Stroke PP&NP CA

Question 1

What are the three components of the Glasgow Coma Scale?

Answer 1

Eye opening response, Verbal response, Motor response

Question 2

What are the components of Conscious Level Charting (CLC)?

Answer 2

1. GCS
2. Vital signs
3. Pupillary response
4. Limb motor assessment

Question 3

You are assessing the motor component of a patient’s GCS. They are unable to obey commands but bend their elbow when their finger nail bed is stimulated. What do you do next?

a. Record ‘Normal Flexion’
b. Apply supraorbital notch pressure
c. Apply a trapezius Pinch

Answer 3

C is correct. If a patient bends their elbow when the finger is stimulated, the next step in assessing the motor response is to test if they can localise to a trapezius pinch.

Question 4

A patient reacts to supraorbital pressure by moving their hand up to his face. How would you record this response?

a. Normal Flexion
b. Extension
c. Localises

Answer 4

C is correct. If a patient brings their hand up above their clavicle in response to either trapezius pinch or supra-orbital notch pressure the rating is Localising.

Question 5

Normal flexion, where a patients elbow bends and their arm moves rapidly away from their body and from a stimulus, is given what number in the Glasgow Coma Scale?

a. Motor 2
b. Motor 4
c. Motor 1

Answer 5

B is correct Normal flexion (Withdraws from pain) is allocated a number of Motor 4.

Question 6

If your patient’s Glasgow Coma Scale was E2, V3, M5, how would you interpret this?

a. The patient’s eyes open to sound, they are orientated are able to obey commands

b. The patient’s eyes open to pressure, they can utter some words but do not form sentences, and they are able to localise to trapezius pinch.

c. The patient’s eyes open spontaneously; they are orientated and able to obey commands

Answer 6

B is correct.

E2: Eyes open to pain
V3: Inappropriate response, words discernible
M5: Purposeful movement to painful stimuli

Question 7

In which of these scenarios of assessment of the motor component of the Glasgow Coma Scale is the best response on the patient’s right-hand side?

a. R arm localises, L arm flexing
b. R arm no response, L arm extension
c. R arm localises, L arm obeys commands

Answer 7

A is correct. Localising represents less impairment than flexion so the response on the right side is the better.

Question 8

What GCS score indicates a minor brain injury?

Answer 8

13-15 points

Question 9

What GCS score indicates a moderate brain injury?

Answer 9

9-12 points

Question 10

What GCS score indicates a severe brain injury?

Answer 10

3-8 points

Question 11

What vital signs to assess during CLC?

Answer 11

HR, PR, RR, Temp, SpO2

(to detect S&S of increased ICP and any presence of infection– temp)

Question 12

How to assess pupillary response?

Answer 12

How to assess:
1. Assess size of each pupil before shining light (both equal in size).

2. Shine pentorch from outer cantus into inner cantus
3. Indicate pupil size and reaction to light (brisk/sluggish/absent), (equal/unequal)
   **Document “NT” if patient’s eyes cannot be opened due to swelling or surgery

Question 13

How to interpret pupillary response?

Answer 13

1. Unequal pupils
   Could indicate increased ICP on one side, possibly from brain swelling or a hemorrhage
2. Pinpoint pupils (constricted)
   Could be due to damage to the pons (part of the brainstem), possibly due to ischemia from a stroke (could also be due to opioid overdose
3. Dilated pupils
   If dilated and non-reactive, may indicate damage to oculomotor nerve, due to increased ICP or a mass effect (hemorrhagic stroke or brain swelling), indicates severe damage or impending brain death

Question 14

What are the signs and symptoms of increased ICP?

Answer 14

• Headache
• N&V
• Altered LOC
• Papilloedema (swelling of optic discs, causing blurred/double vision)
• Dilated pipils
• Cushing reflex (late signs): Bradycardia, Widening of pulse pressure, Altered breathing pattern (RR)

Question 15

When should we escalate to senior staff/doctor when evaluating outcomes of CLC?

Answer 15

Any decrease of GCS score ≥ 2 indicates possible underlying neurological deterioration.

Must be reported to Dr in charge. Refer to GCS baseline of pt, confirm if there is any deviation from previous assessment.

Question 16

What is the scoring for Eye Opening Response component in the GCS?

Answer 16

E4: Eyes open spontaneously
E3: Eyes open to verbal command
E2: Eyes open to pain (applied to nailbed/trapezius/supra-orbital)
E1: No eye opening

Question 17

What is the scoring for the Verbal Response component in the GCS?

Answer 17

E5: Oriented

E4: Confused, but able to answer questions (not able to answer correctly but still in context of qn)

E3: Inappropriate response, words discernible
(answer not even in context of qn e.g. Is it day/night time? My favourite colour is blue.)

E2: Incomprehensible sounds (e.g. grunting)

E1: No verbal response

Question 18

What does the RAPIDS tool stand for?

Answer 18

Rapid Assessment of Patients in Deteriorating Situations (comprises of ABCDE and ISBAR)

R – Recognize early signs of deterioration.
A – Assess the patient’s condition using systematic methods (A-B-C-D-E approach).
P – Prevent further deterioration by initiating immediate action.
I – Intervene with appropriate clinical care.
D – Document findings and interventions clearly.
S – Support the patient and escalate care as needed by using structured communication tools like ISBAR.

Question 19

What are the components of the ABCDE assessment?

Answer 19

Airway
Breathing
Circulation
Disability
Exposure/examine

Question 20

What to assess & actions to take for “Airway”?

Answer 20

Assess for signs of airway obstruction by look/listen/feel (stridor, choking, inability to speak)

Perform head tilt chin lift or jaw thrust (to prevent tongue from obstructing aiway)

Place patient on side (recovery position: to maintain clear airway, prevent aspiration pneumonia)

Insert artificial airway (OPA/NPA)

Perform suctioning to remove fluid and secretions

Question 21

What to assess & actions to take for “Breathing”?

Answer 21

Count RR, assess breathing pattern and effort (regularity and depth)

Assess chest movement (use of accessory muscles, symmetry)

Check for cyanosis

Measure SpO2

Auscultate chest for breath sounds

Place patient in head-up position

Initiate oxygen therapy, titrate oxygen (keep SpO2>94%, for COPD, keep SpO2 90-92%)

Question 22

What to assess & actions to take for “Circulation”?

Answer 22

Palpate peripheral pulses

Measure HR, BP, temp

Observe skin colour, feel skin temperature

Check for any bleeding

Check urine output

Measure capillary refill time

Lower patient head of bed position (Trendenlenburg position) if any signs of poor circulation, or hypovolemic shock to increase blood flow to vital organs

Establish IV access, prepare IV line with NS 0.9%

Attach a cardiac monitor, perform 12-lead ECG

Question 23

What to assess & actions to take for “Disability”?

Answer 23

Assess LOC using AVPU or GCS

Examine pupillary reaction and size (reactivity and symmetry)

BGM

Question 24

What to assess & actions to take for “Expose/examine”?

Answer 24

Expose body to examine head to toe (injuries, scars, oedema)

Examine dressing site or drainage system

Examine pain using COLDSPA/PQRST

Examine medical history on EMR

Insertion of NGT/IDC (if applicable)

Question 25

What are the types of stroke?

Answer 25

Ischemic & Hemorrhagic stroke

Question 26

What is an ischemic stroke?

Answer 26

When a blood vessel supplying blood to the brain is blocked, usually by a blood clot. This blockage reduces blood flow and oxygen to the brain, causing brain cells to die.

Question 27

Most common type of ischemic stroke

Answer 27

Large Vessel Disease , Non-embolic stroke, related to the Middle Cerebral Artery

Question 28

Which region of the brain is salvageable if perfusion is established during the early hours of an ischemic stroke?

Answer 28

Penumbra (Note: pharmacologic interventions are most likely to be most effective)

Question 29

Types of ischemic stroke

Answer 29

Thrombotic Stroke: Caused by a blood clot (thrombus), often atherosclerosis plaque, forming in one of the arteries supplying blood to the brain. Large vessel (MCA infarct), small vessel (Lacunar infarct) Embolic Stroke: Dislodge of blood clots away from the brain (caused by carotid plaque, chronic AF, atherosclerotic plaques) , which travels through the bloodstream to block a brain artery. Transient Ischemic Attack: when blood flow to a part of the brain is temporarily blocked.

Question 30

Characteristics of a TIA

Answer 30

1. Duration: TIA lasts for a few seconds to a few minutes, should recover within 24hrs. 2. Pathogenesis: Low-flow states in vascular obstruction. Small emboli which get dissolved later.

Question 31

What are some EARLY S&S of increased ICP?

Answer 31

Headache N&V Confusion, irritability and restlessness Photophobia, diplopia

Question 32

What are some LATE S&S of increased ICP?

Answer 32

Deterioration in LOC, GCS decrease Changes in pupillary size, shape and responsiveness to light Increase in systolic BP, widening PP, bradycardia and irregular RR (Cushing's triad) Decorticate and decerebrate posturing; flaccid (end stage)

Question 33

What is a hemorrhagic stroke?

Answer 33

Blood vessel inside the brain ruptures

Question 34

Types of hemorrhagic stroke

Answer 34

1. Intracerebral hemorrhage (ICH) Bleeding within the brain Occurs without warning Caused by hypertension and thrombolytic drugs (impt to STOP ASAP) 2. Subarachnoid hemorrhage (SAH) Bleeding in subarachnoid space Severe, "thunderclap" headache Can be triggered by activities Caused by aneurysm rupture

Question 35

Pathophysiology of ischemic stroke

Answer 35

1. Reduced blood flow in arteries due to thrombosis or embolism 2. Reduction in blood flow deprives cells of O2 and glucose 3. Lack of energy causes membrane dysfunction and entry of ions 4. Cytotoxic edema of cells occurs, followed by death of cells 5. Vascular changes aggravate edema

Question 36

Common signs and symptoms of stroke

Answer 36

FAST (facial weakness, arm weakness, speech problems, time; sudden onset) Sudden weakness or numbness on one side of the body Difficulty in finding words or speaking in clear sentences Sudden blurred vision or loss in sight in one or both eyes Sudden memory loss or confusion and dizziness or a sudden fall A sudden, severe headache

Question 37

What are the non-modifiable risk factors for stroke?

Answer 37

1. Gender (females more protected till menopause) 2. Age (incidence doubles every decade after 55) 3. Race (due to dietary habits) 4. Hereditary

Question 38

Modifiable risk factors for stroke

Answer 38

1. Lifestyle habits (smoking, alcohol) 2. Hypertension 3. Diabetes 4. Hyperlipidemia 5. Obesity

Question 39

Mechanism affecting stroke

Answer 39

1. Extra-cranial factors (outside brain) - Systemic blood pressure (MAP): low MAP means poor cerebral perfusion, which can cause ischemic stroke; high MAP weaken blood vessels in brain, more prone to rupture, which can cause hemorrhagic strokes - Cardiac output Low CO increases risk of ischemic stroke. AF increases risk of embolic stroke - Viscosity of blood Higher viscosity, blood flows more slowly, increases risk of ischemic stroke, increases risk of thrombosis and a subsequent embolic stroke 2. Intracranial factors - ICP Influences CPP, CPP= MAP-ICP When ICP increases, CPP decreases, increases risk of ischemic stroke, increases risk of brain herniation - Atherosclerosis Contributes to the narrowing and blockage of arteries that supply blood to the brain, increases risk of ischemic and hemorrhagic stroke - Blood vessels Aneurysm of intercranial artery or any artery in the circle of Willis

Question 40

Assessment and stabilisation of stroke patients in A&E

Answer 40

1. Assess ABC and vital siggns 2. Provide oxygen if hypoxemic 3. Obtain IV access 4. Obtain blood samples, BGM, treat if needed 5. Perform neurologic screening assessment (GCS/NIHSS) 6. Activate stroke team, order immediate brain CT scan 7. Obtain 12-lead ECG

Question 41

What are the main distinguishing features between an ischemic and hemorrhagic stroke?

Answer 41

1. Presenting features: Ischemic: Effect takes time e.g. first few mins left sided weakness, feel numb, last few mins lose grip, not able to speak (dysarthria) Whole process above takes 30-45 min Hemorrhagic: Sudden, severe headache, vomiting, seizure, weakness on one side of face/body, rapid deterioration in neuro function or LOC 2. Imaging results Early ischemic changes may not be immediately visible. Over time, areas of infarction will appear as hypodense (darker) regions. A MRI is more effective in detecting ischemia early. On CT scan, a hemorrhage will appear as a hyperdense (bright) area immediately, indicating blood. 3. Prognosis For ischemic stroke, early treatment with thrombolytics (tPA) or thrombectomy can improve outcomes significantly, lower risk of mortality. Hemorrhagic stroke generally has a worse prognosis due to the potential for brain herniation, increased ICP, and mass effect. Often requires surgical intervention. 4. Treatment Ischemic: tPA, thrombectomy Hemorrhagic: BP control, ICP management, Surgical intervention

Question 42

What are the distinguishing features between an ischemic and hemorrhagic stroke on imaging findings?

Answer 42

Ischemic Stroke: - CT scan often shows no early changes (within the first few hours of stroke onset) - Often shows as a dark patch (low density) - MRI is more sensitive for ischemia, showing areas of reduced blood flow (infarction). - CT angiography or perfusion imaging may show a blocked artery. Hemorrhagic Stroke: - Blood appears as bright white patches (high density) - MRI can also identify bleeding but is usually done later. CT is preferred initially due to its speed and ability to detect blood. - If SAH suspected but not confirmed on CT, a LP can show blood in CSF

Question 43

Symptoms of stroke

Answer 43

FAST Facial weakness Arm weakness Speech problems Time to call 999 Sudden weakness/numbness on one side of body including legs, hands or feet Difficulty finding words/speaking in clear sentences Sudden blurred vision/loss of sight in one or both eyes Sudden memory loss/confusion and dizziness/fall Sudden, severe headache: Hemorrhagic stroke "Thunderclap" headache: Subarachnoid stroke

Question 44

Principles of managing ischemic strokes

Answer 44

1. Timely recanalisation/revascularisation of the occluded artery and reperfusion of ischemic tissue (IV tPA and thrombectomy) 2. Optimise collateral flow 3. Avoid secondary brain injury

Question 45

Principles of managing haemorrhagic stroke

Answer 45

Control of MAP, ICP and CPP

Question 46

What is the formula for CPP? What is the optimal CPP?

Answer 46

CPP=MAP-ICP Keep CPP>60mmHg

Question 47

What information does an ED nurse need to gather from a suspected stroke patient during history taking?

Answer 47

AMPLE A: Allergy M: Medications P:Past history (medical and surgical) L: Last meal, last known well E: Events surrounding injury I.e. what happened

Question 48

What is the role of an ED nurse in receiving a stroke patient?

Answer 48

1. Assessments - ABC - VS (BP, HR) - BGM - Weight - GCS/NIHSS 2. Arrange for transfer to scan room (prep transport monitor, equipment, call CT scan room, arrange porter) 3. Set IV cannula, send off blood investigations 4. 12-lead ECG 5. Arrange CXR if needed

Question 49

What is the subsequent role of a stroke nurse at the ED?

Answer 49

1. Take history from patient/monitor neuro status 2. Review eligibility for tPA or/and EVT, MONITOR BP CLOSELY - KEEP BP <185/110mmHg (PRE-tPA) 3. Obtain tPA from pharmacy and dilute accordingly, administer safely MONITOR BP CLOSELY - KEEP BP <180/105mmHg (POST-tPA)

Question 50

How is IV tPA administered in HD/ASU? (APIE)

Answer 50

Assessment - dosage by weight: 0.9mg/kg (Max dose 90mg) Planning - 10% of first dose administered as IV bolus over 1 min (by Dr) - remaining 90% delivered via infusion pump over 1hr Implementation - On continuous cardiac monitoring & frequent neuro assessment - VS every 15mins for first 2 hrs, every 30mins for 6hrs and then hrly for 24hrs - Keep SBP<180 and DBP<105 Evaluation - Monitor for side effects (bleeding? in urine, stool, secretions, IV sites) - Documentation

Question 51

What is the timeframe for effective IV tPA administration?

Answer 51

IV tPA is most effective when administered within 3 to 4.5 hours after the onset of stroke symptoms Hence important to find out the LAST KNOWN WELL!

Question 52

Who is eligible for IV tPA?

Answer 52

ONLY USED FOR ISCHEMIC STROKE CASES NO FOR HAEMORRHAGIC STROKE! Other factors to consider: - No recent history of bleeding or surgery - Blood pressure should be controlled - No active bleeding disorders - No severe head trauma within the last three months - >= 18y/o Consider labs value: - Coagulation profile (INR/PT, platelet count) PT: Time it takes for blood to clot (high value means slow clotting process) INR: High means increased risk for bleeding

Question 53

What are some nursing problems to consider in acute stroke patients?

Answer 53

1. Impaired gas exchange 2. Ineffective breathing patterns 3. Anxiety 4. Difficulty swallowing dysphagia 5. Impaired speech ability (dysarthria, aphasia) 6. Impaired communication 7. Self-care deficit

Question 54

Reasons for continuous cardiac monitoring during IV tPA therapy

Answer 54

Risk of A Fib (especially in pts with history of A Fib) Risk of reperfusion arrthymias (when blood flow is suddenly restored to an area after clot dissolution)

Question 55

What is the BP range to maintain POST tPA?

Answer 55

Keep BP <180/105mmHg

Question 56

What is the BP threshold for patients with ischemic stroke?

Answer 56

for ischemic stroke patients, BP is often allowed to be higher to maintain cerebral perfusion in the ischemic penumbra, as sudden reductions in BP could worsen the stroke threshold of 220/120 mmHg is typically used, treat BP when threshold is exceeded Treat BP if pt has: ACS/heart failure/aortic dissection/hypertensive encephalopathy/acute renal failure Note: be careful when lowering BP by 15% during first 24hrs of stroke

Question 57

Post-IV tPA care (bleeding is suspected)

Answer 57

1. Stop tPA infusion 2. CT scan immediately 3. Blood workup: FBC, PT/aPTT, d-dimer, GXM, fibrinogen level 4. Administer cryoprecipitate 10 units 5. Recheck fibrinogen level 1 hr after cryoprecipitate transfusion, target fibrinogen>=1.5g/L 6. Repeat cryoprecipitate if necessary 7. Refer to neurosurgery 8. KIV refer haematology 9. Repeat CT brain in 6hrs

Question 58

Potential nursing problems post-stroke

Answer 58

1. Risk for aspiration pneumonia 2. Risk for PU r/t deficits in movement and sensation 3. Risk for fall r/t hemiplegia (muscle paralysis) 4. Disturbed body image 5. Risk for self-injury r/t seizures

Question 59

Potential post-stroke neuro and cardio complications?

Answer 59

Neuro: - Stroke progression! - Stroke recurrence Cardio: - Cardiac ischemia

Question 60

Potential post-stroke pulmonary and GI complications?

Answer 60

Pulmonary: - Pneumonia! - Pulmonary embolism! GI: - Dysphagia! - Malnutrition - GI bleed - Constipation

Question 61

Potential post-stroke genitourinary and psychological complications?

Answer 61

UTI Depression & Pain

Question 62

When the patient is lying on his/her back, the nurse should adjust the height of the EVD such that its zero mark (0cmH2O) on the EVD scale level with the: _______ (anatomical reference)

Answer 62

Tragus of ear

Question 63

When the patient is lying on his/her side, the nurse should adjust the height of the EVD such that its zero mark (0cmH2O) on the EVD scale level with the: _______ (anatomical reference)

Answer 63

mid sagittal line (between the eyebrows)

Question 64

When caring for patient with EVD, the nurse should level the HOB at ___ degrees.

Answer 64

30 degrees

Question 65

What are the characteristics of abnormal CSF?

Answer 65

* Xanthochromia discoloured – usually pale yellow, due to breakdown of RBC from previous bleeding * Slightly blood stained, moderate blood stained or heavily blood stain * Turbid (Cloudy) occurs due to presence of CNS infection e.g. meningitis. *Bright red– indication of acute haemorrhage

Question 66

Potential side effects of IV tPA

Answer 66

1. Symptomatic intracerebral hemorrhage 2. Asymptomatic intracerebral hemorrhage 3. Systemic bleeding 4. Angioedema

Question 67

Who should NOT receive tPA?

Answer 67

1. Ischemic stroke in last 3 months 2. Previous ICH 3. GI malignancy 4. Intracranial or intraspinal surgery within last 3 months 5. Persistent BP elevation (SBP>= 185 or DBP>= 110) 6. Active internal bleeding 7. Platelet <100,000/mm3 8. Current anticoagulant use with INR>1.7 9. Full dose of clexane in the last 24hrs 10. Current use of direct oral anticoagulant (DOAC) in last 48hrs

Question 68

How is BP lowered when it is above the recommended threshold after tPA administration?

Answer 68

IV labetalol (beta blocker) 10mg over 1 to 2 mins (undiluted) then 20ml NS flush Note: requires frequent monitoring after thrombolysis to keep BP within range Note: Labetalol should NOT be given for stroke pts who are not treated with tPA, unless hypertension is extreme (SBP>220 or DBP>120), this is to allow improved perfusion to infarcted area

Question 69

Indications for External Ventricular Drainage Device (EVD)

Answer 69

1. Treat hydrocephalus 2. Relieve and monitor raised ICP in SAH and ICH pts 3. Drain infected or bloodstained CSF following infection, neurosurgery 4. Administering medications such as antibiotics and thrombolytics for pts with CSF infection or significant intraventricular clot volume

Question 70

Contraindications for EVD

Answer 70

1. Receiving anticoagulation therapy or known history of coagulation problems 2. Has a scalp or brain infection

Question 71

EVD Nursing care implications/complications

Answer 71

1. Mechanical complications: Dislodgement & blockage 2. Infective complication: Ventriculitis, meningitis 3. Under drainage of CSF: Increased ICP 4. Over drainage of CSF: Subdural hematoma 5. Trauma by EVD: haemorrhage in ventricles or in brain tissue, aneurysm rupture Note: Goals of nursing care is to promote healing and prevent harm

Question 72

How is levelling of the EVD system conducted?

Answer 72

1. Position the patient with HOB 30 deg or as ordered by doctor. 2. Adjust the height of the EVD such that its zero mark (0cmH2O) on the EVD pressure scale levels with the *tragus of ear using the carpenter’s spirit level. (*When the patient is lying on one side, this anatomical reference point becomes at the mid sagittal line (between the eyebrows). 3. Adjust the collection drip chamber aligned to the desired height as ordered (e.g. 10cm above tragus of ear). *Always level transducer and drainage chamber

Question 73

When do we perform the levelling or verification of the EVD?

Answer 73

1. when taking over the care of patient 2. when patient moves or repositions 3. anytime if unsure Note: Must ensure there is no sudden raising/lowering of head of bed or patient care activites, bed control must be disabled to prevent over/under drainage

Question 74

Care of EVD

Answer 74

Ensure the EVD chamber facing the foot of bed. Check and observe at frequent intervals for the drainage tubing for patency, free from kinks, traction, and leaks. Ensure prescribed height is maintained at all times All connections of the monitoring system must be tight to maintain the integrity of the closed system. Touching any components of EVD, must be an aseptic procedure

Question 75

Checking of CFS drainage

Answer 75

1. Read meniscus at eye level 2. Ensure EVD system is OPEN to patient for drainage (NEVER CLOSE PT STOPCOCK) 3. Observe quantity and quality (colour and clarity) of CSF in drip chamber 4. Drain drip chamber hourly or as ordered (when it is 3/4 full)

Question 76

How to prevent increased/decreased intraventricular pressure which leads to over drainage of CFS?

Answer 76

1. regular bowel habits, using stool softeners as constipation may increase ICP 2. BE CAREFUL when moving patient such as sudden bed position changes, coughing or suctioning 3. Use bed lock to avoid sudden bed changes

Question 77

Transportation of patient with EVD

Answer 77

1. Maintain EVD system in an upright position, air-vent of EVD must be kept dry at all times 2. Empty drip chamber into drainage bag prior to any procedures where the EVD system has to be placed down 3. Do NOT clamp EVD during transportation 4. Turn off pt stopcock to stop drainage just prior to transferring from one area to another (e.g. bed to bed, turn on after adjusting EVD at prescribed level)

Question 78

Post op management of EVD insertion

Answer 78

1. Reduce risk of rebleeding SBP 120-140 mmHg 2. Prevent vasospasm Nimodipine 3. Prevent seizure (common complication) Phenytoin / Valproate Control ICP/BSL/Fever (Temp)