Stroke and Neurological disorders Flashcards
What are ways in which we can determine if a stroke is hemorrhagic or ischemic?
DWI (diffusion weighted mri), CT scan (stat), ECG, carotid doppler, PET scan
(if you were to remember anything, it is a CT scan and the diffusion weighted MRI)
What is the major cause of stroke?
Atherosclerosis
What are the three most common causes of death in Canadians?
Heart disease, cancer, stroke
Stroke is the layman’s term, what is it called medically?
What is a new layman term being used to help non-medically educated individuals understand the severity?
CVA - cerebrovascular accident
Brain attack
What are the two stroke types? Which is more common?
Ischemic (80%) or hemorrhagic (20%)
TIA = ?
- temporary ______ loss of neurological function
- caused by _______, lasting less than _____, often less than ______
- TIAs are a ________ _____ of progressive cerebrovascular disease
Transient ischemic attack
focal
ischemia, 24 hours, 15 minutes
warning sign
What is a TIA not?
Not a mini stroke
Stroke risk factors - non-modifiable: - Age - Gender - Ethnicity - Heredity Describe the impact of each.
Age - after 55, risk doubles q10 years; 2/3rds of all strokes occur over the age of 65
Men > women (however, since women live longer the absolute number is the same)
Blacks are 2x as likely to die from strokes and suffer more extensive physical impairments
Cannot change your genetics
Describe the treatment/impact of the following, modifiable risk factors for stroke:
- HTN
- heart disease
- high cholesterol
- Obesity/sedentary lifestyle
- Elevated hematocrit
HTN - meds
Heart disease - meds
Cholesterol - often in 200s - modify with diet first, then meds
- lose weight, exercise
- Hematocrit - want to lower - i.e. dilate blood
Describe the treatment/impact of the following, modifiable risk factors for stroke:
- diabetes
- (sickle cell anemia)
- oral contraceptives
- smoking
- periodontal disease
diabetes - keep blood sugar consistently below 10, and between 4-7 for fasting
- oral contraceptives and smoking can predispose
- good oral hygiene is important to prevent bacteremia
What does the fast acronym stand for?
Face (Drooping)
Arms (one arm drifts downwards)
Speech (repeating, slurred, strange)
time (to call 911)
If a patient in London has TIA symptoms, they will be screened right away. What do HCPs look for?
Look at patency of the carotid arteries - usually quite occluded - may perform a carotid endarterectomy.
Describe the ischemic cascade.
Vessel becomes occluded leading to hypoxia.
This causes cells to perform anaerobic respiration, thereby increasing lactic acid, and acidifying the pH.
Anaerobic respiration cannot meet the ATP demands, and cells begin to die
The resulting neurological deficits of a (ischemic) stroke are dependent on what 3 factors?
The location of the obstruction
The size of the area of inadequate perfusion
the amount of collateral blood flow
Describe the resulting manifestation of stroke in the following areas:
- Broca’s
- Wernicke’s
Broca’s - the patient will have difficult producing speech/language
Wernicke’s - the patient will have difficulty understanding speech/language
Which is more severe, an ischemic or hemorrhagic stroke?
Hemorrhagic
Describe the effect of collateral blood flow/circulation in dictating the severity of a stroke.
In the case of an ischemic stroke, if a person has a good collateral circulation, the lack of blood flow can be compensated by the secondary blood flow to that same area.
Ability to branch off when needed and grow into an area of blood flow decline or deficit
Collateral circulation
Slowed or slurred speech that is difficult to understand.
Medical term for double vision
Decreased vision or blindness in one eye.
Dysarthria
Diploplia
hemianopsia
If the cerebral infarct is on the right side of the brain, the resulting neurological deficit will manifest on the ____ side of the body.
left
If a person develops emotional lability following a stroke, where did the stroke most likely attack.
Frontal lo`e
In some stroke patients, they completely neglect one side of their body. Which brain region was affected?
Parietal lobe
For the following, describe whether right side or left side brain damage is more likely:
- left side hemiplagia or neglect
- Spatial-perceptual deficits
- impaired comprehension related to math and language
- impaired speech, language aphasia
- impulsive and impaired judgement
- impaired time concepts
- aware of deficits and prone to depressoin and anxiety
- denial of problems
- impaired left and right discrimination
Right, right, left, left, right, right, left, right, left
difficulty speaking related to paralysis of muscles
Loss of speech
Dysarthria
Aphasia
Inability to perform previously learned tasks, a disconnect between brain (thoughts) and abilities
Apraxia
Psychological deficits are most often seen when brain damage occurred here.
Frontal lobe
Hemorrhagic stroke:
- Generally, ______ severe deficits, ______ recovery time
- Bleeding into the brain tissue, _______ or _________ space
- Spontaneous rupture accounts for __% of hemorrhagic strokes, and is primarily caused by uncontrolled _________
- alteration in _____ is often the earliest sign of deterioration in a client with a hemorrhagic stroke
more, longer
ventricles, subarachnoid
80, HTN
LOC
In a hemorrhagic stroke, an ________ or _____ enlarges and presses on nearby cranial nerves/brain tissue, or ruptures.
aneurysm
AVM
If a stroke is ischemic, what must be administered? When?
Clot busters within 3 hours
Type of stroke caused by bleeding within the deep structures of the brain (Thalamus, basal ganglia, pons, and cerebellum).
deep intracerebral hemorrhage
Dilation of the walls of the cerebral artery
Intracranial aneurysm
Disorder of the blood vessels in the brain in which an abnormal connection exists between arteries and veins. It is present at _____. Appear as a tangle of normal or dilated blood vessels. They can occur in this part of the brain.
AVM
birth - congenital
Anywhere in the brain
Bleeding in the area between the brain and the meninges. May occur as a result of AVM, intracranial aneurysm, trauma or HTN.
Subarachnoid hemorrhage
Manifestations of hemorrhagic strokes:
- Wide variety of neurological deficits, similar to ischemic strokes
- Rupture of aneurysm or AVM usually produces sudden, unusually severe _______
- may also seen pain or rigidity of the ______, dizziness or tinnitus
- Physician will diagnose using this
- Major method of prevention is through control of _____.
headache
neck (nuchal area)
CT scan
controlling HTN
Prior to treatment with ______, acute hemorrhage must be ruled out.
T-plasminogen activator (t-PA)
Although CT scans are often used, the research shows that _____ is the way to go for diagnosing a stroke type.
DWI - diffusion weighted MRI
For management of a stroke, describe the following:
- IV hydration - purpose
- How do we minimize activity and keep stimulation to a minimum?
- What is the purpose of surgery?
- What medication type is given (hemorrhagic)?
- How do we prevent bleeding in an un-ruptued aneurysm?
IV hydration - decrease blood viscosity and improve cerebral blood flow
Minimize activity through bed rest and sedation
Surgery may be used to remove the clot
Anti-HTN drugs
Reinforce or clip un-ruptured aneurysm to prevent bleeding there
When is a carotid endarterectomy performed?
Aka carotid stenting; used for those who are at high risk for surgery (for moderate to severe carotid stenosis and TIAs)
Describe the four components of interpreofessional treatment for a stroke patient.
Prevention
Thrombolytic drugs: tPA
Medical and/or surgical treatment
Rehabilitation
Thrombolytics must be administered within this time frame. Why?
3 hours
This is because re-vascularization of necrotic tissues after 3 hours increases the risk for cerebral edema and hemorrhage
Thrombolytics:
- administration within __ hours
- _______ size of stroke
- Dosage based on ______
- Side effects include ______
3
decreases
weight
bleeding
Eligibility for clot busting medication:
- age = ?
- no _____ within past 2 weeks
- Within __ hours of onset
- not currently on this medication type
- no ___
- not _____ < 30 days
adult surgery 3 blood thinners MI post-partum
Prevention therapy for stroke:
- Low dose ______ daily (___mg) or other _______-inhibiting medications
- Anticoagulants such as coumadin (____ routine)
- Herbal remedies to avoid when on anticogaulants following a stroke or TIA are _____ and _____
aspirin (81), platelet
INR
ginkgo, garlic
Pts after a stroke will often be on medications for ____.
if a patient returns home on coumadin, it will be taken ______, but is given _______ in the hospital.
After a few months, a patient may switch from coumadin to _____ if they are stable.
life
orally, SQ
aspirin
When a patient is on coumadin, will take blood every day to check _____.
INR
Initially, after a person has just had a stroke, they are NPO. Why?
They may have dysphagia and are unable to swallow
A swallowing assessment is completed within 24 hours of the client being alert - patient is NPO until this is completed
If the choking risk is too high for a post-stroke patient, what is done?
Thickened fluids, may have NG or G-J tube to give nutrition (may be for the rest of their life)
Describe the stroke prevention diet.
Low fat, cholesterol and sodium diet
also exercise
What are nursing interventions based on?
Based on the client’s nursing diagnosis
For a nurse, what is the number one priority? (think of what you look for during an emergency)
ABCs
What is the purpose of elevating the HOB (head of the bed) for a patient that may have a stroke?
Due to ischemia or a hemorrhagic stroke, the brain will swell and the edema will increase intracranial pressure.
Elevating the HOB will promote venous drainage, thereby lowering ICP (intracranial pressure)
Elevate the HOB between 30-90° (i.e. not High Fowler’s as this occludes the femoral artery), but change elevation gradually
What is the purpose of giving osmotic diuretics for stroke patients?
Reduces ICP
When performing hemodynamic monitoring of a stroke patient, what values do we aim for?
systolic < 180 and diastolic below 100
at what frequency should neurological assessments be performed for a patient with a potential stroke?
q30 minutes, then q1h, then q2h and then q4h when stable
Positioning and ROM exercises are crucial for stroke patients. Why?
A patient that is insensate is at risk for developing pressure ulcers
ROM exercises must be done to prevent contractures and ensure blood flow to tissues and prevent atrophy
At the beginning of recovery after a stroke, the patient will need to use the unaffected limb to aid the affected limb. This will be particularly jarring for the patient. What must we remember when helping these patients?
Have PATIENCE
Because the number one cause of stroke is atherosclerosis, when a patient returns home they will, at the minimum, take this every day.
Baby aspirin
