CVA Flashcards
(106 cards)
1
Q
Cerebral Vascular Accident (CVA)
AKA?
A
sudden loss brain function due to loss/disruption of blood supply to parts of the brain, resulting in nervous system abnormalities
AKA: Brain Attack; Stroke
2
Q
Ischemic Stroke (Acute Ischemic Stroke; AIS)
A
caused by occlusion (blockage) of a cerebral/carotid artery that interrupts perfusion
3
Q
Most stroke are ______
A
ischemic
4
Q
What are the two types of Ischemic strokes?
A
- Thrombotic Stroke
- Embolic Stroke
5
Q
Thombotic Stroke
A
(type of ischemic stroke) caused by thrombus (clot); associated with atherosclerosis
6
Q
Embolic Stroke
A
(type of ischemic stroke) caused by embolus (disolodged clot) that breaks off and travels to cerebral arteries
7
Q
Hemorrhagic Stroke
A
vessel integrity interrupted and bleeding occurs into brain/subarachnoid space, causing an ↑ in ICP
8
Q
What are the two types of hemorrhagic strokes?
A
- Intracerebral Hemorrhage
- Subarachnoid Hemorrhage
9
Q
Intracerebral Hemorrhage
A
bleeding in the brain tissue, usually due to severe/sustained HTN
10
Q
Subarachnoid Hemorrhage
A
bleeding into subarachnoid space, usually due to ruptured aneurysm
11
Q
Aneurysm
A
abnormal ballooning of an artery
12
Q
T/F: TIA usually result in permanent brain damage/cell death
A
False, TIA usually are not permanent. They are typically precursors to ischemic strokes
13
Q
Carotid bruit
A
sound heard over an artery through a stethoscope that indicates turbulent blood flow usually due to a narrowed or partially obstructed blood vessel (indication of atherosclerosis)
14
Q
Myocardial Infarction (MI)
AKA?
A
interruption of blood flow to heart muscles
Heart Attack
15
Q
Dysarthria
A
difficulty with speech
16
Q
Extinction
A
neglect (forgets they have arm/leg)
17
Q
Decussation
A
crossing over of nerve fibers/tracts from one side of the CNS to the othe
18
Q
Aphasia
A
receptive &/or expressive - inability to comprehend or formulate language
19
Q
Agraphia
A
inability to write
20
Q
Alexia
A
inability to read
21
Q
Acalculia
A
inability to calculate
22
Q
Ataxia
A
loss of full control of body movements (disorganized movement; lack coordination)
23
Q
Apraxia
A
inabiility to perform particular, purposeful movement
24
Q
Agnosia
A
inability to interpret sensations and recognize things
25
**Dysphagia**
difficulty/discomfort swallowing
26
How long does it take for brain tissue to die without perfusion?
12 minutes
27
What are the primary causes of an ischemic/embolic stroke?
**Atherosclerotic narrowing of cerebral arteries → reduced blood flow (ischemia) → leads to low oxygen (hypoxia) and low glucose (hypoglycemia) to brain tissue → which causes cell death and stroke symptoms.**
- Atherosclerosis stenosis
-> ↓ cerebral perfusion due to hardening/thickening of blood veseels in brain that causes narrowing
- Ishchemia
- Hypoxia
- Hypoglycemia
28
What is the pathophysiological result of ischemia in the brain?
Loss of blood flow → infarction/necrosis → death of brain tissue
29
What is the #1 risk factor for hemorrhagic stroke?
Hypertension (HTN)
30
What are the primary causes of an hemorrhagic stroke?
**HTN causes cerebral aneurysm formation → aneurysm ruptures → bleeding into the brain → tissue anoxia**
- HTN
- Cerebral aneurysm
-> ↑ ICP due to bleeding in brain/subarachnoid space
- Tissue anoxia (tissue deprived of oxygen)
31
What is the pathophysiology of a hemorrhagic stroke?
Bleeding = pressure on brain tissue + loss perfusion
32
What is the cause of a thrombotic stroke?
Thrombotic plaque
(atherosclerosis)
33
What is the primary cause of an embolic stroke?
Atrial fibrillation
34
What are the causes of a hemorrhagic stroke (arterial blowout)?
Hypertension and aneurysm rupture
35
Name the risk factors that can contribute to strokes (both ischemic and hemorrhagic)
- HTN (lead risk factor for both types of) strokes
- Atherosclerosis
- Cardiovascular disease
- Valvular heart disease
- A-fib
- CAD
- High chloesterol (dyslipidemia)
- Poor lifestyle
-> Sedentary (30 minutes of exercise/day can decrease risk stroke)
-> Smoking/Alcohol/Drugs (smoking 2x ischemia; 3x subarachnoid hem)
- Poor diet
-> Obesity
-> DM
- Ethnicity
- Oral contraceptives
- TIA (precursor)
36
A patient comes into the emergency room claiming that they suddently started having the worst headache of their life. Which type of stroke is the patient most likely experiencing?
**Hemorrhagic Stroke**
(Arterial Blowout)
37
What is a TIA (transient ischemic attack)?
A temporary loss of blood flow to the brain causing neurologic dysfunction that resolves within several minutes to 24 hours
38
What are common causes of TIA?
- Exertion
- Rising from lying to standing
- Strenuous exercise
39
What are the signs and symptoms of a TIA?
- Temporary visual, motor, sensory, speech deficits
- Confusion
- Carotid bruit (can indicate atherosclerosis)
- Diminished carotid pulses
| SXS last for few minutes (usually)
40
How should TIA be treated?
- Carotid endartectomy (surgery used to remove atherosclerostic plaque build up)
- Angioplasty (wire that keeps vessel open)
- Anticoagulants
- Antiplatelet Agents (Plavix, ASA)
- Antihypertensive
- Lipid lowering agents
- Safety Precautions/Seeking Medical Aid
- Diet
| treat like unstable angina
41
T/F: TIA are reversible
True, they are reversible and lifestlye changes can occur now before the patient experiences a stroke
42
T/F: TIA are not treated like strokes
False, TIA should be treated as a stroke until it can be ruled out that it is not a stroke
43
The longer TIA symptoms last = ____ (lower/greater) risk of stroke
greater
44
TIA are usually precursors to strokes and can increase the risk of a CVA in the next _______-_______ years
2 - 5 years
45
A way to identify signs of a stroke is by using an acrynoym called **BE FAST**. Be able to describe what this stands for ?
- **Balance** – Is the person unsteady on his feet?
- **Eyes** – Have you lost vision in one or both eyes?
- **Face** – Does the person’s face look uneven?
- **Arms** – Is one arm hanging limp?
- **Speech** – Are you having trouble speaking?
- **Time** – Call 911 if you have experienced any of the above.
46
Another way to identify signs of a stroke is by using the **Suddens** method. Be able to describe what this stands for/means
- Sudden numbness or weakness of the face, arm, or leg
- Sudden confusion, trouble speaking, or understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness or loss of balance/coordination
- Sudden severe headache
47
T/F: It is okay to start assessing a patients LOC and gaining a patients history and physical when a patient is newly admitted in the ED with signs of a stroke
NOOOOO, take care of the ABCs first before performing other assessments (history, physical, LOC, NIH Stroke Scale)
48
What is the NIH Stroke Scale (NIHSS)?
assessment tool that measures the severity of a stroke in a patient and neurological status
49
What kind of CT scan is required in stroke diagnosis?
What conditions can a CT scan detect?
**MUST BE NON CONTRAST CT SCAN**
If negative, indicates it is NOT hemorrhagic
- Thrombosis
- Embolism
- Hemorrhage
- Cerebral Edema
50
CT Scans are a way to diagnosis a stroke. There are a few other ways to diagnose a stroke. Name those other ways
- **CT Scan**
- **MRI/MRA**
-> look at tissue / tissue perfusion
- **Brain Scan / Angiography**
-> ID Brain Ischemia
- **EEG**
51
What labs should be taken when attempting to diagnose a patient with a stroke?
- Clotting Factors (PT, PTT, INR)
- H/H (Hbg and Hct)
- Platelets
52
Name the three stroke damage assessment scales
- **National Institutes of Health Stroke Scale (NIHSS)**
-> tells how severe stroke is and and neurlogical status
-> determine eligibility of IV fibrinolytic (thrombolytic); greater than 25 = unable to get tPA
- **Glasgow Coma Scale**
- **Neurological Flow Sheet**
| NIHSS = scale 0 - 40; higher the number = more deficits
53
Describe: **National Institute of Health Stroke Scale (NIHSS)**
Include: Scoring, Purpose, When to Use, MISC
**Scoring**
- Score 0 - 40
-> Low score = best
-> High score = poor (more severe stroke)
**Purpose**
- Determines extent of neurologic deficits and severity of stroke
- determine eligibility for IV fibrinolytics
**When to Use**
- ASAP when pt arrives to ED
**MISC**
- Gold standard to use
54
Describe: **Glasgow Coma Scale**
Include: Scoring, Purpose
**Scoring**
- 15 = best
- 7 = coma
**Purpose**
- Monitor changes in pt LOC
**When to Use**
- x
**MISC**
- x
55
What are the cognitive effects of a Left (Brain) CVA?
- Deficient language, math, analytic thinking
-> Aphasia – receptive and/or expressive
-> Agraphia – inability to write
-> Alexia – inability to read
-> Acalculia – inability to calculate
- **Low verbal, high performance**
56
What are the cognitive effects of a Right (Brain) CVA?
- Poor judgement
- ↓ common sense
- ↓ attention span
- **High verbal, low performance**
57
What are the motor effects of a Left CVA?
Right sided weakness
58
What are the motor effects of a Right CVA?
Left sided weakness
59
60
What are the motor effects that are present in both L and R CVA?
- Hemiparesis
- Ataxia (disorganized movement)
- Apraxia (unable to perform purposeful movement)
- Dysphagia
- Incontinece
61
What sensory effects are seen in L sided CVA?
Right visual field cut
62
What sensory effects are seen in R sided CVA?
- Left visual field cut
- Spatial difficulties
-> Visual/depth perception deficits
- Neglect syndrome (negleects L side of body)
63
What sensory effects are seen in both L and R CVA?
- Visual field cuts
- ↓ pain/temp sensation
- Agnosia (cannot make sense of sensory info)
64
What language/speech deficits are seen in Left CVA?
- Receptive/Expressive aphasia
65
What language/speech deficits are seen in Right CVA?
- Language intact
- Loss of tone differentiation
66
How is memory affected in Left CVA?
Difficulty with new information
67
How is memory affected in Right CVA?
Difficulty with orientation to environment
68
How is behavior affected in Left CVA?
- Underestimate abilities (afraid/cautious)
- Frustration -> aware of deficits
- Depressed
- Pessimistic
69
How is behavior affected in Right CVA?
- Unaware of deficit = Denial
-> safety concerns, risk for injury
- Overestimate abilities (impulsive)
- Euphoric
- Disoriented
- ↓humor
70
How is behavior affected in Right and Left CVA?
Emotionally labile - unpredictable/inappropriate
71
How does rehab difficulty differ between patients with L and R sided CVA?
**L CVA**
- Better prognosis for rehab
**R CVA**
- Worst prognosis (more difficult to rehab)
72
Neglect syndrome is commonly seen in _______ CVA
Right
73
What is Homonymous Hemianopia
condition where vision is lost in the same half of the visual field in both eyes
74
If a patient has a homonymous hemianopsia, what is an important thing to educate your patient on?
teach patient to scan starting from the unaffected side to the affected side
75
A nurse is caring for a patient who has experienced a right-hemispheric stroke resulting in left-sided neglect. When performing a neurological assessment, which of the following actions should the nurse take?
**A**. Approach the patient from the left side and begin the assessment there.
**B**. Place the call light and personal items on the left side of the bed.
**C**. Begin the assessment on the right side and gradually move to the left side.
**D**. Perform all assessments from the foot of the bed to minimize confusion.
**C**. Begin the assessment on the right side and gradually move to the left side.
76
What is the normal size, shape, and reaction to light for pupils? What would a sluggish response to light indicate?
- **Size**: normal range 2-5mm
- **Shape**: normally round
- Reaction to light - should be brisk and consensual
-> Sluggish response = increase P on third cranial nerve
77
If a patient has oval pupils, what can it indicate?
If a patients pupil is fixed and dilated, what can it indicate?
- If oval, can indicate increased ICP
- If fixed and dilated, can indicate severe damage to brain
78
What are s/s of ICP
**HCL FINS**
- Headache
- Confusion
- Loss of consciousness
- Fixed pupils
- Increase BP
- Nausea/Vomitting
- Seizures
79
What can you do to relieve ICP?
Drilling holes, craniotomy
80
What are the major functional deficits for: Motor, Sensory, Memory, Speech/Language, Mood/Behavior
**Motor**:
- Flaccid, Paralysis, Spasms, Bowel/Bladder
- Dysphagia/Swallowing/Gag Reflex
- Gait/Coordination
**Sensory**:
- Vision, Hearing
- Tactile/Proprioception
- Neglect Syndrome
**Memory**:
- Short Term/PPTE
**Speech/Language**:
- Aphasia (Expressive vs. Receptive), Alexia, Agraphia, Acalculia
**Mood/Behavior**
81
**Penumbra**
area of brain tissue surrounding core of a stroke -> heading towards infarction, but not there yet
| If intervene, may be able to restore blood flow and save area
82
What is the first goal in treating an ischemic stroke?
Re-perfuse the brain tissue get CT scan ASAP
83
What medication is used to bust a clot in ischemic stroke? AKA?
How much time to you have to use that medication?
- Thrombolytic (**tPA**) - clot buster
-> **AKA**: Altepase
- Must be given with 3 hrs (AHA says you can give within 4.5 hours of onset)
84
Why do we want to keep the blood pressure somewhat high in an ischemic stroke?
What should the blood pressure goal be before giving antihypertensives in ischemic stroke?
- Keeping the blood pressure somewhat high increases cerebral blood flow to the affected area (aid in recovery and mimize further brain damage)
- SBP 140 - 150
85
What is the primary goal in treating hemorrhagic stroke?
Stop the bleeding + Plug the leak
86
What (2) should you monitor for in hemorrhagic stroke?
- Increased intracranial pressure
- Clotting times
87
What should the blood pressure goal be in hemorrhagic stroke?
Keep blood pressure moderately low — How low? < 140/90
88
What are the risk factors of giving tPA ?
- Brain Bleeds
- GI Bleeds
- Death
89
What should you monitor for when treating a patient with an ischemic stroke vs a hemorrhagic stroke?
**Ishchemic Stroke**
- Monitor ICP - watch for changes in ICP
**Hemorrhagic Stroke**
- Watch for hydrocephalus and increase ICP
90
What procedures/medications can you give to treat patients with ischemic stroke?
(Refer to chart)
**Thromboytic Therapy**
- check clotting labs first (PT, PTT, INR - Clotting factors)
**Clot Buster**
- check clotting labs first (PT, PTT, INR)
- **tPA** - adminstered peripheral IV
OR
- **Intra-arterial Thromolysis -urokinase**: intra-arterially via a catheter directy to teh site of the thrombosis (cath lab)
**Clot Retrival System - MERCI Procedure**
- Mechanical emobolism removal by threading corkscrew into clot (use Floro with contrast in cath lab)
**Carotid angioplasty with stenting**
**Carotid endartectomy** (for carotid atheroscloesis)
**Anticoagulants, Antiplatelet Agents, Anticonvulsants, Antihypertensives**
91
If you are administering tPA to a patient, what medications should you NOT given within 24 hours of the tPA adminsitration?
DO NOT give blood thinners (heparin, aspirin) within 24 hours of tPA administration
92
What are the treatment options of a hemorrhagic stroke (aneurysm) ?
- Cerebral Angioplasty / Craniotomy
- Aneurysm Clipping
-> Coil anurism and clip it to prevent from bursting
93
What are the 9 core measures for ischemic stroke patients by the Joint Comission?
- Venous thromboembolism (VTE) prophylaxis
- Thrombolytic therapy as indicated.
- Discharge with antithrombotic therapy.
- Antithrombotic therapy re-evaluated by end of hospital day 2.
- Discharge with anticoagulation therapy for atrial fibrillation/flutter.
- Discharge on statin medication (decrease cholesterol)
- IV t-pA initiated within 3 hours of last known well
- Stroke education provided and documented.
- Assessment for rehabilitation
93
For strokes that happened within the first 72 hours (acute), what are the priority interventions?
- Maintain Airway – SaO2 > 93% / give O2
- Side lying – unconscious? HOB degrees
- Suction/Ventilation
- VS/Neuro Checks
- Fluids and Electrolytes
- Seizure Precautions
-> Padded bed rails
-> Bed low
- Meds: diuretics, anticoagulants (24h after tPA), anticonvulsants, antihypertensives
94
What are the interventions for patient in the rehab phase?
**Dysphagia Precautions**:
- ✓ Gag reflex—coughing when swallowing
- ↑ HOB 30 - 45 degrees
- NPO until Swallowing evaluation
- After eval → + → may start on thickened liquids
- May need tube feeding
- Remind to swallow
- Massage throat
| Rehab phase starts day of brain attack
95
# **Intervention - Swallow Screen**
Who is qualified to conduct a swallow screen test?
What is the patient’s dietary status before the swallow screen is completed?
What position should the patient be in for a swallow screen?
What should the patient be given to swallow during the screen?
What are signs that the patient may have failed the swallow screen after swallowing?
What should happen to the larynx when the patient swallows?
What is required if the patient fails the swallow screen?
**Who is qualified to conduct a swallow screen test?**
- A specially trained RN or Speech Therapist.
**What is the patient’s dietary status before the swallow screen is completed?**
- The patient must be kept NPO (nothing by mouth) until the screen is done
**What position should the patient be in for a swallow screen?**
- Sit the patient up at 90 degrees
**What should the patient be given to swallow during the screen?**
- A spoonful of liquid
**What are signs that the patient may have failed the swallow screen after swallowing?**
- Coughing, choking, or altered voice tone
- Gurgling, dribbling, or watery eyes
**What should happen to the larynx when the patient swallows?**
- Larynx should rise
**What is required if the patient fails the swallow screen?**
- Keep the patient NPO and conduct a full Swallow Evaluation by a Speech Therapist
96
VTE phrophylaxis refers to strategies to prevent blood clots from forming in the veins, which is essential for patients with stroke. What interventions would be helpful to include in VTE prophylaxis in stroke patients?
- Active ROM (AROM) of ankles **BEST**
-> Advise to do during every commercial on TV
- Pneumatic compression stockings, boots, TEDs
97
T/F: CVA patients need blood thinners
True, CVA patients need blood thinners because CVA leads to vessel wall damange, venous stasis, and blood becomes coagulable
98
Your stroke patient hasn’t had a bowel movement in three days and strains during toileting. What nursing actions would help address this?
- Implement a laxative regimen, since straining can increase intracranial pressure (ICP)
- Assisting to commode/schedule (toileting)
99
You’re caring for a bedbound stroke patient. What are your nursing priorities to promote skin integrity?
Turn the patient frequently and perform regular skin checks
100
Why should a nurse perform oral care before eating to patients with stroke?
Cleaning the patient’s mouth to reduces aspiration risk (bc debris is removed)
101
Your stroke patient has expressive aphasia. They’re getting frustrated trying to speak. What’s your best approach?
- Be patient
- Speak slowly and clearly
- Use brief, simple instructions
- Use communication boards
102
T/F: For patients with homonymous hemianopia, you want to approach them from their affected side
FALSE, approach from unaffected visual side
103
How do you address the emotional care for patients who experienced a L CVA vs R CVA?
**L CVA**
- Support, encouragement
**R CVA**
- Protection, Prevention
104
T/F: In regards to body meachanics, you should lead with the affected side?
False, lead with the unaffected side
105
T/F: In regards to using a cane, you should use on the affected side?
False, use on unaffected side
