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88 Cards in this Set

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Akinesia
Loss of skilled voluntary movements
Aneurysm
Congenital or acquired weakness of the arterial wall resulting in dilation and ballooning of the vessel
Aphasia
Total loss of comprehension and use of language
Carotid Endarterectomy
Removal of an atherosclerotic plaque that is obstructing an extracranial artery
Dysarthria
A disturbance in the muscular control of speech
Dysphasia
Difficulty related to the comprehension or use of language
Embolic Stroke
A stroke that occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel
Expressive aphasia
Communication deficit resulting in difficulty speaking and writing
Hemiparesis/plegia
Weakness or paralysis of one side of the body
Hemorrhagic Stroke
A stroke that results from bleeding into the brain tissue itself (intracerebral or intraparenchymal hemorrhage) or into the subarachnoid space or ventricles (subarachnoid hemorrhage or intraventricular hemorrhage)
Homonymous hemianopsia
Blindness occurring in corresponding halves of the visual fields of both eyes
Intracerebral hemorrhage
Bleeding within the brain caused by a rupture of a blood vessel
Ischemic Stroke
Stroke that results from inadequate blood flow to the brain due to partial or complete occlusion of an artery
Lacunar Stroke
A stroke resulting from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue
Neglect Syndrome
Neurological deficit occurring with damage to nondominant hemisphere resulting in neglect of opposite side
Receptive aphasia
Communication deficit resulting in lack of comprehension of written and spoken language
Reversible ischemic neurologic deficit
Neurologic deficit present 24 hours after stroke with no residual effect after days to weeks
Stroke in evolution
Progression of neurologic deficit from stroke over hours or days
Stroke
Death of brain cells that occurs when there is ischemia (inadequate blood flow) to a part of the brain or hemorrhage into the brain
Subarachnoid hemorrhage
A stroke resulting from intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia matter membranes on the surface of the brain
Thrombotic stroke
A stroke resulting from thrombosis or narrowing of the blood vessel
Transient ischemic attack (TIA)
A temporary focal loss of neurologic function caused by ischemia of the brain, lasting less than 24 hours, and often lasting less than 15 minutes; episode of cerebrovascular insufficiency, usually associated with partial occlusion of an artery by atherosclerotic plaque or an embolism
Thrombotic Stroke
Cerebral thrombosis is a narrowing of the artery by fatty deposits called plaque. Plaque can cause a clot to form, which blocks the passage of blood through the artery.
Embolic Stroke
An embolus is a blood clot or other debris circulating in the blood. When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks the flow of blood.
Hemorrhagic Stroke
A burst blood vessel may allow blood to seep into and damage brain tissues until clotting shuts off the leak.
Warning Signs of Stroke: If someone is having one or more of these signs, do not ignore them. Call 911 and get medical help immediately
*Sudden weakness, paralysis, or numbness of the face, arm or leg, especially on one side of the body
*Sudden dimness or loss of vision in one or both eyes
*Sudden loss of speech, confusion, or difficulty speaking or understanding speech
*Unexplained sudden dizziness, unsteadiness, loss of balance or coordination
*Sudden severe headache
Full consciousness
Patient is awake and alert, appropriate in conversation. Patient is oriented to person, place, and time.
Confusion
Patient has short attention span and poor memory and demonstrates difficulty following commands. Patient experiences increased agitation at night and is disoriented first to time, then place, and possibly self.
Delirium
Patient is restless, agitated, and possibly combative. Patient is disoriented to time and place and is possibly hallucinating.
Obtundation
Patient rouses easily when stimulated and engages in simple but limited conversation and will sleep when undisturbed; lethargy, somnolence, and drowsiness are synonymous terms.
Stupor
Patient is very drowsy and appears unresponsive. When repeatedly and vigorously stimulated, patient will withdraw extremities purposefully and possibly speak incoherently.
Semicomatose
Patient is unresponsive to stimuli, although painful stimuli to the skin may result in moaning or stirring. Corneal, pupillary, and gag and tendon reflexes (called brain-stem reflexes) are intact.
Comatose
Patient is unrousable and does not stir or moan in response to painful stimuli. Most brain-stem reflexes are intact. Patient may exhibit decorticate or decerebrate posturing. (not purposeful movement)
Deeply comatose
Patient is completely unarousable and unresponsive to all stimuli, including pain. Brain-stem reflexes are absent.
What is the most sensitive indicator of changes in neurological status?
Level of consciousness
Right-brain damage
(Stoke on right side of the brain)
*Paralyzed left side: hemiplegia
*Left-sided neglect
*Spatial-perceptual deficits
*Tends to deny or minimize problems
*Rapid performance, short attention span
*Impulsive, safety problems
*Impaired judgement
*Impaired time concepts
Left-brain damage
(Stroke on left side of the brain)
*Paralyzed right side: hemiplegia
*Impaired speech/language aphasias
*Impaired right/left discrimination
*Slow performance, cautious
*Aware of deficits: depression, anxiety
*Impaired comprehension related to language, math
Cerebral Vascular Accident (CVA)
Definition
*CVA is a cardiovascular disease that affects blood vessels that supply blood to the brain
*Occurs when there is ischemia (inadequate blood flow) to a part of the brain or hemorrhage that results in death of brain cells
Embolic
*2nd most common, 24% of strokes
*Occlusion of cerebral artery with an emboli
*20% related to afib
*Rapid occurrence
Intracerebral Hemorrhage
*Bleeding from a ruptured blood vessel(s) within the brain
*No pre-warning
*Poor prognosis
*HTN most important cause***
Subarachnoid Hemorrhage
*Intracranial bleeding into the cerebrospinal fluid filled space
*Commonly caused by rupture of a cerebral aneurysm
*Other causes: AVMs, trauma, illicit drug abuse
*Many patients die, many left with significant cognitive difficulties
Transient Ischemic Attack (TIA)
*A temporary focal loss of neurological function caused by ischemia of one of the vascular territories of the brain.
*Lasts <24 hours, often <15 minutes
*Most resolve within 3 hours
*Warning sign of a progressive CVA
Types of CVA's
*Ischemic
1. Thrombotic
2. Embolic
*Hemorrhagic
3. Intracerebral Hemorrhage
4. Subarachnoid Hemorrhage
Thrombotic
*Most common
*Injury to a vessel wall
*Formation of a blood clot
*Pre-Warning: TIA (30-50%)
*Evolves over hours to days
*Accounts for 611% of strokes
Risk Factors: Non-modifiable
-Age
-Gender
-Race
-Heredity
-Prior CVA or TIA
Risk Factors: Modifiable
*HTN
*Atherosclerosis
*Carotid stenosis
*DM
*Heart Disease, afib
*Heavy ETOH
*Hypercoagulability
*Hyperlipidemia
*Obesity/Abdominal Obesity
*Oral contraceptive use
*Physical inactivity
*Sickle cell disease
*Smoking
*Drug abuse (cocaine)
Health Promotion
*Education and Screenings
-Smoking cessation
-Blood Pressure Screenings
-Healthy Diets
-Limit ETOH use
-Exercise
-Maintain proper body weight
-Have regular checkups
Warning Signs-*Note time of onset and call 911
*Sudden change in LOC
*Sudden numbness/weakness of the face, arm or leg (unilateral)
*Sudden confusion, trouble speaking or understanding
*Sudden trouble with vision (seeing)
*Sudden trouble walking, dizziness, loss of balance or coordination
*Sudden severe HA with no known cause
Medical Treatment to Prevent Ischemic CVA
*Antiplatelet Medications
-Act by keeping platelets from adhering to an injured blood vessel wall or other platelets
*Anticoagulation Medications
-Disrupt the coagulation cascade and thereby suppress production of fibrin
Antiplatelet Medications: ASA
*Dose
81 mg daily
325 mg daily
*Side Effects
-GI Bleeding
Antiplatelet Medications: Ticlid
(same class of drug as Plavix)
*Dose
250 mg twice a day
*Side Effects
-Neutopenia
-Thrombotic thrombocytic purpura
Antiplatelet Medications:Plavix
(same class of drug as Ticlid)
*Dose
75 mg twice a day or daily
*Side Effects
-Thrombotic thrombocytic purpura
-Skin disorders
Anticoagulation Medications
*Heparin
*Coumadin
*Lovenox
Surgical Treatment to Prevent CVA
*Carotid Endarterectomy (CEA)
-Removal of the blockage to improve blood flow (remove plaque in carotid artery)
*Extracranial-Intracranial Bypass
-Microvascular Bypass beyond an area of obstruction to increase cerebral perfusion
Post-Operative Care
*Neuro signs q 2h
*Assess cranial nerves q 2h (facial nerve)
*Keep HOB straight-DO NOT FLEX HEAD
*Elevate HOB when VSS 30 degrees best position
*Assess airway q 1h
*Keep emergency tracheostomy kit at bedside
*Apply cold to operative site
*Administer medications as ordered to promote blood flow
*Report any change in neuro/mental status STAT
Interventional Treatment to Prevent CVA
*Transluminal Angioplasty
-insertion of a balloon to open a narrowed artery
*Stenting
-intravascular placement of a stent in an attempt to maintain patency of the artery
Neurological Assessment
*Level of consciousness* MOST IMPORTANT
*Eye Position/Pupils
*Movement & Strength of Extremities
*Protective Reflexes
*Glasgow Coma Scale
Assessment: Level of Consciousness
*Full Consciousness
*Confusion
*Delirium
*Obtundation
*Stupor
*Semi-comatose
*Comatose
*Deeply comatose
Assessment:Pupils
*Appearance
*Response
*Accommodation
P = pupils
E = equal
R = round
R = reactive
L = light
A = accomodation
Assessment: Pupils
*Bring light from lateral side of head toward eye
*Observe: constriction
*NORMAL: Brisk & Equal
*ABNORMAL: Sluggish & Unequal (anisocoria)
Assessment: Muscle Strength
*Facial
-Droop
-Smile
-Tongue (midline)
-Speech
*Extremities
-Hand grasps
-Arm strength
-Foot pushes
-Leg lifts
Assessment: Protective Reflexes
*Corneal Reflex (Protective)
-Using a cotton swab, "tickle" the cornea (input stimulus) the eye lids should close (output reaction) Indicative of brain stem reflexes
*Gag and Cough Reflex
-Using a cotton swab, "tickle" the back of the throat (input stimulus) and look for a gagging motion (output reaction)
Posturing
*Assessment of ICP
*Inappropriate response to painful stimuli
*Assessment of brain stem function and reflexes
*LOC-pt is comatose
Posturing
*Decorticate Posturing (BAD)
-Rigid spine, flexed and adducted arms
-Extended and externally rotated legs, plantar flexion
-Cerebrum dysfunction
*Decerebrate Posturing (WORSE)
-Rigid or arched spine
-Rigidly extended, pronated arems with flexed wrists and palms facing backward
-Extended legs with plantar extension
-Brainstem dysfunction
Assessment: Glasgow Coma Scale
*Usually used to assess the unconscious client
*Basis for consistent assessment and documentation
*Best score = 15
*Worst score = 3
Clinical Manifestations of a CVA: Right CVA
*Right CVA
*left-sided neglect*
-left hemiplegia/hemiparesis
-Spatial-Perceptual Deficits
-Deny or Minimize problems
-Rapid Performance-short attention span
-Impulsive
-Impaired judgement
-Impaired time concepts
-Agnosia (inability to recognize or comprehend sights, sounds, words, or other sensory information)
-Apraxia (inability to carry out spontaneous movements)
Clinical Manifestations of a CVA: Left CVA
Right-sided neglect
-Right Hemiplegia/Hemiparesis
-Impaired Speedh - Aphasia
-Impaired L/R discrimination
-Slow performance-cautious
-Aware of deficits: depression & anxiety
-Impaired Comprehension-language and math
Diagnostic Tests
-Labs/EKG -determine the presence of risk factors to guide treatment
-EEG -low voltage, sluggish waves suggests ischemia; high voltage, sluggish waves suggest hemorrhage
-Doppler US -non-invasive, measures the velocity of blood flow in the major cerebral and carotid arteries
Diagnostic Tests
*CT
-Primary diagnostic - size and location, differentiates if ischemic or hemorrhagic
*CTA
-Determines presence of abnormalities in intracranial and extracranial vessels
*MRI
-Used to determine extent of brain injury, greater specificity than CT (used to determine treatment)
Diagnostic Tests
*MRA
-greater specificity than CTA
-Non-invasive method of assessing vascular occlusive disease of head and neck
*Angiography
-GOLD standard for imaging carotid arteries
*LP
-Looks for evidence or RBCs if subarachnoid hemorrhage is suspected or CT showed hemorrhage
Treatment: Acute Phase
*Goal
-To preserve life, prevent further brain damage and reduce disability
Brain Attack
*Describes stroke and the urgency of recognizing stroke symptoms and treating stroke as a medical emergency like a heart attack
CT scan within 25 minutes, read within 40 minutes, TPA administered within 60 minutes
Treatment: Acute Phase
*TPA
*Platelet inhibitor/Anticoagulant Rx/ASA
*Closely monitor
Tissue Plasminogen Activator (TPA)
*Localized fibrinolysis
*Reestablishes blood flow through a blocked artery to prevent cell death in patients with acute stroke symptoms
*Must be administered within 3 hours of onset of clinical symptoms of ischemic stroke
*Reduces disability -- incidence of increased death first 7-10 days secondary to intracranial hemorrhage
*NO ANTICOAGULANTS OR ANTIPLATELET DRUGS FOR 24 HOURS AFTER TPA*
Screening / TPA
*CT or MRI to r/o hemorrhagic stroke
*Blood tests (INR, PTT, Platelets)
*Absolute Contraindications:
-Recent GI bleeding
-Any stroke/head trauma within 3 months
-Major surgery within 14 days
-Pregnancy B/P >200
Treatment: Acute Care (for anyone having a stroke)
*Manage ABCs-airway, maintain adequate oxygenation
*Baseline neuro assessment with close monitoring
*Monitor B/P closely
*Maintain fluid and electrolyte balance
Treatment: Acute Care (for anyone having a stroke)
*Institute measures to decrease ICP
-Increase HOB, maintain head/neck alignment
-Avoid hip flexion
-pain management
-avoid hypervolemia
-manage constipation
-CSF drainage/ICP monitoring
-Diuretic drugs (Manitol & Lasix)
-Bone flap
*Monitor for and treat hyperthermia
*Monitor for seizures
*Monitor for increased ICP
Surgical Intervention: Acute
*Immediate evacuation of aneurysm >3cm
*Ruptured aneurysm - clipping, wrapping or coiling aneurysm to stop and prevent rebleeding
*Ventriculostomy - for intracerebral or subarachnoid hemorrhage - catheter inserted into the ventricle connected to a transducer and external drainage system (ICP monitoring device)
Nursing Diagnosis: Acute
*Impaired Tissue Perfusion: Cerebral
*Impaired Gas Exchange
*Ineffective Airway Clearance
*Impaired Tissue Perfusion: renal, cardiac, peripheral
*Risk for Aspiration
Rehabilitation
*Outcomes
-Attain maximum physical functionings/self-care
-Maintain stable body functions/bladder control
-Maintain adequate nutrition
-Maintain stable or improved LOC
-Maximize communication abilities
-Avoid complications of CVA
-Maintain effective personal and family coping
-Safety/education
Disruption of Function: Communication (Left CVA)
*Total Aphasia-Global Aphasia
-Involves sensor and motor areas of the brain
-Receptive & Expressive aphasia
*Partial Aphasia
*Receptive aphasia (Wernicke's)
-Involves sensory area of the brain
*Expressive aphasia (Broca's)
-Involves motor area of the brain
Disruption of Function: Motor Function
*Outcomes of loss of motor function
-Chewing & Swallowing
-Self-Care
-Physical Mobility
-Unilateral Neglect
Disruption of Function: Nutrition
*Alteration in nutrition - less than body requirements
-Loss of ability to chew and swallow
-Decreased LOC
-Loss of ability to self feed
How do we intervene for dysphagia?
*HOB up
*Test gag reflex with cotton swab
*Test swallowing with applesauce
*Give thickened liquids
*Speech & Swallow Consult
*Place food in unaffected side of mouth
*Check mouth after for food and remove
Nursing Process
*Sensory perceptual alterations
*Self-Care deficit: feeding, bathing, dressing, toileting
*Unilateral neglect
*Impaired physical mobility
*Altered nutrition: less than body requirements
*Risk for aspiration
Nursing Process
*Risk for infection (pneumonia)
*Risk for impaired skin integrity
*Risk for constipation
*Risk for diarrhea (tube feedings)
*Impaired Verbal Communication
*Anxiety
*Ineffective Coping
*Impaired Social Interactions
*Altered Role Performance
Current Trends
*Induced hypertension in non-hemorrhagic stroke with vasopressor augmentation-MGH with phenylephrine
*Mechanical embolus removal in cerebral ischemia (MERCI)device - corkscrew-shaped device used to remove clots blocking the cerebral artery under direct flouroscopy
Current Trends
*Constraint-induced Movement Therapy (CIMP)
*Guglielmi Detachable Coil
*DSPA - vampire bat saliva for acute treatment (up to 9 hrs ischemic stroke)
*Four Score Measurement Tool (better than glasgow coma scale)