6-cerebrovascular accidents (CVA, brain attack, stroke)
Cocaine use
45-year-old male patient presents to the ED complaining of trouble speaking and numbness of the right arm and leg. The nurse suspects an ischemic stroke. Which of the following insults or abnormalities can cause an ischemic stroke?
______
Administering supplemental oxygen and maintaining the hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated at 30 degrees, but this is not the most important intervention. The patient is at risk for seizures, but monitoring for this is not the most important intervention. Stool softeners are recommended to prevent constipation and straining, but this is not the most important intervention.
Rational
Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected patients to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complications are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes)
Poor abstract reasoning, decreased attention span, short and long term memory loss.
After having a stroke, a patient has cognitive deficit's. What are the cognitive deficit's the nurse recognizes the patient has as a result of the stroke?
Bleading is the most common side effect of TPA administration, that's the patient as closely monitor for any bleeding at the IV insertion sites urinary catheter site, endotracheal tube, nasogastric tube, urine, stool, emesis, or other secretions.
After the nurse administers the TPA what common side effect is it important that Mrs. Cole be monitored for?
hemorrhagic strokes
Arteriovenous malformations are associated with_______ Trauma and intracerebral aneurysm are associated with hemorrhagic strokes Intracerebral aneurysm rupture is associated with hemorrhagic strokes.
Fourth
As a cause of death in the United States stroke currently ranks______
_____
Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure (ICP), and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety elevate blood pressure, which increases the risk for bleeding.
By dissolving the blood clot that is blocking blood flow to the brain
Describe how thrombolytic agents treat ischemic stroke
Dysphasia
Difficulty in swallowing
hemonymous hemianopsia
Difficulty judging distances
parathesia
Difficulty with proprioception
Diplopia
Double vision
Rationale
For impaired physical mobility, instruct the patient on the use of a walker to improve mobility. The patient may experience weakness and the use of the walker will assist with ambulation. For self-care deficit: Wide grip utensils help the patient to feed himself independently, addressing the self-care deficit related to nutrition and self- feeding.
Brain tissue, the ventricles, the sub arachnoid space
Hemorrhagic strokes are caused by bleeding into
aspirin
If warfarin is contraindicated,______ is the best option, although other medications may be used if both are contraindicated.
receptive aphasia
In________, the patient is unable to form words that are understandable.
expressive aphasia
In________, the patient is unable to form words that are understandable. The patient who is unable to speak at all is referred to as mute.
Cva interventions
Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the patient with meals, and testing the patient's gag reflex prior to offering food or fluids.
Which of the following are contraindications for the administration of tissue plasminogen activator (t-PA)?
Intracranial hemorrhage, c) Major abdominal surgery within 10 days
Arteriosclerosis
Is the most common cause of cerebrovascular disease.
_____
Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues.
Meds
Medication may be effective in the treatment of vasospasm. Based on one theory, that vasospasm is caused by an increased influx of calcium into the cell, medication therapy may be used to block or antagonize this action and prevent or reverse the action of vasospasm if already present. The most frequently used calcium channel blocker is nimodipine (Nimotop). The other interventions and medications are not used in treating vasospasms.
Before receiving TPA the patient assessed using the national institutes of health stroke scale NIHSS standardized assessment tool that helps evaluate stroke severity.
Misco a 51-year-old woman is brought into the emergency department by her husband. Her husband states she began slurring her words about 30 minutes ago and he noticed that her mouth is turned down on the left side. He recognize that she is exhibiting signs of a stroke and brought her in immediately for treatment. Miss Cole was immediately taken foreight CT scan of the brain and it was determined that she suffered and ischemic stroke. The physician rights in order to initiate TPA. What should be done prior to initiating therapy?
receptive aphasia
Nursing management of the patient with _________includes speaking slowing and clearly to assist the patient in forming the sounds. Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet.
Severe headache
Patient is exhibiting classic signs of hemorrhagic stroke. What complaints from the patient would be an indicator of this type of stroke?
Re-bleeding or hematoma expansion, cerebral Vasospasm, a cute hydrocephalus, seizures
Potential complications of a hemorrhagic stroke include
Rational:
Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in patients with ischemic stroke lead to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
4.5 hours
Since 1996, thrombolytic therapy with recombinant plasminogen activator (t-pa) for ischemic stroke has significantly decreased power stroke symptoms. However, the treatment challenge is that the therapy house to be given within_______
Ataxia
Staggering, unsteady gait
ischemic and hemorrhagic
Stroke is divided into two categories
Impaired swallowing: Provide a pureed diet., d) Disturbed sensory perception: Stand on the patient's unaffected side., b) Impaired verbal communication: Repeat words and instructions.
The following statements match nursing interventions with nursing diagnoses. Which statements are true for a patient with a stroke?
Rational:
The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the ED to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment). Further diagnostics include a carotid Doppler, ECG, and a transcranial Doppler.
Provide a dimly lit environment., d) Elevate the head of bed 30 degrees., a) Administer Colace per order.
The nurse is caring for a patient diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The patient is awaiting surgery. Which of the following nursing interventions would be appropriate for the nurse to implement?
Psychosis, disorientation, delirium, insomnia, and hallucinations
The nurse is caring for a patient following an aneurysm coiling procedure. The nurse documents that the patient is experiencing Korsakoff syndrome. Which of the following symptoms characterizes Korsakoff syndrome?
Semi Fowler's
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
Difficulty swallowing
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern?
Stroke; brain attack
The primary cerebral vascular disorder in the United States is_______ which is also called a_______ to emphasize the urgency of its occurrence.
The dash diet is high and fruits and vegetables moderate and low-fat dairy products and low in animal protein it has a substantial amount of plant protein from legumes and nuts.
The risk of coronary heart disease and stroke has decreased in women on the dietary approaches to stop hypertension or the dash diet. What does this dietary regimen consist of?
cryptogenic strokes
Two classifications of ischemic strokes are________, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug.
receptive aphasia
Unable to comprehend the spoken word
expressive aphasia
Unable to form words that are understandable
Warning signs of CVA
Warning Signs of CVA The warning signs of CV include: • Sudden numbness • Weakness of face, arm, or leg, especially on one side • Sudden confusion, including trouble speaking or understanding • Sudden trouble seeing in one or both eyes • Trouble walking • Sudden severe headache with no known cause A patient with any of these signs should seek medical attention immediately, time is of the essence. Many organizations have protocols in place to identify a stroke, especially a stroke caused by an embolism. This quick identification allows for early treatment which can limit the deficits caused by the clot.
Left visual field deficit
What clinical manifestations does a nurse recognize when a patient has had a right hemispheric stroke?
The day the patient has a stroke
When should the nurse plan the rehab have a patient who is having an ischemic stroke?
Intracranial hemorrhage
________, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being age 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.
Intracranial hemorrhage
_________, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being age 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.
Cerebrovascular accidents (CVA, brain attack, stroke)
____________: Cerebrovascular accidents produce a sudden impairment of the circulation in one or more blood vessels in the brain from a thrombosis, embolus or hemorrhage. The oxygen supply is diminished or interrupted, causing brain damage. There are multiple objective findings depending upon which cerebral artery has been affected. The patient may report feeling dizzy, have visual disturbances or a headache. There may be an altered level of consciousness, aphasia, slurred speech, dysphagia, blindness, incontinence, personality changes, impaired sensory or motor function, or ataxia. Approximately 50% of the survivors become disabled. A high proportion experience a reoccurrence within weeks or years.
Cerebrovascular accidents
damage to the brain that occurs when the blood flow to the brain is disrupted; also known as a stroke
The following are neurological deficits of stroke: Motor Deficits
• Hemiparesis: Paralysis occurring on one side of the body • Hemiplegia: Weakness occurring on one side of the body • Ataxia: Unsteady gait • Dysarthria: Difficulty speaking due to weakness of the muscles • Dysphagia: Difficulty swallowing
The following are neurological deficits of stroke: Sensory Deficits
• Parasthesia: Numbness and tingling of arms and legs • Agnosia: Inability to recognize familiar objects • Apraxia: Inability to perform activities that had been previously learned • Ptosis: Drooping of the eyelids • Touch/pain: May not be able to discern due to defects
Diet to prevent cva
A low-fat, low-cholesterol diet, and increasing exercise Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including a low-fat low-cholesterol diet, and increasing exercise. Recent evidence suggests that eating fish two or more times per week reduces the risk of thrombotic stroke for women.
1-3 days
A patient Is in an acute phase of an ischemic stroke. How long does the nurse know that this phase me last?
Dysarthria
A patient diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as which of the following?
Aspirin
A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is which of the following?
Atrial fabulation
A patient has a cardioemblic stroke. What is the most common cardiac dysrhythmia that is observed on the monitor?
Form understandable words and comprehend the spoken word
A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions?
This is significant for for neurologic outcomes
A patient having an acute stroke with no other significant medical disorders has a blood glucose level 420 MG per deciliter. What significance does the hyper glycemia have for this patient.?
Help the patient sit upright when eating and feed slowly.
A patient is experiencing dysphagia following a stroke. Which of the following measures may be taken by the nurse to ensure that the patient's diet allows for easy swallowing?
Noncontrast CT scan
A patient is suspected of having had a stroke. Which of the following is the initial diagnostic test for a stroke?
Dysphagia
A patient suffering a stroke is having a difficult time forming words. What would the nurse document this finding as?
Lioresal (baclofen)
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administered to help alleviate this problem?
Rational
A pureed diet is often prescribed for a patient with impaired swallowing Other interventions for this patient may include a thickened liquid diet, use of the chin tuck techniques, and sitting upright. The patient may have disturbed sensory perception related to visual disturbances, so standing on the patient's unaffected side will allow him or her to see the nurse.
Frontal
A stroke victim is experiencing memory loss and an impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
50mg
An emergency department nurse understands that 110 pound recent stroke victim will receive at least a minimum dose of recombinant tissue plasminogen activator TPA. What minimum Dose will the patient receive?
Receptive aphasia
Dysarthria is difficulty in forming words. Dysphagia is difficulty swallowing._________ is the inability to comprehend the spoken word. Diplopia is double vision.
Nimodipine (Nimotop) po
Eight days following a subarachnoid hemorrhage, a transcranial Doppler ultrasonography detects cerebra I vasospasms in a patient experiencing lethargy. The nurse anticipates which of the following therapeutic interventions?
Management of Stroke Acute Phase (1 to 3 days)
Elevate the head of bed no higher than 10 degrees • Neurologic assessment—changes in LOC, orientation, movements, muscle tone • Eye opening, pupil size, and reaction • Ability to speak or communicate • Temperature, pulse, respirations, arterial blood gases, arterial blood pressure • Blood pressure control • Evaluation of the ability to swallow without aspiration (should be completed before taking anything orally)
______
Emergency airway supplies, including those needed for a tracheostomy, must be available. The patient's neck pain and mild BP elevation need addressing but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.
Eating techniques
Having the patient sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest as he or she swallows will help prevent aspiration. The patient may be started on a thick liquid or puréed diet, because these foods are easier to swallow than thin liquids. The diet may be advanced as the patient becomes more proficient at swallowing If the patient cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. The patient should be allowed to rest before meals because fatigue may interfere with coordination and following instructions.
The nurse will administer 6.48 mg. The dosage for the TPA is 0.9 mg per kilogram with a maximum dose of 90 mg. 10% of the calculated dose is administered as an IV bolus over one minute.
Misco weighs 72 kg how much TPA well the nurse administer in the first minutes as a bolus dose?
Rational
Modifiable risk factors for transient ischemic accidents (TIAs) and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, history of smoking, and chronic alcoholism. Hypertension, type 1 diabetes, and cardiac disease are modifiable risk factors for TIAs and ischemic stroke. Chronic alcoholism is a modifiable risk factor for TIAs and ischemic stroke. Advanced age, gender, and race are nonmodifiable risk factors for stroke.
Small, penetrating artery thrombotic strokes affect one or more vessels, and are the most common type of ischemic stroke.
Name the most common type of ischemic stroke's
global aphasia
Nursing management the patient with __________includes speaking clearly to the patient in simple sentences and using gestures or pictures when able. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation.
Left hemispheric damage
Patients with right hemispheric stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body._________ causes aphasia, slow, cautious behavior, and altered intellectual ability.
CVA nursing assessment
Scenario Analysis Nursing assessment will include determining the patient's response to verbal commands and degree of orientation. Questioning patients as to where they are and what year it is generally is a starting point to determine orientation to person and time. The patients will also be asked to open their hands and squeeze the hands of the examiner to determine a state of alertness and motor response. Purposeful movement is assessed as well as a response to painful stimuli. An increase in intracranial pressure (ICP) is indicated by a change in level of consciousness, so this must be closely monitored.
Aphasia interventions
The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; timit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken.
Carotid enterectomy
The main surgical procedure for managing transient ischemic attacks TIAs is______
Hypertension
The most common cause of intracerebral hemorrhage is
hemiplegia
The most common motor dysfunction is_______ (paralysis of one side of the body) caused by a lesion on the opposite side of the brain.
hemiplegia
The most common motor dysfunction of a stroke is
Spatial-perceptual deficits
The nurse has just received report on a patient in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which of the following findings does the nurse understand is indicative of a right hemispheric stroke?
Maintaining a patent airway
The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important?
Establishing eye contact
The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient?
Placing food on the affected side of mouth
The nurse is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient?
History of smoking
The nurse is participating in a health fair for stroke prevention. Which of the following will the nurse say is a modifiable risk factor for ischemic stroke?
The patient is weighed to determine the dose of t-PA. Typically two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids). The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg . Of the calculated dose , 10 % is administered as an IV bolus over 1 minute . The remaining dose ( 90 % ) is administered IV over 1 hour via an infusion pump. First, the nurse must convert the patient's weight to kilograms (132/2.2 60 kg), then multiply 0.9 mg x 60 kg 54 mg. Next , the nurse figure out that 10 % of 54 mg is 5.4 ( 54x , 10 ) . The nurse will initially administer 5.4 mgs IV bolus over 1 minute.
The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg / kg t - PA . The nurse understands that 10 % of the calculated dose is administered as an IV bolus over 1 minute , and the remaining dose ( 90 % ) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?
1 hour
The nurse knows that symptoms associated with the TIA usually a precursor of a future stroke usually subside in that period of time?
A low-fat, low-cholesterol diet, and increasing exercise
The nurse recognizes health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including which of the following?
A thrombus formation at the side of the endarterectomy
The patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, patient states all of a sudden I'm having trouble moving my right side. What concern should the nurse have about this complaint?
Noncontrast computed tomography
The patient has brought into the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually perform in the Mergen see department, with the nurse prepare patient for?
administer mannitol, Maintaining the partial pressure of carbon dioxide within a range of 30 to 35MMHG, administering supplemental oxygen if the oxygen saturation is below 80%
The patient has had a large ischemic stroke and is hospitalized and the neurological intensive care unit. What interventions will be provided for this patient to decrease intercranial pressure?
Rationale
The patient with impaired verbal communication may benefit from repetition of words or instructions. Other interventions include facing the patient, establishing eye contact, using short phrases, using communication boards, decreasing background noise, and allowing the patient time between phrases to understand the information.
——-
The patient's inability to swallow without difficulty would cause the nurse the most concern. Difficulty in swallowing, hoarseness or other signs of cranial nerv e dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway
5 types of ischemic strokes
There are five types of ischemic strokes: • Large artery thrombotic strokes • Small penetrating artery—the most common type of ischemic stroke • Cardiogenic embolic • Cryptogenic • Other—which is comprised of various other types
ischemic stroke
There are several risk factors that can lead to the occurrence of a CVA. There are factors that are modifiable, meaning they can be changed or altered and those that are non-modifiable. The non-modifiable risk factors are age, gender, and race. These factors cannot be changed. The modifiable factors are listed below: • Hypertension • Atrial fibrillation • Hyperlipidemia • Obesity • Smoking • Diabetes • Heart disease—valvular heart disease, endocarditis, or asymptomatic carotid stenosis • Periodontal disease • Hypercoagulability • Migraine headaches • Sickle cell anemia • Heavy alcohol use
Ischemic strokes
There are two major categories of stroke or CVA. They are ischemic and hemorrhagic. Ischemic strokes are the result of a thrombus or clot. This results in a disruption of blood flow to a portion of the brain due to obstruction.
left-hemisphere
This patient would have deficits on the left side. Expressive aphasia typically occurs with__________ stroke.
3 hours
Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome?
loss of peripheral vision
Unaware of the borders of objects
_______
Visitors, except for family, are restricted. Dim lighting is helpful because photophobia (visual intolerance of light) is common. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. No enemas are permitted, but stool softeners (Colace) and mild laxatives are prescribed. Both prevent constipation, which would cause an increase in ICP, as would enemas.
Intracranial hemorrhage, c) Major abdominal surgery within 10 days
Which of the following are contraindications for the administration of tissue plasminogen activator (t-PA)?
Blurred vision • Numbness of the face • Weakness on one side
Which of the following are symptoms of a stroke?
Neglect of the left side
Which of the following clinical manifestations would be exhibited by a patient following hemorrhagic stroke of the right hemisphere?
Hemiplegia
Which of the following is the most common motor dysfunction seen in patients diagnosed with stroke?
Speak slowly and clearly to assist the patient in forming the sounds.
Which of the following statements reflect the nursing management of a patient with receptive aphasia?
Homonymous hemianopsia
Which of the following terms will the nurse use when referring to blindness in the right or left halves of the visual fields of both eyes?
Homonymous hemianopsia
_________occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.
Global aphasia
________is a combination of expressive and receptive aphasia and presents tremendous challenge to the nurse to communicate effectively with the patient.
Ataxia
________is impaired ability to coordinate movement. Diplopia is double vision.
Hemiparesis
________is weakness on one side of the body.