticoagulation) and to protect the neurons from hypoxia.
Antithrombotics include the use of aspirin or other antiplatelet drugs (e.g., clopidogrel [Plavix]) and are the standard of care for treatment following acute ischemic strokes and for preventing future strokes. Sodium heparin and other anticoagulants, such as warfarin (Coumadin, Warfilone), are used in the presence of atrial fibrillation. Anticoagulants are high-alert drugs that can cause bleeding, including intracerebral hemorrhage.
An initial dose of 325 mg of aspirin (Ecotrin, Ancasal) is recommended within 24 to 48 hours after stroke onset (CDC, 2017). Aspirin should not be given within 24 hours of fibrinolytic administration. Aspirin is an antiplatelet drug that prevents further clot formation by reducing platelet adhesiveness (clumping or “stickiness”). It can cause bruising, hemorrhage, and liver disease over a long-term period. Teach the patient to report any unusual bruising or bleeding to the primary health care provider.
A calcium channel blocking drug that crosses the blood-brain barrier such as nimodipine (Nimotop) may be given to treat or prevent cerebral vasospasm after a subarachnoid hemorrhage. Vasospasm, which usually occurs between 4 and 14 days after the stroke, slows blood flow to the area and causes ischemia. Nimodipine works by relaxing the smooth muscles of the vessel wall and reducing the incidence and severity of the spasm. In addition, this drug dilates collateral vessels to ischemic areas of the brain.
Stool softeners, analgesics for pain, and antianxiety drugs may also be prescribed as needed for symptom management. Stool softeners also prevent the Valsalva maneuver during defecation to prevent increased ICP.
Ongoing Drug Therapy.
92
Risk for Aspiration
Self-care deficit
Impaired swallowing
Impaired walking
Risk for injury
Anxiety
Constipation
Look at pt and see what exactly happening with pt
N. diagnosis - CVA
93
Speech therapy/Swallow study
PT/OT/Nursing
Speech therapy
PT: need Assistive devices (walker) - N. help them learn how use assistive devices
Side rails up x3/low bed, call light within reach
Fluids (PO or IV) - make sure can swallow if IV
Interventions - CVA
94
Thickened liquids
Chin tuck when swallowing - from speech therapy
Speech therapy
95
Aphagia: big one
Dysarthria
Sensory perception
Communication - CVA
96
Language or speech problems are usually the result of a stroke involving the dominant hemisphere. The left cerebral hemisphere is the speech center in most patients. Speech and language problems may be the result of aphasia or dysarthria. Aphasia is caused by cerebral hemisphere damage; dysarthria (slurred speech) is the result of a loss of motor function to the tongue or the muscles of speech, causing facial weakness and slurred speech.
Aphasia can be classified in a number of ways. Most commonly, it is classified as expressive, receptive, or mixed (Table 45-3). Expressive (Broca's, or motor) aphasia is the result of damage in Broca's area of the frontal lobe. It is a motor speech problem in which the patient generally understands what is said but cannot speak. He or she also has difficulty writing but may be able to read. Rote speech and automatic speech such as responses to a greeting are often intact. The patient is aware of the deficit and may become frustrated and angry.
Expressive - not get out info trying to
Receptive - talking to them and not understand
Mixed - combo above
Global - complete constellation
Aphagia: big one
97
Present one idea in a sentence
Simple one step commands
Speak slowly and use verbal and visual cues
Avoid yes and no questions - need lot explanation
Look at other Communication alternatives - story boards, spelling, letter boards
Do not rush - lot time with guys
Interventions: Dysarthria
98
Visual
Spatial-perceptual
Interventions
Sensory perception
99
Understand what is going on around them
Visual - Sensory perception
100
Understand what is going on
Not have understanding or know part body
Spatial-perceptual - Sensory perception
101
Nearly blind, no peripheral vision, blind on side side each eye
Teach the patient to touch and use both sides of the body
Dress the affected side first
Diplopia/double vision = eye patch
Always approach the patient from the unaffected side, which should also face the door. - see what is happening
Patients with right hemisphere brain damage typically have difficulty with visual-perceptual or spatial-perceptual tasks. They often have problems with depth and distance perception and with discrimination of right from left or up from down. Because of these problems, patients can have difficulty performing routine ADLs. Caregivers can help the patient adapt to these disabilities by using frequent verbal and tactile cues and by breaking down tasks into discrete steps. Always approach the patient from the unaffected side, which should face the door of the room!
Unilateral inattention, or neglect syndrome, occurs most commonly in patients who have had a right cerebral stroke. However, it can occur in any patient who experiences hemianopsia, in which the vision of one or both eyes is affected. This problem places the patient at additional risk for injury, especially falls, because of an inability to recognize his or her physical impairment or because of a lack of proprioception (position sense).
Teach the patient to touch and use both sides of the body.
When dressing, remind the patient to dress the affected side first.
If homonymous hemianopsia is present, teach the patient to turn his or her head from side to side to expand the visual field because the same half of each eye is affected. This scanning technique is also useful when the patient is eating or ambulating.
Place objects within the patient's field of vision. A mirror may help visualize more of the environment. If the patient has diplopia (double vision), a patch may be placed over the affected eye and changed every 2 to 4 hours.
The patient with a left hemisphere lesion generally has memory deficits and may show significant changes in the ability to carry out simple tasks, such as eating and grooming. Help with ADLs but encourage the patient to do as much as possible independently. To assist with memory problems, re-orient the patient to the month, year, day of the week, and circumstances surrounding hospital admission. Establish a routine or schedule that is as structured, repetitious, and consistent as possible. Provide information in a simple, concise manner. Apraxia may be present. Typically the patient with apraxia exhibits a slow, cautious, and hesitant behavior style. The physical therapist (PT) helps the patient compensate for loss of position sense.
Interventions - Sensory perception
102
PT/OT/Speech therapy
VTE prophylaxis - stockings, LMWH,
Antithrombotic therapy
Anticoagulation therapy (a fib)
Statin medication - high lipids
Stroke education - secondary stroke may look like
Rehab assessment - if where going
Home assessment for safety
Manifestations of new stroke
Lifestyle modification
Importance of taking Medications
CVA - discharge safety instructions
103
Evaluate the care of the patient with stroke based on the identified priority patient problems. The expected outcomes are that the patient:
Has adequate cerebral PERFUSION to avoid long-term disability
Maintains blood pressure and blood sugar within a safe, prescribed range
Performs self-care and MOBILITY activities independently, with or without assistive devices
Learns to adapt to SENSORY PERCEPTION changes, if present
Able: Communicates effectively or develops strategies for effective communication as needed
Has adequate nutrition and avoids aspiration - eat and get adequate nutrition
CVA - evaluation
