stroke Flashcards
what is the leading cause of disability?
stroke
what is an ischemic stroke?
blockage/obstruction of cerebral artery
is afib a stroke risk?
yes
what is a hemorrhagic stroke?
rupture/opening of cerebral artery with bleeding into other brain areas
prognosis isn’t good
main presenting symptoms of hemorrhagic stroke
decreased LOC
might tell you they have the worst headache of their life
etiology of stroke
- thrombotic stroke
- embolic stroke
- hemorrhagic stroke
time is brain, act F.A.S.T.
Face (is one side of smile drooping)
Arms (ask person to raise their arms, is one week)
Speech (is it slurred)
Time (call 911 at first sign of stroke
why is the mono-kellie hypothesis important in strokes?
they usually head to swelling which can lead to death
non-modifiable risk factors for stroke
-age (above 55), assigned male at birth, African American or black
modifiable risk factors for stroke
-hypertension is primary risk factor
-previous stroke
-cardiovascular disease
-afib.
-carotid stenosis
-atherosclerosis
-elevated hematocrit
-estrogen replacements
-DM
-obesity
-sleep apnea
-migraines
-hypercoaguable states (postpartum, post-surgery)
-periodontal disease
-smoking
-excessive alcohol consumption
-illicit drugs
Transient ischemic attack (TIA)
-temporary neurologic deficit resulting from impairment of cerebral blood flow
-symptoms last 1-2 hours
-brain imaging shows NO evidence/damage of ischemia
-“warning of impending stroke”
diagnostic work-up to investigate causes, risk factors, prevent future stroke
-have to get imaging to know
-get CT to see if bleeding, if no bleeding can use contrast
preventative treatment of strokes
-health promotion measures: healthy lifestyle, stop smoking healthy diet & weight
-anticoagultion therapy for afib.
-anti platelet therapy
-“statins”
-antihypertensive meds
-carotid artery stenosis treatments
carotid endarterectomy
-physically go in & clean our carotid artery
-can be seen via US at bedside
-as a nurse priority is assessment
-after they’re placed in ICU & have neuro assessments
-worry about clots flicking out
-need good BP
ischemic stroke clinical manifestations
-manifestations depend on the location and size of the affected brain area, generally sudden and new/worse from the person’s baseline
-monitor weakness of face, arm, legs, esp one sided
-speech changes, dysarthria, expressive aphasia, receptive aphasia
-balance problems, ataxia, dizziness
-sensory changes
-vision changes
-cognition changes
if someone has vision changes post stroke what do you do?
take them to scan the room
stroke diagnostics
-careful history: time last seen as well
-rapid and focused neurological and physical examination (GCS, NIH stroke scale)
-get CT within minutes (no contrast if unsure of bleed or awful kidneys)
-lumbar puncture (only is ICP is not expected to be elevated)
-EKG
how long do you have to save brain tissue?
4-6 hours
how long does it take to see ischemic stroke?
24 hours
when do you not give TPA
after 6 hours
if there’s a bleed
how long after a stroke will you see dead tissue on an mRI?
12-24 hours
acute medical management of ischemic stroke
-thrombolytic therapy (tPA to dissolve clot)
endovascular therapy (direct removal of clot)
-hemodynamic monitoring & management
-intracranial pressure monitoring, & management
-intubation, mechanical ventilation & sedation
tPA
-converts plasminogen into plasmin and causes lysis of clot
-given IV bolus followed by infusion over 1 hour
-goal is to ADMINISTER 4.5 HOURS OF SYMPTOM ONSET (60 minutes of ED arrival)
nursing management when giving tPA
-see if it’s working via neuro checks every 15 minutes for 6 hours & every 15 minute vital signs
-headaches are a red flag
if there’s a change in vital signs or headache while giving tPA what do you do?
stop drip, anticipate cat scan, stay with patient
eligibility criteria for tPA
-onset of symptoms under 4.5 hours before beginning treatment
-over 18
-no bleeds or surgery for last 3 months
-can’t do is with SBP over 185 or DBP over 110
-INR should be less than 1.7
warnings of when to weigh risk/benefit with tPA
-serum glucose less than 50
-pregnacy
-over 80
before tPA administration
-prior to initiate invasive procedures prior to administration
-bleeding precautions and ICU for 24 hours after
-BP must be under 185/110 prior ro treatment
need CT first to rule out bleed
after tPA
-24 hour “no touch” period, no invasive procedures
-bedrest
post stroke work-up/treatment
-NPO until speech sees them
-depending on size of stroke, may need to watch for secondary cerebral edema
-assess stroke factors
-statin therapy
-lifestyle modification
-PT/OT/SLP evaluations
-need rehab evaluations
see any decline or change in neurologic function or LOC?
report to provider immediately
therapy for someone who neglects side of body after stroke?
make them touch it
most common stoke cause?
HTN
hemorrhagic stroke
bleeding into brain tissue
causes of hemorrhagic stroke
-rupture of small vessels primarily related to HTN
-trauma
-cerebral amyloid antipathy
when does functional recovery plateau for hemorrhagic stroke?
18 months
hemorrhagic stroke clinical manifestations
-sudden & severe headache, described as worst headache of their life (specifically for SAH)
-vomiting, nuchal rigidity, photophobia
-focal neurological deficits
-collapse, LOC if severe
initial acute complications of hemorrhagic stroke
-cerebral ischemia (ineffective perfusion)
-re-bleeding
-increased ICP, drowsy or confused,
-hypothalamus/pituitary dysregulation
-cardiac arrhythmias
in first 24 hours of hemorrhagic stroke what do you want SBP under?
less than 150
when is brain herniation more dangerous?
24-72 hours after stroke, know via change and assessment
CPP less than 50?
results in neurological damage
what is the goal range for CPP?
greater than 60
early clinical manifestations of increased ICP
-decreased LOC
-any change in condition, restlessness, confusion, increased respiratory effort, purposeless movements
late clinical manifestations of increased ICP
-decreased or erratic HR/RR, widening pulse pressure
-worsening respiratory pattern, including cheyne-stokes breathing & respiratory arrest
-loss of brainstem reflexes: pupil, gag, corneal
-cushing’s triad
if there’s a intrventricular catheter what should you do?
clamp it if doing anything with patient
management for increased ICP
reduce cerebral edema via IV meds like: osmotic diuretics (manitol), hypertonic fluids, loop diuretics
surgical management of increased ICP
-craniotomy
-craniectomy
-cranioplasty
-burr holes
-endovascular
SAH other complications
-first 21 days: vasospasm causes cerebral ischemia, seizures, hyponatremia, hydrocephalus
-longterm: personality changes
cerebral vasospasm
-for 21 days Q1hour neurochecks
-secondary injury that SAH are at risk for, peak is usually 7-10 days post bleed
-causes cerebral arteries to constrict and can lead to ischemic infarcts
-prevention is Nimodipine (calcium channel blocker), hydration
treatment of cerebral vasospasm
-induced hypertension and aggressive hydration & endovascular treatment
