Nurb test 3: stroke Flashcards
- hypertension: number one greatest risk factor=edu can encourage to take med to keep in control,
-other heart disease= a fib-throw clot from heart up in brain: keep up on meds to keep reg rhythm,
-diabetes 4-5 times greater risk of a stroke,
-Diet: cholesterol, low sodium, avoid tobacco, be more active, limit obesity,
-oral contraceptives= low dose as possible, no good idea to add if overweight or smoke
-sickle cell anemia=blood is clumping, onset of episodes which will have less viscosity of the blood and won’t move as well, do things to prevent exacerbation
cocaine use
excessive alcohol usage= men greater than 2 drinks per day/ women greater than 1 drink per day
Modifiable risk factors for a stroke
-protective mechanisms to help maintain blood flow even when things are happening in the body, does it by cerebral vasodilation=keep as much blood there as possible
Cerebral auto regulation
factors that affect blood flow
- highest percentage of the major types of stroke it is 80%, from inadequate blood flow to brain, obstruction of the brain, some are partial or complete of occlusion, blood is unable to pass through the artery, more gradual onset
ischemic stroke
- dev from rupture of artery, bleed into the brain tissue, 15 percent, sudden in onset, higher mortality rate
hemorrhagic stroke
narrowing of blood vessels over time Ex: atherosclerosis=plaque buildup in the artery over time build up enough to gradually occlude and block the artery partially or completely
-develop clot in that area of the artery
Often do occur during sleep, or right after awake
-bp decreases: already have impeded blood flow, now bp is not as forceful as during the day, more risk
- Affects depends on how large and much tissue is involved
Types of Ischemic Stroke
1a. Thrombotic-
Types of Ischemic Stroke
thrombotic
lacunar
embolic
transient ischemic attacks
- dev of area of injury occurred in smaller artery not a main one, ruptures into the brain tissue, hole dev in the tissue, more rare than 2 other types
Lacunar stroke
ischemic
- clot that originates from another part in the body,
Ways to have:
A. a fib= left chamber of heart thrown into the carotid artery
B. plaque formation from somewhere else
-occur more suddenly
1c. Embolic
ischemic
-Episodes of neurological deficit
-Resolves in minutes to hours
-Considered a warning sign for a stroke= concerned for future stroke, will be put on preventative med
-Temporary loss of neuro function, mini stroke, onset with stroke like symptoms, last usually 3-24 hours, short onset, most often related to microemboli= temporary block flow of blood
1/3 will never have another one, 1/3 can progress into a stroke, 1/3 will keep having onsets of tias after initial episode
1d. Transient Ischemic Attacks
ischemic
- area around the area of injury, the tissue that is at risk
Pneumbra
– within the brain tissue, hypertension is the number one cause that can cause that aneurysm to ruptured, sudden onset, associated with activity
-high mortality, 50% of people die in 48 hours, high risk for rebleeding= which increases mortality rate as much as 80 percent
2a. Intracerebral
hemoragic stroke
- from a rupture or bleed Ex: aneurysm, artery ruptured, trauma
Both= at risk for cerebral vasospasm= in cerebral artery massive vasoconstriction of the blood flow to the brain, prevent that, more of the subarachnoid than the intracerebral, high risk could cause further damage
- Hemorrhagic Stroke
Sx: very severe headache, n/v, decreased level of consciousness, high bp
intracerebral hemorrhagic stroke
rupture into that space, mortality rate 40%, high risk to bleed after it has stopped,
2b. Subarachnoid-
hemorrhagic stroke
Sx: sudden severe headache, *heard a pop, can have same symptoms
subarachnoid hemorrhagic stroke
decreased cerebral blood flow= rupturing in brain tissue ->, increased cerebral edema-> increases pressure in the brain-> herniation-> can displace tissue/ will get less blood flow and more cell death
Pathophysiology: Hemorrhagic Stroke-
droopy face, paralysis of one side of the body, slurred speech, arm drop=weakness of one side or the other, vision problems, complain of headache, common onset symptoms of dizziness
Clinical Manifestations: Stroke
Warning signs of stroke:
weakness on one side of the body/ affected opposite side of the brain affected Ex: Rt sided stroke weakness on left side
A. Motor Deficits
Mobility-
- loss of all voluntary movement
Akinesia motor deficit stroke
- weakness on one side, partial
Hemiparesis motor deficit
- paralysis on one side of the body, permanent loss, almost flaccid, complete loss
Hemiplegia motor deficit
uncoordinated gate or movement
Ataxia- motor deficit
- complete loss of body part is unable to move it, no reflexes, might present with
Flaccidity motor deficit
-provide range of motion, keep joint moving, and proper
position
Leg- hip externally rotate, foot planter flex and rotate in
arm- hand flexed, shoulder internally rotated
contractures motor deficit
start to see first 48 hours to 6-8 weeks, spasms of muscles that were flaccid, good sign means they might be able to get function back
Spasticity- motor deeficit
chewing a problem
Lack of Gag reflex
Swallowing-
motor deficit
- trouble swallowing, high risk, may not be able to swallow, testing done to see if and when they can eat
Dysphagia
motor deficit
extensive rehab to get function back
Self-care abilities- motor deficit
- responses can be mixed based on where it happened in the brain
- some type of loss with expression, speaking, ability to understand, comprehension of language, could be writing
B. Clinical Manifestations: Stroke Communication
Aphasia/ Dysphasia-
- trouble speaking, from brain trouble getting words out of head
- Expressive aphasia
- trouble understanding what you are saying, jumbled words that make no sense
- Receptive aphasia
- usually referred as complete loss of all speech and understanding
- Global aphasia
- words that are real words come out fairley smoothly but make no sense to the context / kind of like word salad
- Fluent aphasia
- word makes more sense, language is very broken, takes a great deal of effort to say what they are trying to say, short phrases, can get meaning if take time with it
Nonfluent aphasia
- nonfluent and expressive aphaisa- trouble getting out of brain and getting words to flow smoothly
Brocha syndrome
aphasia
expressive and fluent have word usage doesn’t make sense, but have trouble understanding -problem with speech is left side of the brain stroke/ usually right handed person it is dominate side of the brain, is the opposite side where the speech center
Wernicke- aphasia
weakness in face, may have muscular difficulty saying words, cant articulate and pronouncing words
- Dysarthria- aphasia
-perceptual deficits, decreased touch or sensation with anywhere in the body, can have visual problem
C. Clinical Manifestations: Stroke Sensory
-unilateral, forget that they have one side or the other, doesn’t mean that they can’t move, remind them about the other side Ex: wash only one side of the body
. Neglect sensory
- loss of vision, blindness as same side of both eyes, see half of things, no sensation that anything else is there, takes a lot of work to overcome would have to scan the room Ex: left side of both eyes, missing half of a room
Homonymous hemianopsia sensory
- inability to recall what an object by site Ex: hairbrush and think it is a toothbrush
Agnosia
sensory
- forgotten how to carry out a task, will have to relearn Ex: tie shoes, feed self
Apraxia sensory
- Loss of peripheral vision
6. Diplopia- double vision
sensory symptoms
neglect homonyomous hemianopsia agnosia apraxia loss of peripheral vision diplopia
stroke sensory symptoms
expressive receptive global fluent nonfluent brocha syndrome wernicke dysarthria
communicatoin stroke symptoms
numbness and tingling, have burning like pain on opposite side of the body where the brain injury is, it can last a long time, can be chronic
Paresthesia-
- not normally affected long term, short term can have incontinence with the stress and lack of mobility both bladder and bowl
Elimination
depends, impaired memory, judgment, concentration
- loss of consciousness, confusion acoma
- Can be short term or long term
- Left side memory will be affected will be slow and conscious with mov
- Right side think more impulsively, jump up out of bed
Cognitive Deficits-
can see any range, difficulty controlling emotion, sudden outburst of anger or tears, frustration, depression
Emotional Deficits-
Right sided
Right side: paralyzed hemiplegia, often show opposite sided neglect, more impulsive and more of a safety problems, spatial-perceptual deficits, tends to deny or minimize problems, rapid performance and short attention span, impaired judgment, impaired time concepts
Left sided
Left sided: paralyzed right side- hemiplegia, impaired speech/ language aphasias, impaired right/left discrimination Ex: touch them don’t know which arm that you touched, slow performance and cautious, aware of deficits-causes anxiety and depression, impaired comprehension related to language and math
is the primary diagnostic test- quickest way to figure out cause
Should be obtained within 25 minutes and read within 45 minutes of arrival at ER
ct
what is able to lice a clot, break up clot to allow blood to flow through artery, can be given iv, can be given in the groin or in the brain
-not given with hemorrhagic, good assessment: won’t be given with recent bleed= gi, want to know major surgeries, on Coumadin
Recommendation- needs to be given in 4.5 hours of onset
- Stroke will allow the blood pressure to run a little bit high to prevent vasoconstriction 160-180 systolic
Recombinant tissure plaminogen activator (tPA)-
Collaborative Care: Drug Therapy Hemorrhagic Stoke
- Antihypertensives
anticonculsants
ca channel blocker
A. = allow some
B. = extra fluid bc want intravascular volume to be higher, more fluid in there less likely vessels will clamp down don’t want in overload
C. - fluid to dilute blood thinner and flows easier
*treat any type of hyperthermia- brain metabolism increases which increases brain damage, running a fever= Tylenol to bring down
- HHH Therapy
hypertension
hypervolemia
hemodilution
hob up 30 degrees, head is straight, anything that would increase avoid: agitation, stress, stimuli/ Resp concerns suctioning to two passes at most and time down
Nursing actions to drop intracranial pressure:
-Care for all of them
ABC
Neurologic assessment: no worsening of symptoms NIH and Glauscoma scale
Manage B/P- watch closely, okay to be a little high
Fluid and electrolyte balance
Seizure precautions
Management of ICP- specially with hemorrhagic
Emergency Management
- initially very often q 1 hour then 2 then 4 hours
- check responses
1. eye opening: spontaneously, to speech, to pain, none
2. Verbal response: orientated, confused, inappropriate, incomprehensible, none
3. Motor response: obeys commands, localizes to pain, withdraws from pain, flexion to pain, none - Higher the score the better, lowest score can get is a 3, max score can get is 15
- changing that it can imply neurological function is decreasing
Glauscoma scale
- Certified to do the scale
- On admission or transfer to see where the patient is at
- What we want to gain at rehab
NIH nursing assessment
- alert or not alert
- ask tell month and age
- open and close eyes and make fist
Level of consciousness
Loc questions
Loc commands
nih
- follow an object pencil horizontally follow with eyes
- all 4 : peripheral field how many fingers in each visual field make them look forward
- Best gaze
- Visual fields
nih
- strength of the cranial nerve drooping of the face, show teeth, smile, close eyes, raise eyebrows= see if they do it with symmetry
Facial palsy
nih
- strength extend arm and hold ten seconds with both arm
- extend leg for 30 degree angle and hold for 5 seconds
- Motor arm
- Motor leg
nih
- upper and lower body for coordination, finger to nose to someone else finger/ lower body heel to the shin and run down smoothly down the shin=smooth normal
Limb ataxia
nih
- pen prick on both extremities leg arm and face/ see if they can feel
- language and understanding, give situation and see how they explain/ picture to point identify, how much they can explain
- Sensory
- Best language
nih
clarity of speech, say words on list
– identify having signs of neglect, tell which side of the body I touch and when, left- left, both –both/ sensation and be able to tell which
- Dysarthria-
- Extinction and inattention
nih
Preserving life- 1st
Preventing further brain damage- focused
Reduce disability- return to highest level that we can
Collaborative Care Goals
ABC=Respiratory: stable, aren’t affected - May need a vent Ongoing assessment Oxygenation Suctioning/airway clearance Mobility Aspiration precautions- because of the swallowing difficulty, can lead to resp problem
Nursing Implementation
- Monitor for signs of extension of the stroke
- Monitor ICP
Nursing Implementation Neurological
VS
Fluid balance- to prevent vasospasm
Cardiac rhythm/heart sounds
DVT prevention- bed ridden for a while because lack of mobility, don’t want another emboli
Cardiovascular
-Position to prevent edema: elevate extremities
-Prevention of contractures
-careful with moving patient: support side that is flaccid, use two people, use a gait belt, don’t grab flaccid arm, tuck arm back so it isn’t in the way
Best to move them to non-affected side to the chair able to grab chair, strong side to where you are going
Prevention of muscle atrophy
Rehab: balance training, CIMT= constraint induced movement therapy, strengthening that side want to work that side, will make them work down the road, will be several weeks after initial, further along
Nursing Implementation specific to stroke Musculoskeletal
- very susceptible because immobility
Prevent breakdown
Integumentary
Prevent constipation
Urinary: monitor intake and output
Manage incontinence- can usually resume function
Intermittent catheterization program- short term
Bladder training
Nursing Implementation Gastrointestinal
Assess swallowing- risk for aspiration
swallow eval : to check if aspiration
-difficulty found will have speech therapist consulted, set up guidelines for swallowing precaution
Initiate swallowing precautions
Have to be cleared to eat
High fowler’s position when eating: up in chair
Head flexed forward- tuck chin when swallow
Swallow and swallow again: 2 for every bite, small bites =right side might shovel food in
Thickening agents- usually referred to things other than water= no bacteria
Frazier water protocol- no water with meals
Learn to place food on the unaffected side of mouth- chew better and stronger
Crush medicine so aren’t swallowing pill
Check and open mouth for pocketing periodically- eat and when take medicine, look like the swallowed
Need good mouth care- before can stimulate appetite, and after to make sure no food is left
Visual fields having difficulty seeing, right side neglect wont eat that side/ see if can see and within reach/ will need guidance
* we should be there to watch eating to asses swallowing for first couple of times/ don’t delegate to can
Nursing Implementation Nutrition
- curved forks that fit over the hand, rounded plates help keep food on the place, special grips and swivel handles are helpful, knives with rounded blades are rocked back and forth to cut, plate guards to help keep food on the place, and cup with special handle
Assistive Devices for Eating
-Assess ability to speak and understand
-decrease stimuli, treat pt as an adult,
-Keep questions simple
-Speak in normal tone and volume
-Allow time to answer don’t interrupt
Utilize gestures- show me, or point, picture boards
Don’t push to communicate when tired or upset aphasia worsens when tired and anxious
Nursing Implementation Communication
-Perceptual Keep items in patient’s visual field Safety Diplopia=Eye patch Coping
Nursing Implementation Sensory
weakness: sudden loss of strength or sudden numbness in the face arm leg / even if temporary
Trouble speaking: sudden difficulty, or sudden confusion/ even if temporary
Vision problems: sudden trouble/ even if temporary
Headache: sudden severe and unilateral
Dizziness: sudden of balance, especially with any of the above signs
Nursing Implementation Health Promotion
Teach risk factors
Warning signs:
