Ischemic Stroke Assessment and Management

Ischemic Stroke

• Characterized by a blockage in the blood supply to the brain.
• Types include thrombotic (clot forms in a blood vessel) and embolic (clot travels from elsewhere).
• Key assessments include GCS (Glasgow Coma Scale), FAST (Face, Arms, Speech, Time), and NIHSS (National Institutes of Health Stroke Scale).
• Important diagnostic steps involve reporting symptoms, determining last known well (LKW) or last seen normal (LSN), and conducting a non-contrast CT within 30 minutes.
• Additional imaging tests can include MRI, MR angiography (MR-A), and CT angiography (CT-A).
• Management involves initial assessment and stabilization, administering tPA (tissue plasminogen activator) within 3-4.5 hours of symptom onset, and ensuring treatment initiation within 60 minutes of arrival.
• Monitor for complications such as airway obstruction, cardiac issues, and immobility-related problems.

Assessment and Diagnosis of Pain

• Essential to evaluate the nature of pain (acute or chronic), fatigue, radiculopathy, sciatica, mobility, sensory changes, and muscle strength.
• Diagnostic tools include a focused history and physical exam, imaging (X-ray, CT, MRI), blood studies, and potentially a bone scan or ultrasound.
• Treatment may involve analgesics, muscle relaxants, anti-anxiety medications, tricyclic antidepressants, SNRIs, and anticonvulsants.

Medication and Non-Pharmacologic Management of Pain

• Avoid acetaminophen and corticosteroids for pain relief in certain cases.
• Non-pharmacologic methods include rest, activity modification, physical therapy, heat/cold application, cognitive behavioral therapy, and proper body mechanics.
• Document response to all treatments to tailor ongoing management effectively.

Fractures

• Distinction between closed (no skin penetration) and open fractures (bone protrudes).
• Factors affecting fracture risk include lifestyle (smoking, poor diet), comorbidities (e.g., malignancy, osteoporosis, diabetes), and certain medications (e.g., steroids).

Complications of Fractures

• Potential complications include hypovolemic shock, vascular injury, infection (osteomyelitis), and compartment syndrome.
• Compartment syndrome presents with neurovascular damage, characterized by pain, paresthesia, pallor, paralysis, and absence of pulse.
• Immediate management involves reducing compartment pressure.

Dislocation and Subluxation

• Defined as misalignment of articular surfaces, leading to acute pain and reduced range of motion.
• Diagnosis is confirmed through bilateral assessments and X-rays.
• Medical management may include immobilization, reduction techniques, and analgesic medications.

Bone Structure Disorders: Scoliosis

• Identified by abnormal lateral spine curvature, uneven shoulders, and prominence of scapula.
• Diagnosis relies on physical examination findings.

Bone Infection: Osteomyelitis

• Characterized by inflammation and necrosis of bone tissue, often due to a bloodborne infection or direct contamination from trauma or surgery.
• High-risk groups include diabetics, older adults, and individuals with poor nutrition or IV drug use.
• Symptoms include fever, pain, swelling, and systemic signs of infection.
• Diagnosis confirmed via imaging (X-ray, MRI) and laboratory tests.

Metabolic Bone Disease: Osteoporosis

• Linked to altered calcium absorption, predominantly affecting postmenopausal women and older men.
• Symptoms include back pain, spontaneous fractures, and height loss.
• Diagnosis typically involves X-ray and DEXA scan for bone density measurement.

Paget's Disease

• Characterized by abnormal bone remodeling, leading to deformities and possible pathologic fractures.
• Diagnosis confirmed through imaging and an elevated alkaline phosphatase level.

Osteomalacia

• A metabolic disorder involving softening of bones due to inadequate mineralization.
• Assessment reveals deformities and tenderness; diagnosis involves imaging and blood tests indicating low calcium and phosphorus.

Bone Cancer

• Symptoms may be asymptomatic initially, but can include pain, weight loss, malaise, and pathologic fractures.
• Diagnosis through imaging (CT, MRI) and biopsy for confirmation.

Muscular Dystrophy

• Progressive muscle degeneration and weakness often associated with dysphagia and potential cognitive deficits.
• Diagnosis through physical examination and muscle biopsy; management focuses on supportive care to maintain function.

Osteoarthritis

• Common condition marked by joint pain, stiffness, and functional impairment.
• Diagnosis made via laboratory assessments and imaging showing joint space narrowing and osteophytes.

Secondary Joint Dysfunction: Psoriatic Arthritis

• Involves inflammatory back pain, worsening at night, with diagnosis based on inflammatory markers and treatment focusing on maintaining mobility and managing pain.

Secondary Joint Dysfunction: Gout

• Characterized by recurrent severe inflammation, often linked to high uric acid levels, with diagnosis confirmed through serum levels and clinical features.
• Management includes pain relief, dietary adjustments, and medication to reduce uric acid.

Carpal Tunnel Syndrome

• Symptoms include numbness, night pain, and weakness in hand coordination, often exacerbated by repetitive wrist movements.
• Diagnosis through tests like Phalen's and Tinel's tests; management may require wrist immobilization or surgery.

Amputation

• Indicated for patients with significant circulation issues, tissue necrosis, or infection leading to gangrene, considering both elective and emergency procedures.### Traumatic and Elective Injuries
• Traumatic Management: Differentiates between elective care for perfusion issues and traumatic care related to injury.

Diagnosis

• Methods: Diagnosis involves physical examinations and various diagnostic studies.

Medical Management

• Dressing Application: Use rigid dressings for wound management; remove to assess and replace to manage edema.
• Rehabilitation Goals: Focus on achieving highest level of independence and functionality, including prosthetic fitting and support group participation.

Nursing Interventions

• Pain Control Techniques: Utilize sandbags to alleviate muscle spasms and optimize body comfort.
• Wound Care: Conduct thorough wound assessments to promote healing.
• Psychosocial Support: Help patients enhance body image, cope with grief, and adjust understanding of body changes.
• Positioning: Post-operative uses of elevation versus proning techniques essential for recovery.

Complications

• Potential Risks: Includes hemorrhage, hypoperfusion, phantom pain, infections, neuromas, and flexion contractures.

Psychosocial Considerations

• Emotional Impact: Address issues related to loss, grieving processes, and alterations to lifestyle following injury.

Nursing Diagnoses

• Common Diagnoses:
  • Anxiety related to back injuries,
  • Ineffective coping and impaired physical mobility due to pain,
  • Chronic or acute pain management,
  • Risks for constipation and diversional activity deficits,
  • Risks for neurovascular dysfunction and infection,
  • Self-care deficits relating to daily activities and transfer abilities.

Unit 5 Review: Neurologic Disorders

• Acute Brain Disorders: Focus includes Transient Ischemic Attack (TIA), Reversible Ischemic Neurological Deficit (RIND), ischemic, and hemorrhagic strokes.

TIA/RIND

• Characteristics: Symptoms, including motor, sensory, and visual loss, last 1-2 hours; serves as a warning for possible ischemic stroke.
• Diagnostic Tool: Non-contrast CT scan is the initial test used.

Ischemic Stroke

• Blood Flow Disruption: Occurs due to thrombi or emboli obstructing blood vessels.
• Symptoms: Presentation includes hemiplegia, confusion, and sudden severe headache.
• Treatment Window: Thrombolytic therapy if administered within 3 to 4.5 hours of symptom onset; smoking cessation and healthy lifestyle are preventive measures.

Hemorrhagic Stroke

• Causes: Results from bleeding due to ruptured vessels or aneurysms, often associated with hypertension.
• Symptoms: Similar to ischemic stroke, plus severe headache and altered levels of consciousness.
• Management: Requires bed rest, sedation, and potentially surgical intervention for stable recovery.

Right vs. Left Hemispheric Stroke

• Right Hemispheric Stroke: Affects left side paralysis, visual deficits, and impulsive behavior.
• Left Hemispheric Stroke: Manifests as right side paralysis, aphasia, and cautious behavior.

Nursing Care Post-Stroke

• Care for Aphasia: Establish eye contact, use clear speech, limit discussions to concrete topics, and incorporate visual aids for communication.### Management Strategies for Visual and Hearing Impairments
• Consistency with words and gestures is essential for effective communication.
• Reducing background noise helps patients focus on interactions.
• For hemianopsia, place objects within the intact visual field and encourage head movements toward the visual loss area.
• Use eyeglasses and canes to aid navigation and object identification.
• Ensure items are consistently located for ease of use.

Seizures and Related Conditions

• Seizures arise from electrical disturbances in nerve cells with classifications of focal, generalized, or unknown.
• During a seizure, maintain privacy, ease the patient to the floor, protect the head, and facilitate airway patency.
• After a seizure, ensure the patient remains on their side, check the airway, and provide reorientation.
• Status epilepticus consists of prolonged seizures leading to potential brain damage, often treated with IV medications like diazepam or lorazepam.

Parkinson Disease

• A progressive neurological disorder resulting in dopamine depletion.
• Symptoms include tremors, rigidity, bradykinesia, and postural instability.
• Management includes medications for dysphagia and advanced options like deep brain stimulation.

Bell Palsy and Trigeminal Neuralgia

• Bell Palsy is characterized by unilateral facial paralysis due to cranial nerve inflammation; treatment includes corticosteroids.
• Trigeminal Neuralgia involves sudden facial pain often triggered by light stimuli, treated pharmacologically with carbamazepine or surgery.

Headache Types

• Migraines can last hours to days and may be accompanied by aura; prevention involves avoiding known triggers.
• Common triggers include certain medications, stress, and dietary factors.

Hearing Impairment Disorders

• Conductive hearing impairment can result from cerumen impaction or otosclerosis; management may include irrigation or stapedectomy, respectively.
• Sensorineural hearing impairment can arise from drugs or trauma; ototoxicity often leads to permanent hearing loss.
• Acute otitis media is an infection mainly seen in children treated with antibiotics and possibly surgical drainage.

Visual Impairment Disorders

• Cataracts lead to lens cloudiness and are a primary cause of blindness; surgical options include phacoemulsification.
• Retinal detachment presents as a curtain-like shadow and requires surgical interventions like scleral buckle.
• Diabetic retinopathy is linked to uncontrolled diabetes and necessitates regular eye exams.

Bone and Soft Tissue Injuries

• Sprains involve ligament injuries; management includes the PRICE method (protection, rest, ice, compression, elevation).
• Osteomyelitis, an infection of the bone, poses significant risks and requires careful management in at-risk populations.
• Osteoporosis involves decreased bone density, primarily affecting postmenopausal women; prevention includes weight-bearing exercises and proper nutrition.

Musculoskeletal Disorders

• Osteoarthritis results in joint pain and stiffness, managed by pain relief and physical therapy.
• Gout is characterized by increases in serum uric acid and is managed through dietary restrictions and medications like colchicine.

Carpal Tunnel Syndrome and Amputations

• Carpal Tunnel Syndrome affects the median nerve, leading to symptoms in fingers; treatment includes corticosteroid injection and splints.
• Amputations are performed primarily due to vascular issues or trauma, with focus on postoperative care to enhance recovery and manage complications such as phantom limb pain.

This quiz covers the key concepts of ischemic stroke, focusing on blockage types, assessment methods such as GCS and FAST, and diagnostic procedures like non-contrast CT and MRI. Test your knowledge on the correct management steps and critical symptoms to report in nursing assessments.