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55 Cards in this Set
- Front
- Back
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Name the types of stroke
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Ischemic
Hemorrhagic |
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What are the causes of ischemic stroke?
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Thrombus formation-
Lacunar Ischemic stroke |
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What is lacunar?
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thrombosis of small penetrating arteries
a fib causes |
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What are the s/s of a stroke?
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F - Sudden vision changes in one or both eyes
Sudden trouble walking, dizziness, or loss of balance A - Sudden weakness or numbness on one side of the body S - Sudden confusion, trouble speaking or understanding Sudden, severe headache (H) |
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What are the risk factors?
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>65
Male (more women die) African American Family Hx HTN Hypercholesteremia DM CV Hypercoagulopathy Tobacco OCT w/smoking menopause obesity |
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What is the difference in Transient Ischemic Stroke (TIA) and Complete ischemic stroke?
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TIA: acute that reduces blood flow and symptoms return to normal in 24hrs
Complete: disability is perm. in 2hrs |
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What are the causes of TIA?
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A Fib
CAD Large and small artery disease |
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What is the flow of circulation in the brain?
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Internal Carotid Arteries (ICA) - anterior
Vertebral Arteries (VA) - posterior Circle of Willis controls the circulation |
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What symptoms occur if theres a clot in the right hemisphere?
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Left visual field deficits
Flat or bland affect Apraxia—partial or complete inability to execute purposeful movement Left hemiplegia/hemisensory loss |
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What symptoms occur if theres a clot in the left hemisphere?
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Speech changes—expressive, receptive, global
Left lateral gaze preference Right visual field deficits Right hemiplegia/hemisensory loss |
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What is the clinical presentation if there is a clot in the brain stem?
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Hemiplegia/quadriparesis
Loss of sensory in ½ of body or all four limbs Dysarthria Dysphagia Ataxia Nausea and vomiting Cranial nerve changes |
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What is the clinical presentation if there is a clot in the carotid artery
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Opposite motor/sensory loss
Amaurosis fugax (fleeting blindness) Right—knowing where body parts are Left—speech |
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What are the interventions for hyperacute stroke?
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hyperacute (first few hrs after onset)
Reestablish flow. Consider thrombolytic therapy if onset of witnessed symptoms is within 3 hours of time patient was last well. Administer antiplatelet agents: Aspirin Ticlid® Aggrenox® Plavix® |
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What is the National Institutes of Health Stroke Scale (NIHSS)?
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a tool used to measure neurological fx
0-42 >22 = greater risk for hemorrhage |
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What is the only drug approved for ischemic stroke?
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t-PA
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What are the S/S of middle cerebral artery clot?
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Motor/sensory changes on opposite side of body
Arm weakness greater than leg weakness Same side visual changes Left—speech Right—knowing where body parts are |
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What are the s/s of posterior cerebral artery clot?
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Opposite-side sensory loss
Same-side vision loss Left—communication Right—knowing where body parts are Graying of vision |
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What are the s/s of vertebrobasilar clot?
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Dizziness
Nausea and vomiting Ataxia Dysarthria Dysphagia Eye movement Facial weakness Hearing loss |
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What is the criteria for thrombolytic therapy?
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CT scan negative for blood
>18 years old Symptom onset <3 hours SBP <185 and DBP <110 No GI bleed in past 21 days No surgery in past 2 weeks Arterial puncture at noncompressable site in the past week No seizure No history of any of the following within 3 months: Intracranial surgery Head trauma Previous stroke MI |
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How is thrombolytic therapy given?
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0.9 mg/kg
Maximum 90 mg 10% of dose given as bolus Remaining 90% given as infusion over 1 hour |
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What should you assess with thrombolytic therapy administration?
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BP: SBP < 185, DBP < 110
VS: every 15 minutes x 2 hours, then every 30 minutes x 6 hours, then every hour x 16 hours. Neurological deterioration Report immediately: Bleeding No sticks for first 24hrs Medications for blood pressure: Labetalol Sodium nitroprusside (Nipride) Nicardipine (Cardene) |
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WHen should you avoid antiplatelet therapy?
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Avoid with:
hemorrhagic stroke the first 24 hours after t-PA infusion |
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What are the treatment for ischemic stroke?
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Thrombolytic Therapy
Platelet therapy neurointerventional procedures: Intra-arterial t-PA angioplasty carotid stenting |
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What are the surgical interventions for stroke?
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Carotid endarterectomy
Hemicraniectomy- allow flow preventing edema worsening |
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What are the nursing interventions for stroke?
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Assessing for changes in deficits (worsening)
Weakness, dysphagia, aphasia, visual field cuts Monitoring BG, BP, T (inc T is bad), IICP Prevent DVT Bladder/Bowel management Assist with ADL Establish communication Educate about future stroke risk |
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Name the types of Hemorrhagic stroke?
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Intracerebral Hemorrhage (ICH)
Subarachnoid Hemorrhage (SAH) - Arteriovenous Malformation (AVM) |
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What is ICH?
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Blood vessel damage because of high BP or deposits of amyloid proteins
Formation of hematoma Compression of tissue, ischemia, and edema with increasing ICP |
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What are the s/s of ICH?
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Elevated blood pressure
Sudden focal neurological deficit HA NV Dec LOC Seizures |
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WHat is the treatment for ICH?
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ABCs
Patient euvolemic Strict BP Keep MAP <130 mm Hg preoperatively. Keep MAP <110 mm Hg postoperatively. Insertion of external ventricular drain (EVD) if hydrocephalus or IICP is suspected Seizure prevention SCD Temperature management Occupational, physical, and speech therapy should be involved. Nutrition may be instituted following swallowing study or may suggest the start of tube feeds. If treatment is aggressive and ventilator-dependent, then a tracheostomy and gastrostomy tube (G-tube or PEG) should be used. |
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When is surgery indicated for ICH?
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Hematoma >3 cm
Neurological deterioration Brainstem compression Hydrocephalus ICH from a structural lesion |
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When is only medical management indicated?
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Hematomas <20 cc
Minimal neurological deficits Glasgow Coma Scale (GCS) score <4 Large hemorrhages in dominant hemisphere Determine advanced directives Provide comfort care |
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What is postop care for IHC?
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Check neuro, I/O, and VS
Monitor electrolyte and osmolality levels. pain meds Monitor surgical site for drainage. Assess gag/swallow prior to starting diet. Apply compresses to eye area as needed. Apply eye lubricant/ointments PRN for irritation and dryness of eyes. Stool softener - constipations = IICP Keep bed side rails up; restraints may be needed. Space activities apart. |
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What are the causes of SAH and who are they found in?
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aneurysms
Female population Genetic disorders (polycystic KD, Ehlers-Danlos syndrome) Smoking and alcohol abuse Diabetes Positive familial history |
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What are the s/s of a patient with an aneursym in SAH?
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worst HA of life
warning headaches in the weeks before Transient LOC Nausea/vomiting, blurred vision Photophobia Seizures Cushings Triad (late sign) Cranial nerve deficits (especially III, IV, or VI) Nuchal rigidity |
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What is the initial management of aneursym/ SAH?
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Admit to ICU
ABCs Possible external ventricular drain (EVD) Strict blood pressure management Nimodipine (Nimotop) stool softeners ulcer, seizure, and DVT prophylaxis Preventing re-bleed |
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How do you prevent re-bleeds?
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Coiling - always check for re-bleed after
Strict blood pressure control |
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What are some SAH precautions/ nursing interventions for environment?
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SAH precautions:
close monitoring quiet, dark room accommodations analgesia for pain and headache limitation of visitors |
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What system measures SAH?
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Fisher Grading System
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What is the treatment for aneurysms?
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angiogram
if positive - do nothing until pbm, coil, clip if negative - recheck later |
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What are the complications of SAH?
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Cerebral vasospasm
f/e disturbances Hydrocephalus IICP |
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What is a cerebral vasospasm?
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Narrowing of the cerebral vessels near or distant to the SAH causing cerebral ischemia
Occurs 4-14 days post SAH |
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What are the s/s of cerebral vasospasm?
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Focal speech/motor deficit
altered level of consciousness diagnostic imaging showing vasospasm |
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How do you treat cerebral vasospasm?
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Angioplasty
Nimotop Triple H Therapy (HTN, Hypovolemia, Hemodilution) |
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How does Triple H work?
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Hypertension – elevate the SBP per MD order with fluids or vasopressors, i.e., dopamine or neosynephrine
Hypervolemia – keep PCWP 10-16 and CVP 8-12 using N/S, albumin, crystalloids, colloids or PRBC Hemodilution – maintain HCT <40% using N/S and albumin |
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What are the potential complications of SAH?
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Syndrome of inappropriate antidiuretic hormone (SIADH)—too much antidiuretic hormone (ADH)
Cerebral salt wasting (CSW)—primary loss of sodium Hyponatremia: causing confusion, lethargy, n/v, seizures, and an inc risk of vasospasm Diabetes insipidus—too little ADH: Not seen as commonly as SIADH or CSW in the SAH patient Treated with fluids administration of ADH or drugs which may stimulate the hypothalamus Hydrocephalous IICP |
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What is Hydrocephalous?
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Arachnoid villi are unable to reabsorb CSF sufficiently; often laden with byproducts of blood breakdown from SAH
A EVC might be inserted, then it is removed to test if the blood can be filtered, if not a AV fistula is placed |
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What are AV malformations
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system of dilated vessels that shunt arterial blood directly into the venous system
without the capillary network predisposing the vessels to rupture and hemorrhage Causes vascular steal syndrome - ischemia to tissues surrounding it |
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How does a pt present with AV malformations?
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Intracranial hemorrhage in 50% of patients
Seizures Headache Progressive neurological deficits |
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WHat is the Tx for AV malformations?
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Surgical resection of AVM
Stereotactic radiosurgery (SRS)—radiation used to cause inflammation, inducing vessel thickening and thrombosis Embolization—particles or glue lodged in the nidus 3-30 days before surgery or 30 days before SRS |
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What are the Cx of surgery for AV malformations?
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Hemorrhage
Normal perfusion pressure breakthrough Occlusive hyperemia Seizures Rebleeding from retained nidus |
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What are the Cx for Stereotactic Radiosurgery?
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Headaches, nausea, and vomiting in 16% of patients
Seizures within 24 hours of treatment in 10% of patients Radionecrosis Effective only after 1-3 years |
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What are the Cx of embolism?
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Intracerebral hemorrhage
Occlusive hyperemia Normal perfusion pressure breakthrough Ischemic stroke |
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What are the interventions for AV malformations?
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Monitor:
Neuro hypertension headache, administer analgesics seizure activity Education regarding lifestyle choices to prevent sudden increases in BP (e.g., avoiding contact sports and lifting) |
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What are the nursing interventions for AV malformations that are ruptured?
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Hemorrhage usually is intracerebral; therefore care and problems are the same as for patients with ICH.
Vasospasm is usually not a concern for this population. Rebleeding is a risk. |
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What are the medications used for AV malformations?
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BP:
Nicardipine (Cardene) Nitroprusside (Nipride) Labetolol (Trandate) Famotidine (Pepcid)—H2 antagonist Docusate sodium (Colace)—stool softener that prevents rises in ICP associated with straining Mannitol (Osmitrol)—osmotic diuretic for cerebral edema Fosphenytoin (Cerebyx)—seizure prophylactic Nimodipine (Nimotop)—calcium channel blocker for vasospasm |
