Med Surge - Test 5 P.1-8

Front 1

Cranial Nerve
-Olfactory

Back 1

smell

Front 2

Cranial Nerve
-Optic

Back 2

central and peripheral vision

Front 3

Cranial Nerve
-Oculomotor

Back 3

eyelid and eyeball movement
pupil constriction

Front 4

Cranial Nerve
-Trochlear

Back 4

turns eye downward and laterally

Front 5

Cranial Nerve
-Trigeminal

Back 5

chewing, sensation of the face, scalp

Front 6

Cranial Nerve
-Abducens

Back 6

lateral eye movement

Front 7

Cranial Nerve
-Facial

Back 7

controls facial expression, secretion of tears, saliva, taste

Front 8

Cranial Nerve
-Vestibulocochlear

Back 8

-hearing and balance

Front 9

Cranial Nerve
-Glossopharyngeal

Back 9

swallowing, saliva, taste

Front 10

Cranial Nerve
-Vagus

Back 10

swallow, gag reflex, talking, heart rate and peristalsis

Front 11

Cranial Nerve
-Accessory

Back 11

controls trapexius and sternocleidomastoid muscles, controls swallowing movements

Front 12

Cranial Nerve
-Hypoglossal

Back 12

controls tongue movements

Front 13

-if the pt can cooperate, the nurse should test which CN because extraocular movements may be diminished because of increased ICP and hydrocephalus.

Back 13

3, 4, and 6

Front 14

-damage to the optic chiasm or optic tract may cause

Back 14

visual field deficits, or diplopia (double vision)

Front 15

-in the unconscious patient, additional oculocephalic and oculivestibular tests are performed to test the integrity of the brain stem (which cranial nerves?)

Back 15

CN, 3,6, 7

Front 16

CVA
-cerebrovascular accident

is also called?

Back 16

-also called a stroke & brain attack

Front 17

CVA - Stroke

caused by:

Back 17

a disruption in the normal blood supply to the brain

Front 18

CVA - Stroke

is it about the (venous or arterial system) is not delivering blood to a specific area in the brain

Back 18

arterial

Front 19

CVA - Stroke

-Considered a medical emergency & should be treated immediately to prevent neurologic deficit and permanent disability!
(true or false)

Back 19

true

Front 20

CVA - Stroke
Patho:
-The brain can’t store oxygen and glucose and therefore must receive a constant flow of blood to provide these substances for normal function.
-blood flow is important for removal of metabolic waste (carbon dioxide and lactic acid). If blood supply to any part of the brain is interrupted for more than a few minutes,
--what happens?

Back 20

cerebral tissue dies (infarction).

Front 21

CVA - Stroke
Patho

-brain metabolism and blood flow after a stroke are affected (in what 2 areas)

Back 21

around the infarction as well as in the CONTRALATERAL (OPPOSITE SIDE) hemisphere

Front 22

CVA - Stroke
Patho

-effects of a stroke on the nonaffected side may be due to what?

Back 22

brain swelling and further changes in blood flow throughout the brain

Front 23

What is the most common cause of stroke:

Back 23

Thrombosis – most common (blood clot)

Front 24

Causes of stroke:
Embolism

Back 24

moving clot

Front 25

Causes of stroke:
-Vegetative thrombi

what is this?

Back 25

a thrombi that forms within the heart, along the valves of heart which occurs secondary to a bacteria (strep).
White cells and debri of bacteria is what vegetative thrombi is composed of.

-You cant do anything for a vegetative clot but support the patient. Ask if they have had an infection?

Front 26

Causes of stroke:
4

Back 26

Hemorrhage stroke
AV malformation
aneurism that ruptures
secondary to hypertension.

Front 27

What is:

Cerebral arterial spasm (close and opening) when it opens, your symptoms resolve.

Back 27

TIA – Transient Ischemic Attack


If it stays closed, the TIA can become a non-hemorrhagic stroke

Front 28

Strokes are classified as:

Back 28

ischemic (occlusive) or hemorrhagic

Front 29

________ strokes are classified as either thrombotic or embolic in origin

Back 29

ischemic strokes

Front 30

Ischemic
-Thrombotic stroke or Embolic stroke

-associated with the development of atherosclerosis of the blood vessel wall (plaques develop on the inner wall of the affected arterial vessel)

Back 30

Thrombotic stroke:

Front 31

Ischemic
-Thrombotic stroke or Embolic stroke

-rupture of one or more plaques exposes foam cells to clot promoting elements in the blood. The end result is clot formation. If the clot is big enough, it may interrupt the blood flow to the brain tissue supplied by the vessel, causing an occlusive stroke.

Back 31

Thrombotic stroke:

Front 32

Ischemic
-Thrombotic stroke or Embolic stroke

-this can occur over many years and therefore have a slow onset

Back 32

Thrombotic stroke:

Front 33

Ischemic
-Thrombotic stroke or Embolic stroke


-the bifurcation (point of division) of the common carotid artery and the vertebral arteries their junction with the basilar artery are the most common sites involved

Back 33

Thrombotic stroke:

Front 34

Ischemic
-Thrombotic stroke or Embolic stroke

-caused by clot that breaks off from one area of the body and travel to the cerebral arteries via the carotid artery or vertebrobasilar system.

Back 34

Embolic stroke

Front 35

Ischemic
-Thrombotic stroke or Embolic stroke

-usual source is the heart.
3 other places they can occur?

Back 35

Embolic stroke

Emboli can occur in pts with afib, ischemic heart disease, insertion of a prosthetic valve

Front 36

Ischemic
-Thrombotic stroke or Embolic stroke

-they tend to become lodged in the smaller cerebral blood vessels at their point of bifurcation of where the lumen narrows

Back 36

Embolic stroke

Front 37

Ischemic
-Embolic stroke

-the pt experiences the s/s of a stroke when?

Back 37

as the clot occludes the vessel, ischemia develops and the pt experiences the s/s

Front 38

Ischemic
-Thrombotic stroke or Embolic stroke

are characterized by the sudden developed and rapid occurrence of neurologic deficits then clearing of symptoms over gours or days!

Back 38

Embolic stroke

the occlusion may be temporary if the embolus breaks into smaller fragments, enters smaller blood vessels, and is absorbed.

Front 39

An aneuryism is what?

Back 39

an abnormal ballooning or blister along a normal artery.

Front 40

-an aneurysm rupture causes bleeding into the subarachnoid space, the ventricles and or intracerebral tissue.

Then what happens?

Back 40

Vasospasm, a sudden and periodic constriction of a cerebral artery, often results.

Blood supply to distal areas of the brain supplied by the artery is diminished, which leads to cerebral ischemia and infarction and further neurologic dysfunction

Front 41

Risk Factors for Developing a Stroke

Back 41

see page 4

Front 42

What is a TIA

Back 42

-Transient Ischemic Attack

Front 43

Transient Ischemic Attack (TIA)
-what is it?

Back 43

a vessel opens and closes, spasms, resolves

Warning of brief interruption of blood to the brain!

Front 44

Transient Ischemic Attack (TIA) is also called what?

Back 44

a silent stroke

Front 45

Transient Ischemic Attack (TIA)
-how long does it last?

-brain damage can be seen on what?

Back 45

-Lasts a few minutes to 24 hours.
-Brain damage can be seen on CT and/or MRI (can see deoxygenated tissue/dead tissue)

Front 46

Risk Factors for Developing a Stroke

Back 46

see page 4

Front 47

What is a TIA

Back 47

-Transient Ischemic Attack

Front 48

Transient Ischemic Attack (TIA)
-what is it?

Back 48

a vessel opens and closes, spasms, resolves

Warning of brief interruption of blood to the brain!

Front 49

Transient Ischemic Attack (TIA) is also called what?

Back 49

a silent stroke

Front 50

Transient Ischemic Attack (TIA)
-how long does it last?

-brain damage can be seen on what?

Back 50

-Lasts a few minutes to 24 hours.
-Brain damage can be seen on CT and/or MRI (can see deoxygenated tissue/dead tissue)

Front 51

Transient Ischemic Attack (TIA)

-Will not cause brain damage with a TIA

True or False

Back 51

True
BUT, Multiple TIA’s increases the risk of a major stroke!

Front 52

Transient Ischemic Attack (TIA)

-causes temporary neurologic dysfunction resulting from

Back 52

a brief interruption in cerebral blood flow, possibly due to cerebral vasospasm or arterial hypertension.

Front 53

Transient Ischemic Attack (TIA)
S/S - Visual deficits (4)

Back 53

-Blurred Vision
-Diplopia (Double Vision)
-Blindness in one eye (if they only have this, it’s retinal detachment)
-Tunnel Vision

Front 54

Transient Ischemic Attack (TIA)
S/S - Motor Deficits
(2)

Back 54

Transient weakness (arm, hand, or leg)

Gait Disturbance (ataxic)

Front 55

Transient Ischemic Attack (TIA)
S/S - Sensory Deficits (2)

Back 55

- Transient Numbness (face, arm, or hand)

- Vertigo

Front 56

Transient Ischemic Attack (TIA)
S/S - Speech Deficit
(2)

Back 56

- Aphasia (not able to speek)
- Dysarthria (slurred speech)

Front 57

Test for a stroke
-drif test

Back 57

-drift test – hold 2 arms out (if arm goes to the left, it says there is something going on in the right side of the brain)

Front 58

S/S of TIA
-How long do they typically last?

Back 58

-last a few minutes to 24 hours
-symptoms of a TIA resolve within 30-60 minutes
-it’s not unusual for symptoms to resolve by the time the pt reaches the ER
-brain damage can be seen on CT and/or MRI with repeated instances
-multiple TIAs indicate high stroke risk

Front 59

What stroke is considered "occlusive"

Back 59

ISCHEMIC

Front 60

-is caused by an occlusion of a cerebral artery by either a thrombus or embolus.

Back 60

ISCHEMIC (Occlusive)

Front 61

A stroke that is caused by a thrombus (clot) is referred to as a thrombotic stroke, whereas a stroke caused by an embolus (dislodged clot) is referred to as an embolic stroke. also called?

Back 61

-also called a silent stroke

Front 62

Ischemic
-Thrombotic vs Embolic Stroke

Account for more than half of all strokes

Back 62

Thrombotic Stroke

Front 63

Ischemic
-Thrombotic vs Embolic Stroke

Commonly associated with development of atherosclerosis of the blood vessel wall if there is plaque in your heart, there is plaque in your carotid arteries

Back 63

Thrombotic Stroke

Front 64

What stroke is considered "occlusive"

Back 64

ISCHEMIC

Front 65

-is caused by an occlusion of a cerebral artery by either a thrombus or embolus.

Back 65

ISCHEMIC (Occlusive)

Front 66

A stroke that is caused by a thrombus (clot) is referred to as a thrombotic stroke, whereas a stroke caused by an embolus (dislodged clot) is referred to as an embolic stroke. also called?

Back 66

-also called a silent stroke

Front 67

Ischemic
-Thrombotic vs Embolic Stroke

Account for more than half of all strokes

Back 67

Thrombotic Stroke

Front 68

Ischemic
-Thrombotic vs Embolic Stroke

Commonly associated with development of atherosclerosis of the blood vessel wall if there is plaque in your heart, there is plaque in your carotid arteries

Back 68

Thrombotic Stroke

Front 69

Athersclerosis is a noninflammatory degenerative disease that can affect any cerebral blood vessel

The atheromatous plaques build up on the interior of the vessel wall & the artery loses its elasticity & hardens & occludes the lumen, thereby diminishing blood flow – hence transient ischemia!

Back 69

Thrombotic Stroke

Within 72 hours the area is edematous and necrotic, and cavities develop

Front 70

will the CT scan show edema?

will the CT scan show a stroke?

Back 70

edema will show CT scan..CT scan will not show a stroke) MRI will indicate stroke.

Front 71

Thrombotic or Embolic

These tend to have a slow onset!

Back 71

Thrombotic Stroke

Front 72

What artery is most often involevd in an embolic stroke?

Back 72

The Middle Cerebral Artery** (MCA)

Front 73

When does the patient show the s/s of the stroke?

Back 73

As emboli occlude the vessels, ischemia develops, & patient has clinical manifestations of stroke!

Front 74

Thrombotic or Embolic Stroke

-Occlusion is often temporary; & the embolus breaks into tiny fragments & is absorbed.

Back 74

Embolic Stroke

Front 75

Thrombotic or Embolic Stroke


Sudden focal neurological deficits, then clearing of symptoms over hours or days!

Back 75

Embolic Stroke

Front 76

Thrombotic or Embolic Stroke


rapid occurrence of neurologic deficits

such as: (2)

Back 76

Embolic Stroke



(paralysis and expressive aphasia)

Front 77

Thrombotic or Embolic Stroke


Or plaque that breaks off from carotid sinus or internal carotid artery

Back 77

Embolic Stroke

Front 78

what kind of stroke?

vessel integrity is interrupted and bleeding occurs into the brain tissue or into the spaces surrounding the brain (ventricular, subdural, and subarachnoid).

Back 78

HEMORRHAGIC

Front 79

Hemorrhagic stroke:

hemorrhage into the brain generally results from (2) things?

Back 79

a ruptured aneurysm (localized weakening and distortion of vessel wall), or severe hypertension

Front 80

Hemorrhagic stroke:

 will lead to ischemia secondary to the distal part of the arterial system not getting blood. Blood is not a friend of brain tissue and blood sitting against brain tissue causes the cerebral tissue to swell. Now you have cerebral edema and more cerebral hypoxia.


Edema does what?

Back 80

increases ICP.

Front 81

Hemorrhagic stroke:

gradual or sudden onset?

Back 81

sudden onset

Front 82

S/S of a Hemorrhagic stroke:

4

Back 82

•pt in stupor or coma
•seizures
•CSF is bloody
•happens during activity

Front 83

Hemorrhagic stroke:

4 causes

Back 83

- A ruptured saccular (berry) aneurysm
- A ruptured arteriovenous malformation (AVM)
-cocaine
- Hypertension: Weakening of arterial wall of the brain from

Front 84

S/S of ischemic stroke

6

Back 84

-difficulty speaking or understanding speech (aphasia)
-difficulty walking
-dizziness or lightheadedness (vertigo)
-numbness, paralysis, or weakness, usually on one side of the body
-seizure (rare)
-severe headache with no known cause

Front 85

S/S of ischemic stroke

5

-sudden or gradual??

Back 85

-sudden confusion
-sudden decrease in LOC
-sudden loss of balance or coordination
-sudden vision problems (blurry vision, blindness in one eye)
-vomiting

Front 86

ischemic stroke

-happens during activity or during sleep?

Back 86

sleep

Front 87

Causes of an ischemic stroke

3 causes

Back 87

-occlusion of a cerebral artery by either a thrombus or an embolus
-thrombus- clot
-embolus- dislodged clot
-rupture of 1 or more plaques exposes foam cells to clot-promoting elements in the blood

-interruption of blood flow to brain tissue (can occur over years) may cause an occlusive stroke


-atherosclerosis of the blood vessel wall

Front 88

S/S of a stroke:
Right Hemisphere--

Think _______

Back 88

sensory

Front 89

S/S of a stroke:
Right Hemisphere is involved in _______ , _______, and _________.

Is the patient aware

Back 89

-Right hemisphere – involved in visual & spatial awareness & proprioception.


-Often unaware of deficits & are disoriented.

Front 90

S/S of a stroke:
Right Hemisphere

Tell me about the personality changes

Back 90

Personality changes include impulsivity & poor judgment.

Front 91

S/S of a stroke:
Right Hemisphere

“we have the right to think” so you will have difficulties

Back 91

with thinking

Front 92

S/S of a stroke:
Right Hemisphere

Back 92

-Disoriented
-Impulsive/poor judgment
-Euphoria
-Denial of illness
-Overestimation of injuries
-Loss of depth perception

Front 93

S/S of a stroke:
Left Hemisphere

Left Hemisphere (think ____________)

Back 93

memory and hesitation

Front 94

S/S of a stroke:
Right or Left Hemisphere

dominant hemisphere in all but 15-20 %, is the center for language, math skills, & analytic thinking.
-These result in ________.

Back 94

Left


APHASIA (unable to speak or understand language)

Front 95

S/S of a stroke:

“right to think” and “left to communicate” or “I’m left with my memory”

Back 95

:)

Front 96

S/S of a stroke:
Left Hemisphere


S/S:

Back 96

-Expressive/Receptive Aphasia
-Alexia – cannot understand written language
-Agraphia – difficulty writing

Front 97

S/S of a stroke:
Left Hemisphere

3 S/S

Back 97

-Slow / Cautious
-Depression
-Anger/Frustration

Front 98

meds that compound Hemorrhagic stroke: 3

Back 98

amphetamine abuse,cocaine use, cigarettes..

Front 99

S/S of a stroke:
Right or Left Hemisphere

dominant hemisphere in all but 15-20 %, is the center for language, math skills, & analytic thinking.
-These result in ________.

Back 99

Left


APHASIA

Front 100

S/S of a stroke:

“right to think” and “left to communicate” or “I’m left with my memory”

Back 100

:)

Front 101

S/S of a stroke:
Left Hemisphere


S/S:

Back 101

-Expressive/Receptive Aphasia
-Alexia – cannot understand written language
-Agraphia – difficulty writing

Front 102

S/S of a stroke:
Left Hemisphere

3 S/S

Back 102

-Slow / Cautious
-Depression
-Anger/Frustration

Front 103

meds that compound Hemorrhagic stroke: 3

Back 103

amphetamine abuse,cocaine use, cigarettes..

Front 104

-Thrombotic strokes occur gradually or rapidly

Back 104

gradually

Front 105

-If s/s come & go, that may be possible indicate what?

Back 105

a TIA or a reversible ischemic neurologic deficit (RIND).

Front 106

What stroke?
-s/s don’t go away and things get worse fast

Back 106

Hemorrhagic

Front 107

Did symptoms worsen after the initial onset? (___________stroke)

Did symptoms improve after the initial onset? (_____________stroke)

Back 107

hemorrhagic



embolic

Front 108

___________strokes occur during activity.

Back 108

hemorrhagic

Front 109

which 2 stroke has symptoms that occur abruptly?

Back 109

Embolic or hemorrhagic

Front 110

What type of things would the nurse assess for/on a stroke pt

Back 110

Priority assessment of ABCs
Neuro assessment
Stroke scale
CV assessment

Front 111

-pt with __________strokes may have murmurs, dyrsthmias, or high BP..

Back 111

embolic

Front 112

What type of things would the nurse assess for/on a stroke pt

what happens to H&H?

Back 112

-increase H & H lack as the bodies tries to compensate for the lack of oxygen from the brain

Front 113

What type of things would the nurse assess for/on a stroke pt


Why will PT, PTT, and INR be drawn?

Back 113

to establish a baseline in case anticoagulation therapy is started

Front 114

Stoke
-Cognitive changes:

what is the first sign that you are experiencing and increase in ICP?

Back 114

-changes in LOC*,

Front 115

-When your LOC decreases, your ICP goes up. LOC varies deepening on the extent of ICP caused by the stroke and the location of the stroke. The pt is most at risk for increased ICP resulting from edema when?

Back 115

during the first 72 hrs after onset of the stroke. P. 1037 S/S

Front 116

Hemiparesis means what?

Back 116

1 side of the body has paralysis

Front 117

Stoke
-Cognitive changes:

Back 117

paralysis
spatial & proprioceptive dysfunction (awareness of body position in space),

impaired memory, judgment, or problem-solving & decision-making skills.

Decreased ability to concentrate and attend to tasks

Front 118

Stoke

-The right cerebral hemisphere is more involved with visual and spatial awareness and proprioception.
-example of this

Back 118

The pt is unaware of any deficits and may be disoriented to time and place.

Front 119

The _____cerebral hemisphere is the center for language, math skills, and analytic thinking. So a _____hemisphere stroke results in aphasia (inability to use or comprehend language), alexia or dyslexia (reading problems) agraphia (difficulty with writing) and acalculia (diff. with math calculation)

Back 119

left

Front 120

Motor Changes from a stroke

Assess patients muscle tone for what?

Back 120

Flaccid? Hypotonia (some ton but not a lot)

These cannot overcome the forces of gravity, & extremities tend to fall to the side.

Front 121

Motor Changes from a stroke

How do they extremities feel

Back 121

heavy, & muscle tone is inadequate for balance

Front 122

Motor Changes from a stroke

Hypertonia is AKA:
-it causes what

Back 122

Hypertonia (spastic paralysis) tends to cause fixed positions or contractures.

Front 123

Motor Changes from a stroke

Tell me about ROM ?

Back 123

ROM of the joints is restricted & shoulder subluxation may occur.

Front 124

Sensory Changes from a stroke

Patients need to adapt to changes in -3

Back 124

vision, proprioception (sense of position) and sensation

Front 125

Sensory Changes from a stroke

-2 "A" words

-decreased sensation typically occurs on the affected side of the body

Back 125

-Agnosia – inability to use an object correctly.
-**Apraxia – inability to carry out purposeful actions.

Front 126

Sensory Changes from a stroke

“Neglect Syndrome” is what?

Back 126

– patient is unaware of the existence of his or her paralyzed side. Comes over time, they forget that the side of the body is injured and they hurt themselves. Ex: pt sitting in a wheelchair , learning to the left with the arm caught in the wheelchair wheel. When questioned, the pt often states that everything is fine and believes that he or she is sitting up straight in the chair

Front 127

Cardiovascular Assessment from a stroke

Patients with _______strokes often have a heart murmur, dysrhythmia, or hypertension.

Back 127

embolic

Front 128

Cardiovascular Assessment from a stroke


It’s not unusual for a patient admitted to the hospital to have a BP greater than:
180/110 or 200/120
-why is that ok??

Back 128

After a stroke, a BP of 150/100 is needed to maintain cerebral perfusion. If above this limit, another stroke can occur!

Front 129

Cardiovascular Assessment from a stroke

•Stroke: diastolic is what?

what is it telling you?

Back 129

(resting pressure in your arterial system)

its telling you what the pressure will be against the blood vessels