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Adult Exam 1- Stroke > Stroke > Flashcards

Stroke Flashcards

1
Q

stroke occurs when there is (1)___________ or (2)________

A

1) ischemia (inadequate blood flow to the brain)
2) hemorrhage into the brain that results in the death of brain cells
* functions are lost or impaired in the area of the affected brain. Severity of loss of fx depends on the location and extent of brain involved

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2
Q

stroke is the __ most common cause of death in the US and Canada. ___% of survivors will live with perm. disability and ___% will require long term care

A

4th most common cause of death
15-30% will be left with perm disability
26% will require long term care after 3 months

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3
Q

blood is supplied to the brain either anteriorly by the ______ _______ or posteriorly by the ________ ________

A

anteriorly by the carotid arteries

posteriorly by the vertebral arteries

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4
Q

3 factors that affect blood flow to the brain

A
  • systemic BP
  • Caridac output
  • blood viscosity
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5
Q

Non- modifiable risk factors

A
  • age, gender, ethnicity, race, family hx, heredity
  • stroke risk doubles each decade after age 55
  • more common in men, but more women die
  • ## more common in african americans (so is hypertension, obesity, and diabetes)
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6
Q

modifiable risk factors

A
  • hypertension (single most important modifiable factor)
  • heart disease ( A. Fib., M.I., cardiomyopathy, valve abnorm.,)
  • serum cholesterol
  • smoking (nearly doubles risks, but will decrease over time if smoker quits)
  • excess alcohol consumption (women who drink more than one/day, and men who drink more than two/day)
  • obesity
  • sleep apnea
  • metabolic syndrome
  • lack of exercise
  • poor diet
  • drug abuse
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7
Q

Transient ischemic attack (TIA)

A
  • a past history of a TIA is another factor associated with stroke risk
  • TIA is a transient episode of neurologic dysfunction cause by focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain. May be caused by microemboli that temp. block blood flow.
  • clinical sx last less than 1 hour.
  • warning sign for a possible stroke *1/3 of TIA progress to stroke
  • warning sign for progressive cerebrovascular disease
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8
Q

Strokes are classified based on thier underlying pathophysiologic findings as either
1) ________
or
2)__________

A

1) ischemic- inadequate blood flow to brain from partial or complete occlusion of artery) nearly 80% of strokes
2) hemorrhagic- approx 15% of all strokes result from bleeding into brain tissue itself or into subarachnoid space or ventricles.

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9
Q

Ischemic strokes- _____ is usually precursor

A

TIA is usually precursor of ischemic strokes

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10
Q

two types of ischemic stroke:

1) _______ stroke
2) _______ stroke

A

1) thrombotic stroke- occurs from injury to blood vessel wall and formation of a clot that results in narrowing of vessel lumen, which blocks passage of blood in the artery
2) embolic stroke- an embolus is a blood blot or other debris circulating in the blood. When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks flow of blood

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11
Q

Define and describe a thrombotic stroke

A

A thrombotic stroke is a type of ischemic stroke that occurs from injury to blood vessel wall and formation of a clot that results in narrowing of vessel lumen, which blocks passage of blood in the artery

  • most common cause of stroke (60% of strokes are from thrombosis).
  • 2/3 of thrombotic strokes are associated with HTN and diabetes
  • signs and sx develop slowly and onset is usually during or after sleep
  • TIA is a warning sign in 30%-50% of cases
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12
Q

Define and describe an embolic stroke

A

An embolic stroke is a type of ischemic stroke and occurs when an embolus (blood clot) or other debris circulates in the blood. When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks flow of blood

  • second most common cause of stroke (24% of strokes)
  • majority of emboli originate in the inside layer of the heart, with plaque breaking off from the endocardium and entering circulation
  • onset is sudden and is a single event. Signs and symptoms develop quickly
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13
Q

define and describe hemorrhagic stroke

A
  • approx 15% of strokes
  • occurs as result of bleeding into brain tissue itself (intracerebral or intraparenchymal hemorrhage) or into subarachnoid space or ventricles (subarachnoid or intraventricular hemorrhage)
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14
Q

Intracerebral Hemorrhage is bleeding in the brain caused by _____________________? Describe its manifestations and prognosis.

A
  • caused by rupture of a vessel and accounts for about 10% of all strokes.
  • sudden onset of sx
  • Manifestations: neurological defects, headache, nausea, decreased LOC, HTN.
  • progression is over minutes to hours because of ongoing bleeding
  • number one cause is uncontrolled HTN (other causes include: vascular malformations, coagulations disorders, anticoagulant and thrombolytic drugs, trauma, brain tumors, ruptured aneurysms)
  • hemorrhage usually occurs during periods of activity
  • poor prognosis (30 day mortality rate is 40%-80%)
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15
Q

Subarachnoid Hemorrhage occurs when there is intracranial bleeding into the _________? Describe its manifestations and prognosis.

A
  • occurs when there is bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain.
  • common cause is cerebral aneurysm that is either saccular or berry), trauma, or drug abuse (cocaine).
  • majority of aneurysms are in the circle of willis
  • describe as “worst headache of their life” is characteristic symptom of ruptured aneurysm
  • May have loss of consciousness (depends on severity of bleed), focal neurologic deficit, nausea, vom, seizures, stiff neck.
  • incidence increases with age and is higher in women than men.
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16
Q

describe a carotid endarterectomy

A

preformed to prevent impending cerebral infarction. A bruit heard at the carotid would be an indication that patient may need a carotid endarterectomy

  • tube inserted above and below blockage to reroute blood flow
  • atherosclerotic plaque is common carotid is removed
  • once artery is stitched closed, the tube the tube is removed.
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17
Q

Describe the nursing assessment after a cardiac endartectomy procedure or TIA/stroke prevention

A
  • neurovascular assessment is important
  • BP management
  • assessment of stent occlusion or retroperioneal hemorrhage as complications
  • minimize complications at insertion site by keeping patients leg straight for prescribed period of time.
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18
Q

Describe MERCI Retriever procedure

A
  • removes clots in patients who are experiencing ischemic strokes
  • retriever is long, thin wire (corkscrew-like) that is threaded through a catheter into a femoral artery, and it latches to the clot so the clot can be pulled out.
    (Mechanical Embolus Removal in Cerebral Ischemia= MERCI)
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19
Q

Clinical Manifestations for all strokes depend on what?

A
  • manifestations depend on the part of the brain/neural tissue that is injured. Neural tissue destruction is the basis for neurologic dysfunction.
  • the body functions affected are related to the artery involved and the area/half of the brain to which the artery supplies blood.
  • degree of injury depends on the time/onset of symptoms, and the length of ischemia.
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20
Q

Clinical manifestations can affect body functions such as….?

A
  • motor activity
  • elimination
  • intellectual fx
  • spatial-perceptual alterations
  • personality
  • affect
  • sensation
  • swallowing
  • communication
  • nurses must ask time of onset of symptoms. time can affect treatment decisions
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21
Q

An important assessment questions nurses must ask a stroke patient is……?

A

nurses must ask time of onset of symptoms. time can affect treatment decisions

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22
Q

manifestations of right-brain damage (stroke on right side of brain)

A
  • paralyzed left side
  • left-sided neglect
  • spatial-perceptual deficits
  • tends to deny or minimize problems
  • rapid performance, short attention span
  • impulsive, safety problems
  • impaired judgement
  • impaired time concepts
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23
Q

manifestations of left-brain damage- stroke on left side

A
  • paralyzed right side, hemiplegia
  • impaired speech/language aphasias
  • impaired right/left discrimination
  • agnosia- cant recognize objects
  • slow performance, cautious
  • aware of deficits: depression, anxiety
  • impaired comprehension related to language and math
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24
Q

Motor function deficits of stroke

A
  • impaired mobility
  • impaired respiratory fx (need ventilator)
  • impaired swallowing/speech
  • impaired gag reflex
  • impaired self-care abilities
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25
Q

the characteristic motor deficits include

1) loss of skilled _________ _________
2) impairment of _________ ___ ___________
3) alterations in _________ _______
4) alterations in ___________

A
  • loss of skilled voluntary movements (akinesia)
  • impairment of integration of movements
  • alterations in muscle tone
  • alterations in reflexes (initially patients will have hyporefelexia- depressed reflexes, and it progresses to hyperreflexia)
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26
Q

with loss of motor function, patients will have a period of ____________ for a few days-weeks. ______ _________ reflexes willl be non-responsive. Following this, muscles will become ______ and they will stay that way.

A
  • patients will have a period of flaccidity for days to several weeks. (related to nerve damage).
  • Deep tendon reflexes will be non responsive
  • following flaccidity, muscles will become rigid (spasticity) and they will stay that way.
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27
Q

Communication :
The ______ hemisphere is dominant for language skills.
Language disorders involve expression of _______ and ______ words

A
  • left hemisphere is dominant for language skills

- written and spoken words

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28
Q

Aphasia (receptive, expressive, global)

A
  • can be receptive –> loss of comprehension
  • can be expressive –> inability to produce language
  • can be global –> total inability to communicate
  • patterns of aphasia may differ since stroke affects different areas of the brain.
29
Q

dysphasia

A
  • impaired ability to communicate (used interchangeably with aphasia)
  • dont confuse with dysphagia (diff. swallowing)
30
Q

nonfluent pattern of aphasia

A
  • minimal speech activity with slow speech that requires obvious effort
  • damage to Broca’s area, frontal lobe damage
  • speak in short phrases that don’t make since but are produced with great effort. Often omit small words “is”, “and”, “the”
    Examples: “walk dog” or “book book two table” (there are two books on the table)
  • typically understand speech of others, are aware of difficulties and become easily frustrated
31
Q

fluent pattern of aphasia

A
  • speech is present but contains little meaningful communication
  • damaga to wernicke’s area, in left temporal lobe, but can be damage to right lobe.
  • may speak in long sentences that have no meaning and unnecessary words, or create made-up words
  • difficult to follow what they are saying
  • have difficulty understanding speech
  • often unaware of mistakes
32
Q

global aphasia

A
  • non fluent
  • damage to extensive parts of language areas
  • severe comm. difficulties
  • limited in ability to speak and comprehend language
33
Q

Problems with Affect

A
  • mood/emotions
  • emotional responses may be exaggerated or unpredictable
  • depression and feelings associated with changes in body image, loss of fx, can make this worse
  • nurse should help family recognize that frustration and depression are common in first year after a stroke
34
Q

problems in intellectual functioning

A
  • memory and judgement may be impaired
  • left-brain stroke more likely to result in memory problems related to language
  • patients with left brain stroke often are cautious in making judgements (example- patient may move very slowly and cautiously from a wheel chair)
  • patient with right brain stroke tend to be impulsive and move quickly (example- patient may try to rise quickly from wheelchair without locking the wheels or raising foot rests)
35
Q

spatial-perceptual alterations (4 types of problems in this area)

A
  • -individuals with stroke on right side are more likely to have problems with spatial perceptual orientation
    4 types:
    1) result of damage to parietal lobe and causes patient to have incorrect perception of self and illness. patients deny illness or own body parts
    2) patient neglects all input from affected side (erroneous perception of self in space), and may be worsened by homonymous hemianopsia. (*Risk for pressure ulcers or contractures)
    3) agnosia (inable to recognize an object by sight or touch or hearing
    4) apraxia (inable to carry out learned sequential movements on command )
    *patients may not be aware of their own spatial-perceptual alterations so nurse should assess for this potential problem since it will affect their rehab/recovery.
36
Q

problems with elimination

A
  • usually temporary
  • one side affected –> good prognosis for normal bladder fx
  • initially patient may experience frequency, urgency, incontinence.
37
Q

diagnostic studies are done to….. ? (2 reasons)

A

1) confirm that it is a stroke and not another brain lesion

2) identify the likely cause of the stroke

38
Q

what is primary diagnostic test done after a stroke?

A

CT

  • non contrast CT done to find out if stroke is occlusion (ischemic) or hemorrhage.
  • rapid assessment to determine type of stroke is really important and necessary before treatment can begin.
39
Q

CT should be obtained within ____ minutes and read within ____ minutes of arrival at ER.
CT will indicate _____ & ______ of lesion, and differentiate between _______ or _______ stroke

A
  • obtained within 25 min and read in 45 min of arrival
  • CT will indicate size and location of lesion
  • differentiate between ischemic and hemorrhagic stroke.
40
Q

______ can be given within ___ to ___ hours to dissolve clot

A

TPA can be given within 3- 4.5 hours to dissolve clot

41
Q

CTA- CT angiography

A
  • provides visualization of cerebral blood vessels
  • preformed after or during the non contrast CT.
  • provides estimate of perfusion and detect filling defects in cerebral arteries
42
Q

MRA- Magnetic resonance angiography

A
  • can detect vascular lesions and blockages similar to CTA
43
Q

cardiac imaging/angiography

A
  • rec. because many strokes are caused by blood clots from the heart
  • can ID cervical and cerebrovascular occlusion, atherosclerotic plaques, and malformation of vessels
    -definitive study to identify the source of SAH
    -*risks of angiography include dislodging an embolus, causing a vasospasm, inducing further hemorrhage, provoking an allergic reaction to contrast media
    (consider DSA)
44
Q

DSA- digital subtraction angiography

A
  • reduced dose of contrast material, uses smaller caths, shortens length of the procedure compared with conventional angiography
  • involves injection of a contrast agent to visualize blood vessels in the neck and large vessels of the circle of willis. less vascular manipulation is required (safer)
45
Q

stroke preventative therapy

A 
healthy diet
weight control
regular exercise
no smoking
limitation on alcohol consumption
routine health assessements
* closely manage patients with risk factors- diabetes, hypertension, obesity, high serum lipids, cardiac dysfunction
46
Q

patients who have had a TIA are usually prescribed ___________ drugs

A

anti-platelet drugs are used to prevent development of thrombus or embolus.
- aspirin is most common, dose @ 81- 325 mg/day

47
Q

for patients who have atrial fib., ___________ are usually prescribed

A
  • anticoagulants (warfarin, Xarelto)
48
Q

Goals for nursing management of stroke

A
  • maintain stable or improved level of consciousness
  • attain maximum physical functioning
  • maximize self care abilities
  • maintain stable body functions
  • max. communication abilities
  • avoid complications of stroke
  • maintain effective personal and family coping
49
Q

nursing diagnoses for stroke

A
  • risk of ineffective cerebral tissue perfusion
  • ineffective airway clearance
  • impaired physical mobility
  • impaired verbal communication
50
Q

Interventions for acute care for all strokes

A
  • preserve life
  • prevent further brain damage
  • reduce disability
  • investigate for time and onset of sx
  • individualize care based on type of stroke
51
Q

acute care for ischemic stroke

A
  • baseline neuro assessment —>(Awake, alert, oriented. Deep tendon reflexes, PERRLA), monitor closely for signs of increasing neurologic deficit, and signs of increasing ICP
  • elevated BP is common immediately after a stroke –> protective response to maintain cerebral perfusion.
  • carefully work to control fluid and electrolyte balance –> goal is to promote perfusion and decrease further brain injury. Adequate fluid intake, via IV or oral, or tube feedings is priority. Monitor urine output to make sure patient isnt dehydrated.
  • manage ICP—> elevate head of bed to 30 degrees, use interventions that improve venous drainage
52
Q

Acture care for ischemic stroke:
If secretion of ADH increases in response to stroke, urine output will _________, and fluid will be ________. This can cause what effect on blood levels? What IV solutions should be avoided in this case?

A

urine output will decrease and fluid will be retained.

  • may cause low serum sodium (hyponatremia)
  • IV solutions with glucose and water should be avoided because they are hypotonic and may further increase cerebral edema and ICP.
53
Q

ICP is more common in _________ strokes. Management of ICP includes …?

A
  • improving venous drainage (elevating head of bed)
  • maintaing head and neck in alignment
  • avoiding hip flexion
  • mangage hyperthermia (goal temp is 96.8- 98.6)
  • drug therapy to prevent seizures
  • avoid hypovolemia
54
Q

tPA can be used for _______ strokes but CAN NOT be used for _____ strokes

A

can be used for ischemic (embolic) strokes

can NOT be used for hemorrhagic strokes because TPA breaks up clots and they would bleed to death.

55
Q

tPA= Recombinant tissue plasminogen

A

used to reestablish blood flow through blocked artery to prevent cell death. works by fibrinolytic therapy- enzymes digest fibrin to lyse clot.

  • must be administered within 3 to 4.5 hours of onset of clinical signs to ischemic stroke
  • patients are screen carefully before tPA is given with a non contrast CT to rule out hemorrhagic stroke
  • also pre-screened for blood glucose level, coagulation disorders, recent Hx for GI bleeding, stroke, head trauma within the past 3 months.
56
Q

after an ischemic stroke patient has stabilized, and to prevent further clot formation, patients with strokes caused by thrombi and emboli may be treated with ___________ and _________ ____________

A

treated with anticoagulants and platelet inhibitors

- ASA, Ticlid, Plavix, Persantine

57
Q

Hemorrhagic stroke- what is contraindicated

A
  • anticoagulants and platelet inhibitors are contraindicated
58
Q

what is the main focus of mangament for hemorrhagic stroke?

A
  • management of hypertension is the main focus
  • oral and IV agents are used to maintain BP within a normal to high-normal range (systolic 160 or less- since these patients typically have high BP already)
  • seizure prophylaxis is situation specific
59
Q

surgical therapy for hemorrhagic stroke

A
  • resection
  • clipping of aneurysm - metal clip on neck of aneurysm to block blood flow and prevent rupture. remains in place for life.
  • evacuation of hematomas
60
Q

describe a GDC coil

A
  • procedure for protecting against a hemorrhage
  • reduces blood pulsations within the aneurysm
  • coil is used to occlude aneurysm. The coil assumes the shape of the aneurysm . Packing the aneurysm with coils prevents the blood from circulating through the aneurysm, reducing risk of rupture.
61
Q

intervention for respiratory system

A
  • advancing age and immobility increase risk for atelectasis and pneumonia
  • risk for aspiration pneumonia is high bc of impaired consciousness or dysphagia (dysphagia after stroke is common)
  • airway obstruction-> problems chewing , swallowing, tounge falling back
  • brainstem stroke or hemorrhagic stroke may require endotracheal intubation and mechanical ventilation
  • all patients should be screened for ability to swallow and kept on NPO until dyphagia is rulled out
  • nurse should frequently assess airway patency and function, provide O2, suction, promote mobility, encourage deep breathing. If patient is on mechanical ventilation, provide oral care every 2 hours to reduce risk of VAP
62
Q

intervention for neuro system

A
  • NIH stroke scale to predict severity of stroke, and outcomes
  • assess mental status, pupillary response, extremity movement, strength
  • closely monitor vitals
  • ## decreasing LOC man indicate increasing ICP
63
Q

intervention for cardiovascular system

A
  • aim is maintaining homeostasis
  • monitor vitals frequently
  • monitor hemodynamics
  • monitor cardiac rhythms
  • calculate intake and output and noting imbalances
  • regulating IV infusions
  • adjusting fluid intake to individual patients needs
  • monitor lungs for crackles to indicate pulm congestion
  • monitor heart sounds for murmurs or for S3 or S4 .
64
Q

interventions for musculoskeletal system

A
  • goal is to maintain optimal function by preventing joint contractures or muscular atrophy
  • ROM exercises and positioning are important in acute phase
  • position each joint higher than the joint proximal to it to prevent dependent edema
  • prevent foot drop
  • trochanter roll to prevent external hip rotation
  • hand cones (rolled wash cloths) to prevent hand contracture
  • arms supports with slings to prevent shoulder displacement
  • hand splints to reduce spasticity
65
Q

interventions for skin

A
  • pressure relief by position changes, a special mattress, or wheel chair cushions
  • good skin hygiene
  • emollients applied to dry skin
  • early mobility
  • max of 2 hrs in a position, but position patient on the weak or paralyzed side for only 30 min
66
Q

elimination interventions- GI

A
  • constipation is most common problem
  • may be put on stool softeners and/or fiber
  • physical activity will promote bowel fx
    enemas are last resort bc that may cause increased ICP by vagal stim.
  • bowel retraining program- put patient on bedpan and take them to bathroom at a regular time daily. good time is 30 min after breakfast.
67
Q

elimination interventions- Urinary

A
  • primary problem is poor bladder control –> incontinence
  • avoid use of indwelling cath (remove cath as soon as patient is neurologically and medically stable)
  • if urinary retention is problem –> use intermittent cath
  • bladder retraining program–> adequate fluid intake with most given between 7 am- 7pm, and scheduled toileting every 2 hrs.
  • observe for signs of restlessness bc may indicate need to urinate
  • asses for bladder distention by palpation.
68
Q

interventions for atypical emotional response

A
  • distract the patient
  • explain to patient and family that emotional outbursts may occur
  • maintain calm environment
  • avoid shaming or scolding patient
69
Q

Homonymous hemianopsia

A
  • blindness in same visual field of both eyes

- teach patient to scan environment

Adult Exam 1- Stroke (1 decks)

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