Beth - Week 5 - Exam 2 Flashcards
(102 cards)
1
Q
what is the normal processes for the brain?
A
- constant blood flow
- blood flow removes waste
- cerebral autoregulation
2
Q
what occurs in the event of a stroke?
A
ischemia → hypoxia and hypoglycemia (lack of O2 and nutrients) → infarct (death of cell)
3
Q
T/F we want to save the penumbra
A
YAAASSS
4
Q
what is the penumbra?
A
the area that is surrounding the dead core that is minimally being perfused
5
Q
the ability to save the penumbra depends on three things. what are they?
A
- timely return of adequate circulation
- volume of toxins released by dead cells
- degree of cerebral edema
6
Q
TEST: what are the main risk factors for stroke?
A
- atherosclerosis
- a. fib
- diabetes
- HTN
- heart disease
- hyperlipidemia
- oral contraceptives
- obesity
- prior stroke
- sedentary lifestyle
- smoking
7
Q
what are the other risk factors for stroke?
A
- age
- gender - male
- familial tendency
- African American
- TIA
- vasospasm
8
Q
what is the warning sign of a stroke?
A
TIA - transient ischemic attack
- **temporary stroke symptoms
- **must be taken seriously
9
Q
what are the sxs of a TIA?
A
confused, slurred speech, CT scan → blood in brain → seems normal in ER → red flag
10
Q
T/F: a key point of TIA is that they are a precursor to thrombotic strokes
A
TRUE
11
Q
how long can TIA s/sx last?
A
a few minutes to < 24hr
12
Q
___% of stokes are preventable
A
80
13
Q
stroke is the ____ leading cause of death in the US
A
5th
14
Q
what are the types of stroke?
A
- ischemic (87%) and hemorrhagic
15
Q
what are the two types of ischemic strokes?
A
thrombotic and embolic
16
Q
what is usually the cause of hemorrhagic strokes?
A
HTN
17
Q
TEST: what are the clinical manifestations of a right hemisphere stroke?
A
- left hemiplegia
- spatial-perceptual defects
- denial of deficits
- neglect lt. side
- euphoric/smile
- impaired sense of humor
- poor judgment
- defects in lt. visual field (Hemianopsia)
- impulsive
18
Q
T/F there is a better outcome for a right hemisphere stroke
A
TRUE
19
Q
what are the clinical manifestations of a left hemisphere stroke?
A
- right hemiplegia
- neglect rt side
- defects in rt visual field
- expressive/receptive aphasia or global aphasia (broca)
- unable to discriminate words/letters (wernicke)
- worry/depression/emotional lability
- quick anger/frustration
- intellectual impairment (cognitive)
- slow/cautious
20
Q
how to acute ischemic strokes (thrombotic) occur?
A
vessel loses elasticity (hardens) → narrowing of the vessels lumen
**NOT d/t a bleed
21
Q
what is the #1 risk factor for acute ischemic stroke (thrombotic)?
A
atherosclerosis
22
Q
how do sxs appear for acute ischemic stroke (thrombotic)?
A
- symptoms sudden or often during sleep or in morning (HTN spikes)
- OR a gradual process → collateral circulation plays a role
23
Q
how do acute ischemic strokes (embolic) occur?
A
- traveling blood clot
- tends to lodge in small vessels or bifurcations
24
Q
how to the sxs present for an acute ischemic stroke (embolic)?
A
sudden onset of symptoms - could follow by a clearing for hours to few days
25
TEST: where does the AIS (embolic) occur?
middle cerebral artery - major game changer - now capable to do treatment endovascularly - pull out clot/plaque
26
TEST: what is the number 1 cause of AIS embolic? and what meds can we use as tx?
A. Fib → control A. fib and put on blood thinner
27
how does a hemorrhagic stroke occur?
integrity of the vessel is interrupted
| - bleeding into tissue or subarachnoid space
28
for a hemorrhagic stroke, _____ immediately shows bleed
CT
29
what are the three examples of hemorrhagic stroke?
- Intracerebral bleed
- subarachnoid hemorrhage
- AVM
30
T/F hemorrhagic stroke are less common
TRUE
31
what should you do to prevent hemorrhagic stroke?
control HTN
32
what is the most often occluded artery in a stroke?
the middle cerebral artery (MCA)
33
what is the largest branch of the internal carotids?
the middle cerebral artery
34
the MCA provides blood to where?
- the frontal lobe
- lateral surface of temporal and parietal lobes
- motor and sensory
- face, throat, hand, arm
- if dominant - speech
35
A patient arrives in the ER with new symptoms of hemiparesis, sensory loss, gaze deficit and aphasia. what are these symptoms of?
consistent with MCA stroke → time is essence, call code stroke.
36
the brain requires ____ of total body's O2 and ___ of cardiac output
20; 10
37
the arterial artery of brain: where does the anterior circulation originate from?
the carotids
38
the arterial artery of the brain: where does the posterior circulation originate from?
the vertebral
39
where do the anterior circulation and the posterior circulation merge?
the circle of willis
40
what are the 4 large vessel strokes?
- carotid, vertebral (COW, ACA, MCA, PCA)
- ischemic stroke (occlusion d/t thrombus)
- ICH (hemorrhage at junctions and vessel turns)
- SAH (aneurysms form at vessel junctions and turns)
41
what are the 3 small vessel strokes ?
- ischemic stoke vessels (occlusion d/t atherosclerosis)
- ICH (hemorrhage occurs d/t amyloid fibribr (fibrous protein deposits) tumor, or vascular malformation)
- SAH (aneurysm or vascular malformation)
42
what are the major structures affected when there is a stroke in the anterior cerebral artery?
Frontal lobe
Olfactory cortex
Corpus callosum
Leg motor cortex
43
what are the anterior cerebral artery stroke symptoms?
Apathy
Conjugate eye deviation
Contralateral motor/sensory loss (Leg>arm)
44
what are the structures affected when there is a middle cerebral artery stroke?
- Speech & language
- Motor & sensory
- Gaze
- Basel ganglia
45
what are the major stroke symptoms with a middle cerebral artery stroke?
- Aphasia (dominant)
- Neglect (nondominant)
- Eye deviation or gaze preference
- Contralateral hemianopsia
- Contralateral Motor/ sensory (face/arm>leg)
46
what are the structures affected in a cerebral artery stroke?
- occipital lobe
- visual cortex
- midbrain
- thalamus
- corpus callosum
47
what are the major stroke symptoms of a cerebral artery stroke?
- contralateral loss of pain or temp (thalamus - can't ID hot or cold or even a pen on arm)
- visual field loss
48
what two diagnostics are used for a cerebral artery stroke?
- cerebral angiogram (contrast - blood flow)
| - cerebral MRA (contrast - well defined)
49
what is a hemorrhagic stroke: intracerebral bleed and what is it caused by?
- bleeding into the brain
| - caused by HTN and age (vessels older/not great integrity)
50
when do intracerebral bleed hemorrhagic strokes usually occur?
typically during an activity → muscles need blood flow
51
what are the characteristics of an arterio-venous malformation hemorrhagic stroke?
- congenital anomaly
- high pressure to low pressure
- age 10 - 40
52
T/F the assessment for arterio-venous malformation hemorrhagic stroke is similar to SAH
TRUE
53
what is a subarachnoid hemorrhagic stroke?
cerebral aneurysm leak or burst
54
why is it called a subarachnoid hemorrage?
because the bleeding occurs in the sub arachnoid space.
55
what is the most common sxs of a SAH stroke?
"worst HA i have ever had"
56
what are the test finds for a SAH stroke?
- blood on LP
| - CT/MRI shows aneurysm on angiogram - berry aneurysm
57
what are the symptoms of a ruptured aneurysm?
- Sudden, extremely severe headache
- Nausea and vomiting
- Stiff neck
- Blurred or double vision
- Sensitivity to light
- Seizure
- A drooping eyelid
- Loss of consciousness
- Confusion
58
T/F ruptured aneurysms are hard to tx and often confused with meningitis
TRUE
59
what are the sxs of a UNruptured aneurysm?
- Pain above and behind one eye
- A dilated pupil
- Change in vision or double vision
- Numbness of one side of the face
60
what is the surgical intervention to manage arterio-venous malformation?
lilgation
61
what are the complications for an AVM pre/post surgery
- vasospasm
| - rebleed
62
what is the role of health care providers in the event of a stroke?
- ID with FAST assessment if pt has stroke symptoms
| - activate the code stroke system
63
what is the code stroke system?
- Complete assessment (NIH scale)
- Obtain Blood sugar
- Obtain CT scan
- IV start with Blood draw
- Follow the Stroke Protocol
- Frequently re-assess patient (any change report immediately; can figure out what artery → IR → tx)
64
what does FAST stand for ?
Face, Arms, Speech, Time
65
what we assessing for Face?
- does one side droop when asked to smile?
66
what are we assessing for Arms?
- does one arm drift downward when asked to raise arms
67
what are we assessing for Speech?
- speech slurred or strange when stating a simple phrase
68
what are we assessing for Time?
if you observe any signs, call 911
69
what are the nursing interventions when we see someone who has sxs of a stroke?
- Call a CODE Stroke
- Stay with the patient
- Communicate last known well time
- Complete Stroke scale assessment
- Do a Fingerstick
- Plan for CT scan
- Document
- Check IV site/status
- Lab draw for CMP, Pt, Ptt-INR (love but don't need)
- Swallow evaluation
- Prepare for Medical
70
the treatment window for a stroke is ______ from the ONSET of symptoms
3 - 4.5
71
what is the first diagnostic test for a stroke?
CT non-contrast (within 25 min) to r/o bleed
72
what is the tx after bleed is r/o?
TPA
73
how is "altered tissue perfusion" different for ischemic vs hemorrhage?
ichemic → going to be able to give meds → stop/break up clot
| hemorrhagic → bleed more with drugs → death
74
If it is a ischemic stroke, we would then screen for ____
TPA - total time: onset < 3-24hr
75
after screening for tPA we would then do what?
begin fibrionlytic tx within 60 min and up to 24 hrs and transfer to ICU
76
what are the meds for fibrinolytic tx?
streptokinase or tPA (alteplase)
77
what are the characteristics for giving fibrinolytic tx?
- IF diagnosed as an ischemic stroke only!
- IF within 3-24hours of onset of neuro symptoms
- IF age 18 or older
- IF other issues were ruled out….
78
T/F the initial CT scan might be negative for an ischemic stroke
TRUE
79
what are the nursing implications for someone on fibrinolytic tx after a stroke?
• Assess/Reassess neuro Q2-4h
• Monitor cardiac rhythm (greater risk of a fib)
• Antiplatelets/anticoagulants (immediate or 24 hrs
after tPA) (if ischemic stroke)
• Discharge Meds—might be anticoags and/or statins
80
what is the gold standard med for a non hemorrhagic stroke?
tPA - dissolves clot - given 24 hrs after onset of symptoms
81
what procedure is used with tPA?
endovascular procedures - defuse 3/rapid
82
what are the invasive interventions to treat ischemic strokes?
```
Corkscrew type-Merci, Solitaire, & Trevo
Penumbra Systems
Snarelike devices
EKOS Utz devices
(acoustic pressure)
```
83
what are the three methods of tx interventions/surgical management for SAH?
- to prevent re-bleeding
- endovascular therapy or coiling
- surgical aneurysm clipping
84
what is the one non surgical tx for SAH?
medical tx
85
TEST: what are the complications of SAH?
- Re-bleed
- Hydrocephalus
- Seizure
- Vasospasm (diagnosed with Transcrainal doppler- TCD)
- breakdown of blood
- influx of calcium
- MI, new aneurysm rupture, cerebral edema
- Brain infarction
86
what are the NI for managment of cerebral vasospasm?
- Balloon angioplasty
- Nimodipine 60mg q 4hr for 21 days
*** HHH Therapy – (Hypervolemia, HTN, Hemodilution) – controversial
- IVF +/- Inotropes/vasopressors
- CVP 10-12mmHg
- SBP 160-200 if aneurysm clipped and 120-150 if
unclipped
- IR-Selective intra-arterial verapamil, papaverine, or nitroprusside or Angioplasty can also be used
87
what are the interventions for hypertensive post stroke patients?
* parameters?
* high B/P needed for perfusion?
* is there a cause for the HTN? vomiting?
* too high = rebleed
88
what are the interventions for hypotensive post stroke patients?
* too low B/P = poor or slow perfusion
| * Ischemia Infarction!!
89
T/F ALWAYS clarify with MD about parameters
TRUE
90
what are the nursing precautions/interventions for stroke in general?
```
• Calm/Quiet
• Pain meds
• Nausea
• Dim lights
• frequent assessment
• ↓ stimulation; quiet
• ↑ HOB
• Limit Val-Salva
• SBP maintained 120-150
- Fibrinolytic therapy patients treat BP>185/110
- Labetalol or Nicardipine
- Watch for DI or SIADH
- Keep Normothermic
- I & O balance
- Regulate Glucose between 120-200
```
91
what are we looking for during frequent assessment?
- Note Neuro changes
- Note Blood pressure changes
- Ensure stool softener is given
- Avoid straining with voiding
92
nursing must monitor what three things?
- seizures
- electrolytes/coags (Na, K, Cl, Pt-INR, PTT, plts)
- DVT (PAS stocking, lovenox after 24hrs LWM heparin/subq heparin)
93
what is important to teach patient and family regarding stroke patients?
- Prevention of complications
- Mobility (falls, around house)
- Communication (speech therapy)
- Swallow Precautions (dysphagia)
- Sensory/Perceptual (tactile & visual)
- Self Care (ADLs)
- Rehabilitation
94
what are characteristics of TIA and stroke preventions?
- Education:
- Diet (Low sodium + Low fat)
- Weight control
- Blood Pressure control
- Exercise routine
- No smoking
95
what are interventions for patients with receptive/expressive/global aphasia?
* Eye contact
* Speak normal-verbal cues
* Minimal correction
* Don't answer for pt.
* Acknowledge frustration
96
what are the interventions for patients with dysphasia/dysarthria?
* Call light?
* Elicit "yes" or "no" responses
* Watch for non-verbal cues
* Check accuracy of "yes" + "no" answers
* Pictures or word board
97
Nursing MUST address mobility and skin integrity. what are the interventions?
```
• Hemiplegia vs. Hemiparesis
• Support affected joint
• Passive ROM
• Turn Q2h
• Alignment of extremities
• Prevent contractures in hands/ankles—keep in a
neutral position--Remove splints Q2h—check skin
• Keep skin clean
```
98
Nursing MUST review dysphagia screening. what are the implications/interventions?
* Aspiration precautions
* High fowlers
* 1 tsp food on unaffected side
* Pt. to sweep own mouth
* Check affected side for pocketing
* Thickeners
* Cold foods
* No straws
* Assess breath sounds after meals
* Allow for extra time to eat
* No milk
* Reinforce keeping chin tucked with swallow
* REQUEST a Swallow Evaluation
99
terms to remember sensory/perceptual?
```
Homonymous
Hemianopsia
Apraxia
Agnosia
Kinesthesia
Paresthesia
Proprioception deficit
• Scan entire room
• unilateral neglect
• Have the patient look at the Clock/Calendar
```
100
Nursing must assess/intervene for neglect. what are the interventions?
* Unilateral Neglect:
* Use cues cards/mirror
* Approach patient on unaffected side (ACUTE phase)
* Give care on affected side (REHAB phase)
* Put call light on unaffected side
* Protect the affected extremity
101
nursing must assess for self care needs. what are the interventions?
```
• Set realistic goals— patient/family
• Reinforce O.T.
• Clocks
• Simple
commands/Praise/Feedback
• Use demonstration
• Foster independence
• Use of devices
• Guide patients hands
```
102
nursing must now rehab phase.. what are the characteristics?
Assessment of Patients
- Ability to perform ADLs, meals, Mobility, continence
- Swallow
- Nutritional support
- Safety level?
- Ability to communicate
- Affect
- Cope
- Physical endurance— can they perform therapy for 3 hrs/day?
- Safety level--which hemisphere stroke is more at risk?
- Home environment—Safe?
- Family circumstances—support system
- Expectations—Set realistic goals
- Ability to learn—can the pt. relearn
