Terms in this set (81)
an interruption in blood flow to the brain that results in the death of brain cells and can have consequences for movement, sensation or emotions
How are ischemic stroke and hemorrhagic stroke distinct?
ischemic is the result of an embolism or thrombosis, hemorrhagic stroke is the rupturing of a cerebral vessel, causing bleeding into the brain tissue
What are the risk factors for stroke?
hypertension (modifiable), prior ischemic episodes (TIA), cardivascular disease/atrial fibrillation, oral contraceptives, emotional stress, family history, advancing age, diabetes mellitus, obesity
Describe the pathophysiology of stroke, ie what happens when someone has a stroke
blood flow reduced or interrupted, which leads to interruption of nerve impulses down corticospinal tract, leading to decreased or absent voluntary movement on one side of the body (fine movements are more affected than coarse movements), leads to later autonomous reflex activity, leading to spasticity and rigidity of muscles
What are the subjective signs and symptoms of a stroke?
2.sudden or gradual loss of movement of extremities on one side
3. difficulty forming words
5 nausea, vomiting
6. history of TIAs
Why is "brain attack" becoming the preferred method of describing stroke?
because it communicates the urgency of the situation, and the need to seek immediate medical attention. Individuals suffering stroke might not always see the need to go in right away
What racial groups have the highest risk of stroke and why?
1.African American, related to increased rates of hypertension, diabetes mellitus, and sickle cell anemia,
2. related to higher incidence of smoking and obesity
3.Native American, Hispanic, and Asian Americans also have a higher incidence than whites
What are the modifiable risk factors for stroke?
3. excessive ETOH consumption
6. metabolic syndrome
7. lack of physical exercise
8. poor diet and drug abuse
11. use of high dose oral contraceptives
What is the single most important modifiable risk factor for stroke?
Besides hypertension, what else is a significant factor for increased stroke risk?
inadequate blood flow to the brain that happens because of a complete or partial blockage of an artery, and accounts for approximately 80% of all strokes
Types of ischemic strokes
thrombotic and embolic strokes
This is usually a precursor to an ischemic stroke
Transient ischemic attack
What is a TIA?
a temporary loss of neurologic function that is caused by focal brain, spinal cord or retinal ischemia, but without an acute infarction (tissue death) of the brain
Why is it important to seek immediate medical treatment for a TIA?
because it may be a warning of a stroke, and they are a warning of progressive cerebrovascular disease
Signs of a stroke
1.sudden numbness or weakness in the face, arm or leg, especially on one side of the body
2. sudden confusion or trouble speaking or understanding; 3.sudden trouble seeing on one or both eyes
4. sudden trouble walking
5. dizziness or loss of balance/coordination
6. sudden severe headache with no known cause
What is the main difference between a TIA and a stroke?
in TIA ischemia occurs without infarction, but in a stroke, infarction and cell death occur
This type of stroke occurs from injury to the blood vessel wall and formation of a blood clot, and occur readily where artherosclerotic plaques have already narrowed blood vessels, accounts for 60% of strokes
This type of stroke happens when an embolus lodges and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel, and many originate in the endocardial layer of the heart
What is the tie between atrial fibrillation and embolitic stroke?
Because many of these types of stroke originate in the endocardial layer of the heart, and because atrial fibrillation may mean that the heart misses beats, causing blood to stagnate and increasing the likelihood of clot formation
What is the onset of an embolitic stroke?
tends to be rapid onset of severe clinical symptoms, warning signs are less common and may or may not be related to activity
What is hemorrhagic stroke?
results from bleeding into the brain tissue or into subarachnoid space or ventricles
What are some causes of intracerebral hemorrhage?
1.hypertension (most important)
3. coagulation disorders
4.anticoagulant and thrombolytic drugs
7.ruptured aneurysms, commonly occurs during periods of activity
What are the symptoms of intracerebral hemorrhage?
3. decreased LOC
What are the nonmodifiable risk factors for stroke?
1.age (2/3rds occur in individuals 65+),
2. more common in men (but women have higher mortality), ethnicity (African Americans)
3. family history
4. prior TIA/stroke
What is the difference between the clinical manifestations of an ischemic and hemorrhagic stroke?
there really aren't any significant differences because destruction of neurologic tissue is what causes symptoms in both kinds of stroke
How would right brain damage affect motor function?
1. left side hemiplegia
2. left side neglect, shoulder on affected side rotates internally and hip rotates externally.
How is affect/mood affected by right brain damage?
1. tends to deny/minimize problems
3. poor attention span
4.impulsivity = safety problems
6.impaired time concepts
How is affect/mood affected by left brain damage?
1. slow performance
3. aware of deficits
5.impaired comprehension related to math and language
Which side of the brain would result in speech/language aphasias?
Which side of the brain would involve impaired right/left discrimination?
Which side of the brain would result in impaired comprehension related to language and math?
Which side of the brain would result in impaired time concepts?
Which side of the brain would result in a minimizing or denial of problems?
total loss of comprehension and the use of language or inability to communicate
impaired ability to communicate
disturbance in the muscular control of speech
What side of the brain would you suspect is damaged if your client is having difficulty with language?
How is affect impacted by stroke?
patients may have emotional responses that are unpredictable or exaggerated, and may also become depressed or frustrated with their condition
Which side of the brain is associated with memory problems related to language?
Which side would you suspect a patient had a stroke if you saw them displaying impulsivity and quick movements?
Which side of the brain is more likely to produce problems with spatial-perceptual alterations?
What kinds of sensory alterations are commonly observed with stroke?
1.incorrect perception of self and illness, erroneous perception of self in space
2.difficulty with spatial orientation (judging distances), 3.agnosia
blindness occurs on the same half of the visual fields of both eyes
What are some concerns with elimation in stroke patients?
problems with urinary and bowel may be temporary and prognosis for normal bladder function is excellent if stroke affects one hemisphere of brain. Problems may be related to inability to express need to toilet or manage clothing
What is the single most important diagnostic tool for patients who have experienced a stroke and why?
noncontrast computerized tomography (CT) scan because it can rapidly distinguish between ischemic and hemorrhagic stroke and help determine size and location of the stroke
What does a CT angiography provide in stroke assessment?
visualization of cerebral blood vessels, provides an estimate of perfusion and detect filling defects in the cerebral arteries
What is an MRI used for in diagnosis/assessment of stroke?
determining the extent of brain injury. MRA can detect vascular lesions and blockages
What assessments would be used to diagnose a stroke?
What assessments would be used to assess cerebral blood flow?
cerebral angiography, carotid angiography, digital subtraction angiography, Transcranial Doppler ultrasonography, carotid duplex scanning
What other lab tests might be done for a patient with a stroke?
CBC including platelets, PTT, aPTT, electrolytes, BG, renal and hepatic studies, lipid profile, CSF analysis
What medications would you expect to be administered for patients with TIA/stroke?
antiplatelet (aspirin), toclopidine, Plavix/clopidogrel, dipyridamole (Persantine), Aggrenox, statins (simvastatin, lovastatin)
What is the medication of choice for individuals with have atrial fibrillation and who have had a TIA?
What is a carotid endarectomy?
the artheromatous lesion is removed from the carotid artery to improve blood flow
What is an important nursing consideration for patients receiving a caroitid endarectomy?
protection of airway, ensuring patency
What is the single most important piece of information from a patient experiencing a stroke?
the time of onset
What are the main goals of collaborative care in the acute phase?
preserving life, preventing further brain damage, and reducing disability
What are some important airway/breathing considerations in the acute phase of a stroke?
1.maintenance of airway r/t decreased LOC
2. absent gag/swallow reflex
3.maintaining adequate oxygenation
4. avoiding hypoxia and hypercarbia
5, realize need for O2
7.mechanical ventilation might be required
When is use of drugs to lower BP recommended after a stroke?
only if BP is markedly increased (220+/130+)
What can a nurse do to help control fluid and electrolyte balance during the acute phase of a stroke?
1.ensure adequate fluid intake
2.monitor urine output,
3.avoid solutions with glucose and water because may increase cerebral edema/ICP
4, monitor for hyperglycemia.
What are major nursing considerations related to the administration of tPA?
can only be administered within 3-4.5 hours of onset of signs of clinical ischemic stroke, need for inserting a catheter, NG tube, multiple IVs before tPA can be administered, monitoring V/S and neuros while tPA administered, BP followed closely up to 24 hours after administration
Besides tPA, what else might be administered during the acute phase of a stroke?
aspirin within 24-48 hours after the onset of an ischemic stroke
Why is the administration of anticoagulants not recommended during the acute phase of a stroke?
because of the increased risk for intracranial hemorrhage
What kind of drugs should NOT be used in patients with hemorrhagic stroke?
anticoagulants and platelet inhibitors
What is the main drug therapy for patients with hemorrhagic stroke?
management of hypertension, po and IV
What can we do to help prevent a stroke from happening in the first place?
teach strategies to reduce risks associated with modifiable factors
What are the common complications of immobility in a stroke patient and what can be done to prevent them?
joint contractures and muscle atrophy, prevented through range of motion and positioning. Dependent edema-position each joint on paralyzed side higher than the joint proximital to it.
What can the nurse do to optimize musculoskeletal function in a stroke patient?
trochanter roll at hip to prevent external rotation, hand cones to prevent contractures, arm supports with slings and lap boards to prevent shoulder displacement, avoiding pulling the patient by the arm to prevent shoulder displacement, posterior leg splints, footboards or high top tennis shoes to prevent footdrop, hand splints to reduce spasticity
What is the most common GI problem for patients who have experienced a stroke and what are nursing interventions for this problem?
constipation, increased fiber, stool softeners, fluid balance,
What is included in a bladder training program?
1. adequate fluid intake with majority between 8 am and 7 pm, 2. scheduled toileting every 2 hours using bedpan, commode and bathroom 3. noting signs of restlessness which might indicate need to go to the bathroom
Why are long term catheters contraindicated in stroke patients?
because of the risk of infection and because it interferes with a bladder training program
What needs to happen before a patient can recieve oral feedings?
they need to have their gag reflex checked using a tongue blade, water or crushed ice
What are some nursing interventions that can help facilitate feeding in stroke patients?
elevating the bed to high fowler's position, pt should remain for 30 minutes after meal, mouth care can stimulate sensory awareness and salivation, facilitating swallowing. Foods should be easy to swallow and provide enough texture, temperature and flavor to stimulate a swallow reflex, thin liquids should be avoided, avoid milk products -> increase viscosity of mucus and increase salivation. Place food on unaffected side of mouth. follow with oral hygiene
How can a nurse help a stroke patient who is having difficulties with communication?
assess both ability to speak and understand. use simple words, sentences, use visual cues and gestures, speak slowly and calmly, give extra time to comprehend and respond, present one thought/idea at a time
What interventions would be appropriate in patients with sensory-perception alterations?
putting things in field of vision, training to scan both sides (hemianopsia), provide for safety in environment,
What should a nurse do to assist patients and families with coping after a stroke?
clear explanations about diagnostic and therapeutic procedures and about what has happened, upholding patient's wishes and right to decision making, advanced directives should be honored, daily family meetings, repeat explanations later if needed r/t anxiety and fear, refer to social services if necessary (family generally does not have time to prepare and needs support) Use writing and communication boards if appropriate
What interventions are involved in a bowel management program?
placing pt on toilet or commode or bedpan at regular time daily to promote regularity, generally 30 minutes after breakfast
What nursing interventions will assist with maintenence of bladder function?
assessment for bladder distention by palpitation, offering bedpan/urinal/toilet q 2 hours during waking hours and 3-4 hours at night, focusing patient on need to urinate with direct command, assistance with clothing and mobility, scheduling most of fluid intake between 7AM-7PM, encouraging usual position for urinating
What medication reverses Coumadin?
What assessment findings would there be in a patient who has sufffered from a TIA?
generally symptoms are gone when they come to the hospital, but they may have high blood pressure
What labs are used to monitor anticoagulant therapy?
PTT, INR, PT, heparin level