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Flashcards in Stroke Module Deck (37):

Major risk factors of stroke (modifiable)

Hypertension (most important; control the HTN to prevent stroke)
Metabolic syndromes (diabetes)
Heart disease (atherosclerosis)(CAD)
Heavy ETOH consumption
Poor diet
Drug abuse
Sleep apnea
Physical inactivity


What is the most significant modifiable risk factor for stroke?



Ischemic stroke

Ischemic strokes result from
Inadequate blood flow to the brain from partial or complete occlusion of an artery
80% of all strokes are ischemic strokes
Ischemic strokes can be
A. Thrombotic (arthrosclerosis)
B. Embolic (traveling blood clot)


Hemorrhagic stroke

Account for approximately 15% of all strokes
Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles
Intracerebral hemorrhage
Bleeding within the brain caused by rupture of a vessel
HYPERTENSION is the most important cause
Hemorrhage commonly occurs during periods of physical activity (sex, exercise)


Non modifiable risk factors for stroke

Genetics/family history


What is a TIA?

Transient Ischemic Attack (TIA) is a temporary focal loss of neurologic function caused by ischemia.
Most TIAs resolve within 3 hours; beyond 3 hours is a stroke
TIAs may be due to microemboli that temporarily block the blood flow
TIAs are a warning sign of progressive cerebrovascular disease


Thrombotic stroke (Ischemic)

Thrombotic stroke
Thrombosis occurs in relation to injury to a blood vessel wall and formation of a blood clot
Result of thrombosis or narrowing of the blood vessel
Most common cause of stroke
Two-thirds are associated with hypertension and diabetes mellitus
Often preceded by a TIA


Embolic stoke (Ischemic)

Embolic stroke
Occurs when an embolus lodges in and occludes a cerebral artery
Results in infarction and edema of the area supplied by the involved vessel
Second most common cause of stroke
Majority of emboli originate in the inside layer of the heart, with plaque breaking off from the endocardium and entering the circulation
Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms


MANIFESTATIONS: Intercerabral hemorrhage d/t hemorrhagic stroke

Often a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding
Neurologic deficits
Nausea and/or vomiting
Decreased levels of consciousness


Subarachnoid hemorrhage

Intracranial bleeding into cerebrospinal fluid–filled space between the arachnoid and pia mater
Commonly caused by rupture of a cerebral aneurysm
An aneurysm may be saccular or berry
Majority of aneurysms are in the circle 
of Willis
“Worst headache of one’s life”
Most frequent surgical procedure to prevent rebleeding is clipping of the aneurysm
Coiling is another procedure


Stroke Features: Thrombotic

ONSET: Gradual, in minutes to hours
LOC: Preserved
Neuro: Deficits Headache, speech, visual, confusion
Duration: Improvements over weeks to months


Stroke Features: Embolic

ONSET: Sudden
LOC: Preserved
Neuro Deficits: Paralysis, aphasia
Duration: Rapid but may be persistent if embolism is not absorbed


Stroke Features: Hemorrhagic

ONSET: Usually sudden
LOC: Stuporous, coma
Neuro Deficits: Focal deficits
Duration: Variable, permanent deficits possible


Clinical manifestations of stroke: Cognitive changes

Cognitive changes
- increased ICP, confusion

- right sided = vision/spatial, personality changes
- left sided = aphasia, decreased analytical skills


Clinical manifestations of stroke: Motor changes

Motor changes
- hemiplegia, hemiparesis
- hypotonia, flaccidity
- incontinence
- seizures, unequal pupils, facial drooping


Clinical manifestations of stroke: Sensory changes

Sensory changes

- apraxia (lack of purposeful movement)

- neglect syndrome (RCVA, client unaware of L paralysis)

- dysphagia, poor mastication


Lab & Diagnostic studies for stoke

Elevated WBC
Elevated Hgb, Hct
PT/INR (baseline)


More Lab & Diagnostic studies for stroke

Brain scan
Doppler studies
Cardiac monitoring


Nursing Care: Goals during the acute phase

Goals for collaborative care during the acute phase are
Preserving life (ABC)
Preventing further brain damage from occuring - what kind of stoke? Give TPA if under 3 hours
Reducing disability-getting the patient in terms of rehab once stabilized.


Nursing Care of the Client With TIA and CVA

Initiate aspiration precautions are key
NPO, until swallow evaluations are done
Initiate fall precautions d/t unilateral weakness
Sequential compression devices (depending on cause of stroke) (Not if stroke was DVT)
Vital signs Q 1-2 hours
Neuro checks Q 1-2 hours (GCS)
Thrombolytic meds 
- Recombinant tissue plasminogen activator (rt-PA), for those who meet criteria, within FIRST 3 HOURS)


Nursing Care of the Client With TIA and CVA (cont.)

Lipid lowering agents (preventative measures)
Intracranial pressure monitoring (ICP)
- special transducer calibration
- monitors cerebral perfusion pressure, waveforms
-Monitor for signs & symptoms of infection (i.e. ICP device insertion site)
-Elevate HOB no greater than 30 degrees
-Avoid clustering nursing interventions
-Decreased sensory stimuli i.e. noise and lighting
-IV fluids as ordered
-Approximately 5% to 7% of patients who experience a stroke will have seizures, usually within 24 hours
Phenytoin is given if seizures occur


Nursing Care: Respiratory system

Respiratory system
Management of the respiratory system is a nursing priority
Risk for atelectasis d/t weakness
get the on the IS
Risk for aspiration pneumonia - post proper signs
Risks for airway obstruction - they may pocket food, so make sure to check the inside of their cheeks.
May require endotracheal intubation and mechanical ventilation


Nursing Care: Neurologic system

Neurologic system
Monitor closely to detect changes suggesting extension of the stroke
Recovery from stroke symptoms


Nursing Care: Cardiovascular

Cardiovascular system - Key assessment area after a pt suffers from a stoke.
Goals aimed at maintaining homeostasis
Many patients with stroke have decreased cardiac reserves from the secondary diagnoses of cardiac disease
Monitoring vital signs frequently
Monitoring cardiac rhythms (a-fib?)
Calculating intake and output, noting imbalances
Regulating IV infusions
Adjusting fluid intake to the individual needs of the patient
Monitoring lung sounds for crackles and rhonchi (pulmonary congestion)
Monitoring heart sounds for murmurs or for S3 or S4 heart sounds
After stroke, patient is at risk for deep vein thrombosis
Related to immobility, loss of venous tone, and ↓ muscle pumping in leg
Most effective prevention is keeping the patient moving


Nursing Care: Musculoskeletal

Musculoskeletal system
Goal is to maintain optimal function
Accomplished by the prevention of joint contractures and muscular atrophy
In the acute phase, range-of-motion exercises and positioning are important
Paralyzed or weak side needs special attention when positioned
Trochanter roll at hip to prevent external rotation
Hand cones to prevent hand contractures
Arm supports with slings and lap boards to prevent shoulder displacement
Avoidance of pulling the patient by the arm to avoid shoulder displacement
Posterior leg splints, footboards, or 
high-topped tennis shoes to prevent foot drop
Hand splints to reduce spasticity


Nursing Care: Integumentary

Integumentary system
Susceptible to breakdown related to
Loss of sensation
Decreased circulation
Compounded by patient age, poor nutrition, dehydration, edema, and incontinence
Pressure relief by position changes, special mattresses, or wheelchair cushions
Good skin hygiene
Emollients applied to dry skin
Early mobility
Position patient on the weak or paralyzed side for only 30 minutes


Nursing Care: GI

Gastrointestinal system
Stress of illness contributes to a catabolic state that can interfere with recovery
Constipation is the most common bowel problem
Patients may be placed on stool softeners or fiber prophylactically
Physical activity promotes bowel function


Nursing Care: Urinary system

Urinary system
In the acute stage, poor bladder control results in incontinence
Efforts should be made to promote normal bladder function
Commode near the bed
Avoid the use of indwelling catheters because that is a way for infection to occur.


Nursing Care: Nutrition

Stoke patients have a high need for proper nutrition.
Nutritional needs require quick assessment and treatment
May initially receive IV infusions to maintain fluid and electrolyte balance
May require nutrition support
First feeding should be approached carefully
Test the swallowing, chewing, gag reflex, and pocketing before beginning oral feeding
Feedings must be followed by scrupulous oral hygiene to avoid thrush


Stroke Complications: Communication

Stroke Complications: Communication
Nurse’s role in meeting the psychological needs of the patient is primarily supportive
Patient is assessed for both the ability to speak and the ability to understand
Speak slowly and calmly, using simple words or sentences
Gestures may be used to support verbal cues (blinking, simple yes and no ?s)


Stroke Complications: Sensory

Blindness in same half of each visual field is a common problem after stroke
Known as homonymous hemianopsia
Other visual problems may include
Diplopia (double vision)
Loss of the corneal reflex
Ptosis (drooping eyelid)
Train the patient to scan their visual field



The nurse should get the social worker involved due to major role changes post stroke. Get the proper people involved because stroke affects the family involved


Ambulatory and home care

Ambulatory and home care
Nurses have an excellent opportunity to prepare the patient and family for discharge through
Evaluation of self-care skills


Rehabilitation goals

Rehabilitation goals are mutually set by
Other members of rehabilitation team (speech and OT)


Nursing Care Mnemonic

Adventurous Nasty Famous People
Squeeze Vampires Near Texas
Aspiration precautions
Fall Precautions
VS q 1-2
Neuro checks q 1-2
Tpa if less than 3 hours


Nursing Care Mnemonic II

Lucky Men Irritate Elephants
Confused Poodles Bite Ice Packs
Lipid lowering agents
Monitor ICP
Infections, monitor for
Elevate the HOB
Clutter, avoid
Peaceful environment
IV therapy
Phenytoin for seizures


Manifestations Mnemonic

Nasty Hitmen Need Long Headshots
Neurological defects
Loc, decreased