OA: Stroke Flashcards
TIA
mini stroke - do not call it that
Transient ischemic attack
Hemorrhagic stroke
- 15% of strokes
- bleeding into the brain tissue, subarachnoid space, or ventricles
Warning signs of stroke
- numbness
- tingling
- difficulty with speech
- weakness
- dizziness
- sudden intense headache
- sudden nausea and vomiting
- sudden inability to remember events
- heavy arm
- facial dropping
What happens with a hemorrhagic stroke?
-accumulation of blood causes pressure on brain tissue leading to ischemia and infarction
CVA
Cerebrovascular Accident or Stroke
When does a stroke occur
when there is ischemia to a part of the brain or hemorrhage into the brain that results in death of brain cells
Stroke Risk Factors
- HTN
- Heart disease
- Diabetes Mellitus
- Sleep Apnea
- Blood Cholesterol Levels
- Smoking
- Substance abuse
- Living in the SE US
Types of Strokes
classified on the basis of underlying pathophysiologic findings
- Ischemic
- Hemorrhagic
Ischemic
lack of blood flow to brain cells
first goal of potential stroke patient
CT scan
CT scan
primary diagnostic test and the first priority after stabilizing the patient
When symptoms of a stroke occur, diagnostic studies are done to..
- confirm that it is a stroke
- identify the likely cause of the stroke (Hemorrhagic vs. Ischemic)
Treatment options for hemorrhagic
- Evacuate the bleeding
- BP control (more focused on MAP and Cerebral Perfusion Pressure)
Treatment options for ischemic
-tPA administration
tPA
- VERY strict criteria
- Dose is based on pt’s weight…so get an exact weight (always kg)
Clinical Manifestations of Stroke
- do not significantly differ between ischemic and hemorrhagic stroke
- destruction of neural tissue is the bass for neurologic dysfunction caused by both types of stroke
Brain components
10%: Cerebrospinal fluid
12%: Intravascular blood
78%: Brain tissue
Modified Monro-Kellie hypothesis
If volume of any one of the cranial vault components increases, the volume from another component is displaced, but the total intracranial volume will not change
ICP
Intracranial Pressure
-pressure inside the skull and thus the pressure on the CSF, brain matter, vasculature, and cerebral blood flow
Normal ICP is maintained through…
balance of the CSF, brain tissue, and intravascular blood volume
Factors that worsen ICP
- pain
- head not midline
- increased intrathoracic pressure
- cerebral edema
- bright lights/loud noises
- supine or high Fowlers position (HOB at 30 degrees is ideal)
Clinical Manifestations: Motor Function
- loss of skilled voluntary movement
- impairment of integration of movements
- Alterations in muscle tone
- Alterations in reflexes
GCS
Glasgow Coma Stroke
- Best Eye Opening Response (1-4) no response to spon.
- Best Motor Response (1-6) no resp to obeys verbal comm.
- Best Verbal Response (1-5) no resp. to oriented x3
NIH Stroke Scale/Score
- well validated, reliable scoring system specific to stroke
- quantifies stroke severity (0-42)
- objectively tracks changes and provides standard language amongst healthcare professionals
NIH Scoring
Mild: 0-5
Mod: 5-15
Mod-Severe: 15-20
Severe: 21-42
Who completes the NIH Stroke Scale?
MD prior to tPA admin
How does blood sugar relate to stroke?
low blood sugar can result in stroke like symptoms such as confusion
tPA Administration
- IV
- Tissue Plasminogen Activator
- Fibrinolytic Agent (“clot buster”)
FDA & tPA
tPA is the first FDA approved acute ischemic stroke treatment in 1996
tPA has better outcomes associated with….
earlier intervention
tPA is indicated for…
management of acute ischemic stroke in adults for improving neurological recovery and reducing the incidence of disability
Activase; Alteplase
tPA drugs
Bolus dose for tPA
10% of total dose and given over 2 minutes followed by continuous infusion
Who verifies tPA?
dual verified by two RNs and pharmacist
What is monitored with tPA patients?
improvement in stroke symptoms and/or S/S of bleeding
Why are surgeries performed for stroke patients?
- prevent occurrence of a stroke
- restore blood flow when a stroke has already occurred
- repair vascular damage or malformations
What types of surgeries are performed for stroke patients?
- carotid endarterectomy
- extracranial-intracranial bypass
- carotid angioplasty with stenting
carotid endarterectomy
- done at the carotid artery bifurcation
- removes atherosclerotic plaque
extracranial-intracranial bypass
-done when occluded or stenotic vessel is not directly accessible
carotid angioplasty with stenting
- newer option for treating cerebral stenosis
- opens narrowed carotid arteries.
-aka CAS (carotid artery stenting)
Dysarthria
disturbance in the muscular control of speech that may involve:
- pronunciation
- articulation
- phonation
Prevent Aspiration
- NPO until swallowing assessed
- observe facial drooping, asymmetry, drooling, hoarseness, incomplete mouth closure, or cranial nerve palsies
- check gag reflex
- check cough reflex
- thickened liquids
- position while eating
- patient education
Promote Mobility
- encourage independence as much as possible
- refer to PT
- provide ordered DVT prophylaxis/sequential stockings
- reposition every two hours
- provide ROM to decrease contractures
Promote Communication
- one idea in each sentence
- simple one step commands
- speak slowing, not loudly
- use cues and gestures
- avoid yes and no questions
- tell the patient if you dont understand, don’t guess
- implement other forms of communication
Promote Elimination
- start bowel and bladder training
- ensure adequate PO intake
- provide juices, dietary fiber and laxatives as tolerated
- scan bladder after voiding
Hemianopsia
-unilateral neglect
- increased risk of falls
- encourage patient to touch and use both sides of body
- dress affected side first
- teach to turn head from side to side
Discharge Planning
-case management arranges followup care based on patient ability
Care could take place at…
rehab center, skilled nursing facility, home, or hospice
Care is based on…
needs and tolerance of therapy
Care will include…
- PT
- OT
- Speech
- Neuropsychiatric counseling
- family education and support
Stroke prevention
- lifestyle changes
- medication management to reduce risk factors
- surgery
- platelet inhibitors
- anticoagulants
Anticoagulants are contraindicated for….
patients with hemorrhagic stroke
Collaborative care
work as an interdisciplinary team to care for stroke patient
Stroke Alert protocol
- call stroke alert
- get help from charge RN, CNA, or other RNs
- Ensure ABC’s are adequate, if not, stabilize
- Check blood sugar
- Take patient for CT STAT
- implement prescribed interventions
