Stroke Flashcards by Elizabeth Cruz

Define stroke

occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts

Caused by:
- Ischemia to part of the brain
OR
- Hemorrhage into the brain that results in death of brain cells

Also known as brain attack OR CVA (cerebrovascular accident)

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What are the effects of having a stroke?

Loss of function varies according to the location and extent of brain tissue involved.
Physical, cognitive, and emotional impact on patient and family
Different degrees of damage
Impairment of some sort
Cannot control some impulses

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Non-modifiable risk factors

Age: stroke risk doubles each decade after 55
Gender: more common in men but more women die
Ethnicity/race: higher incidence in African Americans (HTN is very common in African American males, if there is a weak blood vessel in the brain, high pressure, it can rupture and cause bleeding in the brain)
Heredity/family hx

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Modifiable risk factors

Hypertension: exercise, diet, low sodium, weight loss, stress
Heart disease
- Atrial Fibrillation: the blood does not get out well since it pools and starts to form blood clots and getting into circulation and can lodge in many places
Serum cholesterol: diet
Smoking
Excess alcohol consumption
Obesity
Sleep apnea
Metabolic syndrome
Lack of physical exercise
Poor diet
Drug abuse

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Define a TIA (transient ischemic attack)

associated with an increased risk of stroke
TIA is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain.
Episodes of hypoxia
Not a complete stroke and not a complete blockage
Infarction (cutting off) of the blood flow

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Define the types of stroke - ischemic

Ischemic
80% of all strokes
Inadequate blood flow to brain
TIA can be precursor
Thrombotic-vessel wall injury, narrowing of wall, blood clot
Embolic-embolus lodges in cerebral artery, infarction, edema
Cut off of blood flow due to plaque or blood ends up clotting
Blood vessel is narrowing
Plaque makes the blood sluggish
Clot that has now clotted
Ischemia = Narrowing

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Define the types of stroke - hemorrhagic

Hemorrhagic
Intracerebral
Bleeding within brain caused by rupture of a vessel
Sudden onset of symptoms
Progression over minutes to hours because of ongoing bleeding
Prognosis is poor with a 30-day mortality rate of 40-80%.
Subarachnoid
Bleeding into cerebrospinal fluid–filled space between the arachnoid and pia mater
Commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse, arteriovenous malformation (AVM)
Aneurysms silent killer -40% die during the first episode
Brain bleed
Just keep bleeding and can hardly get into it due to location, can cause more issues by doing surgery
Aneurysm: weakened area of an artery that kind of balloons out and with pressure will rupture
AVM: in utero as she was developing, an abnormal tangle of blood vessels connecting arteries and veins, which disrupts normal blood flow and oxygen circulation, children often die from this as they bleed out
Hemorrhagic = bleeding, the pressure will cause a lot of pain making people say it is the worst headache they have ever felt, thunderclaps headache

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Diagnostics for strokes

Diagnostic studies are done to:
- Confirm that it is a stroke
- Identify the likely cause of the stroke
Non-contrast CT scan or MRI:
- Indicate the size and location of the lesion
- Differentiate between ischemic and hemorrhagic stroke

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Define FAST

warning signs of stroke
Face drooping
Arm weakness
Speech difficulties
Time
Have pt. smile, stick their tongue out
Have them say “the sky is blue”
Do they have trouble seeing or walking, feeling dizzy

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Clinical manifestations of stroke - motor

Related to the location of the stroke
Neural tissue destruction is the basis for neurologic dysfunction
Affects many body functions
Related to the artery involved and the area/half of the brain it supplies
Time of the onset of symptoms /length of period of ischemia is important
Droopy face
One sided weakness
Vision issues
Swallowing issues
Paralyzed on both sides
If I have a stroke on the L side, it will take effects on the R side of the body
Most obvious effect of stroke: speech
Include impairment of:
- Mobility
- Respiratory function
- Swallowing and speech
- Gag reflex
- Self-care abilities
Symptoms are caused by the destruction of motor neurons in the pyramidal pathway (nerve fibers from the brain that pass through the spinal cord to the motor cells).

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Clinical manifestations of stroke - communication

Dysphasia refers to impaired ability to communicate
Used interchangeably with aphasia
- Receptive aphasia-loss of comprehension
- Expressive aphasia-inability to produce language
- Global-total inability to communicate
Many patients experience dysarthria
- Disturbance in the muscular control of speech
- Impairments may involve:
  - Pronunciation
  - Articulation
  - Phonation
Dysphasia = speech issues
Dysphagia = swallowing issues
can understand but cannot get the words out
can hear it but cannot understand it

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Clinical manifestations of stroke - affect

Patients who suffer a stroke may have difficulty controlling their emotions
Emotional responses may be exaggerated or unpredictable.
- May be magnified by depression, changes in body image, and loss of function

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Nursing interventions for stroke

Begins with managing “ABC’s”
Primary assessment is focused on:
- Neurologic assessment
- Cardiac status
- Respiratory status
If the patient is stable, obtain a hx

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Stroke Assessment - NEURO

Neurological Assessment
Monitor closely to detect changes
Pupillary responses
Vital Signs
↑ ICP
Recovery from stroke symptoms
Level of consciousness/mental status
- Include NIH Stroke Scale
Cognition
Motor abilities
- Extremity movement and strength

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Nursing Diagnosis for Stroke

Impaired Communication
Risk for Aspiration
Impaired Mobility
Risk for Injury
Difficulty Coping

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Patient Outcomes and Goals for Stroke

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Maintain a stable or improved level of consciousness
Attain maximum physical functioning
Attain maximum self-care abilities and skills
Maintain stable body functions (ie bladder)
Maximize communication abilities
Maintain adequate nutrition
Avoid complications of stroke
Maintain effective personal and family coping

Drug Therapy for Strokes

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Measures to prevent development of a thrombus or embolus are used in patients at risk for stroke
- Antiplatelet drugs are used in patients who have had a TIA related to atherosclerosis
- Aspirin is most frequently used antiplatelet agent
Common dose for aspirin is 81 to 325 mg/day.
Other drugs include ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine), and combined dipyridamole and aspirin (Aggrenox).
For patients who have atrial fibrillation, oral anticoagulation can include warfarin (Coumadin) and the direct factor Xa inhibitors: rivaroxaban (Xarelto), dabigatran (Pradaxa), and apixaban (Eliquis).
The primary advantage of direct factor Xa inhibitors (compared to warfarin) is that these drugs do not need close monitoring or dosage adjustments.
Statins (simvastatin [Zocor], lovastatin [Mevacor]) have also been shown to be effective in the prevention of stroke for individuals who have experienced a TIA in the past.

Drug Therapy for Ischemic Stroke

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Anticoagulants and platelet inhibitors: After patient stabilized to prevent further clot formation, strokes caused by thrombi and emboli
Platelet inhibitors: ASA, ticlopidine, clopidogel, dipyridamole
Stent retrievers
- Becoming the most effective way of managing ischemic stroke
Recombinant tissue plasminogen activator (tPA)
- Used to reestablish blood flow through a blocked artery
- Must be administered within 3 to 4.5 hours of onset of clinical signs of ischemic stroke
Patients are screened carefully before tPA can be given. Screening includes a noncontrast CT or MRI scan to rule out hemorrhagic stroke, blood tests for coagulation disorders, and screening for recent history of gastrointestinal bleeding, stroke, or head trauma within the past 3 months; major surgery within 14 days, or recent active internal bleeding within 22 days.
During infusion of the drug, the patient’s vital signs and neurologic status are monitored closely to assess for improvement or for potential deterioration related to intracerebral hemorrhage. Control of BP (SBP less than 185) is critical during treatment and for 24 hours following.
Intra-arterial infusion of tPA may be used for patients with occlusions of the middle cerebral artery who can be treated within 6 hours of symptom onset. tPA produces localized fibrinolysis by binding to the fibrin in the thrombi. The fibrinolytic action of tPA occurs as the plasminogen is converted to plasmin, whose enzymatic action then digests fibrin and fibrinogen, thus breaking down the clot. Other fibrinolytic agents cannot be substituted for tPA.
To be effective intra-arterial tPA must be administered within 6 hours of the onset of stroke symptoms for patients with an ischemic stroke when mechanical thrombectomy is not an option. In the intra-arterial tPA procedure, the neurovascular specialist inserts a thin, flexible catheter into an artery (usually the femoral artery) and guides the catheter (using angiogram) to the area of the clot. The tPA is administered through the catheter and immediately targets the clot. - - -
Less tPA is needed when it is delivered directly to the clot, which can reduce the possibility of intracranial hemorrhage.
Platelet inhibitors include aspirin, ticlopidine (Ticlid), clopidogrel (Plavix), and dipyridamole (Persantine). Additionally, the use of statins has been shown to be effective for the patient with an ischemic stroke.
For patients who have atrial fibrillation, oral anticoagulants include warfarin and the direct factor Xa inhibitors: rivaroxaban (Xarelto), dabigatran (Pradaxa), and apixaban (Eliquis).
The use of anticoagulants (e.g., heparin) in the emergency phase following an ischemic stroke is generally not recommended because of the risk for intracranial hemorrhage. Acetylsalicylic acid (aspirin) at a dose of 325 mg may be initiated within 24 to 48 hours after the onset of an ischemic stroke. Complications of aspirin (with higher doses) include gastrointestinal bleeding. Aspirin administration should be done cautiously if the patient has a history of peptic ulcer disease.
Stent retrievers (e.g., Solitaire FR) are a way of opening blocked arteries in the brain by using a removable stent system.
- During the procedure, a catheter is used to guide the small stent from the femoral artery in the groin area to the affected artery in the brain. The stent is guided (using neuroimaging) into the part of the artery where a blood clot has formed. The stent expands the interior walls of the artery and allows blood to get to the patient’s brain immediately to prevent as much brain damage as possible. The clot seeps into the mesh of the stent. Then, after a few minutes the stent and clot are removed together.
- The ENROUTE device accesses the carotid arteries through the neck, rather than the groin. The ENROUTE uses a blood flow reversal system to capture pieces of the blockage dislodged during stenting procedures, while also maintaining blood flow to the brain.

Surgical Therapy for Strokes

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Surgical interventions for patient with TIAs from carotid disease include:
- Carotid endarterectomy
- Transluminal angioplasty
- Stenting
- Evaluation must be done to confirm that the signs and symptoms of a TIA are not related to other brain lesions, such as a developing subdural hematoma or an increasing tumor mass.
- Transluminal angioplasty is the insertion of a balloon to open a stenosed artery in the brain and improve blood flow. The balloon is threaded up to the carotid artery via a catheter inserted in the femoral artery.

Surgical Therapy for HEMORRHAGIC Stroke

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Surgical interventions used to treat hemorrhagic strokes include:
- Resection
- Clipping of an aneurysm
- Evacuation of hematomas
- Procedure is chosen based on cause of stroke

Acute Care for Strokes

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Elevated BP is common immediately after a stroke
- May reflect body’s attempt to maintain cerebral perfusion
Control fluid and electrolyte balance
- Adequate hydration
- Promotes perfusion
- Decreases further brain injury
Manage ICP
- Use interventions that improve venous drainage

Acute Care for Strokes - Musculoskeletal

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Goal is to maintain optimal function: prevention of joint contractures and muscular atrophy
In acute phase, range-of-motion exercises and positioning are important
Paralyzed or weak side needs special attention when positioned
Hand cones to prevent hand contractures -Do not use rolled washcloths in place of hand cones
Avoidance of pulling the patient by arm to avoid shoulder displacement

Acute Care for Strokes - Integumentary

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Prevention of skin breakdown
- Pressure relief by position changes, special mattresses, wheelchair cushions
  - Position patient on weak or paralyzed side for only 30 minutes
- Good skin hygiene
- Emollients applied to dry skin
- Early mobility

Acute Care for Strokes - Gastrointestinal

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Constipation is most common bowel problem
- Prophylactic stool softeners or fiber
- Fiber up to 25 g/day
- Physical activity promotes bowel function
- Fluid intake of 1800-2000 ml/day

Acute Care for Strokes - Nutrition

- Nutritional needs require quick assessment and treatment - May initially receive IV infusions to maintain fluid and electrolyte balance - First feeding should be approached carefully - Feedings must be followed by scrupulous oral hygiene

Nursing Management for Strokes - Eating

- Before starting feeding-assess gag reflex, swallowing, chewing, pocketing - Well rested - Mouth care before and after - High Fowler's position - Chair preferred - Head flexed forward for feeding and 30 min after - Easy to swallow foods-texture, temp,flavor - Pureed foods too smoothe, bland - Liquids difficult to swallow - Avoid milk products-increase mucous - Food on unaffected side - Encourage small bites - Be patient

Nursing Interventions - Self-Eating

- Using the unaffected upper extremity to eat - Employing assistive devices such as rocker knives, plate guards, and non-slip pads for dishes - Removing unnecessary items from tray or table, reducing spills A. The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips and swivel handles are helpful for some persons. B. Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the other. C. Plate guards help keep food on the plate. D, Cup with special handle. - After the acute phase, a dietician can assist in determining the appropriate daily caloric intake based on the patient’s size, weight, and activity level. - Interventions to promote self-feeding include using the unaffected upper extremity to eat; employing assistive devices such as rocker knives, plate guards, and non-slip pads for dishes; removing unnecessary items from tray or table, reducing spills; providing a non-distracting environment to reduce sensory overload with distraction.

Nursing Interventions - Communication

- Speech, comprehension, and language deficits are most difficult problem for patient and family - Speech therapists can access and formulate a plan to support communication - Assess patient for both ability to speak and ability to understand: - Speak slowly and calmly, using simple words or sentences - Gestures and visuals may be used to support verbal cues - Frequent, meaningful communication - Structuring conversation so that it permits simple answers by the patient - Picture board

Acute Care for Strokes - Urinary

- In acute stage, poor bladder control results in incontinence - Efforts should be made to promote normal bladder function - Avoid use of indwelling catheters - Bladder retraining program - Scheduled toileting every 2 hours using bedpan, commode, or bathroom - Avoid bladder over-distention-assess by palpation - Encourage patients to wear pants that are difficult to manage - Post-void residual volume-bladder scan - Restlessness may indicate need to urinate

Ambulatory and Home Care for Strokes

Toileting interventions: - Implement a bowel management program for problems with: - Bowel control - Constipation - Incontinence - High-fiber diet and adequate fluid intake - Patients with stroke frequently have constipation, which responds to the following dietary management: - Fluid intake of 2500 to 3000 mL daily unless contraindicated - Prune juice (120 mL) or stewed prunes daily - Cooked fruit 3 times daily - Cooked vegetables 3 times daily - Whole-grain cereal or bread 3 to 5 times daily - Nursing measures are also focused on promoting urinary continence.

Survivorship and Coping With Strokes

- Patients with a stroke may be coping with many losses - Often go through the process of grief - Some patients experience long-term depression - You have a role in supporting coping

Ambulatory Care for Strokes

Patient is usually discharged from acute care setting to: - Home - Intermediate or long-term care facility - Rehabilitation facility - Critical factor: independence in ADLs - Ongoing rehab is essential to maximizing patient's abilities

Health Promotion/ Management of Modifiable Risk Factors

- Healthy diet - Weight control - Regular exercise - No smoking - Limiting alcohol consumption - BP management - Routine health assessments

Evaluating Outcomes for Stroke Patients

- Maintain a stable or improved level of consciousness - Attain maximum physical functioning - Attain maximum self-care abilities and skills - Maintain stable body functions (ie bladder) - Maximize communication abilities - Maintain adequate nutrition - Avoid complications of stroke - Maintain effective personal and family coping

Stroke Flashcards

(34 cards)