Topic 12: Stroke

Question 1

Stroke

Answer 1

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.

Question 2

other terms for stroke

Answer 2

brain attack” or cerebrovascular accident (CVA)

Question 3

what is needed after stroke onset

Answer 3

immediate medical attention is crucial to decrease disability and the risk for death

Question 4

what is the most effective way to decrease the burden of stroke

Answer 4

prevention and teaching of risk factors

Question 5

Nonmodifiable risk factors for stroke

Answer 5

age, gender, ethnicity, race, family history

Question 6

modifiable risk factors for stroke

Answer 6

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

Question 7

Transient ischemic attach (TIA)

Answer 7

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

Question 8

Thrombotic stroke

Answer 8

occurs from injury to the blood vessel wall and formation of blood clots, lumen is then narrowed and becomes occluded

Question 9

Embolic stroke

Answer 9

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)

Question 10

Ischemic stroke

Answer 10

a type of stroke that occurs when the flow of blood to the brain is blocked
-thrombotic and embolic

Question 11

Hemorrhagic stroke

Answer 11

occurs when a blood vessel in the brain leaks or ruptures; also known as a bleed
-intracerebral and subarachnoid hemorrhage

Question 12

Intracerebral hemorrhage

Answer 12

bleed within the brain caused by a rupture of a vessel, prognosis is poor

Question 13

Subarachnoid hemorrhage

Answer 13

occurs when there is intracranial bleeding into CSF- filled space between the arachnoid and pia mater membranes

Question 14

often cause of bleeding in a hemorrhagic stroke is

Answer 14

rupture of a cerebral ANEURYSM (congenital of acquired weakness and ballooning of vessels), warning signs is if ballooning artery caused pressure to brain

Question 15

FAST warning signs for stroke

Answer 15

· Face drooping (smile uneven?)
· Arm weakness (weak, numb, drift downward?)
· Speech difficulties
· Time (critical! Call 911 and get to hospital)

Question 16

Right-brain damage clinical manifestations

Answer 16

· 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

Question 17

Left-brain damage

Answer 17

· 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

Question 18

Receptive (Wernicke’s) aphasia

Answer 18

loss of comprehension

Question 19

Expressive (Broca’s) aphasia

Answer 19

inability to produce language

Question 20

Global aphasia

Answer 20

total inability to communicate

Question 21

Mobility clinical manifestations

Answer 21

· 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

Question 22

Communication clinical manifestations

Answer 22

· Dysphagia
· Dysarthria: a problem with the muscular control of speech

Question 23

Affect clinical manifestations

Answer 23

· May have hard time controlling their emotions
· Depression
Feelings related to changes in body image and loss of function

Question 24

Common long-term disabilities

Answer 24

· Hemiparesis (partial paralysis on one side)
· Inability to walk
· Complete or partial dependence for ADLs
· Aphasia
Depression

Question 25

diagnostic studies

Answer 25

· CT!!
o It is important to get CT right away to determine between ischemic and hemorrhagic stoke
· MRI/MRI Angiography

Question 26

· Blood flow studies

Answer 26

o Cerebral angiography
o Carotid angiography
o Digital subtraction angiography
o Transcutaneous Doppler ultrasonography
o Carotid duplex scanning

Question 27

Preventative therapy (stroke prevention)

Answer 27

· 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

Question 28

what needs to be assessed for a stroke

Answer 28

· 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

Question 29

before a stroke patient eats what needs to be done

Answer 29

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

Question 30

· Position patient to prevent aspiration and atelectasis

Answer 30

o High fowlers position, preferably in a choir, for the feeding and 30 minutes afterward

Question 31

what prophylactic drugs are used for stroke

Answer 31

· Give schedules anticoagulant and antiplatelet drugs

Question 32

Constipation is a common problem after stroke, what is the best intervention

Answer 32

· fluid and fiber intake and prophylactic stool softeners
o Bowel retraining may be needed and continued into rehab phase

Question 33

a swallowing evaluation should be done within

Answer 33

the first 24 hours

Question 34

Assess gag reflex before feeding by

Answer 34

gently stimulating the back of the throat with a tongue blade

Question 35

Assess swallowing ability by

Answer 35

elevating HOB and give patient small amount of crushed ice or ice water to swallow

Question 36

assistive devices for stroke

Answer 36

Employ assistive devices to promote self-feeding (rocker knives, plate guards, nonslip pads

Question 37

Emergency stroke management

Answer 37

· 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

Question 38

Communication with patient with aphasia

Answer 38

· 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

Question 39

Carotid endarterectomy (CEA)

Answer 39

· the atheromatous lesion is removed from the carotid artery to improve blood flow

Question 40

Transluminal angioplasty

Answer 40

insertion of a balloon to open a stenosed artery in the brain and improve blood flow

Question 41

Stenting

Answer 41

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

Question 42

Ambulatory care

Answer 42

· 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

Question 43

patient may be unable to control emotions with

Answer 43

left-sided stroke

Question 44

when the stroke client is unable to control emotions…

Answer 44

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

Question 45

ischemic stroke drugs

Answer 45

· Preventative drugs
· tPA: given IV to reestablish blood flow through a blocked artery to prevent cell death

Question 46

Hemorrhagic Stroke

Answer 46

· Hypertension control (Systolic <160)
· Seizure prophylaxis
· Craniotomy to drain blood & ↓ ICP
· Clip aneurysm
· Coil aneurysm
· Ca++ Channel blocker to ↓ vasospasms: Nimodipine

Question 47

Clip aneurysm

Answer 47

a metallic clip is placed on the neck of the aneurysm to block blood flow and prevent rupture

Question 48

Coil aneurysm

Answer 48

a hydrogel coated platinum coil is inserted into the lumen of the aneurysm

Question 49

before administration of Nimodipine

Answer 49

o Assess BP and apical pulses before administration
If pulses <60 or SBP <90, hold med and contact provider