Topic 12: Stroke Flashcards
Stroke
occurs when there is ischemia (inadequate blood flow) to a part of the brain or hemorrhage (bleeding) into the brain which results in brain death.
other terms for stroke
brain attack” or cerebrovascular accident (CVA)
what is needed after stroke onset
immediate medical attention is crucial to decrease disability and the risk for death
what is the most effective way to decrease the burden of stroke
prevention and teaching of risk factors
Nonmodifiable risk factors for stroke
age, gender, ethnicity, race, family history
modifiable risk factors for stroke
HTN, heart disease, diabetes, smoking, obesity, sleep apnea metabolic syndrome, lack of physical exercise, poor diet, drug and alcohol use, early forms of birth control that have high levels of progestin and estrogen increase women’s risk for stroke
Transient ischemic attach (TIA)
may be due to microemboli that temporarily block the blood flow, they are warning signs of progressive cerebrovascular disease
· Medical emergency since it can lead to an ischemic stroke
Thrombotic stroke
occurs from injury to the blood vessel wall and formation of blood clots, lumen is then narrowed and becomes occluded
Embolic stroke
occludes a cerebral artery resulting in infarction and edema. When a plaque breaks off it enters circulation, travels upward and lodge where a vessel narrows or bifurcates (splits)
Ischemic stroke
a type of stroke that occurs when the flow of blood to the brain is blocked
-thrombotic and embolic
Hemorrhagic stroke
occurs when a blood vessel in the brain leaks or ruptures; also known as a bleed
-intracerebral and subarachnoid hemorrhage
Intracerebral hemorrhage
bleed within the brain caused by a rupture of a vessel, prognosis is poor
Subarachnoid hemorrhage
occurs when there is intracranial bleeding into CSF- filled space between the arachnoid and pia mater membranes
often cause of bleeding in a hemorrhagic stroke is
rupture of a cerebral ANEURYSM (congenital of acquired weakness and ballooning of vessels), warning signs is if ballooning artery caused pressure to brain
FAST warning signs for stroke
· Face drooping (smile uneven?)
· Arm weakness (weak, numb, drift downward?)
· Speech difficulties
· Time (critical! Call 911 and get to hospital)
Right-brain damage clinical manifestations
· Paralyzed left side: hemiplegia
· Left-sided neglect
· Spatial-perceptual deficits
· Tends to deny or minimize problems
· Rapid performance, short attention span
· Impulsive, safety problems
· Impaired judgment
· Impaired time concepts
Left-brain damage
· Paralyzed right side: hemiplegia
· Impaired speech/language aphasias
· Impaired right/left discrimination
· Slow performance, cautious
· Aware of deficits: depression, anxiety
· Impaired comprehension related to language, math
Receptive (Wernicke’s) aphasia
loss of comprehension
Expressive (Broca’s) aphasia
inability to produce language
Global aphasia
total inability to communicate
Mobility clinical manifestations
· Deficits in mobility
o Akinesia (loss of skilled voluntary movement)
· Decreased respiratory function
· Difficulty with swallowing and speech
· Decreased gag reflex
· Decreased self-care abilities
Communication clinical manifestations
· Dysphagia
· Dysarthria: a problem with the muscular control of speech
Affect clinical manifestations
· May have hard time controlling their emotions
· Depression
Feelings related to changes in body image and loss of function
Common long-term disabilities
· Hemiparesis (partial paralysis on one side)
· Inability to walk
· Complete or partial dependence for ADLs
· Aphasia
Depression
diagnostic studies
· CT!!
o It is important to get CT right away to determine between ischemic and hemorrhagic stoke
· MRI/MRI Angiography
· Blood flow studies
o Cerebral angiography
o Carotid angiography
o Digital subtraction angiography
o Transcutaneous Doppler ultrasonography
o Carotid duplex scanning
Preventative therapy (stroke prevention)
· Reduce salt and sodium intake
· Maintain normal body weight
· Follow a diet low in saturated fat and high in fruits and vegetables
· Limit alcohol use to moderate levels
· Maintain a SBP less than 140mmHg
· Exercise 40 minutes 3 to 4 days a week
· Avoid cigarette and tobacco use
· Maintain a normal blood glucose level
· Follow prescribed treatment plan for diagnosed cardiac problems
o Aspirin at dose of 81 mg/day
what needs to be assessed for a stroke
· Assess manifestations of stroke and determine when they started
· Screen patient for contraindications for tPA therapy
· Assess respiratory status and start needed actions such as O2, airway and suctioning
before a stroke patient eats what needs to be done
o KEEP NPO UNTIL DYSPHAGIA IS RULED OUT (assess swallow ability)because airway obstruction can occur because of chewing and swallowing , food pocketing, and the tongue falling back
· Position patient to prevent aspiration and atelectasis
o High fowlers position, preferably in a choir, for the feeding and 30 minutes afterward
what prophylactic drugs are used for stroke
· Give schedules anticoagulant and antiplatelet drugs
Constipation is a common problem after stroke, what is the best intervention
· fluid and fiber intake and prophylactic stool softeners
o Bowel retraining may be needed and continued into rehab phase
a swallowing evaluation should be done within
the first 24 hours
Assess gag reflex before feeding by
gently stimulating the back of the throat with a tongue blade
Assess swallowing ability by
elevating HOB and give patient small amount of crushed ice or ice water to swallow
assistive devices for stroke
Employ assistive devices to promote self-feeding (rocker knives, plate guards, nonslip pads
Emergency stroke management
· Call stroke code or stroke team
· Remove dentures
· Perform pulse oximetry
· Maintain adequate oxygenation with supplemental O2 if needed
· Establish IV access with normal saline
· Maintain BP according to guidelines
· Remove clothing
· Obtain CT or MRI
· Perform baseline lab tests (including blood glucose) immediately and treat if hypoglycemic
· Position head in midline
· Elevate head of bed 30 degrees if no symptoms of shock or injury
· Institute seizure precautions
· Anticipate thrombolytic therapy for ischemic stroke
Communication with patient with aphasia
· Decrease environmental stimuli that may be distracting and disrupting to communication efforts
· Treat patient as adult
· Speak with normal tome and volume
· Present single thought or idea at a time
· Keep questions. Simple or ask yes/no questions
· Let person speak, do not interrupt, allow person tome to complete thoughts
· Make use of gestures as alternative form of communication
· Do not pretend to understand a person if you do not. Calmly say you do not understand. Encourage nonverbal communication or ask person to write out what they want
· Give patient time to process information and generate response
· Allow body contact as much as possible. Realize that touching may be the only way the patient can express feelings
· Organize patient s day by preparing and following schedule
· Do not push communication if person is tired or upset. Aphasia worsens with fatigue and anxiety
· Teach communication techniques to caregivers and family members
Carotid endarterectomy (CEA)
· the atheromatous lesion is removed from the carotid artery to improve blood flow
Transluminal angioplasty
insertion of a balloon to open a stenosed artery in the brain and improve blood flow
Stenting
intravascular placement of a stent to try to maintain patency of the artery, can be used with a tiny filter that opens like and umbrella
Ambulatory care
· Follow-up care with PT, OT, speech therapy, and medical care
· Identify community resources
· Rehabilitation: most patients recover in the first 6 months after a stroke with max benefits 1 year after stroke
· Balance training
· Sitting upright: provide proper support with pillows or cushions
· Supportive/assistive devices: cane, walker, leg braces, etc
· Patient may be apathetic, depressed fearful, anxious, frustrated, or angry. PATIENT MAY BE UNABLE TO CONTROL EMOTIONS
patient may be unable to control emotions with
left-sided stroke
when the stroke client is unable to control emotions…
o Distract the patient who suddenly becomes emotional
o Explain to patient and family that emotional outbursts may occur after stroke
o Maintain a calm environment
Avoid shaming or scolding the patient during emotional outbursts
ischemic stroke drugs
· Preventative drugs
· tPA: given IV to reestablish blood flow through a blocked artery to prevent cell death
Hemorrhagic Stroke
· Hypertension control (Systolic <160)
· Seizure prophylaxis
· Craniotomy to drain blood & ↓ ICP
· Clip aneurysm
· Coil aneurysm
· Ca++ Channel blocker to ↓ vasospasms: Nimodipine
Clip aneurysm
a metallic clip is placed on the neck of the aneurysm to block blood flow and prevent rupture
Coil aneurysm
a hydrogel coated platinum coil is inserted into the lumen of the aneurysm
before administration of Nimodipine
o Assess BP and apical pulses before administration
If pulses <60 or SBP <90, hold med and contact provider
