Week 5: Stroke

Question 1

What are the common manifestations of a stroke

Answer 1

Aphasia, dysphagia, headache, unilateral weakness, facial dropping, ataxia, changes in affect, vision problems, memory and judgment

Question 2

What is a “stroke alert”?

Answer 2

A protocol/quick way to quickly get resources for pt stroke intervention
Ex. rapid assessment, CT scan, priority labs

Question 3

What is the primary test used to diagnose a stroke?

Answer 3

CT scan
-Can indicate size and location, determine whether it is ischemic or hemorrhagic
-Should optimally be obtained within 25 min

Question 4

How does the type of stroke (ischemic or hemorrhagic) affect the plan of care?

Answer 4

-Ischemic stroke tx involves use of anticoagulants which are contraindicated in hemorrhagic strokes
-Hemorrhagic tx mainly involves managing BP, surgical resection of large hematomas or surgical interventions to stop bleeding and preventing vasospasm.

Question 5

What are major factors contributing to an individual’s risk for stroke?

Answer 5

-Hypertension
-Atrial fibrillation
-Hx of TIA

Question 6

Why does Hx of A fib increase risk for stroke?

Answer 6

-Due to ineffective pumping (decreased atrial kick, decreased preload), blood pools in the atria leading to thrombi formation
-Thrombi can be pumped into the cerebral circulation causing emboli

Question 7

What factors influence the manifestations of a stroke?

Answer 7

-*Area/side of brain affected (most influential)
-Speed of one of stroke
-Amount of brain tissue affect
-Type of stroke

Question 8

What is stroke pt positioning?

Answer 8

-HOB usually 30 degrees
-Position head to 1 side to prevent aspiration
-Support weak side, have pt lay on side that they can feel

Question 9

What are the S&S of increasing ICP?

Answer 9

blurred vision, headache, dizziness, high BP, N&V, aphasia/ataxia, changes in LOC/affect

Question 10

What is wernicke aphasia?

Answer 10

-Expressive aphasia
-Difficulty expressing thoughts pt may have sentences that include words that are irrelevent or missing words

Question 11

You receive the following orders for a pt with ischemic stroke:
1. IV normal saline 75ml/hr
2. tPa protocol
3. STAT CBC, PT/INR
4. Neurologic assessment q1h
5. Obtain pt wt
6. VS q1h
7. O2 at 2L/min nasal cannula
8. NPO until swallowing evaluation
How would you prioritize these interventions?

Answer 11

1. Maintaining a patent airway is essential to support oxygenation and cerebral perfusion, so first place pt on O2
2. Then, because the dose of the tPA is based on N.T.’s weight, obtaining an accurate weight is critical.
3. After the weight is obtained, the lab work can be performed, and the IV infusion can be started.
4. The baseline neurologic assessment and vital signs can be obtained before starting the tPA infusion.
5. Place N.T. on NPO status.

Question 12

What tasks can an RN delegate to unregulated care providers?

Answer 12

-Bathing
-Providing personal hygiene
-Collecting urine samples
-Assisting with ambulation
-Taking VS
-CBGs
*RNs cannot delegate any overarching responsibilities of the nursing process (assessment, planning, intervention, evaluation, pt teaching)
*RN must consider the pts currents stability, possible outcomes of the intervention, competency of the UHCP, and when to undelegate

Question 13

Determine the 5 contraindications for thrombolytic therapy:
a) Brain cancer
b) Acute confusion
c) Systolic BP of 150
d) Active peptic ulcer disease
e) Worsening neurologic status
f) Major surgery in the last 14 days
g) Currently on antihypertensive therapy
h) History of myocardial infarction 3 months ago
i) Experienced head trauma within the past 3 months

Answer 13

A, D, F, H, I
*systolic must be less than 185

Question 14

What are the nursing responsibilities during administration of tPA?

Question 14

What assessment finding would indicate that body is attempting to increased cerebral blood flow (due to impaired tissue perfusion)?
1. Increasing BP from baseline
2. Pupils become nonreactive
3. New onset of dysrhythmias
4. Presence of S3and S4heart sounds

Answer 14

1. increasing BP from baseline – this is an expected complication during tPA infusion which is why guidelines will include directives for controlling blood pressure
   -A number of patients experience post-CVA HTN. BP may need to be lowered to reduce the risk of hemorrhage and worsening cerebral edema.
   -However, overly aggressive lowering of the BP may compromise cerebral blood flow in the area surrounding the infarct resulting in stroke extension.

Question 15

What is arteriovenous malformation?

Answer 15

-Malformation of arteries and veins in which they are tangled and form direct connections.
-Usually form at birth or shortly after
-Increased risk for hemorrhage and thus stroke

Question 16

What is dysarthria?

Answer 16

Difficulty communicating due tue motor capacities

Question 17

What are the contraindications to tPA administration?

Question 18

What are the signs of increasing intracranial pressure?

Question 19

What are non-modifiable risk factors for stroke?

Answer 19

Age, gender (male), race, family Hx, low birth weight

Question 20

What are modifiable risk factors for strokes?

Answer 20

HTN, atrial fib, DM, smoking, hyperlipidemia/hypercholesterolemia, sedentary lifestyle/obesity, oral contraceptive use, arteriovenous malformation

Question 21

T or F
Many pts experience a rise in BP after administration of tPA

Answer 21

True
A number of patients experience post-CVA HTN. BP may need to be lowered to reduce the risk of hemorrhage and worsening cerebral edema.
However, overly aggressive lowering of the BP may compromise cerebral blood flow in the area surrounding the infarct resulting in stroke extension.

Question 22

What should the nurse include (at minimum) in their neurological assessment of the stroke pt according to the RNAO?

Answer 22

LOC, orientation, motor (strength, balance, coordination), pupils, speech/language, VS, CBG, sensation and side neglect

Question 23

What preventative treatment for secondary strokes is recommended for pts who have experienced a stroke?

Answer 23

Anticoagulant therapy to decrease risk of further emboli

Question 24

What is the time frame for administering tPA for ischemic strokes?

Answer 24

Must be given within 3-4.5 hours of onset of S&S

Question 25

What are the nursing considerations in relation to recombinant tPA administration?

Answer 25

Perform neurologic check and VS
Inspect infusion site for bleeding q15min for one hour, q30min for next 2 hours and then q1h for 24 hours
Place pt on ECG monitor
Initiate bleeding precautions, monitoring for bleeding, monitoring ptt/INR and labs
If drug is being administered peripherally in unaffected arm, keep it extremely still and straight
No administration of anticoagulants for 24 hours after tPA administration