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Nursing Exam 2020 > Stroke Scenario- Types, Treatment, Care > Flashcards

Stroke Scenario- Types, Treatment, Care Flashcards

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1
Q

What are the 4 main types of stroke?

A

Ischaemic
Embolic
Haemorrhagic
Transient ischemic attack(TIA)

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2
Q

What is an ischaemic stroke?

A

Arteries supplying blood to brain narrow or become blocked.
Caused by blood clots or reduced blood flow, as well as plaque due to atherosclerosis breaking off.
Commonly either thrombotic or embolic.

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3
Q

What is thrombotic stroke?

A

Occurs when a blood clot forms in one of the arteries supplying blood to the brain.
Clot basses through bloodstream and becomes lodged, blocking blood flow.

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4
Q

What is an embolic stroke?

A

Occurs when a blood clot forms in another part of the body (often the heart or arteries in upper chest and neck) and moves through the bloodstream to the brain.
Clot gets stuck in brain’s arteries where it stops blood flow.

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5
Q

What are the causes of embolic stroke?

A

Can be cause by heart conditions.

AF is a common type of irregular heartbeat that can cause blood clots to develop in the heart.

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6
Q

What is a haemorrhagic stroke and what are the 2 types?

A

Occurs when an artery in the brain breaks open or leaks blood.
The blood creates excess pressure in the skull, swelling the brain and damaging brain cells and tissues.
Intracerebral: most common, occurs when tissues in brain fill with blood.
Subarachnoid: less common, causes bleeding in area between brain and tissues that cover it.

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7
Q

What is a transient ischemic attack (TIA)?

A

Occurs when blood flow to the brain is temporarily blocked.
Symptoms are similar to those of a full stroke but are generally temporary and disappear after a few minutes or hours.
Usually caused by a blood clot.

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8
Q

What are the causes of haemorrhagic stroke?

A

Aneurysm (weekend, bulging blood vessel) can be caused by high blood pressure and can lead to a burst blood vessel.
Arteriovenous malformation, an abnormal connection between veins and arteries, can lead to bleeding in the brain.

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9
Q

What are the modifiable risk factors for stroke?

A 
Diet high in salt, fat, cholesterol
Inactivity
Alcohol consumption
Smoking
Cocaine use
Obesity
High blood pressure
diabetes
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10
Q

What are the non-modifiable risk factors for stroke?

A

Age- risk increase with age
Family history- Blood vessel disease, AF, TIA, CVA
Race and ethnicity

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11
Q

What are the unique stroke risk factors for women?

A

Taking birth control pills, particularly in women with additional risk factors.
Being pregnant, due to increase blood pressure and stress on the heart.
Using Hormone Replacement Therapy(HRT)
Suffering from migraines with aura.

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12
Q

What are the immediate actions that should be undertaken for a patient presenting with a stroke?

A

ABCDE- possible threat to life
NBM- prevent aspiration until swallow test can be performed.
Reduce BP to 185/110mmHg if candidate for thrombolysis.
IV access- for hydration, monitoring, thrombolysis
Temperature evaluation- pyrexia can expand ischaemic injury
Blood glucose to exclude hypoglycaemia as elevated glucose levels expands ischaemic injury.
Establish pt history and baseline- to give idea of changing baseline through observation via NEWS and GCS and inclusion/exclusion criteria for clot busting drugs.
Determine time of stroke- determines if clot busting drugs appropriate/within 4.5hr window.
Alert for raised ICP- seizures or headache present
ECG- exclude AF or arrithymias
FBC/Clotting time/U+E’S
Cardiac enzymes- to exclude MI
Evaluation nausea/vomiting- potential for aspiration.
TIME IS BRAIN.

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13
Q

What assessment tools are used to diagnose stroke?

A

FAST- helps to spot 3 most common symptoms of stroke
Rosier- (Recognition of Stroke in Emergency Room) distinguishes between acute stroke and stroke mimics, facilitating early identification of stroke + appropriate referral.
NIH Stroke Score- quantifies the severity of stroke by measuring the cognitive effects to ensure appropriate treatment.

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14
Q

What are the elements of the FAST tool?

A

Face: Can the person smile? Has their face fallen on one side?
Arms: Can the person raise both arms and keep them there?
Speech problems: Can the person speak clearly and understand what you say? Is their speech slurred?
Time: If you see any of these three signs, it’s time to call 999.

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15
Q

What are the elements of the ROSIER Tool?

A 
Uses a points system to determine the presence of acute stroke or stroke mimics
Scores based on:
Loss of consciousness (-1/0)
Seizure activity (-1/0)
New acute onset:
Asymmetrical facial weakness (1/0)
Asymmetrical arm weakness (1/0)
Asymmetrical leg weakness (1/0)
Speech disturbance (1/0)
Visual field defect (1/0)
Score >0 = stroke likely
Score <0 = stroke unlikely but should not be completely ruled out.
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16
Q

What are the elements of the NIH Stroke scale?

A 
Includes a series of questions/tests to determine impairment to various areas through a scoring system:
levels of consciousness, language
neglect
visual-field loss
extraocular movement
motor strength
ataxia
dysarthria
sensory loss
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17
Q

What is thrombolytic therapy?

A

It is the process of giving a clot-busting drug known as alteplase for the treatment of ischaemic stroke.
It aims to disperse the clot, returning blood supply to the brain.
Most effective if given within 4.5 hours of stroke symptoms starting.
Around 10% more people recover from stroke after thrombolysis.
However in 1/25 it can cause bleeding on the brain.

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18
Q

What is the exclusion criteria for thrombolysis?

A

bleed in in the brain.
do not know when symptoms began
not reached hospital in time
bleeding disorders
recent major surgery
previous stroke or head injury within 3 months.
current medication incompatible with alteplase.

19
Q

What are the treatments for ischemic stroke/TIA?

A

Antiplatelets/anti-coagulants- OTC aspirin first line of defence. Should be taken within 24-48 hours of onset.
Clot-busting drugs- thromboylsis, stop stroke and reduce damage.
Surgery- if other treatments unsuccessful. Clot and plaques may be removed from arteries using a catheter or by opening artery.

20
Q

What are the treatments for hemorrhagic stroke?

A

Medications- aim to make blood clot, medication to counteract blood thinners or to reduce BP, prevent seizures and prevent blood vessel constriction.
Coiling- a procedure in which a coil-like device is installed in the area where artery wall is weak, blocking blood flow and reducing bleeding.
Clamping- if aneurysm is discovered, a tiny clamp can be placed at base of it to prevent additional bleeding and a possible broken blood vessel.

21
Q

What are the common stroke medications?

A

tPA(alteplase): emergency medication, clot busting, given within 3-4.5hr of onset, injected into blood vessel for quick effect. Dose- 900mcg/kg over 60 mins, max 90mg, initial 10% by injection remained by IV infusion.
Anticoagulants(warfarin): reduce clotting ability, prevent existing clots from growing, can be used as preventative or post ischemic/TIA.
Antiplatelets(aspirin, clopidrgel): prevent clots by making it difficult for platelets to stick together, can be used as preventative for ischemic and to prevent secondary stroke.
Statins(simvastin): lower high cholesterol, prevent production of plaque.
BP drugs: controlling high BP important in preventing plaque build up.

22
Q

What are the 4 main areas of focus for stroke recovery and why?

A

Speech therapy- can cause speech and language impairment, SALT can aid relearning of speaking or new ways of communicating.
Cognitive therapy- can affect thinking and reasoning skills causing behavioural and mood changes, OT can help to regain former thinking patterns and help to control emotional responses.
Relearning sensory skills- senses can be dulled or absent if region of brain relaying sensory signals affected, therapist can help to adjust to lack of sensation.
Physical therapy- muscle tone and strength weakened, PT will help to regain strength and balance and find adjustments =.

23
Q

Care of stroke patient- what interventions are required to maintain a patent airway?

A

Assessment of airway potency
Airway support- oxygen, suction, oropharyngeal/nasopharyngeal airways, consider ventilation
Nil orally
Positioning in bed

24
Q

Care of stroke patient- what interventions are required to maintain breathing?

A

Monitor respiratory effort- rate, rhythm, depth, effort
Monitor SAT’s - 95-100%
Administer O2 therapy if required
Monitor blood gases
Monitor colour of skin
Monitor for hyperventilation or yawning- warnings of raised ICP

25
Q

Care of stroke patient- what interventions are required to maintain circulation?

A 
Monitor BP, pulse, resps
Monitor CNS using GCS
Document on NEWS chart
BM monitoring
IV line in situ
FBC and U's &amp; E's
26
Q

Care of stroke patient- what interventions are required to minimise pain?

A

Pain assessment tools to establish presence and severity of pain
Visual signs - grimacing, groaning when turned/touched
Administer prescribed analgesic- monitor effect

27
Q

Care of stroke patient- what interventions are required to maintain communication?

A

Talk to patient
Reassure patient + relatives
Orientate
Adhere to ethical principles

28
Q

Care of stroke patient- what interventions are required to maintain nutrition?

A

NBM if required
Swallowing assessment
Nutritional plan

29
Q

Care of stroke patient- what interventions are required if patient is dying?

A 
Honesty with patient and family
Support/reassurance
Ensure access to doctors and senior nursing staff
Advice on support groups
Contact friends/relatives
Warm drinks 
Privacy
Single room for patient
DNACPR
30
Q

Care of stroke patient- what interventions are required if patient is on bed rest?

A 
bed location
appropriate mattress/cot sides
2hrly positional changes
Limb positioning
Monitor and protect pressure areas
Physiotherapy
31
Q

What is dysphagia and why does it occur post-stroke?

Why is it a concern?

A

Dysphagia is an impaired ability to swallow.
It occurs post-stroke if the cortex or brainstem has been damaged by the stroke.

It increases risk of aspiration pneumonia which can be fatal if severe, difficulty with nutrition and administration of medication.
This can lead to complications or increased hospital stay.

32
Q

Dysphagia- what are the signs of potential aspiration?

A 
Coughing or chocking whilst eating or drinking
Wet or gurgly sounding vocal quality during meals 
Increased congestion
Slowness when eating 
Delay in swallowing
Fatigue/sob when eating
weight loss
Drooling
Bouts of pneumonia
Facial weakness
33
Q

What is the dysphagia screening test and what does it include?

A

The STOPPS swallow test is used to assess swallowing.
Indicated on admission in all patients at high risk for aspiration.
Inclusion criteria: (part 1)
Can maintain upright sitting position, and stay alert for 15 mins while upright.
part 2: determines if patient should be excluded from water swallow test and referred to SALT.
part 3 (WST): A.
3x5ml spoonfuls of water without coughing/breathless/hoarse/gurgly
NO= NBM, reassess in 3-12hr
B. 50ml water from glass at comfortable pace without coughing/breathless/hoarse/gurgly
NO= NBM, reassess in 3-12hr.
If fail on 2nd attempt contact SALT.
YES= normal fluids text E diet and monitor

34
Q

Dysphagia- how can nutrition be maintained?

A

Follow recommendations by SALT
Provide appropriate textured diet and thickens fluids
ongoing assessment of fluid and calorie intake
Upright position for meals and for 30 mins after
Allow time for eating and drinking
Check for pocketing of food
Consider stoping NG feeds 1-2 hours prior to oral feeding to stimulate appetite.
Educate family to aid feeding

35
Q

Dysphagia- what should be considered regarding medication?

A

Alternative routes
Check for pocketing if taking oral medication
If on thickens fluids use this consistency for medication administration.

36
Q

Dysphagia- what documentation is required?

A 
Nursing notes up to date
Fluid balance
Must for baseline and screening
Weekly weights
Food and fluid chart
37
Q

Post-stroke care- what is important in regard to mobilisation?

A

Regular positioning to prevent pressure damage
Assess requirement for bed rails
PT assessment to determine required aids
Falls Risk assessment
Weight transference/balance
Appropriate M&H to prevent injury to staff or patient, especially subluxation of shoulder- slings may be appropriate
Posture should be observed in relation to weakness and functionality.

38
Q

What urinary continence problems can occur post stroke?

A

Neurogenic bladder- occurs due to neurological dysfunction, it’s presentation is dependent on which nerve has been damaged. The bladder can become overactive or underactive.
Secondly, the frequency of urine output can increase significantly after stroke.
Functional incontinence- occurs due to the physical effects of a stroke such as reduced mobility and a difficulty unfastening and removing clothes in enough time to use the toilet.
Urgency incontinence- sudden, urgent and uncomfortable need to pass urine, result of bladder spasm or contractions
Urinary retention- inability to fully empty the bladder resulting in urine being retained, it can also be difficult to start urination.
Stress incontinence-small amounts of urinary leakage occurs due to coughing, sneezing or laughing, result of weak or damaged muscles in the pelvic floor or urethral sphincters.

39
Q

What is important to consider with regard to emotional support post-stroke?

A 
Potential for depression/low mood
Altered body image
Effects on self-esteem
Stages of grief- loss of old self
Loss of independence.
Effects of Pseudobulbar affect which causes emotional responses that are unrelated to mood e.g. crying/laughing.
40
Q

Thrombolysis- what is important in the care before?

A
  • Discuss with PT/family-
    • no written consent needed
    • explain what has happened
    • explain how drug works
    • risks
  • avoid cath for 30 min prior
41
Q

Thrombolysis- what is important in the care during?

A
  • signs of haemorrhage - neuro obs-
    • widening pulse pressure
    • bradycardia
    • irregular breathing
    • sudden worse GCS
    • sudden headache/irritability/ restlessness
    • worsening limb movement
    • unequal pupils
  • observe vital signs
  • signs of:
    • orolingual angioedema- oedema in mouth
    • bleeding gums
    • anaphylactic reaction
    • rash
    • urticaria- hives
    • laryngeal oedema- resp distress due to swelling in laryngeal
  • ABCDE
42
Q

Thrombolysis- what is important in the care after?

A

-avoid NG tube insertion for 24hrs
-avoid cath for 24hrs
No anticogagulants/anti platelets/non steroidanal/ anti inflammatorys for 24hrs
-avoid CVP or art lines for 24hrs (include injections)
- commence anti coag (aspirin) if usually taken 24hrs after

43
Q

What is aphasia and what are the causes/treatment?

A
  • impairment of language- production or comprehension
  • damage to Broca’s area and Wernick’s
  • knowing what to say but not having the right words
  • social affect
  • affect mood

Things that help

  • carrying pen +paper
  • use gestures/pictures/ descriptions
  • carry communication card
  • speech and language will carry out a full assessment
  • arrange s&l asap after
  • establish personal needs and priorities +goals

Nursing Exam 2020 (4 decks)

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