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RNSG 2432 - CVA / Brain aneurysm
Terms in this set (54)
ischemic or occlusive stroke
type of stroke; caused by occlusion of the artery; no LOC, better prognosis than hemorrhagic, & may have TIA's before their stroke
- Lacunar infarct
occurs during activity, has a rapid onset, possible LOC, poorer prognosis than occlusive.
- Intracranial hemorrhage (ICH) = caused by a ruptured artery in the brain
- Subarachnoid hemorrhage (SAH) = bleeding into the subarchnoid space from intracranial hemorrhage, a berry (sacular) aneurysm or AV malformation
Non-modifiable: age, gender, ethnicity, race, family hx of stroke or prior TIA.
HTN = most important
, heart disease, smoking, high cholesterol, excessive alcohol consumption, obesity, sleep apnea, poor diet, DM, drug abuse
What are the major non-modifiable & modifiable risk factors for stroke? What is the single most important modifiable risk factor?
Type of ischemic stroke; embolus becomes lodged in artery and causes occlusion. Results in infarction & edema. Bifurcations are most common site
- Sudden onset with immediate deficits
- Other causes
, MI, IE, valvular prostheses, rheumatic heart disease
- Patient remains conscious; may complain of headache (Recurrence is common)
Type of ischemic stroke;
Most common cause of "brain attack"
- Injury to vessel wall; formation of blood clot
- May be preceded by a TIA. *Rapid event, but slow progression (usually reach max deficit in 3 days)
Type of ischemic stroke; Occlusion of a small penetrating artery (form of thrombotic stroke)
- Small, deep penetrating arteries = *Commonly occurs in:
Thalamus, Basal ganglia, Pons
*Usually asymptomatic; If symptoms are present:
contralateral loss of sensory modalities, pure motor hemiplegia, contralateral leg & face weakness, arm & leg ataxia
Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but w/o acute infarction of the brain
--- Symptoms typically last <1 - 2 hrs, sometimes longer but always <24 hrs
Warning sign for stroke
- brief localized ischemia probable d/t microemboli that temporarily block the blood flow
S&S = depend on blood vessel involved
Carotid System: amaurosis fugax (temp loss of vision in one eye), transient hemiparesis, numbness or loss of sensation, sudden inability to speak
Vertebrobasilar System: tinnitus, vertigo, darkened or blurred vision, diplopia, ptosis, dysphagia, ataxia (lack of voluntary coordination of muscles)
What symptoms are usually present for TIA?
IV tPA - MUST be administered within 3 to 4.5 hours of symptom onset (all ischemic strokes EXCEPT TIA)
[After pt stabilized, to prevent further clot formation]
Blood thinner = Plavix
Anticoagulants =Coumadin, Lovenox
- Statins have been shown effective treatment for the patient with an ischemic stroke
1) Carotid endarectomy = Removing an atherosclerotic plaque in the carotid artery to prevent impending stroke (esp if the pt has had several TIA's)
2) MERCI clot removal
What is treatment (medications/ surgical) for TIA (ischemic strokes)?
Treatment must be initiated promptly after screening CT to r/o hemorrhagic stroke
-- Reestablish blood flow through blocked artery
-- Other fibrinolytic agents cannot be substituted for t-PA
IV t-PA MUST be administered within 3 to 4.5 hours of symptom onset.
May be given intraarterial (up to 6 hours)
-- insert a foley, NG tube & multiple IVs before administration
-- Control of BP is critical!
Timing is the most important factor here!!
Describe Thrombolytic Recombinant Alteplase (tPA) therapy.
Trauma within 3 months
History of prior intracranial hemorrhage
AV malformation or aneurysm
Surgery within 14 days, pregnancy, cardiac cath within 7 days
What are the contraindications for tPA?
Bleeding within brain d/t rupture of vessel (10% of all strokes)
Prognosis is poor
; 50% of deaths occur in first 48 hrs
HTN = most common cause
Other causes: vascular malformations, coag disorders, anticoag & thrombolytic, trauma , ruptured aneurysms
S&S = Commonly occurs during periods of activity; Sudden onset of SS; progression of SS over min to hrs.
Initially-SEVERE HA w/ N&V *
Other SS: neurological deficits (weakness, vision changes, slurred speech, loss of balance, dilated pupils, etc.), decreased LOC, HTN, coma
Describe ICH. What causes it? What symptoms would the patient present with?
maintain normal BP (SBP <160)
2) Seizure Prophylaxis: phenytoin (Dilantin), levetiracetam (Keppra), lamotrigine (Lamictal) - seizure activity may result in further neuronal injury & contribute to coma
3) Aneurysm precautions (decrease external and internal stimuli) -- mainly for SAH
4) Meds for aneurysms (aneurysm precautions; stool softeners, antiemetic, for headache, to sedate)
5) Meds that prevent re-bleed: Aminacproic Acid (Ammicar) fibrolysis inhibitor to prevent lysis of the formed clot/ prevent rebleed -- mainly SAH
6) Meds to prevent vasospasms (SAH):
: (Calcium Channel blocker) Nimodipine, minimize cerebral damage
: 'Triple H therapy' (hypertension, hypervolemia and hemodilution)-- vasodilators (Isuprel); induced arterial hypertension (Dopamine); hypervolemic hemodilution (Albumin)
1) Immediate evacuation of aneurysm-induced hematomas, or cerebellar hematomas > than 3 cm
- Use of clipping or coiling of the aneurysm; prevents rebleeding (ex: GDC coil) - used mainly for SAH
What is treatment for a hemorrhagic stroke (ICH & SAH)?
nimodipine (Nimotop) given w/in 24 hours of admission, do not want vasoconstriction cuz that could lead to ischemia, leading to an ischemic stroke on top of the hemorrhagic stroke
What will we assess before giving this medication?
Apical pulse-hold <60
BP-hold if syst <90
How do you prevent vasospasms? (in hemorrhagic strokes only)
TPA, anticoag, antithrombolytic
What meds are contraindicated in patients with hemorrhagic strokes?
Coiling - Used to occlude aneurysm
Metal coil is inserted into the lumen of aneurysm
Prevents blood from circulating through the aneurysm, reducing risk of rupture
Clipping- Reduces blood pulsations to aneurysm
Eventually, thrombus forms within aneurysm
Aneurysm becomes sealed off
What is the difference between coiling & clipping of an aneurysm?
Intracranial bleeding into the cerebrospinal fluid-filled space =
Commonly d/t rupture of a cerebral aneurysm
Other causes: cocaine, trauma
, LOC may or may not occur (can range from alert to comatose), N&V, seizures, stiff neck
prognosis = poor
Describe SAH. What is the most common cause? What are S&S?
Complications = re-bleeding before surgery & vasospasm (6-10 days after initial bleed)
What are 2 complications of SAH?
abnormal tangle of arteries & veins in the brain (frequently in middle cerebral artery)
- Can cause a seizure or ICH; Genetic
1. Endovascular surgery
3. Radiosurgery (if a person has an AVM and experiences a hemorrhagic stroke d/t rupture of the AVM, the tx may be surgical resection and or radiosurgery (ie gamma knife) - This may be preceded by neuroradiology to embolize the blood vessels that supply the AVM
What are AV malformations? What is treatment?
(3-7) severe coma
What is the Glascow Coma Scale
NIH stroke scale.
Measures degree of stroke r/t impairment and change in a patient over time.
Helps determine if degree of disability merits treatment with tPA
(as of 2008 stroke patients scoring greater than 4 points and less than 20 points can be treated with tPA)
Points are given for each impairment:
0= no stroke
1-4= minor stroke
5-15= moderate stroke
15-20= moderate/severe stroke
21-42= severe stroke
** A maximal score of 42 represents the most severe and devastating stroke.
Anti-platelets: decrease platelet aggregation & prevent thrombus formation
- ex: Aspirin, Plavix, Effient
Anti-coagulants: prevent coagulation (clotting) of the blood
- ex: Heparin, Lovenox
What is the difference between anti-platelet and anticoagulant medications? Give the name of an anti-platelet medication? Give the name of an anticoagulant medication?
Motor Function = [
A lesion on one side of the brain affects motor function on the contralateral side
] = Depressed reflexes, spasticity of muscles, weakness to upper extremities
Communication = aphasia, dysphasia, dysarthria, dysphagia
Affect = depression, difficulty controlling emotions
Intellectual Function = impaired memory and judgment
Spatial-Perceptual Alterations= incorrect perception of self and illness
Elimination = constipation, frequency, urgency, incontinence
What general clinical manifestations would you expect to find in patient with a CVA? (motor function, communication, affect, elimination)
Right = 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 judgment, impaired time concept
What manifestations would you expect to find in a patient with right-sided brain damage (stroke on right side)?
Left = paralyzed RIGHT side, impaired speech/ language aphasias, impaired right/ left discrimination, slow performance/ cautious, aware of deficits (depression/ anxiety can occur), impaired comprehension r/t language & math
What manifestations would you expect to find in a patient with left-sided brain damage (stroke on left side)?
Largest cerebral artery (most common occlusion site for ischemic stroke)
- branches off internal carotid artery
- provides blood flow to frontal, temporal, parietal lobes & basal ganglia
Facial symmetry (droopiness)
Discuss the middle cerebral artery (MCA) and clinical manifestations you would expect on a patient if this area was affected by a stroke?
Pain in face, nose, or eye
Affected side numbness, weakness of face
Dysarthria (difficulty controlling speech)
What clinical manifestations would be present if the vertebral artery was affected?
The internal carotid divides into two large branches, the middle and anterior cerebral arteries, and symptoms arise from disruption of blood flow to the areas they supply.
Contralateral paralysis (arm, leg, face)
Contralateral sensory deficits
Aphasia (dominant hemisphere involvement)
Apraxia (motor task)
Agnosia (obj. recognition)
Unilateral neglect (non-dominant hemisphere involvement)
Homonymous hemianopia (vision loss in 1/2 of both eyes)
What clinical manifestations would be present if the internal carotid artery was affected?
F (face) = Ask the person to smile. Does one side of the face droop?
A (arms) = Ask the person to raise both arms. Does one arm drift downward?
S (speech) = Ask the person to repeat a simple phrase. Is their speech slurred or strange?
T (time) = If you observe any of these signs, call 911 immediately.
Describe "Act FAST" and how it describes the warning signs of stroke.
Ensure patent airway!
Call "Stroke Alert" Code
Remove dentures, keep patient NPO
Obtain pulse oximetry
Maintain adequate Sa02 ( > than 95%) ; O2 if necessary
Maintain BP within parameters (check MAP)
Obtain CT scan, immediately!
Obtain baseline labs (ex: glucose), Obtain IV access
Position head midline; HOB 30 (if no shock/injury, or cervical damage)
Institute seizure precautions-suction, pad rails
NIH Stroke Scale, Glasgow Coma Scale
Anticipate thrombolytic therapy for ischemic stroke
What is involved in the initial stroke assessment/ intervention?
CT = single most important dx tool
- Can rapidly distinguish between hemorrhagic & ischemic stroke
2) CT angiography (CTA) - visualization of cerebral blood vessels & estimation of perfusion
3) MRI- determine extent of brain injury
4) Magnetic resonance angiography (MRA)- can detect vascular lesions & blockages
5) Cerebral angiography- Identify source of SAH
Risks = lodging embolus, vasospasm, inducing further hemorrhage, allergic reaction to contrast media
6) Transcranial Doppler - Measures velocity of blood flow in cerebral arteries
7) Lumbar Puncture -Look for evidence of RBC's in cerebrospinal fluid (contraindicated if signs of IICP)
CBC, Electrolytes, Renal & hepatic profiles, Blood glucose , Lipid profile, CSF analysis ,Coag studies , EKG
What diagnostic tests would be ordered for a patient with a potential stroke?
total loss of comprehension & use of language or total inability to communicate
Difficulty with articulation or muscular control for speech; sound like they have mashed potatoes in their mouth
Inability of the senses to perceive stimuli that were previously familiar; may be any of the senses and in varying degrees
impaired ability to communicate
inability to carry out purposeful tasks in the absence of paralysis, or the individual carries out the task inappropriately (ex: tries to comb hair w/ toothbrush)
decreased vision or blindness in half the visual field of one or both eyes, usually on one side of the vertical midline
primary goal = Prevention of increased ICP
Do not position patient on the operative side.
Observe the dressing for color, odor & amount of drainage.
Notify surgeon immediately of excessive bleeding or clear drainage.
Check drains for placement & assess the site.
Once dressing is removed, use an antiseptic soap for washing the scalp.
What are the priority nursing considerations for a post-operative patient who has undergone a craniectomy?
Discharged on antithrombotic therapy (ASA)
Anticoagulation therapy for a-fib/flutter (Coumadin)
Thrombolytic therapy (tPA)
Antithrombotic therapy by end of hospital day 2
Stroke education provided
Assessed for rehabilitation
What are the quality measures for stroke put in place by the Joint Commission?
Primary: (stoke quality measures - see prior slide)
Get With the Guidelines (American Stroke Association)
The Joint Commission
CT scan and/or MRI available 24 hours/day and available for stroke patients within 25 minutes of being ordered
Access to neurosurgical team
Lab tests for stroke patients completed within 45 minutes
Stroke team available 24 hours/day
Designated stroke unit
NIHSS score performed for ischemic stroke patients
Modified Rankin Score
Severity measurement performed for SAH & ICH
Procoagulant reversal agent (INR >1.4 with ischemic)
Nimodipine treatment administered
Median time to revascularization
Thrombolysis in cerebral infarction
What is the difference between a Primary Stroke Center and a Comprehensive Stroke Center measures?
The nurse would expect to find which of the following clinical manifestations in a patient admitted with a left-brain stroke?
B. Impaired speech
C. Left-side neglect
D. Short attention span
Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language aphasias, impaired right/left discrimination, and slow and cautious performance. The other options are all manifestations of right-sided brain damage.
The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which of the following medications might the nurse expect to provide discharge instructions (select all that apply)?
A. Clopidogrel (Plavix)
B. Enoxaparin (Lovenox)
C. Dipyridamole (Persantine)
D. Enteric-coated aspirin (Ecotrin)
E. Tissue plasminogen activator (tPA)
Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke, not prevent TIAs.
Which of the following nursing interventions is most appropriate when communicating with a patient suffering from aphasia poststroke?
A. Present several thoughts at once so that the patient can connect the ideas.
B. Ask open-ended questions to provide the patient the opportunity to speak.
C. Use simple, short sentences accompanied by visual cues to enhance comprehension.
D. Finish the patient's sentences so as to minimize frustration associated with slow speech.
When communicating with a patient with aphasia, the nurse should present one thought or idea at a time; ask questions that can be answered with a "yes," "no," or simple word; use visual cues; and allot time for the individual to comprehend and respond to conversation.
Computed tomography of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. Which of the following is a nursing priority intervention in the emergency department?
A. Maintenance of the patient's airway
B. Positioning to promote cerebral perfusion
C. Control of fluid and electrolyte imbalances
D. Administration of tissue plasminogen activator (tPA)
Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke, and supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.
Which of the following sensory-perceptual deficits is associated with left-brain stroke (right hemiplegia)?
A. Overestimation of physical abilities
B. Difficulty judging position and distance
C. Slow and possibly fearful performance of tasks
D. Impulsivity and impatience at performing tasks
Patients with a left-brain stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-brain stroke.
Info provided by a patient that would help differentiate a hemorrhage stroke from a thrombotic stroke includes:
a) sensory disturbance
b) history of hypertension
c) presence of motor weakness
d) sudden onset of severe headache
A patient with right-sided hemiplegia & aphasia resulting from a stroke most likely has involvement of the:
b) vertebral artery
c) left middle cerebral artery
d) right middle cerebral artery
The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the:
a) amount of cardiac output
b) oxygen content of the blood
c) degree of collateral circulation
d) level of carbon dioxide in the blood
The incidence of ischemic stroke in patients with TIA's and other risk factors is reduced with the administration of:
A. furosemide (Lasix)
B. lovastatin (Mevacor)
C. daily low-dose aspirin (ASA)
D. nimodipine (Nimotop)
A client arrives in the emergency department with an ischemic stroke. The nurse should first:
A. Ask what medications the client is taking
B. Complete a history and health assessment
C. Identify the time and onset of the stroke
D. Determine if the client is scheduled for any surgical procedures
The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will:
A. Have a preference for foods high in salt
B. Eat food on only half of the plate
C. Forget the names of foods
D. No be able to swallow liquids
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's:
C. Blood pressure
When communicating with a client who has aphasia, which of the following are helpful? Select all that apply:
A. Present one thought at a time
B. Avoid writing messages
C. Speak with normal volume
D. Make use of gestures
E. Encourage pointing to the needed object
What is the priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
A. Cholesterol level
B. Pupil size and pupillary response
C. Bowel sounds
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