Stroke Flashcards
Stroke/ brain attack/CVA RF
HTN
Cigarette smoking
Estrogen/progesterone
DM
Carotid artery disease
HX of TIA
Stroke modifiable RF
Stress
Smoking
Wt
Sleep apnea
Diet
Stroke non modifiable RF
Age
Race
Gender
Family hx
Stroke primary, seconday prevention and health goals
Primary:
Smoking cessation, wt loss
Secondary:
BP, knowing lab values
Health goals:
Lower Na intake
Normal wt
Normal BP
Limit smoking
⬆️ exercise
TIA
Temporary focal cerebral ischemia
Caused by transient decrease in blood supply to brain
S/s same as stroke: resolve spontaneously
Last less than 24 hrs
TIA
Diagnostic workup
Management
Workup within 24-48 hrs
Management:
-prevent stroke
-Antplatelets or anti coags.
(Antiplt: ASA, clopidogrel)
(Anticoags: warfarin(inr), (vitk & FFP for antidote)
-control BP
Types of ischemic strokes
Thrombotic:
Clot forming and plaque causes narrowing:
Associated with:
CAD, DM, TIA
Embolic:
Embolis of clot reachs a small artery and blocks it
Associated with:
A-fib
Hemorrhagic stroke
Intracerebral bleeding:
Ruptured vessel
Most common cause:
HTN
Aneurysms/hemorrhagic stroke:
Name
Where mostly occur
Causes
S/s
Risk of
SAH: subarachnoid hemmorrhage (bleed in arachnoid space)
Most are in circle of willis
Causes: trauma or cocaine use
S/s:
Severe HA(thunder clap)
Vomiting
Lethargy
Seizure, coma
Risk of vasospasms up to 2-3 wks post bleed (may mimic stroke like s/s give meds for vasospasms)
ca channel blockers
Sx specific to hemorrhagic stroke
Prevent rupture:
Aneurysm clipping
Coil inserted into the aneurysm
(Immediate protection to pulsations to cause rupture)
Tx if cant do sx for hemorrhagic stroke
Angiography to ID bleed site
Neuro assessment Q1
Monitor increased ICP, VS, MAP(CPP)
tx:
Ca channel blockers: vascular antispasms
Keep BP up so CPP is up but not too high bc can cause rupture
Stroke patho
Brain deprived of O2
primary neuronal injury : Irreversible ischemia to cells in the center of stroke area
Penumbra: zone where there is reversible ischemia
When you have a stroke what bad happens
Biochemical cascade
Edema
Biochemical cascade:
Neurotoxins released
Influx of Ca & Na
Causes cytotoxic edema
Edema increases damage
BEFAST
Balance
Eyes
Face
Arm
Speech
Tongue not midline (also Time)
Call 9-11 if have 1 or more
Sudden:
-Numbness or weakness of face, arm, or leg
-Confusion, trouble speaking or understanding
-Trouble seeing
-Trouble walking, dizziness, loss of balance
-Severe HA with no known cause
Stroke CM
Visual and sensory
Visual field deficits:
Homonymous hemianopsia: loss of vision of the same halves on both eyes
Diplopia: double vision
Sensory deficits:
Paresthesia
Vision changes in stroke
Hemianopia: blindness over half field of vision
Binasal-blindness: inner half of eyes
Bitemporal-blindness: outer half of eyes
Homonymous blindness: same half of visual field each eye
Unilateral visual neglect
Pt starts to neglect one half of their body or dont realize there is another half of things.
Example: may only eat half the plate of food.
Stroke CM
Motor deficits
Incontinence
Motor deficits: usually contralateral
-hemiparesis (unitlateral paresis)
-hemiplegia (unilateral paralysis)
-ataxia: bad balance
-Dysarthria: slurred speech
-Dysphagia
Incontinence:
Frequency, urgency, constipation
Stroke CM
Verbal deficits
Expressive aphasia: trouble verbalizing
Receptive aphagia: trouble understanding communication
Global aphasia (mixed)
Stroke CM communication issues w/
Left sided brain injuries
Wernicke’s (wacky)
-fluent aphasia
-word salad (made up words long sentences)
-difficulty understanding speech
-unaware of their mistakes
Broca’s (broken)
-non fluent aphasia
-short phrases, makes sense but takes effort to talk
-understands speech
-aware of their difficulties
Global aphasia:
-non fluent aphasia
-difficulty understanding and speaking
Behavioral changes
Cognitive and emotional
Cognitive:
Poor reasoning, altered judgement, memory loss
Emotional:
Loss of self-control, emotional lability, depression
Right brain damage
Left sided: hemiplegia
Left-sided neglect
Spatial-perceptual deficits
Tends to deny or minimmize problems
Short attention span
Impulsive
Impaired judgement, impaired time concepts
Left-brain damage
Right side: hemiplegia
Impaired speech/language aphasia
Right/left discrimination impaired
Slow performance
Aware of deficits
Impaired comprehension related to language, math
Horner’s syndrome
Stroke causes paralysis in sympathetic nerves in eyes
Ptosis
Sunken eyeball
Elevation of lower lid
Pupillary constriction
Lack of tearing
Stroke diagnostics:
CT: stat (non contrast) (check if its hemmorragic or ischemic)
MRI (see ischemia happening in the brain)
Angiography (visual of cerebral blood vessels)
EEG
Doppler of carotid arteries
NIH stroke scale
BP (1st)
How to ID stroke early
NIH stroke scale
GCS
history/symptoms
Treatment reconmentdation
Door to needle
Door to MD: 10 min
Access to neuro: 15min
Door to CT complete: 25min
Door to CT read: 45min
Door to treatment: 60min
Admit to ICU/stroke: 3hrs
Protect the ischemic penumbra
Maintain cerebral oxygen
Blood sugary management early: if above 200
Goal temp is: 96.8-98.6 degree
BP recomendations
Ischemic strokes
Lower BP only if SBP >220 or DBP >120
But SBP >185 is a contraindication for thrombolytics
If receiving tPA BP maintained <185 for 24 hrs
***Labetalol is initial drug for BP
BP recomendations
Hemorragic strokes
SBP <160
When a client arrives in the ER with an ischemic stroke, what is the priority assesssment in relation to tx with rt-PA?
A. Current medications
B. Complete hx and physical
C. Time of onset of current stroke
D. Upcoming surgical procedures
C. Time of onset of current stroke
(Need to be given 3-4.5 hours of onset of symptoms)
Recombinant tissue plasminogen activator
-restore cerebral flow using what?
Give in what time frame
CI
Prevent complications
Restore cerebral blood flow:
*evalate for rt-PA therapy
-within 3-4.5hr of onset of symptoms
CI:
GI bleed, hemorrhagic stroke, head trauma 3mo, sx past 14 days
Prevent complications:
Bleeding after rt-PA
-no other anticoags for 24hrs after rt-PA
-monitor BP <185
-stop if:
severe HA, N/V, decreased LOC
Clot removal systems
Penumbra system: disolves clots
Merci clot remover: removes them
Risk after stroke
Cerebral edema: signs
-cushings triad
-increased ICP
Stroke recurrence:
Prevent: go home on ASA 325g and anticoags
when to start REHAB
As soon as hemodynamically stable:
Preferably by 2nd hospital day
Nursing diagnoses
-Impaired verbal communication
-Risk for corneal abrasion
-Disturbed thoughts and vision
-Unilateral neglect
-Ineffective coping
-Ineffective cerebral tissue perfusion
-Hemorrhage
-Risk of aspiration, hyperthermia, impaired skin integrity, contracture development
-Impaired physical mobility
-self-care deficit
Imbalanced nutrition: less thn body requirments
-Dysphagia diets
-Eval from speech therapy
-Aspiration precautions
-Position of pt
-Food to unafftected side
-Alternate bites w/ fluids
-May need thickened fluids
-Assistive devices
