Stroke Flashcards
Chronic blood pressure can cause what kind of stroke
Hemmorage stroke
Stroke assessment
Family history, personal history, loc and orientation, memory- remote or long term, recall, immediate,attention,language and copying, drug use,meds,psych hx, bleeding problems,chronic Bp
Sensory function in stroke assessment
Pain, temp,
Romberg sign
Standing with legs together eyes closed and staying up right..knowing your core proiosection
Reflex assessment
Hyperactive-upper motor neuron issue. Hypo active- spinal cord issue
Decorticate
“Towards the core” happens when doing sternal rub to traumatic Brain injury , possibly reversible
Decerebrate
Rigidity,extension of arms,legs,plantar flexion happens during sternal rub and most likely not reversible
Lab test for stroke pt
Blood cultures for change in loc, skull and spine X-ray,cerebral angiography,ct always with out dye, pet scan
NIH STROKE SCALE
LOC QUESTIONS AND COMMANDS,BEST GAZE VISUAL FACIAL PALSY MOTOR LEG/ARM LIMB ATAXIA BEST LANGUAGE DYSARTHRIA NEGLECT
Ischemic stroke
Embolism-a fib thrombotic carotid artery atherosclerosis. 8-12 hours to show up on ct can have tpa if meet requirements and under 180 min
Tia
Mini stroke actual can happen usually 2 days after its a warning sign to a stroke and a temporary blockage
Thrombolytic therapy
Can only be given up to 180 minutes could be extended to 4 1/2 hours . No antiplatlets for 24 hours avoid dextrose solutions manual Bp only no rectal temp elevate hob npo until speech swallow eval purée meals after loc before meals placed on fall risk and skin breakdown BLEEDING PRECAUTIONS WATCH FOR SUDDEN SEVERE HEADACHE COULD BE FROM INCREASED INTERCRANIAL PRESSURE one Venus puncture per day nursing intervened = bleeding precautions intervened to prevents aspiration and preventable safety precautions
Hemorrhagic stroke
Ruptured aneurysm or av malformation
Av malformation
Usually have multiple and treated with gama radiation occlude abnormal arteries or veins
Epidural hemorrhage
Most dangerous headache then loc in 5 min regain loc tremendous headache disorientation out again
Risk factors for ischemic stroke
Htn, atherosclerosis, dm, a fib, Tia, smoking , oral contraceptives, obesity,
Risk for hemorrhagic stroke
Cocaine use cerebral aneurysm av malformation
Left side of brain stroke
Language , math skills and analytical thinking
Right hemisphere
Visual spatial awareness propriception
Left hemisphere stroke
Aphasia alexia agraphia slow cautious behavior depression and quick frustration visual changes
Right hemisphere stroke
Unaware of deficits loss of depth perception disorientation impulse control diffculty poor judgement visual changes
Broccas area
Speech center
Wernikes area
Written or spoken word area
Brain steam stroke
Bled blood pressure respiratory rate balance coordination speech and swallowing nausea and dizziness
Cerebellum stroke
Balance coordination
Nursing diagnosis
Ineffective tissue perfusion in disturb sensory perception impaired physical mobility a unilateral neglect risk for injury self-care deficit impaired verbal communication impaired swallowing
Nursing assessment
Airway patency swallowing ability aspiration risk airway breathing vital signs hyperthermia lower than 99.5° neurological status level of consciousness Glasgow’s coma scale motor function sensory function stroke associate in the Mont yeah and UTI
Nursing interventions
Maintain pay in airway monitor for changes in level of consciousness’s elevate head of bed to decrease intracranial pressure Cesar precaution everyone at risk with stroke non-stimulating environment Q munication skills say feeding treat fevers less then 99° high both their Mia is associated withPoor outcomes maintain skin integrity passive and active range of motion emotion every two hours all of the affected extremity maintain safe environment fall prevention’s scanning technique DVT prevention and immobility meds ADLs referrals
Shoulder safety
Initially the affected arm of a stroke should always be supported it is said that shoulder problems affect 70% of stroke patients gravity can act as a way in Sue blocks the shoulder joint stroke patient should not be pulled or guided by their affected arm
Neglect
The patient is unaware that a body part or side of the body is there the side of the body maybe flaccid patient likely will let lean to the side of neglect patient will often bump into objects with that side of the body sit or stand on the side of the body the patient is neglecting this will force them to turn their head to look at you place calendar pictures flowers etc. on the side of neglectso patient will become accustomed to scanning or looking to that side
clinical presentation for initiation of stroke team
Aphasia expressive receptive or global ataxia crane on nerve palsy facial droop diplopia dysrhythmia how many Paris thesis loss of sensation hemi Paris sees his or her Quadra Pearcy sis visual field disturbances
Stroke center goals
Door to dock 10 minutes door to CT 25 minutes door to CT reading 45 minutes door to drug 60 minutes
Expressive aphasia
Brokas or motor
Receptive aphasia
Wernecke’s or sensory
Dysphasia
Impaired swallowing three types of diagnostic testing initials screening test identifies likely presence of dysphasia completed by bedside clinician more comprehensive test administered by train Swalling clinician instrumental testing gold standard
Bedside dysphasia screening
Alert enough to participate in the evaluation face is symmetric with out any droop no drooling or dried oral secretions does not require and T or oral suctioning able to cough reflectively oh or if asked cough is neither week nor what test the gag with a tongue depressor or if the gag is this diminished or absent score now swallows his own secretions spontaneously voice is neither week not wet or a gurgly can move his/her tongue up and down and side to side when asked swallowing of 2 teaspoons of water thickened if patient’s normal diet failure if struggling to swallow cough choking loss of fluid from mouth change in vocal quality wet/gurgly it failed either bedside screening or swallowing evaluation and PO and referral to speech pathology if past bedside a valuation in swallowing a valuation referral to speech pathology initiate. Diet with nectar thick liquid’s medications crushed in Pieriel if possible
