Week Eight Modules Flashcards
stroke is the ___ leading cause of death
what are some common stroke warning signs/symptoms?
5th
sudden numbness or weakness of the face/arm/leg; sudden confusion & trouble speaking; trouble seeing or walking; and sudden severe headache with no known cause
what is BE FAST?
what you can identify in an individual if they are experiencing a stroke
B = balance E = eyes (blurry vision) F = face (drooping) A = arm (weakness) S = speech (difficulty speaking) T = terrible headache
what are some non-modifiable risk factors for stroke?
as you age, your risk for stroke _____ and ____ each decade after the age of 55
strokes tend to be more common in ____, but more women ___ of a stroke
______ have twice the incidence of stroke and higher death rate from stroke than any other ethnic group
age; gender; race; and genetics
increases; doubles
men; die
african americans
what are some modifiable risk factors for stroke?
a history of _____ is another risk factor for having a stroke
HTN; heart disease; diabetes; smoking; obesity; sleep apnea; and metabolic syndrome
TIAs (trans-ischemic attacks)
trans-ischemic attacks are defined as a _____ of _____ dysfunction without ____ of the brain
with trans-ischemic attacks, symptoms usually last ____ than ____
TIAs are considered a warning sign of what?
a TIA is treated as a medical emergency since it can lead to an ______
transient episode; neurological; infarction
less; one hour
progressive cerebrovascular disease
ischemic stroke
what are some s/s of increased intracranial pressure?
above ____ mmHg is considered a “wide pulse pressure”
pulse pressure increases after _____
cushing’s triad (systolic BP increases, diastolic BP decreases, and HR decreases)
irregular respirations (cheyene-stokes) and elevated temperature
the patient is experiencing a widening of pulse pressure
60 mmHg
60 years old
is an ischemic stroke more common or is a hemorrhagic stroke more common?
what is a thrombotic stroke?
what is a hemorrhagic stroke?
ischemic
the process of clot formation that results in narrowing of the lumen which can block blood flow through the artery
a burst blood vessel that allows blood to seep into and damage brain tissues until the clotting cascade is activated
THROMBOTIC ISCHEMIC STROKES:
- occurs from ____ to a blood vessel wall
- develops when ______ have become ____
- s/s develop _____
- thrombotic strokes are more common in patients who have ____, ____, or high _______
injury
atherosclerotic plaques; narrowed
slowly
diabetes mellitus, atherosclerosis, cholesterol
a ______ stroke is the most common cause of stroke
thrombotic
EMBOLIC STROKES:
- occurs when an ______ (traveling clot) lodges in the _____ artery causing infarction and cerebral edema
- most emboli originate from the _______
- symptoms are _____ and occur_____
embolus; cerebral artery
endocardium
severe; suddenly
what is an example of a diagnostic study that is done to check for ischemic stroke/embolic stroke?
a fatal ischemic stroke is usually seen on the ____ side of the brain
CT scan –> it’s the single most important test
right
HEMORRHAGIC STROKE
what is the etiology?
what are some causes of hemorrhagic stroke?
- bleeding within the brain caused by a ruptured blood vessel
- HTN is the most common cause; other causes include aneurysms, trauma, and brain tumors
what are some s/s of hemorrhagic stroke?
neurologic deficits; headache (pt. will say “i had the worst headache of my life”); N/V; decreased level of consciousness; HTN
what are some different types of postures to look out for in possible seizure patients?
an involuntary flexion or extension of the arms and legs which indicates a severe brain injury; body extension indicates a more severe prognosis
SUBARACHNOID HEMORRHAGE
what is the etiology?
what are some causes of subarachnoid hemorrhage?
what are some s/s of subarachnoid hemorrhage?
- occurs when there is bleeding in the cerebral spinal fluid filled space b/w the arachnoid and pia mater
- caused by rupture of an aneurysm; trauma; cocaine drug use
- similar to ICH; may not have any warning signs until the aneurysm ruptures; N/V; seizures; stiff neck; cranial nerve deficits
- do neurologic manifestations differ between ischemic and hemorrhagic strokes?
- manifestations of a stroke are related to the _____ of the stroke
no, they don’t differ significantly
location
when it comes to ED point of care how long should a stroke patient wait to get from the door to the physician?
how long should it take to reach the stroke care team?
how long should it take for the stroke patient to get to their CT scan?
less than or equal to 10 minutes
less than or equal to 15 minutes
less than or equal to 25 minutes
VOCAB WE NEED TO KNOW:
_____ = weakness
_____ = paralysis
_____ = unsteady gait
_____ = inability to form words
_____ = difficulty related to comprehension or use of language
_____ = inability to perform simple tasks or use objects
_____ = loss of ability to read
hemiparesis;
hemiplegia;
ataxia;
dysarthria;
dysphasia;
apraxia;
alexia
SYMPTOMS AFTER A STROKE (right sided)
- patient is paralyzed on the ____ side (hemiplegia)
- ____ sided neglect
- spatial-perceptual ____
- patient will ___ or ____ problems
- ____ performance with ____ attention span
- ______ judgment
left;
left
deficits
deny; minimize
rapid; short
impaired
SYMPTOMS AFTER A STROKE (left-sided)
- patient is paralyzed on the ____ side
- ____ speech/language aphasias
- impaired __/___ discrimination
- _____ performance/cautious
- patient is ____ of their deficits which causes things like _____ or ____
right;
impaired;
right/left;
slow;
aware; depression or anxiety
what is homonymous hemianopsia?
a condition which the person is only able to see from one side of the visual world after a stroke
what are the goals of nursing care for a stroke patient?
during the acute phase: preserve life and limit further brain damage
during the rehabilitative phase:
lessen disability; obtain optimum function
ACUTE PHASE NURSING CARE:
- we are focusing on ____ and making sure there is a ____
- our other goal is also working on _____ because the patient might need to be _____
circulation; pulse
breathing; intubated
what are some nursing problems we might identify in a stroke patient?
altered cerebral tissue perfusion; self-care deficit; impaired physical mobility; impaired verbal communication; impaired urinary/bowel elimination; altered body image
NURSING PROBLEM: ALTERED CEREBRAL TISSUE PERFUSION
- with an ischemic stroke, how can we manage altered cerebral tissue perfusion?
- with a hemorrhagic stroke how can we manage altered cerebral tissue perfusion?
- through BP management; hypertension is a protective mechanism (our goal is to have the BP > 160/100)
- control the cerebral edema and decrease intracranial pressure through the use of medications like mannitol; hypertonic saline; sedation/pain management; avoiding extreme head and neck flexion
what consists of the inclusion criteria for altered cerebral tissue perfusion with a tPA stroke?
- patient is ___ years or older
- ischemic stroke with _____ deficits
- time of onset less than _____ hours
- 18
- neurological
- 3 - 4.5 hours
what are some examples of medications used for stroke?
- ____ is used for an embolic stroke (needs to be given within a ___ to ___ hour time window)
- anticoagulants: ____ and _____
- antiplatelet agents like ____
seizure control drugs like _____, _____, and neurontin
tPA; 3 - 4.5
controversial heparin; lovenox
aspirin
gabapentin; carbamazepine
____ is another medication used for stroke, specifically to control ____ in a hemorrhagic stroke
nimodipine; vascular spasm
GLASCOW COMA SCALE
15 maximum = _____
13 - 14 = ____ depressed and ____
9 - 12 = ______ and conscious
3 - 8 = ______ depressed and conscious
perfect score
mildly; consciousness
moderately depressed
severely depressed
NIH STROKE SCALE
if the patient has a score of _____ = _____
___ - ____ = minor stroke
____ - _____ = moderate stroke
____ - _____ = moderate to severe stroke
0; no stroke
1 - 4
5 - 15
16 - 20
BRAIN STENT
usually, a ____ is used to treat blockages in cerebral blood flow
a balloon catheter is used to ____ the stent into an artery of the brain
the balloon catheter is moved to the _____ of the artery and then inflated. the stent then expands due to ____ of the balloon
brain stent
implant
blocked area; inflation
CRANIAL NERVES
cranial nerve II = ____
cranial nerve V = ____
cranial nerve VII = ____
cranial nerve IX = _____
cranial nerve X = ______
(optic) pupil constriction
(trigeminal) chewing
(facial) symmetry
(glossopharyngeal) taste
(hypoglossal) tongue movement
HOW TO IMPROVE/HELP WITH SELF-CARE DEFICIT
PREVENT CONTRACTIONS
- ______ by doing things like turning/positioning, ____ range of motion, splints, slings, and ____
- PREPARE FOR AMBULATION
- work on ____ balance
- watch out for _____
- work on _____ techniques
prevent contractions; active/passive; heel protectors
sitting; orthostatic hypotension; transfer techniques
- what is an example of a diagnostic test we can perform to check for risk for aspiration?
- _____ feeding helps to stimulate sensory awareness and salivation which can help with ____
- you’ll want to collaborate with a _____ or ____ for a swallowing evaluation
what would be some cues to look out for that point to risk for aspiration?
barium swallow test
mouth care; swallowing
neurology nurse; speech therapist
facial drooping; drooling; weak/hoarse voice; uvula deviates to one side
when it comes to tube feedings with a stroke patient what are some steps we might take to prevent aspiration?
check for any residual in the tube; check to see if return contents have been aspirated; always have the head of the bed up at least 30 degrees; pause feeding if head of the bed needs to be lowered
- only begin oral feedings for a stroke patient if they pass the _____ evaluation
- there must be ____ supervision when giving oral foods
- the stroke patient should be placed on a _____ diet
- when beginning oral feedings, you want the environment to be ___ so the patient can focus
- when feeding a stroke patient, you’ll want to press ____ on the tongue to help with the feedings
swallowing
1:1
mechanical soft diet
quiet
down
after completing their meal, the patient should have their HOB raised for __ to ___ minutes afterwards
30 - 60
TIPS FOR PROVIDING CARE TO A POST-STROKE PATIENT
- speak ____ in a normal voice
- use _____ statements
- always ____ the client
- encourage the patient to ____ and give the patient time to _____
- give ____ instructions, try to ask ____ questions
slowly;
simple;
face;
speak; respond
one step; yes/no
NURSING INTERVENTIONS FOR IMPAIRED URINARY AND BOWEL ELIMINATION:
- the patient should be on a _____
- provide ____ to keep normal patterns
- what does the morning bowel routine consist of?
- remember with a bowel routine, you want to ___ time and give the patient ____
bowel program;
assistance
colace, senna, dulcolax, or a suppository with digital stimulation
allow time; privacy
BLADDER INTERVENTIONS FOR STROKE PATIENTS
- ____ the foley asap
- cath the patient every ___ hours if he/she cannot void
- the bladder will often resolve itself within ___ to ___ weeks after a stroke
- encourage the patient to have ____ fluid intake
remove;
4 hours;
2 - 4
adequate
what is expressive aphasia?
what is receptive aphasia?
what is global aphasia?
the patient is able to understand what is being said but struggles to speak and usually slow to respond
the patient is unable to understand spoken or written word; patient can articulate well and speak quickly but it may not always make sense
is a combination of both receptive and expressive aphasia
with expressive aphasia there is damage to the ____ lobe
with receptive aphasia there is damage to the _____ lobe
with expressive aphasia can the patient write?
with receptive aphasia can the patient write?
frontal lobe
tempo-parietal lobe
inability to write
ability to write
ALTERED BODY IMAGE DUE TO PHYSICAL/COGNITIVE DISABILITY
- you’ll want to encourage your patient to ____
- encourage _____ in self care to the extent possible for the patient
- provide _____ to interact with people going through similar experiences
expression their feelings/concerns
participation
opportunities
DISCHARGE ISSUES FOR TEACHING & SUPPORT
- when it comes to emotional status of a stroke patient, they maybe be ____ or have ____
- the patient may have ____ issues when it comes to safety
- teach the patient how they can prevent another ____
depressed; emotional outbursts
judgement issues
stroke
AUTONOMIC NERVOUS SYSTEM
sympathetic nervous system
- location: ____
- responsible for the “______”
parasympathetic nervous system
- location: ______
- responsible for the “______”
T1-L2-L3
fight or flight
brainstem and S2-S4
rest and digest
what is the etiology behind spinal cord injuries?
what are the two mechanisms of injury for spinal cord injuries?
tumors, abscesses, hematomas, osteoporosis, and loss of circulation
the primary injury is caused by things like hyperflexion/hyperextension; compression; rotation; and penetration
the secondary injury is caused by things like edema, hemorrhage, and ischemia
- tetraplegia occurs when there is damage at the ____ spine and ____
- paraplegia occurs when there is damage at the ____ and ____
- there are ____ parts within the cervical spine
- there are ___ parts within the thoracic spine
- there are ____ parts within the lumbar spine
- there are ___ parts within the sacral spine
C8; above
T1; above
8
12
5
5
__ - ___ is responsible for the sympathetic outflow which is in charge of things like ____ and ____
spinal cord T1 - L4; temperature control; blood vessels; lower limb control; and bladder, bowels, and external genitalia
- complete injury of the spinal cord means what?
- incomplete injury of the spinal cord means what?
- total loss of sensory and motor function below the level of injury
- mixed loss of sensory and motor
what are priorities of care during the acute phase of a spinal cord injury?
preserve life and function; maintain alignment; prevent complications; support the client and family’s ability to cope
another priority of care for a patient who suffers from a spinal cord injury would be to perform a ______!
physical assessment
when it comes to preserving life and function what is needed?
intubation is sometimes required to prevent shallow, ineffective respirations
stabilize the patient with a halo brace
what are some nursing care tips when it comes to a halo brace?
pin care and monitor for infection; monitor skin integrity; always have a t-shirt on under the device; know how to remove front in case of cardiac arrest; emotional support for altered body image
what are some things to avoid when providing brace care?
never turn the patient using the device; do not drive/ride a bike; do not shower, bathe in a bathtub, or use a hot tub; do not use lotions or powders under the vest
when you’re trying to maintain alignment/stabilization the patient will be given one of two braces = ____ or ____
when the patient is immobilized what kind of brace will they be given?
TLSO; SOMI
c - collars
what are some positioning techniques to help maintain alignment?
log roll; traction
what is the immediate priority of care?
what are some things we can do to prevent complications?
prevent complications
administer methylprednisolone to prevent secondary injury
METHYLPREDNISOLONE:
should be given within the first ___ to ___ hours of injury and should be continued over __ to __ hours
this medication is known to reduce the incidence of ___ and ____
increases odds of moving to a ____ motor/sensory category
3-8; 24-48
edema; ischemia
higher
SPINAL SHOCK
_____: state of areflexia below the level of injury
spinal shock can last ___ or ____ until reflex arc begins to function again
spinal shock tends to resolve on _____
what are some s/s of spinal shock?
spinal shock
hours; days
its own
loss of reflexes below the level of injury; flaccid paralysis; body temp instability; hypotension/bradycardia; hyperreflexia and muscle spasticity
NEUROGENIC SHOCK
- occurs due to loss of _____ innervation
- usually associated with __ or higher injury
- what are some s/s of neurogenic shock?
sympathetic nervous system
T6
hypotension; bradycardia; warm/dry skin due to vasodilation; and hypothermia
- with a spinal cord injury patient we are trying to prevent _____ or _____
- in order to reduce the risk of pneumonia and atelectasis we can ___ the patient, instruct them to ___ as deeply as possible; provide assistance with cough “_____”, give oxygen, and chest ____
pneumonia; atelectasis
turn; breathe; “quad cough”; physiotherapy
- when does autonomic dysreflexia occur?
what are some things that can cause autonomic dysreflexia
autonomic dysreflexia is _____ which causes the blood vessels to _____ and as a result raises ____
occurs with injuries at or above T6 after spinal shock has been resolved
overstretched/irritated bladder; constipation/impaction; pressure to skin from sitting; restrictive clothing; wrinkles in the sheets
initiated; constrict; blood pressure
what are some signs/symptoms of autonomic dysreflexia?
HTN & bradycardia; pounding headache; flushed face; red blotches on skin above level of injury; sweating; nausea; good bumps and cold skin below the level of injury
how can we treat autonomic dysreflexia?
what are some medications that would be used to treat HTN in a patient experiencing autonomic reflexia?
elevate the head of the bed; find and remove the cause (distended bowel; tight clothing; pain/pressure sores); treat the HTN, and prevent distended bowel or bladder through the use of bowel/bladder programs
nitropaste; sublingual nifedipine; hydralazine IV
with a spinal cord injury patient we also want to prevent what from occurring?
how can we prevent deep vein thrombosis?
deep vein thrombosis
ted hose; heparin/lovenox; adequate fluid intake
why does unopposed vagal stimulation occur?
unopposed vagal stimulation results in what?
what should you do if you notice your pt. is experiencing unopposed vagal stimulation
- due to loss of sympathetic input following injury above the level of T6
decreased pulse; decreased BP and postural hypotension; venous pooling in extremities
frequent vital signs; if pt. is symptomatic you will give an anticholinergic (atropine) and provide fluid replacement
what are some nursing interventions we can do to prevent orthostatic hypotension in a spinal cord injury patient?
ted hose; ace wraps; abdominal binder; and medications like midodrine
how can we prevent constipation/fecal impaction in a spinal cord injury patient?
make sure the patient is placed on a high fiber diet; high fluid intake; stool softeners; rectal stimulation; and consistent time for bowel elimination (30 minutes after eating)
- when it comes to tube feedings, they can either be ___ or ____
- what are some side effects associated with tube feedings?
continuous; intermittent
nausea; diarrhea; cramping; abdominal distention; aspiration; and sinusitis
- what is a spastic bladder?
- what is a flaccid bladder?
- a flaccid bladder can cause what?
what are some medications that can be used to treat spastic bladder?
bladder empties in response to stretch
bladder fills without emptying
overdistention with overflow incontinence
baclofen can be prescribed to decrease bladder spasticity; oxybutynin can be prescribed to suppress bladder contraction
what does bladder training look like for a spinal cord injury patient?
indwelling catheter; intermittent catheterization (every 4 hours); increase fluid intake; give medications like oxybutynin and detrol
what are some musculoskeletal issues we are trying to prevent with a spinal cord injury patient?
muscle atrophy; joint contractures; spasticity; heterotrophic ossification
PRESSURE ULCERS:
what is a stage 1 pressure ulcer?
what is a stage 2 pressure ulcer?
what is a stage 3 pressure ulcer?
what is a stage 4 pressure ulcer?
intact skin; non blanchable redness
partial thickness loss of dermis; shallow open ulcer
full thickness skin loss; subcutaneous fat may be visible
full thickness skin loss; exposed bone/tendon/or muscle; eschar may be present
with a spinal cord injury patient how can we actively save skin integrity?
turn every two hours; specialty air flow beds; pressure relieving cushions; and meticulous skin care
what are some psychosocial concerns we are worried about with a spinal cord injury patient?
what are some nursing interventions we can perform to help with alleviate some psychosocial concerns?
grief; depression; frustration; anxiety; self-esteem; and altered body image
assess coping mechanisms; give control to patient; call light system; psych consult; and setting realistic goals
RESTORING FUNCTION AND REHABILITATION:
- with a C1 - C4 spinal cord injury there is ____ rehab potential, there is ____ difficulty, and ____ of all four extremities
- with C5 - C6 the patient can hold their ____; however, they are completely ____ with ADLs, they will be able to use a _____ motorized wheelchair; they may be able to ____ themselves with self-help devices
little; respiratory; paralysis
head up; dependent; puff powered; feed
RESTORING FUNCTION AND REHABILITATION:
- with a C7 - C8 spinal cord injury the patient has some ____ and some ____ in ADLs with assistive devices
- with a C8 spinal cord injury there is ___, and hand weakness; patient can ____ from wheelchair
- with a T1 - T10 injury the patient has _____ of upper extremities; the patient is relatively ____ in ADLs, and can be ____
arm control; independence
normal arm; transfer
full control; independent; employed
DISABILITY ETIQUETTE:
- always ___ the patient before you help them
- be _____ about physical contact
- speak _____ to the person with a disability not to their caregiver/companion
ask
sensitive
directly
