UNIT 3 CHAPTER 41 CONCEPTS OF STROKE

Question 1

What is a Transient Ischemic Attack

Answer 1

transient ischemic att ack (TIA) A temporary neurologic dysfunction resulting from a brief interruption in cerebral blood flow.

TIA can have many of the same
signs and symptoms of a stroke

• Warning sign of stroke in the
  future
• Symptoms resolve usually within
  30-60 minutes – it is a transient
  issue

*FAKE STROKE

Question 2

Is a stroke a medical emergency?

A. Yes
B. No

Answer 2

Also referred to as a “brain a ttack” to convey the urgency for acute stroke care similar to that provided for acute myocardial infarction (MI; heart a ttack).

A stroke is a medical emergency and should be treated immediately to reduce or prevent permanent disability.

Question 3

Patho of brain Attach (stroke)

Answer 3

The brain cannot store oxygen or glucose and therefore must receive a constant flow of blood to provide these substances for normal function.

Question 4

S/S oF Transient Ischemic Attack

Answer 4

Transient Ischemic A ack
Visual Symptoms
* Blurred vision
* Diplopia (a condition in which the client has double vision)
* Hemianopsia (a condition in which the vision of one or both eyes is affected)
* Tunnel vision
Mobility (Motor) Symptoms
* Weakness (facial droop, arm or leg drift, hand grasp)
* Ataxia (lack of muscle control and coordination that affects gait, balance, and the ability to walk)
Sensory Perception Symptoms
* Numbness (face, hand, arm, or leg)
* Vertigo (a feeling of spinning or dizziness)
Speech Symptoms
* Aphasia (problems with speech and/or language)
* Dysarthria (slurred speech caused by muscle weakness or paralysis)

Question 5

What is a Stroke

Answer 5

stroke A neurologic health problem caused by an interruption of perfusion to any part of the brain that results in infarction (cell death).

Permanent interruption of blood flow to brain
* Can be due to blockage or thrombus (ischemic)
* Can be hemorrhagic

Question 6

What are the 2 types of Strokes?

Answer 6

• Ischemic

-Hemmorhagic

Question 7

What is the pathophysiology of the stroke?

Answer 7

Interruption of blood flow causes tissue death of brain and
therefore loss of function
* What happens when body has dead cells to clean up?
* Body sends in the WBC and phagocytes to clean up the mess,
this can lead to increased edema which can further cause
damage

Question 8

Ischemic Stroke, What is it

Answer 8

An acute ischemic stroke (AIS) is caused by the occlusion (blockage) of a cerebral or carotid artery by either a thrombus or an embolus. A stroke that is caused by a thrombus (clot) is referred to as a thrombotic stroke, whereas a stroke caused by an embolus (dislodged clot) is referred to as an embolic stroke.

if client seeks treatment early enough (Usually within 4.5 hours of
onset of symptoms)
* TPA therapy (Alteplase)
* Must be ruled as ischemic stroke
* Must be placed on bleeding precautions for 24 hours

Question 9

Hemorrhagic Stroke , What is it

Answer 9

An acute ischemic stroke (AIS) is caused by the occlusion (blockage) of a cerebral or carotid artery by either a thrombus or an embolus. A stroke that is caused by a thrombus (clot) is referred to as a thrombotic stroke, whereas a stroke caused by an embolus (dislodged clot) is referred to as an embolic stroke.

Question 10

As a nurse how do you know which stroke a pt is having

Answer 10

USE CT SCAN

Question 11

STROKE PREVENTION

Answer 11

Most strokes are preventable. The CDC and other cardiovascular professional organizations recommend to apply the ABCS of heart health to prevent strokes:

• Aspirin use when appropriate
• Blood pressure control
• Cholesterol management
• Smoking cessation

Question 12

What is BEFAST

Answer 12

B - Balance: Watch for sudden loss of balance
E - Eyes: Check for vision loss
F - Face: Look for an uneven smile
A - Arm: Check if one arm is weak
S - Speech: Listen for slurred speech
T - Time: Call 9-1-1 right away

Question 13

What are the risk factors for Stroke?

Answer 13

Modifiable

• Hypertension
• Use of oral contraceptives
• Hyperlipidemia
• Diabetes mellitus
• Obesity
• Smoking
• Irregular heartbeat (a-fib)
• Alcoholism
• Illicit drug use (especially cocaine)
• Sedentary lifestyle

Nonmodifiable
* Genetic factors
* Age
* Sickle cell disease

Question 14

PTT LAB

Answer 14

20-30 SEC

Question 15

PT LAB

Answer 15

1-12.5 SEC

Question 16

INR LAB

Answer 16

0.9-1.2 SEC

Question 17

S/S of Stroke

Answer 17

Middle Cerebral Artery Strokes (most common)
* Contralateral (opposite side) hemiparesis (one-sided weakness) or hemiplegia (one-sided paralysis); typically the arm is flaccid and the leg is spastic if both extremities are affected
* Dysphagia
* Contralateral sensory perception deficit (numbness, tingling, unusual sensations)
* Ptosis
* Nystagmus
* Homonymous hemianopsia
* Unilateral neglect or ina ention
* Dysarthria
* Aphasia- spech difficulties
* Anomia
* Apraxia- moving difficulties
* Agnosia
* Alexia, agraphia, and/or acalculia
* Impaired vertical sensation
* Visual and spatial deficits
* Memory loss (amnesia)
* Altered level of consciousness: drowsy to comatose

Question 18

Medications for Stroke

Answer 18

Antiplatelet drugs such as aspirin and clopidogrel are the standard of care for treatment following acute ischemic strokes and for preventing future strokes

• . Sodium heparin and other anticoagulants, such as warfarin, are reserved for use in patients who have cardiopulmonary issues such as atrial fibrillation. Anticoagulants are high-alert drugs that can cause bleeding, including intracerebral hemorrhage in the area of the ischemia
• Ca-Channel block to prevent vasospasms after subarachnoid hemorrhage
• Stool softeners (do not want patient to bear down – it will increase
  ICP)
• Analgesics
• Antianxiety

Question 19

Managing Intracranial Pressure in a stroke patient

Answer 19

Want to keep ICP <25mmHg
* Keep HOB >30 degrees (also will increase oxygenation and reduce aspiration risk)
* Keep head midline, neutral position
* Avoid sudden and acute hip or neck flexion during positioning
* Avoid clustering of care
* Hyper-oxygenation (not hyperventilation)
* Avoid coughing and suctioning
* Provide quiet environment, soft lights
* Monitor vs q1-2 hrs. SBP>180 mmHg or DBP >110 is considered dangerous.

Best practices for preventing or managing increasing ICP for patients experiencing a stroke include:
* Elevate the head of the bed per agency or primary health care provider protocol to improve perfusion pressure.

Question 20

Long term symptoms of Stroke

Answer 20

Long-term symptoms of stroke
* Hemiparesis
* Hemiplegia
* Aphasia
* Dysarthria
* Dysphagia
* Apraxia
* Sensory deficits
* Behavioral changes
* Incontinence
* Visual changes
* Homonymous
hemianopia
* Agnosia
* Unilateral neglect

Question 21

Right Side Stroke

Answer 21

The right cerebral hemisphere is more involved with visual and spatial awareness and proprioception (sense of body position). A person who has a stroke involving the right cerebral hemisphere is often unaware of any deficits and may be disoriented to time and place. Personality changes include impulsivity (poor impulse control) and poor judgment.

Question 22

Left Side stroke

Answer 22

The left cerebral hemisphere, the dominant hemisphere in all but about 15% to 20% of the population,

is the center for
LAM
L- language
A-analytic thinking
M-mathematic skills

speech, language, mathematic skills, and analytic thinking. Therefore problems in these areas are expected for patients who have a left-sided stroke.

Question 23

Which statement by a client who had a transient ischemic att ack (TIA) and is at risk for stroke indicates a need for further health teaching by the nurse?
A. “I’m glad I can keep eating protein like red meat.”
B. “I’ll try to walk at least 20 to 30 minutes each day.”
C. “I’m going to talk to my doctor about a weight loss plan.”
D. “I plan to include more fruits and vegetables in my diet.”

Answer 23

A. “I’m glad I can keep eating protein like red meat.”

Question 24

The nurse is caring for a client treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse to report to the primary health care provider?
A. Client has a new-onset mild headache.
B. Client’s blood pressure is 194/120 mm Hg.
C. Client has left hemiparesis.
D. Client continues to be drowsy.

Answer 24

B. Client’s blood pressure is 194/120 mm Hg.

Question 25

What is the first sign of an increase of intracranial pressure

Answer 25

Be alert for symptoms of increased ICP in the stroke patient and report any deterioration in the patient’s neurologic status to the primary health care provider or Rapid Response Team immediately! The first sign of increased ICP is a declining level of consciousness (LOC).

Question 26

What is Aphasia and Dysarthria

Answer 26

. Speech and language problems may be the result of aphasia or dysarthria. Aphasia is caused by cerebral hemisphere damage; dysarthria is the result of a loss of motor function to the tongue or the muscles of speech, causing facial weakness and slurred speech.

Expressive
* Referred to as Broca, or motor, aphasia
* Difficulty speaking
* Difficulty writing

Receptive
* Referred to as Wernicke, or sensory, aphasia * Difficulty understanding spoken words
* Difficulty understanding wri en words
* Speech often meaningless
* Made-up words

Question 27

The nurse is caring for an older client with receptive (sensory) aphasia. Which nursing action is most appropriate for communicating with the client?

A. Refer the client to the speech-language pathologist (SLP).
B. Speak loudly to help the client interpret what is being said.
C. Provide pictures to help the client understand.
D. Ask the client to read messages on a whiteboard.

Answer 27

C. Provide pictures to help the client understand.

Question 28

9.A patient is prescribed an antiplatelet agent to prevent strokes. Which agent was this patient most likely prescribed?
a. Aspirin
b. Warfarin (Coumadin)
c. Acetaminophen (Tylenol)
d. Tissue-type plasminogen activator (tPA)

Answer 28

a. Aspirin

Question 29

. A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for a STAT computed tomography (CT) scan of the head.
4. Notify the speech pathologist for an emergency consult.

Answer 29

3. Schedule for a STAT computed tomography (CT) scan of the head.

A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or an ischemic
accident and guide treatment.

Question 30

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which
clinical manifestation would the nurse document?
1. Hemiparesis of the client’s left arm and apraxia.
2. Paralysis of the right side of the body and
ataxia.
3. Homonymous hemianopsia and diplopia.
4. Impulsive behavior and hostility toward family.

Answer 30

2. Paralysis of the right side of the body and
   ataxia.

The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordi-
nate movement.

Question 31

Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?
1. A 55-year-old African American male.
2. An 84-year-old Japanese female.
3. A 67-year-old Caucasian male.
4. A 39-year-old pregnant female.

Answer 31

1. A 55-year-old African American male.

African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans also suffer more extensive damage from
a CVA than do people of other cultural groups.

Question 32

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?
1. Observe the client swallowing for possible aspiration.
2. Position the client in a semi-Fowler’s position when sleeping.
3. Place a suction setup at the client’s bedside during meals.
4. Refer the client to an occupational therapist for evaluation.

Answer 32

4. Refer the client to an occupational therapist for evaluation.

A collaborative intervention is an inter- vention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.

Question 33

7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
8. An oral anticoagulant medication.
9. A beta blocker medication.
10. An anti-hyperuricemic medication.
11. A thrombolytic medication.

Answer 33

1. An oral anticoagulant medication.

The nurse would anticipate an oral antico- agulant, warfarin (Coumadin), to be pre- scribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

Question 34

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
1. A blood glucose level of 480 mg/dL.
2. A right-sided carotid bruit.
3. A blood pressure (BP) of 220/120 mm Hg.
4. The presence of bronchogenic carcinoma.

Answer 34

3. A blood pressure (BP) of 220/120 mm Hg.

Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which
is a ruptured blood vessel inside the cranium.

Question 35

What is affected in right hemisphere stroke?

Answer 35

MOVEMENT

The right cerebral hemisphere is more involved with visual and spatial awareness and proprioception (sense of body position). A person who has a stroke involving the right cerebral hemisphere is often unaware of any deficits and may be disoriented to time and place. Personality changes include impulsivity (poor impulse control) and poor judgment.

Question 36

What is affected left hemisphere stroke?

Answer 36

LANGUAGE

The left cerebral hemisphere, the dominant hemisphere in all but about 15% to 20% of the population, is the center for speech, language, mathematic skills, and analytic thinking. Therefore problems in these areas are expected for patients who have a left-sided stroke.