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N353: Practice of Nursing II > MedSurg Mod 4: Stroke > Flashcards

MedSurg Mod 4: Stroke Flashcards

1
Q

Most strokes are ___

A

ischemic (85%)

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2
Q

What are the 2 main types of Ischemic Stroke

A

Thrombotic

Embolic

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3
Q

Embolic Stroke

A

Clump of something like a thrombus, fat, or cells move to the brain and block flow

ex: Cells can be anything from infection lodging on valves of the heart, or chunks and pieces of cellular debris, when people inject non sterile materials into their veins, etc

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4
Q

Thrombolic Stroke

A

Results from vascular sclerosis –> Narrowing of the artery

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5
Q

TIA

A

transient ischemic attack

type of thrombotic stroke

occlusion of a small artery

resolves quickly within 24 hours and with little residual deficit

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6
Q

Another term for stroke

A

CVA

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7
Q

CVA occur when …

A

blood supply to the brain is disrupted

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8
Q

___ is the primary cerebrovascular disorder and the ___ leading cause of death in the US

A

stroke; 3rd

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9
Q

Non Modifiable risk factors and patient profile for strokes

A

age (>55)

gender

ethnicity (higher in African American pop. d/t diabetes, vascular disorders, HTN risk)

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10
Q

Modifiable risk factors and patient profile for strokes

A

lifestyle issues like diet, SMOKING, alcohol, lack of physical activity

drug use - cocaine, amphetamines, OTC cough and cold drugs (SUDDEN VASOCONSTRICTION)

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11
Q

What are some lifestyle related diseases that increase stroke risk

A

HTN - #1 - risk for both ischemic and especially hemorrhagic stroke

Hyperlipidemia

Obesity

Diabetes

Periodontal Disease because gingivitis can lead to generalized body inflammation

A Fib - quivering causes blood pool stasis and clotting that can move from L ventricle –> aorta –> brain

OC - Oral contraceptives

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12
Q

How does smoking contribute to CVA

A

it has a role in blood vessel damage

it damages the endothelium lining in particular causing inflammation and increasing the chance for plaque and blood clots to form

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13
Q

A healthy lifestyle can reduce CVA risk by ___%

A

50% (to even 80%)

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14
Q

An ounce of ___ is worth a pound of cure

A

prevention

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15
Q

Transient Ischemic Attack

A

form of thrombotic stroke that occludes a very small artery or arteriole

affects only a small portion of the brain tissue meaning there usually is no permanent neurological compromise

lasts <5 minutes and symptoms must resolve within 24 hours

Despite minor issues, do not ignore this

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16
Q

Why should TIA not just be ignored for being not very serious itself?

A

because TIA is considered a forewarning for further stroke issues

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17
Q

What is the Approach to Care after a TIA

A

Same as Stroke Prevention

  1. Lifestyle - focus on modifiable areas intensively
  2. Medications - aspirin and other antiplatelet; anticoagulants if A Fib
  3. Surgical/Catheter Interventions - endarterectomy, stenting, etc
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18
Q

Carotid Endarectomy

A

Removal of plaque from the lining of carotid arteries thus reopening the blood vessels

Indicated as a surgical response to TIA or Mild CVA with 70-99% carotid blockage and significant risk for stroke

It is reserved for significant occlusion though since there is a chance to damage the vessel wall

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19
Q

Carotid Stenting

A

Less invasive surgical procedure indicated for TIA or mild CVA

Used for those with high surgical risk - must less invasive than an endarectomy

Mesh tubes are inserted in the vessel allowing trapping of clots and allowing blood to get through - the tube prevents collapse and the filter will grab and break the clots

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20
Q

What is involved in the post op nursing care for stroke surgeries and for what reason?

A

Monitor VS/neuro status (cranial nerve impairment?)

Facial Pulses (Adequate circulation?)

Assess incision for edema, hematoma, tracheal deviation (Airway compromise?; Neck edema –> tracheal deviation –> airway obstruction?)

Elevate HOB and position off operative side (promote drainage and wound visibility)

Notify MD if VS are not within parameters

Worry about cranial nerves

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21
Q

Warning signs and symptoms of CVA`

A

trouble walking

trouble speaking and understanding

paralysis or numbness of the face, arm, or leg

trouble with seeing in one or both eyes

HA

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22
Q

FAST`

A

signs of stroke

Face - does it look uneven

Arm - does one arm drift down

Speech - does their speech sound strange

Time - if you notice F A or S then call 911

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23
Q

What are the human responses to the acute phase of CVA

A

change in LOC or responsiveness

presence or absence of voluntary or involuntary movements

change in quality/rates of pulse and respiration

change in ability to speak

presence of bleeding

vital signs / O2 saturation

visual changes

abnormal movements that may mimic a seizure even

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24
Q

What are the human responses to the post acute phase for CVA

A

mental status changes - judgment and behavior in general changed

loss of motor control – uni or bilateral

swallowing ability impairment - do not feed until evaluated

self care compromises

sensation and perception changes

changes in nutritional and hydration status

skin - because of immobility

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25
Q

S/S of CVA

A

RELATIVELY INDEPENDENT OF CAUSE

It depends on the size of the lesion, amount of pre existing collateral blood flow, and the location of the lesion (is it a lobe of the brain or an entire hemisphere?)

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26
Q

Frontal Lobe

A

movement and personality!!!

motor area for speech, emotional behavior and complex intellectual abilities

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27
Q

Parietal Lobe

A

Sensations!!!

pain, cold, pressure, size, shape, texture, location and intensity of stimuli, awareness of body parts

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28
Q

Temporal Lobe

A

Senses!

hearing, taste, smell, interpretations of sound

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29
Q

Occipital

A

Vision!

visual stimuli

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30
Q

Do s/s of stroke depend on whether it is ischemic or hemorrhagic?

A

no it depends on the size of the lesion, how much is affected, and what parts of the brain is blocked off

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31
Q

Hemiplegia

A

Hemi - Half

Plegia - paralysis

Cannot move half the body

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32
Q

Hemiparesis

A

paresis - weakness

Half weak but it can move still

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33
Q

Dysarthria

A

difficulty expressing language due to issues neurologically which effect the muscles of the jaw, tongue, etc

trouble with speech

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34
Q

Aphasia

A

“without understanding”

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35
Q

Expressive Aphasia

A

trouble expressing oneself

speaking non sense but it makes sense in their head

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36
Q

Receptive Aphasia

A

cannot understand the incoming words

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37
Q

Global Aphasia

A

elements of both expressive and receptive aphasia

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38
Q

Hemianopsia

A

loss of vision in half of the visual field

ex: cannot see out the right side of both eyes

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39
Q

What may damage to the left hemisphere look like

A

paralysis and weakness on the Right side

Right visual field deficit

Aphasia - expressive, receptive, or global

Altered intellectual ability

Slow cautious behavior

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40
Q

What may damage to the right hemisphere look like

A

paralysis and weakness on the left side

left visual field deficit

spatial perceptual deficits

increased distractibility

impulsive behavior

poor judgment

lack of awareness of deficits

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41
Q

Why do we say left hemisphere CVA patients are LEFT BEHIND

A

because these lesions tend to cause more slow, cautious, and behaviorally slow to perform s/s

42
Q

Why do we say right hemisphere CVA patients are ALWAYS RIGHT

A

because they are distractible, have spatial perceptual issues, and are unaware of their deficits so they always feel like they are right without issue

43
Q

What is the first test done if stroke s/s appear

A

CT Scan

44
Q

CT Scan for CVA

A

Done with or without contrast

Details tissue and bone images

Can detect hemorrhage, tumor, fracture, abscesses hydrocephalus, edema, ventricular or vascular anomalies

45
Q

The standard of care for CVA CT scans means it must be done within what time period

A

within 30 minutes of a suspected stroke

46
Q

Cerebral Angiogram

A

Angio = Blood vessels ; Gram = picture

Used to assess vasculature in the brain

A contrast dye is injected into an artery and a series of images is obtained from perfusion through the entire brain

a blockage will be seen as an area without vessels

47
Q

What 2 things are required prior to a cerebral angiogram?

A
  1. Written consent
  2. NPO prior to test
48
Q

What is preferred, cerebral angiogram or CT for CVA patients?

A

CT Scan

49
Q

What are some other diagnostic procedures that can be done for CVA/neurological issues

A

lumbar puncture

CT scan

PET scan

MRI

Angiography

EEG

50
Q

When is a lumbar puncture done

A

if there is suspicion something is wrong with the CSF

51
Q

When is a PET done and why?

A

It is more specific but it can give an idea of metabolic activity in regions of the brain including blood flow and other metabolic activities

52
Q

Why use an MRI

A

it is more detailed than a CT - but it may not be needed for a stroke assessment

it can show size and location of a lesion

53
Q

Why use an EEG

A

more so for seizure activity not so much stroke

assesses localized damage

so if local damage is affecting electric signals this may be done

54
Q

What diagnostic test always supercedes others for CVA?

A

CT Scan looking for edema, lesions, and structure

55
Q

What are the goals of acute medical care of a CVA patient

A

prevent/minimize the risk of re-bleeding OR remove blood clot AND re-vascularize affected brain tissue

assess initial injury

prevent and treat complications

56
Q

What sort of complications can occur from a CVA that we must monitor for

A

seizures

bleeding

bradycardia

respiratory compromise

57
Q

What sort of ways can we manage acute medical care for a CVA patient

A

sedation

reduce intracranial edema and pressure

intubation to preserve the airway

surgical intervention if indicated

t=PA administration

clot retrieval

58
Q

Why do we sedate CVA patients

A

to lower the metabolic demand of the brain

59
Q

Why do we worry about respiratory compromise in CVA

A

because if the respiratory centers were affected in the brain if can have dire impacts

60
Q

In what ways do we reduce intracranial edema and pressure for CVA

A

osmotic diuretics

maintain CO2 range of 30-35

position to avoid hypoxia

elevate the HOB

61
Q

Why give osmotic diuretics to a CVA patient

A

because it can rid of extra fluid in the brain that is contributing to pressure

62
Q

Why is it important to manage CO2 levels between 30-35 in CVA patients

A

because if the brain is sensing there is less O2, it will naturally attempt to compensate via vasodilation which will bring blood flow in while increasing pressure

63
Q

What is the indication for surgical intervention with a CVA

A
  1. Hematoma exceeding 3 centimeters

AND

  1. Glasgow Come Scale score decreases

may need to surgically remove clot to fix this

64
Q

What is a classic thrombolytic agent the body makes that is also given to break up clots

A

t-PA

65
Q

t-PA - Tissue Plasminogen Activator

A

Thrombolytic agent that dissolves the BLOOD clot - not other clots like fat or cells

Given via IV within 3 hours of symptom onset

Requires accurate identification of CVA pathology

66
Q

What is the window of opportunity for t-PA

A

within 3 hours (to 6) of the onset of symptoms

Risk though is that revascularizing necrotic tissue can increase the risk of cerebral edema and hemorrhage so we give early to minimize dead cell perfusion

67
Q

Why is it so important to know CVA pathology before giving t-PA?

A

It should only be given for ischemic strokes (with blood clots) and not hemorrhagic strokes

stroke scale can determine severity as well to allow us to know direness of the situation

68
Q

What are some contraindications for giving t-PA

A

recent trauma

recent surgery

cancer

CVA

GI/GU Bleed

INR > 1/7

BP >185/110

This is all due to risk of causing vessels to burst due to perfusion occurring from clot breakdown

69
Q

Before giving t-PA do a …

A

CT scan

70
Q

Once admitted to the ICU/CCU and given t-PA, what must be done?

A

Frequent monitoring of VS/neuro status (Q15 min to start)

Continuous cardiac monitoring

serial labs

serial CT scans

seizure precautions

71
Q

Why do we not give t-PA after CPR

A

because some ribs may be broken and there is bleeding occurring and we do not want continued bleeding after

72
Q

What are some Nursing Interventions after t-PA is given

A

Monitor all invasive lines for bleeding - IV, catheter, NG tube etc - anything we put in and can bleed

Monitor all output for signs of bleeding

Delay any invasive treatment for 24 hours (injections, lab draws, IV restarts)

Monitor for s/s of intracranial bleeding like HA, LOC change, loss of function, etc

monitor VS and labs

monitor medications for interactions that can cause bleeding and prevent clotting

73
Q

____ is something you should not give to someone on t-PA

A

aspirin

74
Q

Clot Retrieval

A

Approach for ischemic CVA where a micro catheter is guided beyond a thrombus, proximal loops are deployed through the thrombus, and a balloon is inflated to prevent blood flow while the thrombus is retracted into a catheter with aspiration

Basically a catheter will vac suction the clot out of the blood stream

Fast. no bleeding problems or med issues

75
Q

Nursing Interventions after Clot Retrieval

A

t-PA interventions AND…

Keep flat for 4-6 hours to prevent dislodging of a clot at the femoral access site

monitor pulse distal to the access site (pulse, movement, temperature)

76
Q

The access site for a clot retrieval is ___, so we should watch for pulses in the ___

A

femoral; feet

77
Q

How to prevent CVA

A

diet, exercise, and attention to periodontal disease

carotid endarectomy

anticoagulant therapy (w/ something like A Fib)

antiplatelet therapy like aspirin, Plavix, and others

“Statins”

antihypertensive medications (prevent hemorrhagic stroke and long term HTN damage to vessels)

Clipping of Aneurysm

78
Q

Purpose of Statins

A

often thought regarding cholesterol plaque in the heart but it also prevents plaque in the brain vessels (and other peripheral vessels) too - and vessels are never isolated from each other throughout the body so this can be beneficial at preventing an embolus

79
Q

Aneurysm

A

When a person has weakness in the vessel wall and blood flows into there it makes the vessel bulge like a balloon and if it bursts it becomes a hemorrhage

80
Q

Aneurysm Clipping

A

a procedure where a clip is placed at the base of an aneurysm vessels so blood continues to go through the vessel normally instead of getting caught up in the out pouch

81
Q

Aneurysms are a source for ___ stroke

A

hemorrhagic

82
Q

Who tends to have aneurysms?

A

No one in particular we know of - even younger people get them

Sometimes they are found incidentally as we cannot do angiograms and CT scans for everyone

83
Q

Aneurysm Coiling

A

a procedure where an aneurysm is spotted as a large black balloon looking out pouch on CT scan so the surgeon will fill the aneurysm with soft metals like platinum

It is a silly string like metal material that goes into the out pouch and prevents blood from going in because it is full - so no blood going in now causes a clear and non dark area on CT scan

clipping alternative

84
Q

If a man’s left side has something wrong with it and is drooping….

A

then there must be a right hemisphere problem

85
Q

Garbled speech means ___

A

dysarthria

86
Q

Glasgow Coma Scale

A

a scale for neurological checks that has some issues but is a great quick screening tool (used in other areas while more intensive neuro settings have better scales)

Has 3 Areas: Eyes, Verbal, Motor with Eyes being scored 1 to 4, Verbal 1 to 5, and Motor 1 to 6

Higher scores mean more function while 1-2 means no function at all

87
Q

What are some major considerations to make when a CVA patient is recovering

A

potential for aspiration

Aphasia - expressive, receptive, global

Coping

Dysphagia - speech therapy and pneumonia potential

Mobility - PT

enhancing self care - occupational therapy

sensory or cognitive impairment

bowel and bladder control - and retraining

skin care

88
Q

Dysphagia and CVA

A

one must consider if the patient can eat and swallow safely

89
Q

What is one of the first complications considered by the CVA patient

A

mobility issues

90
Q

Ways to improve Mobility for the CVA pt

A

encourage pt to exercise unaffected side

establish a regular exercise routine

muscle exercises recommended by PT

assist the patient OOB ASAP; assess balance; move slowly

91
Q

Functional Independence Measure (FIM)

A

instrument which provides information about current mobility, social, and cognitive function

It is used to evaluate a person holistically and let you know how independent and functional they are on their own

May indicate if they need intensive or gentle rehabilitation and where a person goes and what insurance coverage they get via the score

92
Q

What is the importance of the wall suction unit for CVA patients

A

The CVA patient is at high risk for aspiration so this can allow suctioning to prevent issues of aspiration

The color determines how high the pressure is of suction but we usually do not leave green as high pressure damages mucosa

Yellow and slightly higher may be ok for sticky secretions but orange and red are too high for mucous secretion normally

93
Q

What is the importance of the suction canister for CVA patients

A

it attaches to the bottom of the wall suction unit via small tubing and the long tubing has a suction catheter which actually does the suctioning and goes into the patient

the material will enter the canister and when you swing it the cap will cap off and it can be disposed of

94
Q

What is the importance of the suction catheter for CVA patients

A

it connects to the blue port of the long tubing of the suction canister

it is soft and can suction the mouth, airway in the lungs, and the nose

if there is aspiration, trouble swallowing or choking this will help get things out

95
Q

Yankauer Suction

A

“Tonsil Tip Suction”

A rigid plastic larger opening catheter

It can suction up the secretions in the mouth or back of the throat

96
Q

What is the issue with the Yankauer suction

A

it is rigid so it should only go as far as the back of the throat an now down into the airway like a soft catheter

suctioning beyond the back of the throat can damage tissue in the airways

97
Q

Issue with FAST

A

It can miss posterior circulation issues involving the vertebrobasilar arterial system

Strokes from this area have an 85% mortality rate or higher

98
Q

BE-FAST

A

A newer updated version of fast that can detect the posterior circulation strokes FAST cannot

99
Q

What does BE FAST stand for

A

Balance (Are they suddenly losing balance?)
Eyes (loss of vision in any eye?)

Face (drooping? uneven?)
Arms (Is one weak or numb?)
Speech (Slurred? confused?)
Time (Call 911!)

100
Q

What are the losses seen for BEFAST like?

A

they are sudden losses NOT gradual ones

N353: Practice of Nursing II (14 decks)

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