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Nursing Fundamentals > Stroke, Cranial Nerves > Flashcards

Stroke, Cranial Nerves Flashcards

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1
Q

Cranial nerve 1, function, assessment

A

Olafactory (smell)

Have patient smell something like alc swab

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2
Q

Cranial nerve 2, function, assessment

A

Optic (vision)

Ask how many fingers/reading

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3
Q

Cranial nerve 3, function, assessment

A

Oculomotor (eye movement, pupil constriction)

H formation

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4
Q

Cranial nerve 4, function, assessment

A

Trochlear (eye movement)

H formation

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5
Q

Cranial nerve 5, function, assessment

A

Trigeminal ( face pain, touch, chewing)

Light touch to 6 spots on face

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6
Q

Cranial nerve 6, function, assessment

A

Abducens (eye movement)

H formation

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7
Q

What three cranial nerves are associated with eye movement?

A

Cranial nerves 3,4, and 6

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8
Q

Cranial nerve 7, function, assessment

A 
Facial (facial movement)
Facial expressions (symmetry)
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9
Q

Cranial nerve 8 and function

A

Vestibulaocular (hearing, balance)

Whisper in ear (we don’t test this one)

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10
Q

Cranial nerve 9 and function

A

Glossopharyngeal (taste, swallowing)

Say ah, swallow

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11
Q

Cranial nerve 10 and function

A

Vagus (throat and pharynx muscle)

Say ah, swallow

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12
Q

Cranial nerve 11 and function

A 
Spinal accessory ( neck muscle movement)
Shoulder shrug, hand against head on both sides
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13
Q

Cranial nerve 12 and function

A

Hypoglossal (tongue movement)

Check if tongue is midline

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14
Q

Infarction

A

Death of tissue due to diminished blood supply from obstruction of bv from blood clot or narrowing of bv

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15
Q

Penumbra

A

When an ischemic stroke occurs, some of the tissue damage still may be reversible/salvageable if perfused

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16
Q

What is tPA and when would it be used?

A

tPA (tissue plasminogen activator) is a clot buster; it breaks clots up to allow restoration of blood flow to brain
tPA can be used to revitalize penumbra

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17
Q

Hemiplegia

A

Total or nearly complete paralysis of one side of body, limiting movement

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18
Q

Hemiparesis

A

One sided weakness (some motor function remains in weakened area)

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19
Q

Expressive aphasia and causes

A

One is able to get out a few words at once due to difficulty finding the right words/expressing what they want
Causes: injury to speech/language center of brain from stroke or brain trauma

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20
Q

Receptive aphasia

A

Difficulty understanding language

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21
Q

TIA abbreviation

A

Transient ischemic stroke

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22
Q

What happens in a TIA and how long might it last

A

Cerebral artery temporarily blocked, decreasing blood flow to brain. This causes temporary reduced neuro function
Time: lasts around 15 min or less

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23
Q

What causes ischemic strokes

A

Ischemic strokes occur due to atherosclerosis in bvs —> piece of plaque break off and get lodged causing obstructed blood flow to brain

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24
Q

What causes hemorrhagic stroke

A

BVS stiffen from atherosclerosis, making them likely to rupture (stiffening = weaker). Blood accumulates in brain tissue —> increased ICP

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25
Q

SXS of stroke

A 
Numbness or weakness of face, arm, leg unilaterally 
Speech difficulty
Visual disturbances
Severe sudden headache 
Confusion
Altered mental status 
Difficulty walking 
Loss of coordination/balance
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26
Q

Risk factors of stroke (modifiable)

A

HTN, diabetes, smoking, diet, obesity, sleep apnea, afib, oral contraceptives, cocaine/amphetamines, high cholesterol, alcohol,

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27
Q

Non modifiable risk factors of stroke

A

Family hx, race (African American), 55 y.o>, male, TIA or previous stroke,

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28
Q

Why are African Americans at higher risk for stroke?

A

African Americans since increased risk HTN

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29
Q

What are some changes people can make to decrease their risk of stroke

A 
Decrease alcohol intake
Smoking cessation 
DASH diet 
Exercise 
Manage HTN
Manage dyslipidemia 
Manage diabetes 
Healthy weight
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30
Q

Medical management of stroke (what does provider order?)

A 
Anticoagulants (warfarin) 
Antiplatelets (aspirin, plavix) 
Stent placement in artery 
Bed rest 
Surgery (remove clot, stent placement, clipping aneurysm, cerebral revascularization, draining blood from intracranial space) 
O2 administration
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31
Q

Ischemic stroke treatment

A 
Statins (artorovastatin) 
Antihypertensives (ACE inhibitors and diuretics) 
tPA
Antiplatelets (aspirin)
Endovascular treatment
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32
Q

What is the time frame to administer TPA? Why can’t we give it past this window?

A

3 hours

Can cause ischemic stroke to become hemorrhage or cerebral edema (increased ICP)

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33
Q

Hemorrhage stroke treatment

A 
Bed rest with sedation 
Avoid extreme hypertension or hypotension (BP meds and monitoring BP)
Anticonvulsant meds 
Surgery to evacuate blood 
Surgical clip
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34
Q

What is the significance of “last time patient was seen well?”

A

Determines onset of symptoms of stroke —> guides HCPs decisions for treatment
Avoids under treatment or over treatment
Determines if it is safe to administer tPA
We do not know the state of the penumbra if we don’t know the time frame

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35
Q

What is the time to save the penumbra

A

3 hours to revascularize it before dies completely

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36
Q

Why is it dangerous to give tPA past 3 hours? What can happen?

A

Cause more damage than benefit

If penumbra is dead, revascularization causes ischemic —> hemorrhage bc dead tissue can’t accept

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37
Q

What imaging is used to determine if the stroke is hemorrhagic or ischemic

A

CT scan

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38
Q

What is tPA? How does it work?

A

Tissue plasminogen activator

Protein breaks clots down

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39
Q

FAST (what does it stand for?)

A

Face droop
Arm weakness
Speech difficulty or slurred
Time to call 911

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40
Q

What are some manifestations of stroke

A 
Numbness or weakness of face, arm, legs (on half of body) 
Frustration r/t loss of functions 
Confusion/ altered LOC
Difficulty walking, dizzy 
Loss balance 
Sudden severe headache 
Visual disturbances
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41
Q

How does elevating bed help manage stroke

A

Decreased pressure in brain

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42
Q

How does O2 administration benefit stroke patients

A

Prevents brain tissue from starving and dying

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43
Q

Why implement seizure precautions for stroke patients? What do seizure precautions include?

A

Seizures are likely to occur with stroke patients
Interventions: padding side rails, set up suction, turn on side to prevent aspiration
Antisiezure meds
Frequent neuro assessment

44
Q

Ways to prevent strokes

A 
Control HTN
Diet, exercise, manage weight
Smoking cessation 
Anticoagulant therapy 
Statins 
Anithypertensives
45
Q

What is hemorrhagic stroke

A

Bleeding into brain tissue due to ruptured bv, increasing ICP

46
Q

What are some causes of hemorrhagic stroke

A

Hypertensive crisis

aneurysm (bursted weakened bv wall)

47
Q

Why is hemorrhagic stroke harmful to brain

A

It causes increased ICP which compresses tissue—-> vasoconstriction—-> poor perfusion

48
Q

Are the symptoms of hemorrhagic stroke different from ischemic? How do we know which type of stroke is occurring?

A

symptoms of both types are the same but with hemorrhagic severe headache is common
We need a CT scan to determine which type of stroke

49
Q

Why do seizures occur with hemorrhagic stroke

A

Increased ICP causes seizures to occur

50
Q

Agnosia

A

Decreased ability to recognize/differentiate sound, smell, taste, feel, other senses

51
Q

What are some assessments nurses do when caring for stroke patients

A

Vital signs monitoring, especially BP
Ongoing Neuro assessments
Monitor for complications

52
Q

What are some complications of stroke

A

Musculoskeletal problems, swallowing difficulty, respiratory problems, SxS increased ICP, dysphagia, urine/fecal incontinence, skin break down

53
Q

Why does stroke cause skin break down?

A

Decreased sensation so less responsive to discomfort or pressure

54
Q

Why does stoke cause incontinence

A

Confusion, hard time communicating, impaired motor function control

55
Q

What are some nutritional considerations for stroke patients

A

Dysphagia puts patients at risk for aspiration
Thick liquid diet or puréed (may not want to eat bc doesn’t taste good)
Ng tube (can cause nausea so decreased appetite)
Education on smaller bites so easier to swallow

56
Q

Hemianopsia

A

Blind in half field of vision

57
Q

Nursing interventions for hemianopsia

A

Glasses, good lighting, teach patient to turn head, remind patient about other side of body they can’t see

58
Q

Hemiparesis

A

Weakness on one side of body

59
Q

Hemiplegia

A

paralysis of one side of body

60
Q

Nursing interventions for hemiparesis

A

Place objects within reach on unaffected side
Teach to exercise non-effected side
Asses patients strength bilaterally

61
Q

Nursing interventions for hemiplegia

A

Encourage ROM on effected side to increase blood flow to extremity
Turn Q 2 hrs
Place pillow under axilla in bed to prevent edema

62
Q

Dysphagia

A

Difficulty swallowing

63
Q

Nursing interventions for dysphagia

A

Involve speech therapist for swallow assessment
Educate on small bites, thick liquids
Educate to sit up right and tuck chin
(All to prevent aspiration)

64
Q

Nursing interventions for expressive aphasia

A

Place important objects within reach to maximize independence
Clarify your understanding with pt for better communication
Keep other noises low to help enhance patient’s understanding (less outer stimulus)
Y/N questions
Communication board with common phrases

65
Q

Nursing interventions for receptive aphasia

A

Keep language simple and clear
Provide adequate time for pt to reply so they can take time to process what is asked/said to them
communication board

66
Q

Nursing interventions for cognitive defect

A

Positive feedback to promote self esteem and desire to perform correct behavior
Communicate with neuropsychologist
Observe Nuero exam results to monitor progress

67
Q

Nursing interventions for emotional deficits

A

Familiarize pt with SxS of depression (stroke pts likely to have it)
Encourage independence to promote self esteem
Encourage contact with friends/fam to prevent social isolation

68
Q

How does OT participate in stroke rehab

A 
Help regain independence: 
help modify tasks 
Retrain in self care activities 
Use of adaptive equipment 
Assessing deficits of senses
69
Q

How does PT participate in stroke rehab

A

Implement exercises to promote regaining strength/mobility
Encouraged to move as much as they can on own
Help restore normal motor control, strength, balance

70
Q

How do speech therapists participate in stroke rehab

A

Assess communication difficulties with tests
Address expressive and receptive aphasia
Swallow assessments

71
Q

How to prevent contractures or joint deformity in stroke patients

A

Passive ROM 4-5x/ day prevents contractures in paralyzed extremity
Splints
Encourage movement of weak side by use of strong side

72
Q

How to prevent shoulder pain in stroke patients

A 
ROM exercises (flexing wrists
Avoid laying on shoulder 
Avoid lifting patient from flaccid shoulder 
Avoid shoulder abduction
73
Q

Some ways to encourage self care for stroke patients

A

Perform self care that can be done with one hand using non affected limb
Wear one size bigger
Put clothes on seated

74
Q

How to assist with nutrition for stroke pts

A

Involve speech therapy to assess swallowing
Educate on smaller bites
Educate on food easier to swallow

75
Q

How to help pt attain bladder and bowel control after stroke

A 
Assess voiding patterns 
Provide bed side commode or bed pan frequently 
Intermittent catheter(sphincter control loss)
76
Q

Ways to improve communication in stroke pts

A

Have written schedule available
Checklists
Communication board w/common needs/phrases

77
Q

How to maintain skin integrity in stroke patients

A

Low air loss bed
Skin dry and clean
Turn Q2 hours

78
Q

How to enhance family coping for stroke pts

A

Incorporate family to help set attainable goals

Teach about emotions lability (laughter,sobbing, anger w/o cause) —-> will improve with time

79
Q

What are some goals for stroke recovery

A 
Improve mobility 
Achieve self care 
Relief of sensory deprivation 
Continence (urine/bowel)
Maintain skin integrity 
Achieving form of communication
80
Q

What are possible complications from a stroke

A

Pneumonia from shallow breathing
Decreased blood flow to brain
Inadequate O2 to brain
Seizures

81
Q

What are some reasons stroke patients experience poor nutrition

A

Depression, difficulty eating/swallowing, puréed diet, altered taste

82
Q

Red flags during nuero assessment

A
  • confusion (new)
  • slurred speech
  • facial droop
  • altered pupil size or reaction
  • hemiparesis
  • drift in pronation
83
Q

What are some sensory changes related to aging

A

Vision (presbyopia)
Hearing (presbycusis)
Altered smell or taste
Altered peripheral senses (neuropathy)

84
Q

Presbyopia

A

Decreased ability to focus on close objects

85
Q

Cataracts

A

Spotty vision

86
Q

Macular degeneration

A

Big spot in middle field of vision

87
Q

Glaucoma

A

Peripheral vision effected

88
Q

Diabetic retinopathy

A

Mini hemorrhages in eye vessels causes spotty vision

89
Q

Normal age variations

A 
Slower thought processes 
Decreased sensory ability
Slower gait 
Wider base 
Confused easily 
Decreased reflexes and deep tendon reflex 
Altered coordination
90
Q

Important things to consider/ assess in nuero assessment

A 
History of stroke, seizures, headaches 
Use of drugs, smoking, alcohol 
Meds (opioids, sedatives) 
Surgery 
ADLS 
Sensory deficits
91
Q

When performing the 7 Ps what are we assessing for

A

We are checking for perfusion to extremities; are the extremities receiving adequate blood flow?

92
Q

Why assess polar aspect of 7ps?

A

Indicates blood circulation
cold then circulation is not good
Hot = DVT or infection possible

93
Q

Why assess palor aspect of 7ps

A

“Normal” color can indicate good perfusion, while pale/blue = poor perfusion to extremity

94
Q

Why assess cap refill with 7 ps

A

Represents localized circulation to fingers/toes

95
Q

Why asses pain with 7ps

A

Can be due to swelling or strangulating of nerves

Can be due to injury

96
Q

Why asses puffiness with 7 ps

A

May indicate bleeding into skin
DVT
Surgical patients
Wounds on extremities

97
Q

Why assess pulse with 7ps

A

Tells us if blood is reaching extremities

Recent injury may affect pulse

98
Q

What happens if stroke affects right side of brain

A 
Left sided weakness
Vision problems 
Impulsive behavior 
Left side neglect 
Memory loss
99
Q

What happens if stroke affects left of brain

A

Right side weakness
Difficulty speaking
Slow cautious behavior
Risk for dysphagia

100
Q

How does sleep apnea increase chance of stroke

A

Builds pressure on bvs when trachea closes

101
Q

How does afib increase risk of stroke

A

Pumping pattern of heart makes blood pool in heart and blood clot formation likely

102
Q

How do oral contraceptives increase risk of stroke

A

Estrogen increases clot risk

103
Q

How does cocaine use increase risk of stroke

A

Causes vessel damage (everything speeds up)

104
Q

How does diabetes increase chance of stroke

A

Diabetes damages bvs

105
Q

What is penumbra

A

Inured cell tissue that can be restored

106
Q

Why does infarction of tissue happen in ischemic stroke

A

Blood flow is decreased due to blood flow blockage from obstruction (clot blockage)

107
Q

How is a TIA different from ischemic stroke? When does it resolve? How long might symptoms last?

A

TIA is a temporary blockage that causes temporary neurological deficit
Resolves in ~24 hours
Symptoms ~ 15 min
“Warning sign” of later stoke

Nursing Fundamentals (8 decks)

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