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39 Cards in this Set
- Front
- Back
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Stroke
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Stroke
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Controllable risk factors for strokes
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1. Hypertension
2. Heart disease-Atrial fibrillation in particular 3. Cigarette smoking 4. Excessive alcohol intake 5. High cholesterol levels 6. Obesity 7. Substance abuse 8. Sedentary life-style 9. Oral contraceptive use |
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Uncontrollable risk factors for strokes.
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1. Increasing age
2. Male sex 3. African American 4. Diabetes 5. Previous stroke/TIA 6. Family history of stroke or TIA 7. Sickle cell disease |
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Ischemia: Describe Transient ischemic attack
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-An episode of cerebrovascular insufficiency
-partial occlusion of an artery -Symptoms vary with site and degree of occlusion -sudden loss of motor, sensory, or visual function -Brief lasting only a few minutes to 24 hours |
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TIA Treatment-Explain different types and what it treats
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1. Treatment of hypertension, hypergylcemia
2. Cessation of smoking 3. Treatment of hyperlipidemia 4. Platelet inhibitor drugs-ASA, ticlid, plavix 5. Persantine (coronary vasodilator) 6. Anticoagulant therapy-coumadin 7. Carotid Endarterectomy |
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Explain Carotid Endarterectomy
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Occluded or stenotic vessel per carotid doppler or angiogram
Removes artherosclerotic plaque Position on unoperated side c HOB above 30 degrees Avoid flexing, rotating, or hyperextending the head Complications-Bleed (tracheal deviation), BP decreases, BP increases, cranial nerve impairment (dysphagia) |
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Infarction AKA
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Cerebrovascular Accident CVA
Stroke Brain Attack |
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CVA-Explain
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Ischemic-Thrombotic and embolic
-A blood vessel supplying the brain is obstructed by a clot -The area of brain that is affected begins to suffocate and stops functioning (Thrombus formed in Brain, embolus moved to the brain from something like A-Fib) |
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Hemorrhagic stroke
Types and explain symptoms |
Types: Intracerebral ICH- blood inside the brain
Subarachnoid (SAH)- blood around the brain Poorly controlled hypertension Cataclysmic headache Occur during activity Most often fatal- LOC, coma, death |
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Thrombotic CVA's
Explain |
Occlusion of artery by a clot
Over age 50 Occurs when resting or sleeping Stroke symptoms and progressively worsens over 1-2 days - stroke in evolution Completed stroke is after 3 days |
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Embolic stroke-Explain
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Younger than thrombotic patients
While awake and active Sudden onset-immediate deficits thrombus particle carried through arterial system to the brain Source? -A-Fib |
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State the Symptoms Suggesting a Stroke
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The abrupt onset of hemiparesis
Sudden decline in LOC Cataclysmic headache Acute dysphasia-slurred speech Loss of sensation in half of body- Rt side or left side Sudden loss of vision in one or both eyes or visual field Double vision Ataxia-instability |
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ER assessment to see if one had a stroke-Components
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1. Airway-Side lying position, raised head of bed
2. Breathing-pattern 3. Circulation-VS-BP 4. Accucheck-To rule out hypoglycemia (mimics symptoms of stroke) 5. Time of onset of symptoms-Many strokes are thrombolic or embolic-give activase if a person is within 3 hours of onset of symptoms |
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Gascow coma scale-
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EYES OPEN
-Spontaneously -To Speech -To Pain -No response BEST MOTOR RESPONSE -Obeys commands -Localizes pain -Flexion-withdrawal -Abnormal flexion-Decorticate -Abnormal extension-Decerebrate BEST VERBAL RESPONSE -Oriented -Confused -Inappropriate words -Incomprehensible sounds -No response |
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Neuro check-Abbreviated Neurologic Assessment
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Assess level of consciousness
Obtain vital signs Check pupillary response to light Assess strength of hand grip and movement of extremities Determine ability to sense touch/pain in extremities |
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How is a stroke diagnosed
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Symptoms
Glascow Coma scale Abnormal speech Neurocheck- Arm Drift Cranial Nerve Facial droop Babinski Accucheck to rule out hypoglycemia CT's contrast, MRI-to distinguish type between hemorrhagic and ischemic |
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Acute medical Treatment
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Thrombolytic-only if within 3 hours of onset of symptoms of ischemic CVA
Anticoagulant-Heparin-only if thrombotic stroke and only first 2-3 days Calcium channel blockers to reduce cerebral vasospasm Hyperosmolar solutions or diuretics Anticonvulsants-Cerebyx (metabolizes to dilantin) Vasodilators-Nipride titrate to specified BP |
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Cranial nerves
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IX-glossopharyngeal and X Vagus
-Control gag and cough reflexes-if impaired at risk for silent aspiration -Tongue blade to touch the uvula-patient should retch-if uvula only moves up on one side-the patient does not have an adequate gag reflex so watch when feeding XII--Stick out toungue (midline) and move side to side II-Optic and III-Oculomotor -controls pupillary reflex- II sees the light III responds by constricting the pupil III-Oculomotor and IV-Abducen -Moves eyes in 4 directions -"Look at my fingers please." Snap fingers. -Make sure no white is showing on side looking toward. V-Trigeminal and VII-Facial -motor and sensory nerves to the face -Control the corneal blink reflex -Sterile cotton ball across cornea-if absent, protect the cornea from foreign bodies, abrasions and dehydration VIII Auditory-whisper in ear XI Spinal Accessory (not crucial -shrug shoulders, turn head |
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Nursing Diagnoses
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Altered cerebral tissue perfusion
Unilateral Neglect Self Care deficit: Dressing/Grooming Potential for hyperthermia (if CVA affects hypothalamus) Impaired verbal communication Sensory/Perceptual alterations Risk for fluid volume deficit r/t damage to pituitary |
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Describe unilateral neglect
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Inattention to one side of body.
May occur with some strokes of the middle cerebral artery. Poor hygiene and grooming may be seen in clients with dementing disorders |
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Abnormal gait is seen in:
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Transient ischemic attacks
Strokes Parkinson's disease |
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Emotional swings or changes in personality may be observed with strokes of the _____________
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Anterior cerebral artery
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Aphasia-Define/Describe
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Aphasia (Defective or absent language function) may occur in TIAs. Receptive aphasia (inability to understand verbal or writen language) is often noted in strokes of posterior or anterior cerebral artery. Aphasias are seen with damage to the left cerebral cortex. Aphasias are more often seen with strokes of the right hemisphere than the left hemisphere.
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Dysphonia
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(change in the tone of voice)
Is common in strokes of the posterior or inferior cerebral artery. Dysphonia is seen with paralysis of the vocal cords (cranial nerve X) |
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Dysarthria define/describe
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Dysarthria is difficulty speaking which is seen with lesions of upper and lower motor neurons, the cerebellum, and the extrapyramidal tract. It is also seen in strokes of the anterior inferior and superior cerebral arteries
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Disorientation to time and place may occur in clients with stroke of the ________ ________ hemisphere
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right cerebral hemisphere
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Memory deficits are often seen with strokes of the anterior ______ _______ and _____________ _______
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Anterior cerebral artery
Vertebralbasilar artery |
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Perceptual deficits and impaired cognition may be seen in strokes of the ________ ________ ________
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middle cerebral artery. Perceptual deficits may occur following brain trauma and dementing disorders.
Impaired cognition also may occur with cerebral trauma and brain tumors. |
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Anosmia -Define/Describe
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Anosmia (inability to smell) may be seen with lesions of the frontal lobe and may also occur with impaired blood flow to the middle cerebral artery
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Blindness in one eye may be seen with strokes of the ______ ______ _______
Impaired vision may also bee seen with strokes of the _______ _______ ______ |
Internal carotid artery or with TIAs.
Impaired vision: anterior cerebral artery and brain tumors |
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Nystagmus-explain and where is it seen... seen with strokes of the___
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Nystagmus (involuntary eye movement)may be seen with strokes of the anterior, inferior, and superior cerebellar arteries.
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Ptosis occurs
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Ptosis is drooping eyelids
Ptosis occurs with strokes of the posterior inferior cerebellar artery. |
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Dysphagia-explain
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Dysphagia (difficulty swallowing) is common with impaired blood flow to the vertebralbasilar arteries and to the posterior inferior, anterior inferior, or superior cerebellar arteries.
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1. The client experienced neurologic changes from a transient ischemic attack. Family mambers exhibit an understanding of this condition if they discuss with the nurse that associated deficits from this pathology will be gone within what timeframe?
1. Several hours 2. Several weeks 3. 36-48 hours 4. Over 2-3 months |
Several hours
Rationale: Clients who experience a TIA should have resolution of symptoms within several minutes or within a maximum of 24 hours. Reversible ischemic neurologic deficits usually resolve within several days and with an evolving CVA there are usually permenant neurological deficits. |
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2. In reviewing the client's plan of care, the home care nurse has identified interventions that relate to the client's hemiparesis after the event of an embolic stroke. The nurse would expect to see what documentation by the support staff who had cared for this client within the past month?
1. The use of a walker for mobility in the home. 2. Full active range of motion for all extremities. 3. Full active or passive range of motion for all extremities. 4. Demonstrates use of picture aids for communication. |
3. Full active or passive range of motion for all extremities.
Rationale: The client with hemiparesis, or weakness on one side of the body, needs exercise for both sides of the body. Active range of motion will be done on the unaffected side and passive range of motion will be done on the affected side to maintain or improve joint or muscle function. The other options may be appropriate for a stroke patient but not in relation to hemiparesis. |
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A client has damage to the left hemisphere of the brain. This will affect the client's ability to do what?
1. Hearing 2. Speech 3. Motor 4. Thoughts |
Speech
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Decorticate posturing-Define/describe
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Decorticate posturing-upper arms are close to the sides; the elbows, wrists, and fingers are flexed; the legs are extended with internal rotation; and the feet are plantar flexed
Decorticate posturing occurs with lesions of the corticospinal tracts |
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Decerebrate posturing: Define/Describe
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Decerebrate posturing is where the neck is extended, with the jaw clenched; the arms are pronated, extended, and close to the sides; the legs are extended straight out; and the feet are plantar flexed.
Decerebrate posturing occurs with lesions of the midbrain, pons, or diencephalon. |
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A client with a massive cerebral hemorrhage and loss of consciousness is scheduled for an electroencephalogram (EEG). The nurse is discussing the purpose of the test with the family. It would be most accurate for the nurse to tell family members the test will measure:
A. extent of intracranial bleeding B. sites of brain injury C. activity of the brain D. percent of functional brain tissue |
Answer C: activity of the brain
An EEG measures the electrical activity of the brain. Extent of intracranial bleeding and location of the injury site would be determined by computerized tomography or magnetic resonance imaging. Percent of functional brain tissue would be determined by a series of tests. |
