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Nursing 272: Final Semester > Unit 1: Stroke: Ischemic > Flashcards

Unit 1: Stroke: Ischemic Flashcards

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1
Q

Stroke

A

a disruption in blood flow to the brain

-ischemic or hemorrhagic

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2
Q

Causes of Stroke

A
  • a blockage of a blood vessel (ischemic stroke)
  • temporary blockage (transient ischemic attack; TIA)
  • bleeding into the brain (hemorrhagic stroke)
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3
Q

Non-treatable risk factors for stroke

A
  • age
  • gender
  • race
  • family hx
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4
Q

Treatable Risk Factors for a Stroke

A
  • Hypertension (#1)
  • Cigarette smoking
  • Heart disease
  • Warning signs/ hx of TIA (transient ischemic attack) or stroke
  • High Cholesterol (Hypercholesteremia)
  • Diabetes
  • Obesity + Inactivity
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5
Q

Types of Strokes

A
  • Ischemic: large vessels (carotid, vertebral), small vessel/lacunar (peripheral regions and deep brain structures), embolic, cryptogenic (of unknown)
  • Hemorrhagic: Intracerebral hematoma, subarachnoid hemorrhage
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6
Q

Ischemic Stroke

A

a sudden blockage of a cerebral blood vessel causes a reduction in the supply of oxygenated blood to the region of the brain fed by the involved artery; cause onset of clinical manifestations

  • when blood flow is disrupted, an area of brain tissue suffers irreversible damage (infarction)
  • “brain attack”
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7
Q

Ischemic Penumbra

A

zone of tissue surrounding an infarction

  • contains ischemic tissue that is not irreversibly damaged
  • target of therapies aimed at opening blocked cerebral blood vessels and reestablishing blood flow to ischemic brain tissue, providing optimal chance for functional recovery
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8
Q

Transient Ischemic Attack (TIA)

A

-temporary neurological deficit
-temporary impairment of blood flow
-warning of an impending stroke
>diagnostic workup required
>serial neuro checks done

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9
Q

National Institution of Health Stroke Scale (NIHSS)

A

quantifies and trends neurological dysfunction in patients presenting w/ a suspected stroke
0= no stroke
1-4= minor stroke (>4 for Alteplase [5-20])
5-15= moderate stroke
16-20= moderate-severe stroke
21-42= severe stroke (not candidate for Alteplase)

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10
Q

Occlusion of large cerebral blood vessels (carotid arteries, vertebral arteries)

A

occurs
-when the plaque ruptures, causing a clot to form and block the vessel
-when atherosclerotic plaque accumulates to a point that it critically narrows and then completely obstructs blood flow
>occlusion of a large cerebral blood vessel can cause ischemia in large areas of brain tissue depending on the location of the occlusion (proximal or distal)

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11
Q

Territories

A 
the large areas of brain tissue
-territory name based on the blood vessel that perfuses that particular area:
>anterior cerebral artery 
>middle cerebral artery
>posterior cerebral artery
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12
Q

Most Common Stroke Syndromes

A
  • Left Middle Cerebral Artery Syndrome
  • Right Middle Cerebral Artery Syndrome
  • Basilar Artery Syndrome
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13
Q

Left Middle Cerebral Artery Syndrome

A
  • weakness on the right side
  • decreased sensation on the right side
  • visual field cut on the right side
  • inattention/neglect on the right side
  • dysphagia (difficulty swallowing)
  • make errors in speech
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14
Q

Right Middle Cerebral Artery Syndrome

A
  • weakness on the left side
  • decreased sensation on the left side
  • visual field cut on the left side
  • inattention/ neglect on the right side
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15
Q

Basilar Artery Syndrome

A

back/base of the head

  • dizziness
  • ataxia (involuntary uncoordinated movements)
  • tinnitus
  • nausea + vomiting
  • weakness on one side of the body; ipsilateral or contralateral to side of injury
  • difficulty in the articulation of speech
  • difficulty w/ swallowing; managing oral secretions
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16
Q

Occlusion of small intracranial blood vessels supplying the peripheral (back) regions of the brain and deep brain structures cause Lacunar Stroke

A

small infarction caused by an obstruction of a small blood vessel or group of small blood vessels (perforating blood vessels, b/c they are terminal branches of larger arteries)

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17
Q

Embolization of blood clots from the heart

A
  • can occur in A-Fibrillation b/c blood stagnates in the poorly contracted atria, allowing blood clots to form that may be ejected from the left ventricle, travels up the aorta and flow easily into the left common carotid artery, where they may lodge in a large-or-small caliber blood vessel depending on size of the blood clot
  • smaller portions of a blood clot obstructing a blood vessel can also break off and travel forward into smaller vessels
  • embolism of blood clot can also occur w/ valvular infection or dysfunction
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18
Q

Coagulation Disorders

A

causing hypercoagulability represents another reason for ischemic stroke

  • sickle cell disease: mechanical occlusion of a blood vessel b/c of RBC deformation
  • polycythemia vera: abnormally high number of RBC (from bone marrow) and in some cases WBC + platelets, which makes blood more viscous, resulting in increased RBC volume
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19
Q

Cryptogenic

A

a discrete cause cannot be identified

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20
Q

Diagnostic Studies

A
  • B-E-F-A-S-T
  • National Institute of Health Stroke Scale (NIHSS)
  • CT scan
  • MRI
  • Doppler Ultrasound
  • Cerebral Angiography
  • TTE/TEE (Echocardiogram)
  • Lab tests for coagulation
  • Agitated saline
  • Carotid duplex scanning
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21
Q

B-E-F-A-S-T

A

acronym used to quickly detect stroke
-B (balance); loss of balance, headache/dizziness
-E (eyes); blurred vision
-F (face); one side of face drooping
-A (arms); arm or leg weakness
-S (speech); speech difficulty
-T (time); time to call for ambulance immediately
>findings of balance problems, changes in eyes and vision, facial asymmetry, arm drift, or slurring of speech indicate that time is crucial in order to implement measures to reserve brain tissue

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22
Q

CT Scan

A
  • for patients w/ clinical manifestations
  • determines what type of stroke; hemorrhagic
  • radiographical changes not usually visualized in ischemic stroke within first several hours
  • w/o contrast so blood can be visualized
  • w/ contrast to visualize mass lesion in brain (e.g. tumor)
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23
Q

MRI Scan

A
  • stroke protocol is performed
  • sequences that capture necrotic tissue and areas of the brain that are hypoperfused
  • directly visualizes the blood vessels to detect blood vessel obstruction or another abnormality (aneurysm)
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24
Q

Doppler Ultrasound

A

allows evaluation of the middle cerebral, intracranial carotid, and vertebrobasilar arteries

  • Doppler of the carotid arteries can detect narrowing of the arteries
  • detect narrowing of the inner lumen of the carotid vessels by atherosclerotic plaque
  • can detect narrowing in the carotid vessels before they enter the skull
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25
Q

Cerebral Angiography

A

visualizes abnormalities of blood vessels

-“four-vessel” cerebral angiography

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26
Q

TTE & TEE

A

visualize contraction of chambers of the heart

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27
Q

Agitated Saline

A

(agitation causes microbubbles to form)

-used to assist in determining if pt has a patent foramen ovale

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28
Q

Laboratory Tests

A
  • a hypercoagulable state in blood can cause a stroke
  • for coagulation
  • CBC w/ differential
  • platelet count
  • serum electrolytes, BUN, Creatinine, Cholesterol level
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29
Q

Echocardiogram (TTE, TEE)

A

directly visualize myocardial wall movement and contraction in the chambers of the heart

  • to evaluate current cardiac function; if cardioembolic source is likely
  • TTE used to evaluate overall cardiac function as well as blood cots within the heart that could embolize to brain
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30
Q

Carotid duplex scanning

A

when carotid stenosis or occlusion is the suspected cause of stroke

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31
Q

Paresis

A

weakness

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32
Q

Plegia

A

paralysis

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33
Q

Dysarthria

A

difficulty w/ speech

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34
Q

Dysphagia

A

difficulty swallowing

35
Q

Diplopia

A

double vision

36
Q

Visual field cut

A

only sees half of visual field

37
Q

Hemiparesis

A

paresis (weakness) on one side

38
Q

Medical Management

A

restore blood flow to ischemic neuronal tissue

  • Alteplase
  • Intra-arterial thrombolytic administration
  • Mechanical Thrombectomy
39
Q

Alteplase (rt-PA)

A
  • cerebral blood vessels may be opened or recanalized using IV recombinant tissue plasminogen activator (rt-PA/ Alteplase)
  • blood clot can be dissolved at the site
  • restores blood flow to ischemic neuronal tissue
  • must be given ASAP after ischemic stroke but not outside therapeutic window (3 or 4.5 hours)
  • risk associated: intracranial bleeding
  • must present within 3 hours of stroke symptoms
40
Q

Intra-arterial Thrombolytic Administration

A
  • use of cerebral angiogram to locate vessel occlusion

- rt-PA (Alteplase) delivered directly into blood clots

41
Q

Mechanical Thrombectomy

A

done for large vessel blockages after administration of rt-PA (Alteplase)

  • cerebral angiogram to locate vessel occlusion accompanied by a stent to ensnare the clot and a suction system to reduce the likelihood of embolization of the clot as it is pulled out of the blood vessel with the stent (endovascular technique)
  • complications: damage or rupture of a blood vessel; breakage of the clot which could travel forward and lodge into another blood vessel; and intracerebral hemorrhage
42
Q

Inclusion Criteria for Alteplase (rt-PA)

A
  • measurable deficit with NIHSS <25
  • no hemorrhage/brain tumor on CT
  • time since start of symptoms 3-4.5 hours
  • symptoms present for 30 minutes, not improving
43
Q

Exclusion Criteria for Alteplase (Rt-PA)

A
  • Evidence of intracranial hemorrhage on CT scan
  • Minor or rapidly improving symptoms
  • Active internal bleeding: GI/urinary tract in last 21 days
  • Heparin in last 48 hours
  • Taking anticoagulants
  • PT >15 seconds or INR >1.7 or Platelet count <100,000/mm
  • Major surgery/ trauma last 14 days
  • Stroke, head trauma, brain surgery last 3 months
  • Arterial/lumbar puncture last 7 days
  • Systolic BP >185 mmHg/ Diastolic BP > 110 mmHg
  • Hx intracranial hemorrhage, neoplasm, AV malformation
  • Recent MI
  • Age >80
  • Hx of stroke and diabetes
44
Q

Measures to prevent complications of stroke

A
  • VTE prophylaxis
  • Management of Blood pressure
  • Control of Risk factors
45
Q

Cerebral Autoregulation

A

protective process by which cerebral blood vessels dilate when systemic blood pressure is reduced and constrict when systemic BP is elevated to maintain constant blood flow

  • dysfunctional after stroke
  • avoid abnormally low BP
  • patients should be discharged w/ antiplatelet therapy, lipid-lowering therapy if indicated, anticoagulation if indicated for A-fib, and BP control strategy in patients w/ hypertension
46
Q

Complications of Ischemic Stroke

A
  • Hemorrhagic Transformation
  • Cytotoxic Edema
  • Communication Deficits
  • Motor Deficits
  • Sensory Deficits
  • Depression
  • aspiration of food, fluids, or secretions into the lungs
  • weakness or paralysis of extremities, and associated risk of contracture
  • Homonymous Hemianopia
47
Q

Complication: Hemorrhagic Transformation

A
  • life-threatening
  • hemorrhage into the area of infarcted (dead) brain tissue
  • occurs as a result of blood vessel spasm around a blood vessel that has been occluded by a blood cot, in time resolves, causing the clot to break apart and restring blood flow to surrounding ischemic and infarcted brain tissue; during ischemia, tissues become friable and fragile, and when normal flow or pressure is reestablished, this pressure may cause tissue damage or bleeding
  • may experience in absence of thrombolytic therapy or anticoagulation therapy
48
Q

Complications: Cytotoxic Edema

A
  • occur in a stroke occupying a large vascular territory in the brain
  • caused by breakdown of intracellular process d/t an inadequate oxygen supply, causing fluid to leak out of cells and into interstitial space
  • as ischemia persists and infarction occurs, cerebral edema may increase, causing increased ICP and is at risk for cerebral herniation syndrome
49
Q

Complications: Communication Deficits

A
  • occur when the speech centers located in the left hemisphere of the brain are affected
  • Expressive aphasia
  • Receptive aphasia
50
Q

Expressive Aphasia

A

inability to express oneself

-results from damage to Broca’s area in the frontal lobe

51
Q

Receptive Aphasia

A

inability to understand communication

-d/t damage in Wernicke’s area located in the temporal lobe

52
Q

Complications: Motor Deficits

A

seen on the contralateral (opposite) side of the area of the brain where the stroke occurs
-disturbances in the planning of motor activities (apraxia) often occurs in strokes that involve the frontal and temporal lobes of the brain

53
Q

Complications: Depression

A

-increased in patients w/ a stroke in the left hemisphere of the brain

54
Q

Complications: Sensory deficits

A

-visual field cuts on the contralateral side; patient loses sight in one half of the visual field, often resulting in neglect of that side of the body or of awareness of the environment on the affected side

55
Q

Agnosia

A

neglect to one side of the body

56
Q

Apraxia

A

disturbance in the planning of motor activities

57
Q

Anomia

A

inability to recall names of everyday objects

58
Q

Complication: Homonymous Hemianopia

A

vision loss on the same side of the visual field in both eyes

  • affect an entire side of vision (nasal and temporal fluids)
  • must learn scanning techniques
59
Q

Right Sided Stroke Symptoms

A
  • Deny Deficits
  • Impulsive, Indifferent
  • Poor Judgement
  • Perceptual Deficits
  • Left visual field cut
  • left side hemiplegia
60
Q

Left Sided Stroke Symptoms

A
  • Aphasic
  • Intellect affected
  • Slow + Cautious
  • Depressed
  • Right visual field cut
  • Right side hemiplegia
61
Q

Carotid Endarterectomy

A 
surgeon opens the artery and removes the plaque
-tx w/ this depends on severity of stenosis:
>mild <50%
>moderate 50-75%
>severe 70-99%
-for patients who are symptomatic
-patients for severe carotid stenosis
>check cranial nerves
>monitor swelling; bleeding can go out
>bleeding can go in; problems swallowing, breathing
>mild anticoagulants (baby aspirin)
>statins
62
Q

How is the asymptomatic patient treated?

A
  • lifestyle changes

- medications: anti-platelet drugs, anti-hypertensives, and lipid-lowering drugs (statins)

63
Q

Nursing Actions for Carotid Endarterectomy

A

-routine post-op care
-medications:
>ASA and/or Clopidogrel
>Anti-hypertensives to keep BP <140/90
>Statins
-HOB 30 degrees and head in neutral position
-Assess respiratory status; check trachea for midline deviation
-Frequent neurological assessments (CN VII, X, XI, XII)
-Monitor vital signs:
>systolic BP within ordered parameters
hypotension: HOB flat, fluids, vasoactive drips
hypertension: antihypertensive meds

64
Q

Nursing Actions for Carotid Artery Stenting

A

-Pre-procedure: ASA and Clopidogrel
-During procedure: monitor neuro status
-Post-procedure:
>Monitor Site
>Monitor vital signs: hypotension [HOB flat, fluids, vasoactive drips]; hypertension [anti-hypertensive meds]
>Auscultate carotid arteries for bruit
>Assess renal function d/t dye
>Encourage fluids

65
Q

Nursing Assessments for Ischemic Stroke

A
  • Serial neuro assessments q 1-2 hours
  • NIHSS
  • Vital signs q 1-2 hours, more often after rt-PA
  • Neurovascular assessment of extremities
  • ECG and cardiac enzymes (A-Fib most common cause of ischemic stroke)
  • Puncture site used for arteriogram
  • Serum electrolytes and glucose
  • I & Os
66
Q

Nursing Interventions for Ischemic Stroke

A
  • Arrange for a head CT
  • NPO until swallowing eval done
  • Aspiration precautions if indicated
  • Administer rt-PA (if candidate)
  • Bleeding precautions
  • Elevate HOB 30 degrees or greater
  • With endovascular tx, HOB 15 degrees w/ gradual increase
  • NG tube as needed for nutrition/meds
  • Frequent positioning/elevation of extremities (risk for pressure injury)
67
Q

Assessments: Serial Neurological assessments q 1-2 hours

A
  • changes in LOC are early indicators of increased ICP
  • neurological deterioration must be detected quickly
  • neurological deterioration during or after IV rt-PA (Alteplase) can = intracranial hemorrhage
  • when IV rt-PA is administered, neurological assessments (LOC, motor strength, and pupillary reflexes) are performed q 15 min for 6 hours, q 30 minutes for 2 hours, and q 1 hour for 16 hours
68
Q

How often should you perform neurological assessments for someone who has been given rt-PA (Alteplase)

A
  • LOC, motor strength, pupillary reflexes

- q 15 minutes for 6 hours, q 30 minutes for 2 hours, q 1 hour for 16 hours

69
Q

Assessments: Vital Signs q 1-2 hours or more often when administering medications that alter BP

A

when IV rt-PA is given, the frequency of vital signs: BP, HR, RR is q 15 minutes for 6 hours, q 30 minutes for 2 hours, and q 1 hour for 16 hours, q 1 hour for 16 hours

70
Q

When IV rt-PA is given, how often should you take vital signs?

A
  • HR, BP, RR

- q 15 minutes for 6 hours, q 30 minutes for 2 hours, q 1 hour for 16 hours

71
Q

Assessment: Neurovascular assessment of the extremities

A

pulse checks of dorsalis pedis or posterior tibial artery -used during endovascular therapy must be performed during first 4 hours after procedure
-to detect arterial clotting d/t accessing the artery during angiogram

72
Q

Assessments: Puncture site used for the ateriogram

A

is monitored frequently for the first 4 hours after arterial sheath removal to detect signs of bleeding from the accessed blood vessel
-assessed for oozing of blood from the puncture site and the presence of hematoma when palpating the site

73
Q

Actions: Administer rt-PA as ordered

A
  • allows a blood clot to be dissolved at the site and restore blood flow to ischemic neuronal tissue
  • IV for acute ischemic stroke
  • must present within 3 hours of stroke symptoms to receive
74
Q

Actions: Perform bedside swallow evaluation

A

-after stroke, experience swallowing dysfunction = risk for aspiration and subsequential pneumonia

75
Q

Actions: Elevate HOB > 30 degrees

A
  • is at risk for increased ICP

- keep neck midline

76
Q

Actions: HOB for patients who have undergone endovascular therapy beginning at 0 to 15 degrees, depending on order, and progressing to 90 degrees before patient is able to stand

A
  • to reduce incidence of bleeding at the arteriogram access site
  • do not move affected extremity, for first 4 to 6 hours after procedure
77
Q

Actions: Nasogastric or Postpyloric feeding tube

A
  • for nutrition and medication administration

- to allow time for swallowing function to improve or for more formal swallowing evaluation completed

78
Q

Actions: Aspiration precautions

A
  • supervision of the patient while eating to observe for clinical manifestations or aspiration or choking
  • maintaining HOB at 45 degrees or greater while eating or drinking
  • reducing distractions to assist a patient i concentrating on eating and drinking
  • advocating for evaluation of the patient by an SLP
  • prescribed therapeutic food preparation (soft or pureed)
  • communication to members of the healthcare team involved w/ feeding of patients about precautions and diet
  • tucking chin when swallowing
  • thickening liquids w/ fiber additives
79
Q

Actions: Bleeding precautions

A

for who is receiving thrombolytics or anticoagulants

  • electric razor
  • soft toothbrush
  • alternating BP cuff to prevent bruising
  • avoid rectal temp
  • strict fall precautions
  • risk for bleeding up to 24 hours w/ thrombolytics
80
Q

Medications Prescribed for Secondary Stroke Prevention

A
  • Lipid-Lowering Agents: (Statins)
  • Platelet Inhibitors: (Acetylsalicylic acid [Aspirin]}
  • Anticoagulants: (Warfarin [Coumadin]}
81
Q

Platelet Inhibitors: Acetylsalicylic Acid (Aspirin)

A

Acetylsalicylic Acid (Aspirin)

  • used to prevent platelet aggregation
  • reduces risk of clot formation
  • prescribed for secondary stroke prevention
  • Side Effect: GI bleeding, allergic reactions (anaphylaxis), dyspepsia (indigestion/abdominal discomfort), epigastric destress, nausea
  • Nursing: prolongs bleeding time for 4-7 days, and in large doses may cause prolonged prothrombin time; avoid alcohol consumption; pts who have asthma, allergies, nasal polyps are at increased risk of hypersensitivity reactions
82
Q

Anticoagulants: Warfarin (Coumadin)

A

Warfarin (Coumadin)

  • used to prevent clotting in patients w/ disorders such as A-Fib
  • prescribed for secondary stroke prevention
  • Side Effect: bleeding; assess for signs of bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, tarry black stools hematuria, fall in hematocrit or BP)
83
Q

Lipid-Lowering Agents: Statins

A

lower blood lipids

  • used as part of a total plan including diet and exercise
  • decreases mortality and morbidity of atherosclerotic cardiovascular disease
  • used to prevent ischemic stroke from plaque

Nursing 272: Final Semester (79 decks)

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