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medsurg exam 4
stroke
| Question | Answer |
|---|---|
| incidence of strokes | > 795,000 strokes/year ~610,000 1st time strokes ~185,000 recurrent strokes |
| strokes are the | 5th leading cause of death in US - 140,000 deaths per year |
| If you survive 1st stroke then, | 9x more likely to suffer 2nd stroke |
| non modifiable risk factors for stroke | Men > women Age (increases with age) African-American > Caucasians > Hispanic or Asian/Pacific Islander Family history Previous Stroke or TIA Sickle Cell Anemia |
| modifiable risk factors for stroke | Smoking ETOH Obesity/Excessive weight High cholesterol Hypertension Diabetes Heart Disease |
| heart diseases that are modifiable risk factors | Atrial Fibrillation Heart Failure MI Valvular Disease |
| ischemic stroke occurs when | a clot blocks blood flow to an area of the brain |
| hemorrhagic stroke occurs when | bleeding occurs inside or around brain tissue |
| ischemic stroke types | embolic and thrombotic |
| embolic ischemic stroke | obstruction arises elsewhere, heart is most common location of obstruction - HF, MI, afib, blood stasis: forms clot which breaks off and travels to the brain |
| thrombotic ischemic stroke | local bf is stopped by obstruction which ruptures and releases chemicals into the brain |
| endocarditis can also causes ischemic stroke because | infectious formations on the valve, ppl with valve replacements are at higher risk |
| subarachnoid hemorrhage occurs | outside the brain, on the surface |
| subarachnoid hemorrhage | extreme narrowing of arteries ruptured cerebral aneurysm vasospasms occur which occur in 3 days, breakdown of hemorrhagic blood |
| intracerebral hemorrhage occurs | within structure of the brain |
| intracerebral hemorrhage | hematoma continues to grow until ruptures of is limited, CSF leaks into brain hemorrhage twists and ruptures neurons which causes irreversible brain damage |
| mortality in hemorrhagic strokes is | increased |
| duration of hemorrhagic strokes depends on | location |
| how to spot a stroke | B: balance E: eyes F: facial drooping A: arm weakness S: speech difficulty T: time to call 911 |
| the fast scale is | cincinnati stroke scale |
| CMs of stroke | Headache Dependent on area affected Weakness/paralysis Speech Sensation Visual Decreased LOC Cognitive |
| aphasia types | expressive, receptive, global |
| expressive aphasia | can understand others but can't produce words and speak |
| receptive aphasia | unable to understand and follow commands |
| global aphasia | both receptive and expressive |
| aphasia does not affect | intelligence |
| dysarthia | difficulty speaking |
| dysphagia | difficulty swallowing |
| ataxia | unsteady gait |
| hemiparesis | weak face or leg of one side |
| hemiplegia | one sided paralysis |
| ischemic penumbra | area with dead tissue and around has decrease O2 perfusion, so if you can get to the pt quick enough and administer anticoagulants, you can prevent clot and brain death |
| interventions for ppl with aphasia | speak normally, don't finish their sentences, be sensitive to noise, turn off distracting noises, use other forms of communication, slow down and give them time |
| strokes can cause Homonymous Hemianopia, which is (KNOW) | a visual defect that causes you to only see half the field |
| people with Homonymous Hemianopia | have unsteady footing, get startled by movements on their blind side bruising on shoulder from walking into stuff, difficulty reading, spill drinks, hard time going into public |
| where the clot is decides | the CMs |
| unilateral neglect | attention disorder, pts fail to realize they're not able to move their arm (ex) which can cause injuries |
| lacunar stroke occurs in | deep part of brain/brainstem |
| contralateral deficits | right vs left |
| right sided deficits | Left paralysis Left neglect Short attention Impulsive Impaired judgment Impaired time concepts |
| left sided deficits | Right paralysis Impaired speech Impaired right/left discrimination Depression Impaired comprehension r/t language and math |
| watershed stroke | decrease in BP, can get to main artery but arteries around in are not getting enough blood flow to get o2 to the areas can be unilateral can be a result of CA, drug OD |
| Initial Evaluation | Note time of onset of symptoms Rapid transport Assess ABCs and glucose Use of stroke scales: Cincinnati, NIH Monitor Neuro status EKG Patient history |
| why do you assess glucose | hypoglycemia can mimic a stroke |
| why do you do an EKG | most emboli come from the heart in ischemic strokes, common in afib, pts go on anticoags |
| cincinnati scale | FAST |
| NIH scale | scores from 0-42, based on 11 diff items NIH score >25 = large stroke |
| Diagnostic Studies | CT Scan MRI/MRA Carotid Dopplers TTE/TEE C-spine if any trauma or infection suspected Labs: tox screen, BAL, liver tests or glucose |
| CT scan sensitivity | highest within 6-12 hrs decline to 58% in 6 days |
| MRI types | diffusion and perfusion |
| diffusion MRI | micro water movement in brain, bf decrease and tissue swells |
| perfusion MRI | looking at actual bf to brain |
| MRA | angiography, looking for aneurysms |
| dopplers to | look at carotids |
| treatment of ischemic stroke | Antiplatelet Therapy Decrease dose or stop antihypertensives Continue any statins Utilize insulin sliding scale Stool softener/laxative Tylenol Heparin (IV) |
| Antiplatelet Therapy | ASA Plavix Aggrenox (ASA & persantine) |
| why do we want to decrease dose or stop antihypertensives | because we want to keep BP up, systolic should be above 140 |
| tPA | tissue plasinogen activator |
| when can tPA be used | if onset of symptoms was < 3 hours ago Window of time widen to 4.5 hours for certain criteria |
| who can tPA be used on in 4.5 hrs | anyone besides for >80 yrs, on anticoags, NIH >25 or history of stroke |
| Baseline CT Scan with no hemorrhage to make sure | ischemic not hemorrhagic |
| tPA can only be only is NIH number is greater than/equal to 5 bc | consequences of tPA outweigh the low stroke which Sx will resolve |
| tPA exclusion criteria (KNOW) | Evidence of hemorrhage Minor/rapidly improving symptoms - low NIH Active internal bleeding Known bleeding tendencies (INR >1.5) Heparin in last 48 hours SBP >185 mmHg or DBP > 110 mmHg Recent surgery (2 weeks – 3 months) Seizure at time of stroke |
| Surgical Treatment | bypass graft or put in a stent |
| Endovascular Procedures | can grab clot and pull it out |
| for large ischemic strokes, | keep HOB flat unless aspiration risk or increase in cerebral pressure |
| Tx for Hemorrhagic | Antihypertensives Insulin sliding scale Stool softeners/laxative GI prophylaxis Possible antiepileptic if seizures |
| coiling procedure to | decrease risk of aneurysm rupture |
| coils induce | blood clotting |
| clipping procedure of coiling | open procedure |
| nursing interventions of strokes | Monitor neuro status Monitor BP Positioning Monitor respirations (prevent aspiration) Mobilize!! (PT/OT) (prevent DVTs & con-tractions) Skin care Nutrition Assist communication |
| when monitoring neuro status, keep in mind that | there was trauma to the brain so its expected to have some issues until the swelling goes down |
| when positioning a pt, keep in mind | the HOB up when hemorrhagic stroke 24 hr bed rest initially |
| assess nutrition | depends on if they can swallow, if not then tube feeds |
| collaborative care | PM & R PT OT Speech |
| rehab after a stroke | As early as possible Specialized rehab when possible Need to involve patient and family |
| Psychosocial Impact of a stroke | Affects whole family Changes may be lifelong Independence vs dependence Be aware of fear, apprehension, denial, depression, anger, and sorrow |
| pt and family may need support from | social work, psych, chaplain |
Created by:
leh195