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GRCC 141 CVA Stroke
GRCC PN141 Stroke
| Question | Answer |
|---|---|
| What is the 3rd leading cause of death in US? | CVA- 750,000 CVA's happen each year; |
| Condition where there is a decreased blood flow to the brain and it causes brain defecits | CVA - AKA brain attack or stroke |
| Whose at greatest risk? | Over 65 years old; African American > than caucasions; males; family hx. |
| Risk factors for CVA's | HTN, DM, obesity, Afib, athersclerosis; smoking, High cholesteral diet, excessive ETOH, cocaine & heroin; intake birth control pills |
| What is a warning sign of CVA? | TIA |
| How many TIA's before stroke? | Multiple TIA's can occur. |
| What is a TIA? | A small obstruction but lood flow restored (no actual necrosis/infarction results) |
| Will TIA show up on any tests? | Probably not.....CT and MRI will show up negative |
| Any long lasting defecits with TIA? | Neuro defecits are reversible. |
| How long does TIA last? | Few minutes to one hour (<24 hours) |
| S&S of TIA | Weakness, numbness, facial drooping |
| Why does Afib cause CVA? | Because Blood pools |
| What is the time from between a TIA and CVA? | Hours to months |
| S&S of TIA | Dizziness, visual loss in one eye, one sided numbness or weakness of the fingers, arms, legs or aphasia. |
| What is the goal of tx a TIA? | Preventing a stroke |
| How do you assess if a TIA? | Assess as if it were a stroke. |
| Risk Factors of TIA | HTN, DM, LDL, Smoking, etoh and tlc |
| Risk Factors for CVA | Age >65, Previous stroke (TIA), HTN, atherosclerosis/CAD, Afib; High cholesterol, obesity/sedentary lifestyle;diabetes;smoking |
| What medication increases clotting factor? | Birth control pills |
| What are non-modifiable risk factors? | Congenital defects and heart disease. |
| What are modifiable risk factors? | Smoking, drugs/meds, ETOH abuse, diet, etc.. |
| What is cerebral infarction? | Decrease blood flow to cerebral tissues, decrease oxygen leads to ischemia and eventually cerebral infarction. |
| Irreversible brain damage occurs when? | If brain experiences anoxia for more than 10 minutes |
| What are the signs and symptoms of a CVA? | Depends on the area of the brain, the size of area and collateral blood flow. |
| General complications of CVA | Can affect respiration, elimination and muscle function. |
| Thrombotic CVA | Atherosclerosis of large cerebral arteries. |
| How does atherosclerosis lead to a Thrombolic CVA? | This causes plaque build up in cerebral arteries. If plaque is not removed or treated, a thrombus or clot develops. This leads to ischemia in the brain tissue supplied by the vessel. |
| What type of CVA is from clot formation- impaired blood flow to brain resulting in ischemia to the brain? | Thrombolic CVA |
| Embolic CVA causes | Afib (blood pools), CHF, rheumatic heart disease, mitral valve disease and endocarditis |
| Which type of CVA has a sudden onset with immeadiate defecits? | Embolic CVA |
| Thrombotic CVA onset? | Happens during sleep, because blood flow slows down. |
| What type of stroke involves an embolus that travels from a distant site such as the heart? | An embolic stroke. It usually lodges in a narrow portion of a cerebral artery causes necrosis. |
| What causes Hemorrhagic CVA? | HTN |
| Which type of CVA has a sudden onset with activity? | Hemmorrhagic CVA |
| What type of CVA is caused by HTN? How does this happen? | Hemorrhagic stroke: HTN weakens a cerebral blood vessel causing it to rupture. This leads to bleeding into the brain tissue or subarachnoid space. |
| What is the 2nd most common CVA that has more sudden onset due to activity and causing immeadiate deficits? | Embolism or Embolic CVA |
| Hemorraghic is how common? | It is the 3rd most common cause of CVA with sudden onset usually during activity. |
| What causes a hemorragic CVA? | HTN that leads to cerebral aneuryism or trauma |
| How does HTN cause a hemorragic CVA? | This condition weakens cerebral vessel, it ruptures, and then bleeding in the brain tissue or subarachnoid space. |
| Bleeding in the area between the brain and the thin tissues that cover the brain. | Subarachnoid hemorrhage is? |
| Contralateral deficits | A stroke affecting the right side of the brain may cause contralateral paralysis, affecting the left arm and leg |
| Motor defecits of CVA | Opposite side of infarction; hemiparesis (weakness); Hemiplegia/Paraplegia (paralysis); flaccid then spastic (6-8 weeks post stroke) |
| What are some complications of immobility? | Self care defecit and degradation. |
| Motor defecits lead to what time of problems? | Immobility complications. |
| What are common immobility complications? | Thrombophlebitis;orthostatic hypotension;aspiration and pneumonia;contractures and decubitis ulcers. |
| Hemiparesis | Weakness of the left or ride side of the body. |
| Hemiplegia | paraylsis of the left or right side. |
| What happens initially right after a stroke with regards to hemiplegia | Initially the affected arm and leg are flaccid; they become spastic 6 to 8 weeks post stroke |
| What can spasticity lead to? | It can lead to adduction of the shoulder, flexion of the fingers, wrist, elbows and knee; external rotation of the hip. |
| Name some nursing interventions for motor defecit | Self care defecit- assist with bathing, eating, dressing, grooming, etc. |
| Nursing goal for motor defecits | Help pt to be independent in self care needs....doing things themself without assistance. |
| complication of CVA that affects communication and swallowing. | Speech defecits |
| Expressive (nonFluent) Aphasia | Can comprehend, but can't express or talk. Difficulty speaking or writing and finding the words to communicating. Damage to the Broccas area. |
| Receptive (Fluent) Aphasia | Speaks, but makes no sense and difficult to understand. |
| Global Aphasia | More severe & extensive; is a combination of expressive/receptive aphasia. |
| Dysphagia | Difficulty swallowing |
| Dysarthia | Difficulty speaking related to vocal music; affects quality and loudness. |
| Nursing sonsideration for stroke pt with speech deficits | pt is socially has a huge deficit; will feel isolated and will only hang out with few people if any who are familiar with condition. |
| complications that affect vision | Visual defecits |
| Diplopia | Double vision |
| Homonymous Hemanopia | Can only see half vision (peripheral vision doesn't work) |
| Global Aphasia | More severe & extensive; is a combination of expressive/receptive aphasia. |
| Dysphagia | Difficulty swallowing |
| Dysarthia | Difficulty speaking related to vocal music; affects quality and loudness. |
| Nursing sonsideration for stroke pt with speech deficits | pt is socially has a huge deficit; will feel isolated and will only hang out with few people if any who are familiar with condition. |
| complications that affect vision | Visual defecits |
| Diplopia | Double vision |
| Homonymous Hemanopia | Can only see half vision (peripheral vision doesn't work) |
| Complications of CVA that affects of senses | Sensory perceptual deficits |
| Agnosia | no recognition of familiar (can't recognize a toothbrush); pt won't know what to do. |
| Apraxia | unable to do familiar routine (want/able) e.g. brushing teeth or combing hair, even when paralysis is not present |
| Neglect syndrome (unilateral) | Ignores affected side of body (visual- not blind, sensory, or perceptual, Usually Rt side injury leads to left side neglect. |
| Visually and conceptually unable to see other side. | Neglect syndrome |
| Complication of CVA that affects mood and thought process | Cognitive and behavioral |
| Cognitive and behavioral deficits rt cva | Emotional, poor self-control and tolerance to stress, decreased attention, impulsive, memory impairments, impaired problem solving, depression |
| Right sided cva cog and behavioral deficits | Worst at being compulsive and unable to think logically. |
| Left sided CVA Cog and behavioral deficits | calmer, recognizes deficits and may become depressed and withdrawn. |
| When pt has altered perception of temperature, vibration, pain, pressure and proprioception (awareness of the body's position) | Sensory-perceptual deficits |
| Nursing consideration for pt who loses sensory and perception | This deficit increases risk for injury and self care deficit. |
| Sign and symptom of CVA that affects output | Urinary/GI |
| Urinary/GI deficit last how long post stroke? | if stroke happened in just one hemisphere, then it should be temporary. |
| What happens to urinary/FI initially following a stroke? | Pt may experience frequency, urgency and/or incontinence. |
| Does stroke affect bowel movements or cause constipation? | No. If pt has problem with BM or constipation, it is related to immobility. |
| Factors such as attention deficits and weakness or lac of coordination with tongue often contribute to what problem? | A stroke can impair the ability to swallow. |
| Dysphagia | Chocking, drooling, aspiration, or regurgitation. |
| Nursing consideration rt dysphagia | Inadequate nutrition. |
| What is nursing focus as a result of dysphagia? | It is on promoting adequate nutrition and focusing on preventing aspiration. |
| Right sided deficits | Left sided weakness (right sided facial); vision changes; spatial preception deficits; unilateral neglect; denies or unaware of deficits;easily distracted; poor judgement; impulsive, poor problem solving;Mem – out of sequence, parts of events |
| Left sided deficits | Rt sided weakness;(Lt sided facial) Aphasia/Speech; Aware of deficits ;Impaired intellect ability; Cautious, purposeful;Stress, Sad over losses;STM loss, Learning diff. |
| Client with TIA tx? | Usually will get meds or surgery |
| First steps once a CVA has been determined? | Medical team concentrates on diagnosing the type of CVA and preserving life. |
| First step in making a diagnosis? | MRI- it help to determine size and location and helps diffentiate on whether it is hemorrhagic or ischemic. |
| CT Scan | Is part of the first step process in dgx a stroke. it is comparable to MRI; 1 hour for ischemic. |
| Cerebral Arteriography | First step in Id'ing a stroke. It looks at Vessel abnormalities (such as an aneurysm) |
| What type of blood tests are done to help diagnose a stroke? | Cardiac markers and coag times |
| Carotid Doppler | Evaluates blood flow and id's if carotid artery is partially or fully obstructed. |
| Questions to ask when assesing pt history | Change in memory, confusion Sudden Headache Difficulty speaking, understanding Visual changes Impaired coordination, balance Numbness, tingling, weakness Medical Hx, Smoker, ETOH, Drugs, Meds (anticoags, insulin, anti-htn) |
| Physical assessment in helping to make diagnosis | Vitals & S/S of IICP LOC, Orientation, Affect Smile / Grimace Strength (grips/push-pulls), Gait Sensation Swallow Continence |
| What are s&s of IICP | HA, LOC change, pupil size, vs, temperature. |
| True or False? Is it okay to feed and drink before dgx is complete? | No..this is false. It is unsafe to feed or allow fluid intake until dgx has been finalized. |
| What is the immeadiate action during the acute phase? | The phase lasts between 24 to 72 hours of admission, and this is where the type of stroke is id'd. |
| What is the nurses goal in teaching the public regarding Suspected CVA | Goal is to educate to call 911....better safe than sorry. |
| Goals for the patient during the acute phase? | Preventing Neuro Deficits ABC’s will help with Perfusion; tPA candidate |
| Who is a tPA candidate and what to you have to watch out for? | Is one whose had a hemiplegic stroke- DO NOT GIVE THROMBOLYTIC |
| Another goal during the acute phase? | Decreasing ICP Oxygen (increase needs with IICP) BP Osmotic diuretics Anti convulsants |
| What are the first set of drugs for treatment/prevention of CVA's? | Anti-platelets; ASA (81-325mg), Clopidogrel (plavix) - GI (Aspirin) Ticlopidine (Ticlid) – Diarrhea & Rash Dipyridamole (Persantine)–Headache Aspirin & Dipyridamole (Aggrenox) – Bleeding Risk |
| Uses of Anti-platelets | Tx of TIA's, Acute and prevention Ischemic CVA (non-cardioembolic) |
| Adverse affects of anti-platelets | Thrombocytopenia (low platelet count) & GI, abdominal pain |
| Nursing considerations for using anti-platelets | Monitor signs and symptoms for bleeding, cost comparison. |
| If thrombotic or embolic stroke is suspected, then client is given a thrombolytic drug called alteplase :Activase (r-tPA) | Dissolve blood clots; but to be most effective, it needs to be done in less then 3 hours of stroke onset. |
| Consideration before administering thrombolytic drugs? | Intracerebral bleeding present |
| What type of drug therapy is used for thombotic strokes? | Anti-coagulants because they don't dissolve existing clots, but prevent new ones from forming. |
| Consideration before administering anticoagulants? | They are never given to a client who is bleeding within the brain. |
| When are anti-platelets or heparin started? | These are started 24 hours after thrombolytic therapy. |
| What are the most common anticoagulants given for thrombotic stroke? | Heparin or coumadin. |
| Why would a client recieve an anti-hypertension drugs to control BP? | HTN increases BP and can increase the area of infarction. |
| What is administered to a client with IICP? | Mannitol (an osmotic diuretic) or furosemide (a loop diuretic). |
| Why is a loop diuretic given to a client with IICP? | To help reduce cerebral edema. |
| What other drug is given and why during the acute phase? | Phenytoin is given to prevent or control seizures. |
| When do you give clients Lovenox? | When they have side effects from coumadin. |
| what type of drug do you administer for Ischemic stroke- cardio embolic? | Anti-coagulant therapy: Prevent 2nd CVA /new clots from forming |
| Anti-coagulant meds | Warfarin (Coumadin) Lovenox |
| What are adverse reacctons of coumadin? | Consider nutrition: Need to avoid Vit K cuz it is a clotter. It is a green leafy veg such as spinach. |
| Can someone on coumadin have Vit K? | Yes, as long as it has been part of their regular diet. Can't change anything drastic with diet or will have a spike in their ptINR |
| What are nursing considerations when treating someone on coumadin? | They need to start taking them 24hrs after thrombolytic therapy;PT/INR levels need to be 2-3 |
| Normal PT-INR | 2-3 |
| Nursing Teaching plan for someone on coumadin | Teach proper nutrition and regular doctor visits. |
| Nursing dgx for coumadin use | Ineffective bleeding. |
| Thrombolytic clot busting drug | tPA- Tissue plaminogen activator |
| Nursing consideration for tPA | three hours onset of ischemic stroke and there is not sign of improvement..some research shows 4.5 hours |
| Can;t give thrombolytic under what circumstances? | Can't have stroke or head trauma in the past 3 months, surgery or GI bleed 2-3 weeks from the onset of stroke. |
| If pt has low platelets | Can't give thrombolytics |
| When not to give thrombolytics | BP < 185/110, Platelets, Blood glucose No anticoags or INR < 1.7 |
| Major risk factors of a thrombolytic? | Hemorrhage (ICH) Monitor Neuro and BP Stop if severe HA, N/V, acute HTN Follow-up CT in 24hr |
| When is thrombolyitic (tPA) most effective? | When it is initiated closer to the onset of signs and symptoms |
| When is a Carotid endarterectomy done? | Before surgery is considered, there has to be 70% of carotid blockage. |
| What is the purpose or carotid endarterectomy? | It is done to prevent a stroke, especially for these persons who've had a TIA or in danger of having a CVA. |
| What does the carotid endarterectomy do? | It removes arthesclerotic plaque or a thrombus from the carotid artery. The artery is then sutured or a graft is inserted to restore blood flow. |
| Post nursing care following a carotid endarterectomy- pt positioning | Pt to be placed in supine position and HOB elevated 30 degreees |
| Post nursing care following a carotid endarterectomy- pt teaching | Teach pt to place hands behind head when changing positions |
| Post nursing care following a carotid endarterectomy- monitor the following: | Monitor for patency of wound drains, hemorrhage at wound site, respiratory distress, cranial nerve impairment, another CVA, and hyper or hypotension. |
| Post nursing care following a carotid endarterectomy: monitor for hemorrhage | Assess for hematoma or bleeding at incision site; check neck size and assess for drainage under clients neck and shoulders. |
| Post nursing care following a carotid endarterectomy: Monitor respiratory distress | Assess RRR, depth and effort. Assess for difficulty swalloing, tracheal deviation from midline, restlessness & keep a trach set by bedside. |
| Post nursing care following a carotid endarterectomy: monitor for cranial nerve impairment | Look for facial drooping, hoarsenss, dysphagia, tongue deviation, speech difficulty, or shoulder sag on one side. |
| Post nursing care following a carotid endarterectomy: Monitor for carotid artery occlusion or CVA | Assess for signs of dizziness, slurred speech, hemiparesis and check for cartoid bruit. |
| Post nursing care following a carotid endarterectomy: Monitor for hyper and hypotension | Assess BP at least hourly; report hypertension ASAP because of risk of CVA, artery rupture; assess for hypotension cuz that could lead to MI. |
| Nursing consideration following carotid endarterectomy? | There will be a major pressure change in blood flow...vessels may not be able to handle this, monitor for hyper or hypo tension. |
| Nursing care: initial priority of care following a CVA | To maintain preserving functional brain cells and preventing acute complications. |
| Nursing care after client is stable following a CVA | Assess for problems of mobility, communication, sensory perceptual, deficits, incontinence, & swallowing. |
| IICP signs and symptoms | Decreased LOC;sluggish pupils/only one dilated pupil;unable to assess vision due to decreased LOC;increased BP and widening pulse pressure-bradycardia;decreased respiratory rate;Elevated temp;HA, vomiting |
| Cerebral aneurysm | Abnormal outpouching or dilation or a cerebral artery & occurs at the weakest point of the arterial; weakness is related to atherosclersis due to hypertension or congenital defect. |
| Cerebral aneurysm pathophysiology | No symptoms- usually found on accident or when it starts to leak. |
| Cerebral aneurysm causes | HTN, Atherosclerosis, Anticoagulants, Head Trauma, Congenital defects |
| If Cerebral aneurysm was found by accident, then what would medical staff do? | They'd monitor, but not treat until they complete an assessment on size, location, health history. Depending on what they find and health of pt, they will come up with a game plan on how to treat it. |
| If cerebral aneurysm is leaking what would pt experiennce. | Leaking would cause more pressure leading to sever HA, N&V, and neck pain. |
| How is Cerebral aneurysm treated if it is determined there is a leak. | Sometimes these spontaneously seal with a clot on their own |
| What age group doe cerebral aneurysm happen to? | Any age group |
| What sort of DGX will be done to determine size, location, etc | MRI or &/or a CT scan. |
| What are they s&s of cerebral aneurysm (hemorrhagic CVA) if there is a leak (subarchnoid hemorrhage) | Sudden and explosive HA, Stiff neck (nuchal rigidity), LOC changes, photophobia, N&V, motor deficits, and cranial nerve deficits. |
| Cerebral aneurysm treatment and management: goals | prevention of clot destruction by givng BP meds, prevention or re-bleeding until surgery; stabilize airway, O2, circulation and ICP) |
| Cerebral aneurysm surgery | Surgery is treatment of choice to prevent bleeding and is done when pt condition is stable. |
| What are nursing actions if surgery is not an option for an aneurysm? | Nurse monitors LOC, BP, pulse, and respiration hourly (monitor more frequently depending on clients condition) |
| In stabilizing a pt with an aneurysm, what is important? | That they don't cough or do the valsalva maneuver |
| Medications given for aneuryism before surgery can be done. | NO ASA products Osmotic Diuretics for IICP; Ca Channel Blockers to Decrease vasospasm; Anticonvulsants for Seizure prevention |
| Surgical tx for aneuryism | Coil or clipping |
| Nursing dgx and considerations for all CVA's : Ineffective Tissue Perfusion- Cerebral | Monitoring for IICP; Change LOC; Weakness; Vision Changes;Elevated BP; |
| Nursing dgx and considerations for all CVA's :Risk for Ineffective Airway Clearance | Monitor Resp, Provide oxygen Sidelying position (aspiration risk) |
| Nursing dgx and considerations for all CVA's: Impaired Physical Mobility | Repositions, Body alignment with pillow,Fine Motor skills (such as using Pegs, marbles, rubberbands, balls), ROM, Handsplints |
| Nursing dgx and considerations for all CVA's: Impaired Verbal Communication | Face client, speak clear/slow; Don’t raise voice; Be honest if not understanding;Yes/No questions; Other methods if cannot speak (Gestures, blinking, nodding, pictures) Cue cards, PDAs |
| Nursing dgx and considerations for all CVA's: Disturbed Sensory (at risk for Physical Injury) | Approach unaffected side (visual / physical); Teach to look around (Hom.Hemi); Clutter free;Encourage handling affected side (Touch, Assist in guiding- put hand in yours); Place items on affected side; Not call-light |
| Nursing dgx and considerations for all CVA's:Impaired Bowel/Bladder | Toilet q 2-3hrs Adequate fluids and fiber Limit at HS Skin care Stool softeners Increase phys. activity |
| Nursing dgx and considerations for all CVA's:Impaired Swallowing (at Risk Aspiration) | Sit Upright, tilt head forward;Oral care ac/pc; Thickened, pureed, soft Small bites to unaffected side (pocketing); Limit distractions; Suction available |
| Nursing dgx and considerations for all CVA's:Swallow Evaluation | Assess cough / need for suctioning secretions Assess ability to move tongue Assess for unclear speech or weak voice Give sip of fluid Coughing Number of swallows needed Reassess voice, lung sounds |
| Nursing dgx and considerations for all CVA's:Self-Care Deficit, Health Maintenance, Role Perform. | Encourage use of unaffected side; Dress affected side first because this increases Awareness; Assistive devices (OT, PT); Memory Aids (Association,Visualization,Repitition,Compensation); Thinking Games |
| Goals for rehab nursing | Foster Independence;Support & Encourage; and allow Adequate time |
| Restore to the best of their ability in terms of health and functioning – both mentally and physically and to Prevent worsening (complications) | Goals for rehab nursing |
| Reasons why rehab nursing is important for the pt and the family. | Because, 40% Fall 1yr; risk of Skin breakdown, dependent edema; pt experiences Bowel changes, risk for a Thrombus; at risk for Social Isolation, Emotional changes; Family /Caregiver Adjustments Anxiety over Risk for 2nd stroke; Lifestyle changes |
| What are some preventions that we can help with to prevent a 2nd stroke? | Help to decrease Hypertension (even for those w/o htn?)-30-40% risk reduction Diabetes (fbs <126); treating HTN with an ace/arb; maintain normal Cholesterol LDL <100 (70); advise to quite Smoking; limit Etoh 1-2/d; encourage Weight loss , Activity 30mi |
Created by:
Wends1984
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