Questions and Answers
Which of the following communication problems is characterized by damage in the Broca area?
Which statement is true regarding swallowing deficits?
Cerebral angioplasty is considered a treatment for intracerebral vascular disease.
False
What is the primary goal during post-angiogram nursing care?
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Within how many hours should thrombolytic agents be administered for stroke treatment?
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What type of stroke can thrombolytic therapy help?
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Match the following medications with their primary action:
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Aspirin can be given rectally as a suppository if the patient is NPO.
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What nursing consideration is crucial when administering tPA?
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Which of the following complications can occur after a stroke?
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What is the purpose of carotid endarterectomy?
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What is a leading cause of disability or death?
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Which of the following are risks for stroke? (Select all that apply)
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Time lost equals _____ lost.
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What acronym should be memorized for stroke recognition?
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What type of stroke is caused by a clot blocking blood flow?
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A hemorrhagic stroke is a result of bleeding in the brain.
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What are the two main types of strokes?
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Which of the following are common symptoms of a stroke? (Select all that apply)
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What is the common cause of embolic strokes?
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Transient ischemic attack (TIA) is often referred to as a _____ stroke.
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What diagnostic test is prioritized for stroke assessment?
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Symptoms of a stroke can include sudden dizziness and loss of balance.
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What does the Glasgow Coma Score (GCS) measure?
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What should be done within 10 minutes of a patient arriving at the emergency department for potential stroke?
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Neglect syndrome occurs when a patient fails to acknowledge one side of their body due to right hemisphere damage.
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Study Notes
Neurological Disorders: Stroke
- Stroke is a leading cause of disability or death, and it is essential to recognize and respond quickly to neurological emergencies.
- Risk factors for stroke include A-fib, CAD, HTN, atherosclerosis, and others.
Cerebrovascular Accident (CVA) or Stroke
- Brain attack is a medical emergency that requires immediate attention, as "time lost = brain lost."
- Not everyone considers stroke a severe condition, but it is a medical emergency that requires prompt action.
Pathophysiology
- The brain cannot store glucose or oxygen, and disruption of blood flow can lead to cerebral tissue death (infarction).
- Infarction means obstruction of blood supply to an organ or region of tissue, leading to local death of tissue.
- Factors that determine how much brain damage occurs include where the stroke occurs, how long the blood flow is disrupted, and the amount of tissue involved.
Stroke Recognition
- The importance of recognizing stroke lies in being fast; patient education is critical in identifying the signs and symptoms of stroke.
- The BE FAST acronym is a useful tool for recognizing stroke: balance, eyes, face, arm, speech, and time.
- Signs and symptoms of stroke include loss of balance, blurred vision, one-sided facial drooping, arm or leg weakness, and speech difficulty.
Types of Strokes
- Ischemic strokes occur due to clot blocking blood flow to an area of the brain, leading to ischemia.
- Hemorrhagic strokes occur due to rupture or bleeding related to high BP.
- Ischemic strokes can be further divided into thrombotic and embolic strokes.
Thrombotic Strokes
- Thrombotic strokes present with slow, gradual onset of signs and symptoms, and clot formation occludes the vessel, leading to decreased or absent blood flow to an area of the brain.
- Clot forms in the vessel, and signs and symptoms include numbness, tingling, and inability to move an arm.
Embolic Strokes
- Embolic strokes present with sudden onset and rapid development of neurologic deficits, and a common etiology is atrial fibrillation.
- Clot forms elsewhere and travels to the brain, causing a blockage.
Atrial Fibrillation
- Atrial fibrillation is the most common dysrhythmia, and it increases the risk of stroke.
- Patients with atrial fibrillation have decreased cardiac output, and it is essential to monitor them for signs and symptoms of stroke.
Hemorrhagic Stroke
- Hemorrhagic stroke occurs due to bleeding in the brain, leading to cerebral tissue damage.
- Subarachnoid hemorrhage occurs below the arachnoid space, and intracerebral hemorrhage occurs due to hypertensive emergency or sustained hypertension.
Diagnostic Tests
- CT scan or CT angiography is essential for rapid diagnosis, and the goal is to complete the CT scan within 25 minutes and read it within 45 minutes.
- MRI or MRA can show ischemia earlier than CT scan.
Risk Factors
- Hypertension, smoking, obesity, elevated cholesterol, diabetes mellitus, sedentary lifestyle, and oral contraceptive use are risk factors for stroke.
- Atrial fibrillation, heart disease, diagnosis of aneurysm, hypercoagulability, family history, and substance abuse are additional risk factors.
Transient Ischemic Attack (TIA)
- TIA is a transient episode of neurological dysfunction that lasts from a few minutes to less than 24 hours and usually resolves within 30-60 minutes.
- Symptoms come and go, including motor, sensory, and/or visual function, and common causes include carotid stenosis.
Medical Emergency
- Stroke is a medical emergency that requires rapid diagnosis and treatment to preserve brain tissue.
- Endovascular procedure should be done within 2 hours of arriving at the hospital, and thrombolytics should be administered within 3 hours (up to 4.5 hours) from the last known normal time.
History and Assessment
- Critical questions to ask include when the stroke happened, last time normal, and other important questions such as onset, progression, worsening, and improving.
- Medical history, current medications, and social history are also essential.
Clinical Manifestations
- Clinical manifestations are impacted by the cerebral artery affected, area of the brain supplied by the vessel, and adequacy of collateral circulation.
Assessment and Recognition
- National Institute of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS) are essential assessment tools.
- Level of consciousness (LOC) and orientation should be assessed, and speech, motor response, extremity movement, mood, and behavior should be evaluated.
- Posturing and past medical history should also be assessed.
Glasgow Coma Scale (GCS)
- GCS allows for rapid neurological assessment and is scored on three areas: eye opening, motor response, and verbal response.
- The higher the score, the better, with 15 being the best and 3 being the worst.### Stroke Assessment
- Subtle changes in patient's condition can be a big deal, so document as exactly and detailed as possible.
- Manifestations of Increased Intracranial Pressure (ICP) include:
- Decreased Level of Consciousness (LOC)
- Lethargy
- Restlessness
- Headache
- Nausea/Vomiting
- Vision Changes
- Seizures
- Hypertension (HTN)
Recognizing Cushing's Triad
- Cushing's Triad is a sign of elevated ICP, which can occur due to edema or hemorrhage.
- Characteristics of Cushing's Triad include:
- Widening pulse pressure (e.g., 180/40)
- Bradycardia
- Irregular/decreased respirations
Motor Problems
- Motor nerve fibers cross the midline before going to the spinal cord.
- Right hemisphere problems mean left-sided paralysis.
- Neglect syndrome: damage to the right cerebral hemisphere, which causes the patient to ignore the left side.
Neglect Syndrome
- Unable to recognize impairment on the affected side due to impaired proprioception (body position sensing).
- May only use the unaffected side.
- Educate the patient to use both sides.
- May have hemianopsia; teach them to turn their head to get a better view.
Sensory Problems
- Ptosis (drooping eyelid)
- Hemianopsia (vision loss on one side)
Communication Problems: Aphasia
- Types of aphasia include:
- Expressive aphasia: damage in Broca's area (frontal lobe)
- Receptive aphasia: damage in Wernicke's area (temporo-parietal area)
- Global aphasia: combination of both receptive and expressive aphasia
Swallowing Deficits
- Assess ability to swallow early on and throughout recovery.
- NPO until swallowing is assessed.
- Swallow study: often modified barium under fluoroscopy.
Cerebral Angiogram/Angioplasty
- To visualize cerebral circulation.
- Helps identify abnormalities.
- Gold standard for diagnosis of intracerebral vascular disease.
- Can help restore blood flow to the affected area.
Post Angiogram/Angioplasty Nursing Care
- Assess VS frequently.
- Neurologic assessment frequently.
- Neurovascular checks frequently.
- Check pulses/color/sensation.
- Bed rest with leg straight/immobilized.
- Assess insertion site frequently.
- Encourage fluids.
Stroke Interventions
- Depends on the type of stroke.
- 4.5-hour window for thrombolytic agents.
- ABCs (CABs): airway, breathing, circulation.
- Priority: obtain and maintain a patent airway.
- Monitor for signs of IICP.
Planning and Goals
- Maintain airway.
- Protect from injury.
- Maintain/attain fluid volume balance.
- Maintain skin integrity.
- Effective thermoregulation.
- Effective urinary elimination.
- Encourage family or support system participation.
- NPO until swallow study completed.
- Therapy: PT, OT, or SLP.
Nursing Care of Stroke Patients
- Neurological assessment (ongoing).
- PT/OT/ST/ROM/ADLs.
- Safety.
- Reorient.
- Remind patients with neglect syndrome of their other side.
- Incontinence: bladder/bowel programs, diet, stool softeners.
- Support groups.
Stroke Prevention
- Patient education:
- Hypertension
- Obesity
- Substance use
- Diet
- Comorbidities
- General ABCS rule:
- Aspirin use if appropriate
- Blood pressure control
- Cholesterol management
- Smoking cessation
Anticoagulants/Antiplatelet Medications
- Anticoagulants contraindicated with hemorrhagic strokes.
- Used more to prevent recurrent strokes.
- Need to monitor neurological status closely.
- Dual antiplatelet therapy (DAPT).
- Examples of antiplatelet medications:
- Aspirin
- Clopidogrel (Plavix)
- Ticagrelor (Brilinta)
Aspirin
- Mechanism of action: irreversibly prevents platelet aggregation; prevents blood clotting by reducing platelet adhesiveness.
- Side effects: bruising, GI upset.
- Potential adverse effects: bleeding, liver disease, bleeding, thrombocytopenia, tinnitus (ototoxicity).
Clopidogrel (Plavix)
- Mechanism of action: irreversibly prevents platelet aggregation; slows down clot formation.
- Side effects: diarrhea, dyspepsia, abdominal pain.
- Potential adverse effects: bleeding, thrombotic thrombocytopenic purpura (TTP).
Apixaban (Eliquis)
- Mechanism of action: inhibits factor Xa, preventing thrombin formation and coagulation.
- Side effects: nausea and/or vomiting, dizziness.
- Potential adverse effects: bleeding.
Thrombolytic Therapy
- Need to be administered within 4.5 hours of symptom onset.
- Used for ischemic strokes.
- Dissolves clots.
- Recommended door-to-needle time is 45 minutes.
Tissue Plasminogen Activator (tPA) [Alteplase]
- Mechanism of action: stimulates the enzyme plasmin to break down blood clots.
- Side effects: bleeding, headache.
- Potential adverse effects: hemorrhagic conversion; extension of CVA.
Let me know if you want me to make any changes!### Hemorrhagic Stroke Conversion
- Can result from stroke and requires ICU care with frequent vital checks (every 15 minutes for the first 16 hours, then every hour)
- Typically sent to neuro unit after ICU care
Supplemental Medications
- Goal: Symptom management, not curative for stroke
- Medications used:
- Seizure meds: levetiracetam (Keppra)
- Calcium channel blockers: nimodipine (Nimotop)
- Stool softeners
- Analgesics
- Antianxiety drugs
- Antihyperlipidemic drugs
- Keppra is given via IV as prophylactic for seizures and is well tolerated
- Nimodipine is used for subarachnoid hemorrhage as it crosses the brain blood barrier
- Stool softeners are used to avoid straining and increased pressure on the head
Surgical Interventions: Preventing Aneurysm Rupture
- Endovascular Coiling: AVM/Aneurysm seal or clip
- Endovascular coiling: most of the time with aneurysm, headaches are caused by little pocketed coils
- Body recognizes coil as foreign and clots it off
- AVM: if not coiling, surgical intervention is used to prevent outpouching and seal off vessel
- Craniotomy: a very invasive surgical intervention
Stroke Complications
- Hydrocephalus: extra fluid in ventricular systems, causing increased intracranial pressure
- Vasospasms: when patient has ischemia
- Re-bleed: hemorrhage could occur again
- Conversion: ischemic stroke can become hemorrhagic
- Daily transcranial doppler checks are used to monitor for vasospasms
Carotid Endarterectomy
- Done to prevent stroke or stroke recurrence due to severe narrowing of carotid artery from atherosclerosis
- Restores perfusion through carotid artery
- Process:
- Identify plaque: CTA or MRA Neck
- Surgical incision
- Removal of Plaque
- For stenosis or plaque in carotid arteries, procedure involves cutting out plaque and restoring perfusion to brain
- Blood flow is diverted from plaque area to reach brain another way during procedure
- Neck measurement is taken before procedure to compare with post-procedure measurement, as neck swelling can occur
- Procedure can also cause a stroke if plaque escapes and dislodges
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Description
Recognize and respond quickly to stroke, a leading cause of disability or death, by identifying risk factors and symptoms. Immediate attention is crucial in this medical emergency.
