Stroke PP&NP CA Flashcards
What are the three components of the Glasgow Coma Scale?
Eye opening response, Verbal response, Motor response
What are the components of Conscious Level Charting (CLC)?
- GCS
- Vital signs
- Pupillary response
- Limb motor assessment
You are assessing the motor component of a patient’s GCS. They are unable to obey commands but bend their elbow when their finger nail bed is stimulated. What do you do next?
a. Record ‘Normal Flexion’
b. Apply supraorbital notch pressure
c. Apply a trapezius Pinch
C is correct. If a patient bends their elbow when the finger is stimulated, the next step in assessing the motor response is to test if they can localise to a trapezius pinch.
A patient reacts to supraorbital pressure by moving their hand up to his face. How would you record this response?
a. Normal Flexion
b. Extension
c. Localises
C is correct. If a patient brings their hand up above their clavicle in response to either trapezius pinch or supra-orbital notch pressure the rating is Localising.
Normal flexion, where a patients elbow bends and their arm moves rapidly away from their body and from a stimulus, is given what number in the Glasgow Coma Scale?
a. Motor 2
b. Motor 4
c. Motor 1
B is correct Normal flexion (Withdraws from pain) is allocated a number of Motor 4.
If your patient’s Glasgow Coma Scale was E2, V3, M5, how would you interpret this?
a. The patient’s eyes open to sound, they are orientated are able to obey commands
b. The patient’s eyes open to pressure, they can utter some words but do not form sentences, and they are able to localise to trapezius pinch.
c. The patient’s eyes open spontaneously; they are orientated and able to obey commands
B is correct.
E2: Eyes open to pain
V3: Inappropriate response, words discernible
M5: Purposeful movement to painful stimuli
In which of these scenarios of assessment of the motor component of the Glasgow Coma Scale is the best response on the patient’s right-hand side?
a. R arm localises, L arm flexing
b. R arm no response, L arm extension
c. R arm localises, L arm obeys commands
A is correct. Localising represents less impairment than flexion so the response on the right side is the better.
What GCS score indicates a minor brain injury?
13-15 points
What GCS score indicates a moderate brain injury?
9-12 points
What GCS score indicates a severe brain injury?
3-8 points
What vital signs to assess during CLC?
HR, PR, RR, Temp, SpO2
(to detect S&S of increased ICP and any presence of infection– temp)
How to assess pupillary response?
How to assess:
1. Assess size of each pupil before shining light (both equal in size).
- Shine pentorch from outer cantus into inner cantus
- Indicate pupil size and reaction to light (brisk/sluggish/absent), (equal/unequal)
**Document “NT” if patient’s eyes cannot be opened due to swelling or surgery
How to interpret pupillary response?
- Unequal pupils
Could indicate increased ICP on one side, possibly from brain swelling or a hemorrhage - Pinpoint pupils (constricted)
Could be due to damage to the pons (part of the brainstem), possibly due to ischemia from a stroke (could also be due to opioid overdose - Dilated pupils
If dilated and non-reactive, may indicate damage to oculomotor nerve, due to increased ICP or a mass effect (hemorrhagic stroke or brain swelling), indicates severe damage or impending brain death
What are the signs and symptoms of increased ICP?
- Headache
- N&V
- Altered LOC
- Papilloedema (swelling of optic discs, causing blurred/double vision)
- Dilated pipils
- Cushing reflex (late signs): Bradycardia, Widening of pulse pressure, Altered breathing pattern (RR)
When should we escalate to senior staff/doctor when evaluating outcomes of CLC?
Any decrease of GCS score ≥ 2 indicates possible underlying neurological deterioration.
Must be reported to Dr in charge. Refer to GCS baseline of pt, confirm if there is any deviation from previous assessment.
What is the scoring for Eye Opening Response component in the GCS?
E4: Eyes open spontaneously
E3: Eyes open to verbal command
E2: Eyes open to pain (applied to nailbed/trapezius/supra-orbital)
E1: No eye opening
What is the scoring for the Verbal Response component in the GCS?
E5: Oriented
E4: Confused, but able to answer questions (not able to answer correctly but still in context of qn)
E3: Inappropriate response, words discernible
(answer not even in context of qn e.g. Is it day/night time? My favourite colour is blue.)
E2: Incomprehensible sounds (e.g. grunting)
E1: No verbal response
What does the RAPIDS tool stand for?
Rapid Assessment of Patients in Deteriorating Situations (comprises of ABCDE and ISBAR)
R – Recognize early signs of deterioration.
A – Assess the patient’s condition using systematic methods (A-B-C-D-E approach).
P – Prevent further deterioration by initiating immediate action.
I – Intervene with appropriate clinical care.
D – Document findings and interventions clearly.
S – Support the patient and escalate care as needed by using structured communication tools like ISBAR.
What are the components of the ABCDE assessment?
Airway
Breathing
Circulation
Disability
Exposure/examine
What to assess & actions to take for “Airway”?
Assess for signs of airway obstruction by look/listen/feel (stridor, choking, inability to speak)
Perform head tilt chin lift or jaw thrust (to prevent tongue from obstructing aiway)
Place patient on side (recovery position: to maintain clear airway, prevent aspiration pneumonia)
Insert artificial airway (OPA/NPA)
Perform suctioning to remove fluid and secretions
What to assess & actions to take for “Breathing”?
Count RR, assess breathing pattern and effort (regularity and depth)
Assess chest movement (use of accessory muscles, symmetry)
Check for cyanosis
Measure SpO2
Auscultate chest for breath sounds
Place patient in head-up position
Initiate oxygen therapy, titrate oxygen (keep SpO2>94%, for COPD, keep SpO2 90-92%)
What to assess & actions to take for “Circulation”?
Palpate peripheral pulses
Measure HR, BP, temp
Observe skin colour, feel skin temperature
Check for any bleeding
Check urine output
Measure capillary refill time
Lower patient head of bed position (Trendenlenburg position) if any signs of poor circulation, or hypovolemic shock to increase blood flow to vital organs
Establish IV access, prepare IV line with NS 0.9%
Attach a cardiac monitor, perform 12-lead ECG
What to assess & actions to take for “Disability”?
Assess LOC using AVPU or GCS
Examine pupillary reaction and size (reactivity and symmetry)
BGM
What to assess & actions to take for “Expose/examine”?
Expose body to examine head to toe (injuries, scars, oedema)
Examine dressing site or drainage system
Examine pain using COLDSPA/PQRST
Examine medical history on EMR
Insertion of NGT/IDC (if applicable)
What are the types of stroke?
Ischemic & Hemorrhagic stroke
What is an ischemic stroke?
When a blood vessel supplying blood to the brain is blocked, usually by a blood clot. This blockage reduces blood flow and oxygen to the brain, causing brain cells to die.
Most common type of ischemic stroke
Large Vessel Disease , Non-embolic stroke, related to the Middle Cerebral Artery
Which region of the brain is salvageable if perfusion is established during the early hours of an ischemic stroke?
Penumbra
(Note: pharmacologic interventions are most likely to be most effective)
Types of ischemic stroke
Thrombotic Stroke: Caused by a blood clot (thrombus), often atherosclerosis plaque, forming in one of the arteries supplying blood to the brain. Large vessel (MCA infarct), small vessel (Lacunar infarct)
Embolic Stroke: Dislodge of blood clots away from the brain (caused by carotid plaque, chronic AF, atherosclerotic plaques) , which travels through the bloodstream to block a brain artery.
Transient Ischemic Attack: when blood flow to a part of the brain is temporarily blocked.
Characteristics of a TIA
- Duration: TIA lasts for a few seconds to a few minutes, should recover within 24hrs.
- Pathogenesis: Low-flow states in vascular obstruction. Small emboli which get dissolved later.
What are some EARLY S&S of increased ICP?
Headache
N&V
Confusion, irritability and restlessness
Photophobia, diplopia
What are some LATE S&S of increased ICP?
Deterioration in LOC, GCS decrease
Changes in pupillary size, shape and responsiveness to light
Increase in systolic BP, widening PP, bradycardia and irregular RR (Cushing’s triad)
Decorticate and decerebrate posturing; flaccid (end stage)
What is a hemorrhagic stroke?
Blood vessel inside the brain ruptures
Types of hemorrhagic stroke
- Intracerebral hemorrhage (ICH)
Bleeding within the brain Occurs without warning
Caused by hypertension and thrombolytic drugs (impt to STOP ASAP) - Subarachnoid hemorrhage (SAH)
Bleeding in subarachnoid space
Severe, “thunderclap” headache
Can be triggered by activities
Caused by aneurysm rupture
Pathophysiology of ischemic stroke
- Reduced blood flow in arteries due to thrombosis or embolism
- Reduction in blood flow deprives cells of O2 and glucose
- Lack of energy causes membrane dysfunction and entry of ions
- Cytotoxic edema of cells occurs, followed by death of cells
- Vascular changes aggravate edema
Common signs and symptoms of stroke
FAST (facial weakness, arm weakness, speech problems, time; sudden onset)
Sudden weakness or numbness on one side of the body
Difficulty in finding words or speaking in clear sentences
Sudden blurred vision or loss in sight in one or both eyes
Sudden memory loss or confusion and dizziness or a sudden fall
A sudden, severe headache
What are the non-modifiable risk factors for stroke?
- Gender (females more protected till menopause)
- Age (incidence doubles every decade after 55)
- Race (due to dietary habits)
- Hereditary
Modifiable risk factors for stroke
- Lifestyle habits (smoking, alcohol)
- Hypertension
- Diabetes
- Hyperlipidemia
- Obesity
Mechanism affecting stroke
- Extra-cranial factors (outside brain)
- Systemic blood pressure (MAP): low MAP means poor cerebral perfusion, which can cause ischemic stroke; high MAP weaken blood vessels in brain, more prone to rupture, which can cause hemorrhagic strokes
- Cardiac output
Low CO increases risk of ischemic stroke. AF increases risk of embolic stroke - Viscosity of blood
Higher viscosity, blood flows more slowly, increases risk of ischemic stroke, increases risk of thrombosis and a subsequent embolic stroke
- Intracranial factors
- ICP
Influences CPP, CPP= MAP-ICP
When ICP increases, CPP decreases, increases risk of ischemic stroke, increases risk of brain herniation
- Atherosclerosis
Contributes to the narrowing and blockage of arteries that supply blood to the brain, increases risk of ischemic and hemorrhagic stroke - Blood vessels
Aneurysm of intercranial artery or any artery in the circle of Willis
Assessment and stabilisation of stroke patients in A&E
- Assess ABC and vital siggns
- Provide oxygen if hypoxemic
- Obtain IV access
- Obtain blood samples, BGM, treat if needed
- Perform neurologic screening assessment (GCS/NIHSS)
- Activate stroke team, order immediate brain CT scan
- Obtain 12-lead ECG
What are the main distinguishing features between an ischemic and hemorrhagic stroke?
- Presenting features:
Ischemic: Effect takes time
e.g. first few mins left sided weakness, feel numb, last few mins lose grip, not able to speak (dysarthria)
Whole process above takes 30-45 min
Hemorrhagic: Sudden, severe headache, vomiting, seizure, weakness on one side of face/body, rapid deterioration in neuro function or LOC
- Imaging results
Early ischemic changes may not be immediately visible. Over time, areas of infarction will appear as hypodense (darker) regions. A MRI is more effective in detecting ischemia early.
On CT scan, a hemorrhage will appear as a hyperdense (bright) area immediately, indicating blood.
- Prognosis
For ischemic stroke, early treatment with thrombolytics (tPA) or thrombectomy can improve outcomes significantly, lower risk of mortality.
Hemorrhagic stroke generally has a worse prognosis due to the potential for brain herniation, increased ICP, and mass effect.
Often requires surgical intervention.
- Treatment
Ischemic: tPA, thrombectomy
Hemorrhagic: BP control, ICP management, Surgical intervention
What are the distinguishing features between an ischemic and hemorrhagic stroke on imaging findings?
Ischemic Stroke:
- CT scan often shows no early changes (within the first few hours of stroke onset)
- Often shows as a dark patch (low density)
- MRI is more sensitive for ischemia, showing areas of reduced blood flow (infarction).
- CT angiography or perfusion imaging may show a blocked artery.
Hemorrhagic Stroke:
- Blood appears as bright white patches (high density)
- MRI can also identify bleeding but is usually done later. CT is preferred initially due to its speed and ability to detect blood.
- If SAH suspected but not confirmed on CT, a LP can show blood in CSF
Symptoms of stroke
FAST
Facial weakness
Arm weakness
Speech problems
Time to call 999
Sudden weakness/numbness on one side of body including legs, hands or feet
Difficulty finding words/speaking in clear sentences
Sudden blurred vision/loss of sight in one or both eyes
Sudden memory loss/confusion and dizziness/fall
Sudden, severe headache: Hemorrhagic stroke
“Thunderclap” headache: Subarachnoid stroke
Principles of managing ischemic strokes
- Timely recanalisation/revascularisation of the occluded artery and reperfusion of ischemic tissue (IV tPA and thrombectomy)
- Optimise collateral flow
- Avoid secondary brain injury
Principles of managing haemorrhagic stroke
Control of MAP, ICP and CPP
What is the formula for CPP? What is the optimal CPP?
CPP=MAP-ICP
Keep CPP>60mmHg
What information does an ED nurse need to gather from a suspected stroke patient during history taking?
AMPLE
A: Allergy
M: Medications
P:Past history (medical and surgical)
L: Last meal, last known well
E: Events surrounding injury I.e. what happened
What is the role of an ED nurse in receiving a stroke patient?
- Assessments
- ABC
- VS (BP, HR)
- BGM
- Weight
- GCS/NIHSS - Arrange for transfer to scan room (prep transport monitor, equipment, call CT scan room, arrange porter)
- Set IV cannula, send off blood investigations
- 12-lead ECG
- Arrange CXR if needed
What is the subsequent role of a stroke nurse at the ED?
- Take history from patient/monitor neuro status
- Review eligibility for tPA or/and EVT, MONITOR BP CLOSELY
- KEEP BP
<185/110mmHg (PRE-tPA) - Obtain tPA from pharmacy and dilute accordingly, administer safely
MONITOR BP CLOSELY
- KEEP BP
<180/105mmHg (POST-tPA)
How is IV tPA administered in HD/ASU? (APIE)
Assessment
- dosage by weight: 0.9mg/kg
(Max dose 90mg)
Planning
- 10% of first dose administered as IV bolus over 1 min (by Dr)
- remaining 90% delivered via infusion pump over 1hr
Implementation
- On continuous cardiac monitoring & frequent neuro assessment
- VS every 15mins for first 2 hrs, every 30mins for 6hrs and then hrly for 24hrs
- Keep SBP<180 and DBP<105
Evaluation
- Monitor for side effects (bleeding? in urine, stool, secretions, IV sites)
- Documentation
What is the timeframe for effective IV tPA administration?
IV tPA is most effective when administered within 3 to 4.5 hours after the onset of stroke symptoms
Hence important to find out the LAST KNOWN WELL!
Who is eligible for IV tPA?
ONLY USED FOR ISCHEMIC STROKE CASES
NO FOR HAEMORRHAGIC STROKE!
Other factors to consider:
- No recent history of bleeding or surgery
- Blood pressure should be controlled
- No active bleeding disorders
- No severe head trauma within the last three months
- >= 18y/o
Consider labs value:
- Coagulation profile (INR/PT, platelet count)
PT: Time it takes for blood to clot (high value means slow clotting process)
INR: High means increased risk for bleeding
What are some nursing problems to consider in acute stroke patients?
- Impaired gas exchange
- Ineffective breathing patterns
- Anxiety
- Difficulty swallowing dysphagia
- Impaired speech ability (dysarthria, aphasia)
- Impaired communication
- Self-care deficit
Reasons for continuous cardiac monitoring during IV tPA therapy
Risk of A Fib (especially in pts with history of A Fib)
Risk of reperfusion arrthymias (when blood flow is suddenly restored to an area after clot dissolution)
What is the BP range to maintain POST tPA?
Keep BP <180/105mmHg
What is the BP threshold for patients with ischemic stroke?
for ischemic stroke patients, BP is often allowed to be higher to maintain cerebral perfusion in the ischemic penumbra, as sudden reductions in BP could worsen the stroke
threshold of 220/120 mmHg is typically used, treat BP when threshold is exceeded
Treat BP if pt has: ACS/heart failure/aortic dissection/hypertensive encephalopathy/acute renal failure
Note: be careful when lowering BP by 15% during first 24hrs of stroke
Post-IV tPA care (bleeding is suspected)
- Stop tPA infusion
- CT scan immediately
- Blood workup: FBC, PT/aPTT, d-dimer, GXM, fibrinogen level
- Administer cryoprecipitate 10 units
- Recheck fibrinogen level 1 hr after cryoprecipitate transfusion, target fibrinogen>=1.5g/L
- Repeat cryoprecipitate if necessary
- Refer to neurosurgery
- KIV refer haematology
- Repeat CT brain in 6hrs
Potential nursing problems post-stroke
- Risk for aspiration pneumonia
- Risk for PU r/t deficits in movement and sensation
- Risk for fall r/t hemiplegia (muscle paralysis)
- Disturbed body image
- Risk for self-injury r/t seizures
Potential post-stroke neuro and cardio complications?
Neuro:
- Stroke progression!
- Stroke recurrence
Cardio:
- Cardiac ischemia
Potential post-stroke pulmonary and GI complications?
Pulmonary:
- Pneumonia!
- Pulmonary embolism!
GI:
- Dysphagia!
- Malnutrition
- GI bleed
- Constipation
Potential post-stroke genitourinary and psychological complications?
UTI
Depression & Pain
When the patient is lying on his/her back, the nurse should adjust the height of the EVD such that its zero mark (0cmH2O) on the EVD scale level with the: _______ (anatomical reference)
Tragus of ear
When the patient is lying on his/her side, the nurse should adjust the height of the EVD such that its zero mark (0cmH2O) on the EVD scale level with the: _______ (anatomical reference)
mid sagittal line (between the eyebrows)
When caring for patient with EVD, the nurse should level the HOB at ___ degrees.
30 degrees
What are the characteristics of abnormal CSF?
- Xanthochromia discoloured –
usually pale yellow, due to breakdown of RBC from previous bleeding - Slightly blood stained, moderate blood stained or heavily blood stain
- Turbid (Cloudy) occurs due to presence of CNS infection e.g. meningitis.
*Bright red– indication of acute haemorrhage
Potential side effects of IV tPA
- Symptomatic intracerebral hemorrhage
- Asymptomatic intracerebral hemorrhage
- Systemic bleeding
- Angioedema
Who should NOT receive tPA?
- Ischemic stroke in last 3 months
- Previous ICH
- GI malignancy
- Intracranial or intraspinal surgery within last 3 months
- Persistent BP elevation (SBP>= 185 or DBP>= 110)
- Active internal bleeding
- Platelet <100,000/mm3
- Current anticoagulant use with INR>1.7
- Full dose of clexane in the last 24hrs
- Current use of direct oral anticoagulant (DOAC) in last 48hrs
How is BP lowered when it is above the recommended threshold after tPA administration?
IV labetalol (beta blocker)
10mg over 1 to 2 mins (undiluted) then 20ml NS flush
Note: requires frequent monitoring after thrombolysis to keep BP within range
Note: Labetalol should NOT be given for stroke pts who are not treated with tPA, unless hypertension is extreme (SBP>220 or DBP>120), this is to allow improved perfusion to infarcted area
Indications for External Ventricular Drainage Device (EVD)
- Treat hydrocephalus
- Relieve and monitor raised ICP in SAH and ICH pts
- Drain infected or bloodstained CSF following infection, neurosurgery
- Administering medications such as antibiotics and thrombolytics for pts with CSF infection or significant intraventricular clot volume
Contraindications for EVD
- Receiving anticoagulation therapy or known history of coagulation problems
- Has a scalp or brain infection
EVD Nursing care implications/complications
- Mechanical complications: Dislodgement & blockage
- Infective complication: Ventriculitis, meningitis
- Under drainage of CSF: Increased ICP
- Over drainage of CSF: Subdural hematoma
- Trauma by EVD: haemorrhage in ventricles or in brain tissue, aneurysm rupture
Note: Goals of nursing care is to promote healing and prevent harm
How is levelling of the EVD system conducted?
- Position the patient with HOB 30 deg or as ordered by doctor.
- Adjust the height of the EVD such that its zero mark (0cmH2O) on the EVD pressure scale levels with the tragus of ear using the carpenter’s spirit level.
(When the patient is lying on one side, this anatomical reference point becomes at the mid sagittal line (between the eyebrows). - Adjust the collection drip chamber aligned to the desired height as ordered (e.g. 10cm above tragus of ear).
*Always level transducer and drainage chamber
When do we perform the levelling or verification of the EVD?
- when taking over the care of patient
- when patient moves or repositions
- anytime if unsure
Note: Must ensure there is no sudden raising/lowering of head of bed or patient care activites, bed control must be disabled
to prevent over/under drainage
Care of EVD
Ensure the EVD chamber facing the foot of bed.
Check and observe at frequent intervals for the drainage tubing for patency, free from kinks, traction, and leaks.
Ensure prescribed height is maintained at all times
All connections of the monitoring system must be tight to maintain the integrity of the closed system.
Touching any components of EVD, must be an aseptic procedure
Checking of CFS drainage
- Read meniscus at eye level
- Ensure EVD system is OPEN to patient for drainage (NEVER CLOSE PT STOPCOCK)
- Observe quantity and quality (colour and clarity) of CSF in drip chamber
- Drain drip chamber hourly or as ordered (when it is 3/4 full)
How to prevent increased/decreased intraventricular pressure which leads to over drainage of CFS?
- regular bowel habits, using stool softeners as constipation may increase ICP
- BE CAREFUL when moving patient such as sudden bed position changes, coughing or suctioning
- Use bed lock to avoid sudden bed changes
Transportation of patient with EVD
- Maintain EVD system in an upright position, air-vent of EVD must be kept dry at all times
- Empty drip chamber into drainage bag prior to any procedures where the EVD system has to be placed down
- Do NOT clamp EVD during transportation
- Turn off pt stopcock to stop drainage just prior to transferring from one area to another (e.g. bed to bed, turn on after adjusting EVD at prescribed level)
Post op management of EVD insertion
- Reduce risk of rebleeding
SBP 120-140 mmHg - Prevent vasospasm
Nimodipine - Prevent seizure (common complication)
Phenytoin / Valproate
Control ICP/BSL/Fever (Temp)
