Week Eight Modules Flashcards by Jennifer Flores

stroke is the ___ leading cause of death

what are some common stroke warning signs/symptoms?

5th

sudden numbness or weakness of the face/arm/leg; sudden confusion & trouble speaking; trouble seeing or walking; and sudden severe headache with no known cause

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what is BE FAST?

what you can identify in an individual if they are experiencing a stroke

B = balance 
E = eyes (blurry vision) 
F = face (drooping) 
A = arm (weakness)
S = speech (difficulty speaking) 
T = terrible headache

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what are some non-modifiable risk factors for stroke?

as you age, your risk for stroke _____ and ____ each decade after the age of 55

strokes tend to be more common in ____, but more women ___ of a stroke

______ have twice the incidence of stroke and higher death rate from stroke than any other ethnic group

age; gender; race; and genetics

increases; doubles

men; die

african americans

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what are some modifiable risk factors for stroke?

a history of _____ is another risk factor for having a stroke

HTN; heart disease; diabetes; smoking; obesity; sleep apnea; and metabolic syndrome

TIAs (trans-ischemic attacks)

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trans-ischemic attacks are defined as a _____ of _____ dysfunction without ____ of the brain

with trans-ischemic attacks, symptoms usually last ____ than ____

TIAs are considered a warning sign of what?

a TIA is treated as a medical emergency since it can lead to an ______

transient episode; neurological; infarction

less; one hour

progressive cerebrovascular disease

ischemic stroke

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what are some s/s of increased intracranial pressure?

above ____ mmHg is considered a “wide pulse pressure”

pulse pressure increases after _____

cushing’s triad (systolic BP increases, diastolic BP decreases, and HR decreases)

irregular respirations (cheyene-stokes) and elevated temperature

the patient is experiencing a widening of pulse pressure

60 mmHg

60 years old

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is an ischemic stroke more common or is a hemorrhagic stroke more common?

what is a thrombotic stroke?

what is a hemorrhagic stroke?

ischemic

the process of clot formation that results in narrowing of the lumen which can block blood flow through the artery

a burst blood vessel that allows blood to seep into and damage brain tissues until the clotting cascade is activated

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THROMBOTIC ISCHEMIC STROKES:

occurs from ____ to a blood vessel wall
develops when ______ have become ____
s/s develop _____
thrombotic strokes are more common in patients who have ____, ____, or high _______

injury

atherosclerotic plaques; narrowed

slowly

diabetes mellitus, atherosclerosis, cholesterol

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a ______ stroke is the most common cause of stroke

thrombotic

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EMBOLIC STROKES:

occurs when an ______ (traveling clot) lodges in the _____ artery causing infarction and cerebral edema
most emboli originate from the _______
symptoms are _____ and occur_____

embolus; cerebral artery

endocardium

severe; suddenly

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what is an example of a diagnostic study that is done to check for ischemic stroke/embolic stroke?

a fatal ischemic stroke is usually seen on the ____ side of the brain

CT scan –> it’s the single most important test

right

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HEMORRHAGIC STROKE

what is the etiology?

what are some causes of hemorrhagic stroke?

bleeding within the brain caused by a ruptured blood vessel
HTN is the most common cause; other causes include aneurysms, trauma, and brain tumors

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what are some s/s of hemorrhagic stroke?

neurologic deficits; headache (pt. will say “i had the worst headache of my life”); N/V; decreased level of consciousness; HTN

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what are some different types of postures to look out for in possible seizure patients?

an involuntary flexion or extension of the arms and legs which indicates a severe brain injury; body extension indicates a more severe prognosis

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SUBARACHNOID HEMORRHAGE

what is the etiology?

what are some causes of subarachnoid hemorrhage?

what are some s/s of subarachnoid hemorrhage?

occurs when there is bleeding in the cerebral spinal fluid filled space b/w the arachnoid and pia mater
caused by rupture of an aneurysm; trauma; cocaine drug use
similar to ICH; may not have any warning signs until the aneurysm ruptures; N/V; seizures; stiff neck; cranial nerve deficits

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do neurologic manifestations differ between ischemic and hemorrhagic strokes?
manifestations of a stroke are related to the _____ of the stroke

no, they don’t differ significantly

location

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when it comes to ED point of care how long should a stroke patient wait to get from the door to the physician?

how long should it take to reach the stroke care team?

how long should it take for the stroke patient to get to their CT scan?

less than or equal to 10 minutes

less than or equal to 15 minutes

less than or equal to 25 minutes

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VOCAB WE NEED TO KNOW:

_____ = weakness

_____ = paralysis

_____ = unsteady gait

_____ = inability to form words

_____ = difficulty related to comprehension or use of language

_____ = inability to perform simple tasks or use objects

_____ = loss of ability to read

hemiparesis;

hemiplegia;

ataxia;

dysarthria;

dysphasia;

apraxia;

alexia

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SYMPTOMS AFTER A STROKE (right sided)

patient is paralyzed on the ____ side (hemiplegia)
____ sided neglect
spatial-perceptual ____
patient will ___ or ____ problems
____ performance with ____ attention span
______ judgment

left;

left

deficits

deny; minimize

rapid; short

impaired

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SYMPTOMS AFTER A STROKE (left-sided)

patient is paralyzed on the ____ side
____ speech/language aphasias
impaired __/___ discrimination
_____ performance/cautious
patient is ____ of their deficits which causes things like _____ or ____

right;

impaired;

right/left;

slow;

aware; depression or anxiety

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what is homonymous hemianopsia?

a condition which the person is only able to see from one side of the visual world after a stroke

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what are the goals of nursing care for a stroke patient?

during the acute phase: preserve life and limit further brain damage

during the rehabilitative phase:
lessen disability; obtain optimum function

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ACUTE PHASE NURSING CARE:

we are focusing on ____ and making sure there is a ____
our other goal is also working on _____ because the patient might need to be _____

circulation; pulse

breathing; intubated

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what are some nursing problems we might identify in a stroke patient?

altered cerebral tissue perfusion; self-care deficit; impaired physical mobility; impaired verbal communication; impaired urinary/bowel elimination; altered body image

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NURSING PROBLEM: ALTERED CEREBRAL TISSUE PERFUSION - with an ischemic stroke, how can we manage altered cerebral tissue perfusion? - with a hemorrhagic stroke how can we manage altered cerebral tissue perfusion?

- through BP management; hypertension is a protective mechanism (our goal is to have the BP > 160/100) - control the cerebral edema and decrease intracranial pressure through the use of medications like mannitol; hypertonic saline; sedation/pain management; avoiding extreme head and neck flexion

what consists of the inclusion criteria for altered cerebral tissue perfusion with a tPA stroke? - patient is ___ years or older - ischemic stroke with _____ deficits - time of onset less than _____ hours

- 18 - neurological - 3 - 4.5 hours

what are some examples of medications used for stroke? - ____ is used for an embolic stroke (needs to be given within a ___ to ___ hour time window) - anticoagulants: ____ and _____ - antiplatelet agents like ____ seizure control drugs like _____, _____, and neurontin

tPA; 3 - 4.5 controversial heparin; lovenox aspirin gabapentin; carbamazepine

____ is another medication used for stroke, specifically to control ____ in a hemorrhagic stroke

nimodipine; vascular spasm

GLASCOW COMA SCALE 15 maximum = _____ 13 - 14 = ____ depressed and ____ 9 - 12 = ______ and conscious 3 - 8 = ______ depressed and conscious

perfect score mildly; consciousness moderately depressed severely depressed

NIH STROKE SCALE if the patient has a score of _____ = _____ ___ - ____ = minor stroke ____ - _____ = moderate stroke ____ - _____ = moderate to severe stroke

0; no stroke 1 - 4 5 - 15 16 - 20

BRAIN STENT usually, a ____ is used to treat blockages in cerebral blood flow a balloon catheter is used to ____ the stent into an artery of the brain the balloon catheter is moved to the _____ of the artery and then inflated. the stent then expands due to ____ of the balloon

brain stent implant blocked area; inflation

CRANIAL NERVES cranial nerve II = ____ cranial nerve V = ____ cranial nerve VII = ____ cranial nerve IX = _____ cranial nerve X = ______

(optic) pupil constriction (trigeminal) chewing (facial) symmetry (glossopharyngeal) taste (hypoglossal) tongue movement

HOW TO IMPROVE/HELP WITH SELF-CARE DEFICIT PREVENT CONTRACTIONS - ______ by doing things like turning/positioning, ____ range of motion, splints, slings, and ____ - PREPARE FOR AMBULATION - work on ____ balance - watch out for _____ - work on _____ techniques

prevent contractions; active/passive; heel protectors sitting; orthostatic hypotension; transfer techniques

- what is an example of a diagnostic test we can perform to check for risk for aspiration? - _____ feeding helps to stimulate sensory awareness and salivation which can help with ____ - you'll want to collaborate with a _____ or ____ for a swallowing evaluation what would be some cues to look out for that point to risk for aspiration?

barium swallow test mouth care; swallowing neurology nurse; speech therapist facial drooping; drooling; weak/hoarse voice; uvula deviates to one side

when it comes to tube feedings with a stroke patient what are some steps we might take to prevent aspiration?

check for any residual in the tube; check to see if return contents have been aspirated; always have the head of the bed up at least 30 degrees; pause feeding if head of the bed needs to be lowered

- only begin oral feedings for a stroke patient if they pass the _____ evaluation - there must be ____ supervision when giving oral foods - the stroke patient should be placed on a _____ diet - when beginning oral feedings, you want the environment to be ___ so the patient can focus - when feeding a stroke patient, you'll want to press ____ on the tongue to help with the feedings

swallowing 1:1 mechanical soft diet quiet down

after completing their meal, the patient should have their HOB raised for __ to ___ minutes afterwards

30 - 60

TIPS FOR PROVIDING CARE TO A POST-STROKE PATIENT - speak ____ in a normal voice - use _____ statements - always ____ the client - encourage the patient to ____ and give the patient time to _____ - give ____ instructions, try to ask ____ questions

slowly; simple; face; speak; respond one step; yes/no

NURSING INTERVENTIONS FOR IMPAIRED URINARY AND BOWEL ELIMINATION: - the patient should be on a _____ - provide ____ to keep normal patterns - what does the morning bowel routine consist of? - remember with a bowel routine, you want to ___ time and give the patient ____

bowel program; assistance colace, senna, dulcolax, or a suppository with digital stimulation allow time; privacy

BLADDER INTERVENTIONS FOR STROKE PATIENTS - ____ the foley asap - cath the patient every ___ hours if he/she cannot void - the bladder will often resolve itself within ___ to ___ weeks after a stroke - encourage the patient to have ____ fluid intake

remove; 4 hours; 2 - 4 adequate

what is expressive aphasia? what is receptive aphasia? what is global aphasia?

the patient is able to understand what is being said but struggles to speak and usually slow to respond the patient is unable to understand spoken or written word; patient can articulate well and speak quickly but it may not always make sense is a combination of both receptive and expressive aphasia

with expressive aphasia there is damage to the ____ lobe with receptive aphasia there is damage to the _____ lobe with expressive aphasia can the patient write? with receptive aphasia can the patient write?

frontal lobe tempo-parietal lobe inability to write ability to write

ALTERED BODY IMAGE DUE TO PHYSICAL/COGNITIVE DISABILITY - you'll want to encourage your patient to ____ - encourage _____ in self care to the extent possible for the patient - provide _____ to interact with people going through similar experiences

expression their feelings/concerns participation opportunities

DISCHARGE ISSUES FOR TEACHING & SUPPORT - when it comes to emotional status of a stroke patient, they maybe be ____ or have ____ - the patient may have ____ issues when it comes to safety - teach the patient how they can prevent another ____

depressed; emotional outbursts judgement issues stroke

AUTONOMIC NERVOUS SYSTEM sympathetic nervous system - location: ____ - responsible for the "______" parasympathetic nervous system - location: ______ - responsible for the "______"

T1-L2-L3 fight or flight brainstem and S2-S4 rest and digest

what is the etiology behind spinal cord injuries? what are the two mechanisms of injury for spinal cord injuries?

tumors, abscesses, hematomas, osteoporosis, and loss of circulation the primary injury is caused by things like hyperflexion/hyperextension; compression; rotation; and penetration the secondary injury is caused by things like edema, hemorrhage, and ischemia

- tetraplegia occurs when there is damage at the ____ spine and ____ - paraplegia occurs when there is damage at the ____ and ____ - there are ____ parts within the cervical spine - there are ___ parts within the thoracic spine - there are ____ parts within the lumbar spine - there are ___ parts within the sacral spine

C8; above T1; above 8 12 5 5

__ - ___ is responsible for the sympathetic outflow which is in charge of things like ____ and ____

spinal cord T1 - L4; temperature control; blood vessels; lower limb control; and bladder, bowels, and external genitalia

- complete injury of the spinal cord means what? | - incomplete injury of the spinal cord means what?

- total loss of sensory and motor function below the level of injury - mixed loss of sensory and motor

what are priorities of care during the acute phase of a spinal cord injury?

preserve life and function; maintain alignment; prevent complications; support the client and family's ability to cope

another priority of care for a patient who suffers from a spinal cord injury would be to perform a ______!

physical assessment

when it comes to preserving life and function what is needed?

intubation is sometimes required to prevent shallow, ineffective respirations stabilize the patient with a halo brace

what are some nursing care tips when it comes to a halo brace?

pin care and monitor for infection; monitor skin integrity; always have a t-shirt on under the device; know how to remove front in case of cardiac arrest; emotional support for altered body image

what are some things to avoid when providing brace care?

never turn the patient using the device; do not drive/ride a bike; do not shower, bathe in a bathtub, or use a hot tub; do not use lotions or powders under the vest

when you're trying to maintain alignment/stabilization the patient will be given one of two braces = ____ or ____ when the patient is immobilized what kind of brace will they be given?

TLSO; SOMI c - collars

what are some positioning techniques to help maintain alignment?

log roll; traction

what is the immediate priority of care? what are some things we can do to prevent complications?

prevent complications administer methylprednisolone to prevent secondary injury

METHYLPREDNISOLONE: should be given within the first ___ to ___ hours of injury and should be continued over __ to __ hours this medication is known to reduce the incidence of ___ and ____ increases odds of moving to a ____ motor/sensory category

3-8; 24-48 edema; ischemia higher

SPINAL SHOCK _____: state of areflexia below the level of injury spinal shock can last ___ or ____ until reflex arc begins to function again spinal shock tends to resolve on _____ what are some s/s of spinal shock?

spinal shock hours; days its own loss of reflexes below the level of injury; flaccid paralysis; body temp instability; hypotension/bradycardia; hyperreflexia and muscle spasticity

NEUROGENIC SHOCK - occurs due to loss of _____ innervation - usually associated with __ or higher injury - what are some s/s of neurogenic shock?

sympathetic nervous system T6 hypotension; bradycardia; warm/dry skin due to vasodilation; and hypothermia

- with a spinal cord injury patient we are trying to prevent _____ or _____ - in order to reduce the risk of pneumonia and atelectasis we can ___ the patient, instruct them to ___ as deeply as possible; provide assistance with cough "_____", give oxygen, and chest ____

pneumonia; atelectasis turn; breathe; "quad cough"; physiotherapy

- when does autonomic dysreflexia occur? what are some things that can cause autonomic dysreflexia autonomic dysreflexia is _____ which causes the blood vessels to _____ and as a result raises ____

occurs with injuries at or above T6 after spinal shock has been resolved overstretched/irritated bladder; constipation/impaction; pressure to skin from sitting; restrictive clothing; wrinkles in the sheets initiated; constrict; blood pressure

what are some signs/symptoms of autonomic dysreflexia?

HTN & bradycardia; pounding headache; flushed face; red blotches on skin above level of injury; sweating; nausea; good bumps and cold skin below the level of injury

how can we treat autonomic dysreflexia? what are some medications that would be used to treat HTN in a patient experiencing autonomic reflexia?

elevate the head of the bed; find and remove the cause (distended bowel; tight clothing; pain/pressure sores); treat the HTN, and prevent distended bowel or bladder through the use of bowel/bladder programs nitropaste; sublingual nifedipine; hydralazine IV

with a spinal cord injury patient we also want to prevent what from occurring? how can we prevent deep vein thrombosis?

deep vein thrombosis ted hose; heparin/lovenox; adequate fluid intake

why does unopposed vagal stimulation occur? unopposed vagal stimulation results in what? what should you do if you notice your pt. is experiencing unopposed vagal stimulation

- due to loss of sympathetic input following injury above the level of T6 decreased pulse; decreased BP and postural hypotension; venous pooling in extremities frequent vital signs; if pt. is symptomatic you will give an anticholinergic (atropine) and provide fluid replacement

what are some nursing interventions we can do to prevent orthostatic hypotension in a spinal cord injury patient?

ted hose; ace wraps; abdominal binder; and medications like midodrine

how can we prevent constipation/fecal impaction in a spinal cord injury patient?

make sure the patient is placed on a high fiber diet; high fluid intake; stool softeners; rectal stimulation; and consistent time for bowel elimination (30 minutes after eating)

- when it comes to tube feedings, they can either be ___ or ____ - what are some side effects associated with tube feedings?

continuous; intermittent nausea; diarrhea; cramping; abdominal distention; aspiration; and sinusitis

- what is a spastic bladder? - what is a flaccid bladder? - a flaccid bladder can cause what? what are some medications that can be used to treat spastic bladder?

bladder empties in response to stretch bladder fills without emptying overdistention with overflow incontinence baclofen can be prescribed to decrease bladder spasticity; oxybutynin can be prescribed to suppress bladder contraction

what does bladder training look like for a spinal cord injury patient?

indwelling catheter; intermittent catheterization (every 4 hours); increase fluid intake; give medications like oxybutynin and detrol

what are some musculoskeletal issues we are trying to prevent with a spinal cord injury patient?

muscle atrophy; joint contractures; spasticity; heterotrophic ossification

PRESSURE ULCERS: what is a stage 1 pressure ulcer? what is a stage 2 pressure ulcer? what is a stage 3 pressure ulcer? what is a stage 4 pressure ulcer?

intact skin; non blanchable redness partial thickness loss of dermis; shallow open ulcer full thickness skin loss; subcutaneous fat may be visible full thickness skin loss; exposed bone/tendon/or muscle; eschar may be present

with a spinal cord injury patient how can we actively save skin integrity?

turn every two hours; specialty air flow beds; pressure relieving cushions; and meticulous skin care

what are some psychosocial concerns we are worried about with a spinal cord injury patient? what are some nursing interventions we can perform to help with alleviate some psychosocial concerns?

grief; depression; frustration; anxiety; self-esteem; and altered body image assess coping mechanisms; give control to patient; call light system; psych consult; and setting realistic goals

RESTORING FUNCTION AND REHABILITATION: - with a C1 - C4 spinal cord injury there is ____ rehab potential, there is ____ difficulty, and ____ of all four extremities - with C5 - C6 the patient can hold their ____; however, they are completely ____ with ADLs, they will be able to use a _____ motorized wheelchair; they may be able to ____ themselves with self-help devices

little; respiratory; paralysis head up; dependent; puff powered; feed

RESTORING FUNCTION AND REHABILITATION: - with a C7 - C8 spinal cord injury the patient has some ____ and some ____ in ADLs with assistive devices - with a C8 spinal cord injury there is ___, and hand weakness; patient can ____ from wheelchair - with a T1 - T10 injury the patient has _____ of upper extremities; the patient is relatively ____ in ADLs, and can be ____

arm control; independence normal arm; transfer full control; independent; employed

DISABILITY ETIQUETTE: - always ___ the patient before you help them - be _____ about physical contact - speak _____ to the person with a disability not to their caregiver/companion

ask sensitive directly

Week Eight Modules Flashcards

(78 cards)