Acute Ischemic Stroke

3 words to describe L.sided stroke?

1. SPEECH/ LANGUAGE PROBS 2. CAUTIOUS/ SLOW 3. AWARE/ ANXIETY

If blood flow to brain is totally interrupted: Cellular death occurs in what amount of time?

5 minutes

What is the patient with homonymous hemianopsia at a high risk for?

INJURY! *THINK: May be bashing into wall and not aware of their extremities, pt's with right sided brain injury is impulsive and not aware of their problem, they also have affluent asphagia. Very high risk for injury.

What is the recommended IV thrombolytic agent to be administered within 3-4.5 window of a stroke pt?

IV Alteplase

*What is agnosia?

Inability to recognize an object by sight, touch, or hearing

Do symptoms resolve after a TIA?

YES- but person should still go to the ER

What does tPA aka altaplase, or the "clot buster" do?

reestablish blood flow through a blocked artery to prevent cell death

What is fluent dysphasia?

words are nonsense

*What is a cerebral angiogram?

*This is used to determine CEREBRAL BLOOD FLOW* Angiography is a minimally invasive medical test that uses x-rays and an iodine-containing contrast material to produce pictures of blood vessels in the brain. In cerebral angiography, a thin plastic tube called a catheter is inserted into an artery in the leg or arm through a small incision in the skin. In this x-ray, you can see same patient who have now received thrombolytic and revascularization of entire area afterwards (small blood vessels)

What is the breakdown of symptoms from a TIA?

1/3 have no fewer problems 1/3 have more TIAs 1/3 progress to stroke- this is why need to go to ER and be evaluated if they need prophylactic treatment

What is the timing that a mechanical thrombectomy (w/a stent retriever) can be done after a stroke?

AIS 6-16 hours

What are 2 surgical interventions for a stroke?

Aneurysm-induced hematomas Cerebellar hematomas (>3 cm)

How long should cardiac monitoring be performed after a suspecting of a stroke or having a stroke?

At least 24 hours -recommended to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions

What is homonymous hemianopsia?

Blindness in same half of each visual field *common problem after stroke

Type of ischemic stroke: What is an thrombotic stroke?

Cerebral thrombosis is a narrowing of the artery by fatty deposits called plaque. Plaque can cause a clot to form, which blocks the passage of blood through the artery

What is an Hemorrhagic stroke?

Different from an ischemic stroke: a burst blood vessel may allow blood to seep into and damage brain tissues until clotting shits of the leak

What is common immediately after a stroke?

HTN -Drugs to lower BP are used only if BP is markedly increased

What is the most common type of strokes?

Ischemic strokes = 70% of all

Spatial-percetual alterations are more likely to be r/t what side brain injury?

R. sided brain injury/stroke! Left sided paralysis

What is one key CM of a stroke?

Sudden onset of focal neurologic deficits: -weakness -sensory deficit -difficulties with language

*What is the most important thing when a pt. is experiencing an Acute Ischemic Stroke?

TIME IS BRAIN! -nurses play a critical role in the identification of onset of symptoms

What is it like for the pt w/homonymous hemianopsia on left side?

The person is blind, they do not know they are not seeing something *most effects R.brain stoke= left sided deficit *Treatment is teaching patients to scan their environment, make sure you are approaching within their visual field that they can see, make sure call light etc is within their field of vision

*What is a Transient Ischemic Attack TIA (aka "Mini Stroke")?

Transient episode of neurological dysfunction without acute infarction of the brain- Caused by microemboli

What is a stroke?

acute loss of perfusion to vascular territory of the brain, resulting in ischemia and a corresponding loss of neurologic function.

What is Ptosis?

drooping eyelid

What is the most OBVIOUS affect of a stoke?

motor function impairments

What does hemiplegia mean?

paralysis of one side of the body

In patients with AIS, hyperglycaemia should be treated and closely monitored to achieve what blood glucose levels?

range of 140 to 180 mg/dL -to prevent hypoglycemia

*What is a CT angiography?

*This is used to dx a stroke! (including extent and involvement) a test that uses X-rays to provide detailed pictures of the heart and the blood vessels that go to the heart, lung, brain, kidneys, head, neck, legs, and arms. A CT angiogram can show narrowed or blocked areas of a blood vessel. The test can also show whether there is a bulge (aneurysm) or a buildup of fatty material called plaque in a blood vessel. CT will: -Indicate size and location of lesion -Differentiate between ischemic and hemorrhagic stroke

What are some common problems of a stroke? (read through)

-Altered level of consciousness -Weakness, numbness, or paralysis -Speech or visual disturbances -Severe headache -↑ or ↓ heart rate -Respiratory distress -Unequal pupils -Hypertension -Facial drooping on affected side -Difficulty swallowing -Seizures -Bladder or bowel incontinence -Nausea and vomiting -Vertigo - more of a cerabellar

*What are the 4 types of aphasia?

-Bronca's (nonfluent): speak in short sentences, understand others speech, aware of difficulties and frustrated -Wernicke's (fluent): long sentences w/no meaning, can't understand others speech -Global (nonfluent): severe communication difficulties -Other: some have difficulty repeating words, others difficulty naming objects

**What are the 5 ONGOING nursing interventions for a suspected stroke patient? (while nurses wait for neurologist to determine if a pt. is a candidate for fibrolytic therapy)

-Continually monitor vitals and neurologic status 1. LOC 2. motor/sensory function 3. pupil size and reactivity 4. O2 sats 5. cardiac rhythm

*What is one important thing for the nurse to look for during an neuro assessment?

-Decreased LOC which indicates changes in ICP! Also changes in ICP- Pupil size, orientation, mobility sensation

Intravenous recombinant tissue plasminogen activator (tPA or alteplase) may be administered if the patient meets the following criteria: (just read)

-Patient is within 3-4.5 hours of onset of clinical signs of ischemic stroke, -≤80 y of age, -without a history of both diabetes mellitus and prior stroke, -NIHSS score ≤25, -not taking any oral anticoagulants (OACs), without imaging evidence of ischemic injury involving more than one third of the middle cerebral artery (MCA) territory.

What is the overall collaborative care of a stroke?

-preserving life -preventing further brain damage -reducing disability *treatment differs according to type of stroke and patient changes

What can the nurse to to prevent skin breakdown in the immobilised patient with a stroke?

-regular turning -good skin hygiene -use of specialised mattresses -wheelchair cushions -seating cushions Until mobility returns

What 5 types of pt's is alteplase recommended for within 3-4.5 hours? (just be aware don't memorise)

-≤80 y of age -without a history of both diabetes mellitus and prior stroke, -NIHSS score ≤25 -not taking any OACs -without imaging evidence of ischemic injury involving more than one third of the MCA territory

How long does a TIA usually last?

1 hour

What are 3 CM's of a stoke involving communication?

1. Aphasia 2. Dysphasia 3. Dysarthria

*What are the 4 types of dx studies done to determine a stoke?

1. CT 2. Tests of cerebral blood flow (fig out if bleed) -cerebral angiography -digital subtraction angiography -MRI etc. 3. Labs -CBC -blood studies -renal/haptic studies -lipid profile 4. Cardiac monitoring and tests -chest x-ray -cardiac enzymes etc

**What are the 10 INITIAL nursing interventions for a suspected stroke patient?

1. Ensure patent airway 2. call stroke code or stoke team 3. perform pulse ox 4. maintain adequate O2 5. obtain serumn BG 6. IV access w/normal saline 7. maintain BP according to guidelines 8. remove dentures 9. institue seizure precautions 10. anticipate thrombolytic therapy for ischemic stroke

3 words to describe R. sided stroke?

1. IMPULSIVE 2. UNAWARE 3. SPATIAL/ PERCETUAL PROBS *left sided neglect

*What are the 4 categories of spatial-percetual problems?

1. Incorrect perception of self and illness 2. incorrect perception of self in space 3. inability to recognize an object by sight, touch, or hearing (agnosia) 4. inability to carry out learned sequential movements on command (apraxia)

*What are 7 symptoms of R. sided brain damage?

1. paralyzed left side: hemiplegia 2. left-sided neglect -spatial-perceptual deficits 3. tends to deny or minimise problems 4. rapid performance and short attn. span 5. impulsive, safety problems 6. impaired judgement 7. impaired time concepts THINK: *driving wheelchair into wall because no spatial perception *falling out of bed b/c they forgot they in the the hospital *pt's really don't think they have a deficit

*What are 6 symptoms of L. sided brain damage?

1. paralyzed right side: hemiplegia 2. Impaired speech/language emphasis 3. imparied R/L discrimination (cannot tell difference) 4. SLOW performance, cautious 5. aware of deficits= depression and anxiety 6. impaired comprehension r/t math and language THINK: -difficulty telling difference between right and left -cautious -aware of deficits and depressed b/c of it

*What should daily fluid intake be for a stroke patient?

1500 to 2000 mL daily to maintain cerebral blood flow The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion

If blood flow to brain is totally interrupted: Metabolism stops in what amount of time?

2 minutes

*What is the time frame from symptom onset to when you cans still administer clot buster medication?

3-4.5 hours! -b/c adequate hydration promotes perfusion and decreases further brain injury

If blood flow to brain is totally interrupted: Neurologic metabolism is altered in what amount of time?

30 seconds

Aspirin is used within hour many hours of a stroke?

48 hours

What % of patients have seizures after a stoke and in what time frame?

5-7% of pts. who experience a stoke will have a seizure within 24 HOURS!

What is an ischemic cascade?

A series of metabolic events that happen in response to ischemia: Inadequate adenosine triphosphate (ATP) production--> Loss of ion homeostasis--> Release of excitatory amino acids--> Free radical formation--> Cell death!!!

What is an MRI for stroke?

*This is used to dx a stroke! (including extent and involvement) Brain MRI is commonly used to detect and diagnose many kinds of abnormalities of the skull, brain, and spinal cord. In addition to stroke, MRI is used to diagnose abnormal growths such as tumors, blood vessel abnormalities, infections, or disorders such as multiple sclerosis.

Type of ischemic stroke: What is an embolic stroke?

An embolic is a blood clot or other debris circulating in the blood. When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks the flow of blood.

*What 1 lab should be assessed before the initiation of IV anteplase and why?

BLOOD GLUCOSE -because hyperglycaemia/hypoglycemia may mimic acute stroke presentations

What are 3 other visual problems found in stoke puts?

Diplopia (double vision) Loss of the corneal reflex Ptosis (drooping eyelid)

What is dysarthria and what 3 impairments may it involve?

Disturbance in the muscular control of speech Impairments may involve: -Pronunciation -Articulation -Phonation

What is DTN time?

Door to needle time - goal is that > or = 50% of patients with a (AIS) stroke are treated with IV alteplase in 60 min or less. 60 min or less is the time it takes from when EMS picks up person to time they receive alteplase (IV thrombolytic) in the ER

*What must be monitored carefully immediately after a stroke and why?

Fluid and electrolyte balance b/c Adequate hydration promotes perfusion and decreases further brain injury

*What is apraxia?

Inability to carry out learned sequential movements on command

**What 2 IMPORTANT things will a CT tell us about a pt w/a suspected stroke?*

Indicate size and location of lesion Differentiate between ischemic and hemorrhagic stroke

What can happen if adequate blood flow can be restored early (ischemic cascade can be interrupted) in a stoke?

Less brain damage and less neurologic function lost

*What is the most important nursing implementation in a stroke patient?

NEURO ASSESSMENT

The area of the brain that the stroke affects dictates what?

The clinical manifestations

What does the brain require to provide the O2 and glucose that neurons need to function?

a continuous supply of blood!

What are some s/sx of dysphagia?

coughing, pocketing food, lots of saliva build up, wet sounding voice when they try to talk after they have had food or drink

How long does the initial phase of flaccidity last from after a stoke and what is it followed by?

days - several weeks it is r/t nerve damage followed by spasticity of the muscles r/t interruptions of upper motor neurone influence

What is dysphasia?

difficulty related to the comprehension or use of language -classified as nonfluent or fluent

What is Diplopia?

double vision

What should not be advised in ischemic stroke pts. for DVT prevention?

elastic compression stockings - use a intermittent pneumatic compression (IPC) in addition to routine care (aspirin and hydration) instead

*What should the BP be maintained at for at least the first 24 hours after IV alteplase treatment?

maintained <180/105 mm Hg Labetalol first line treatment for lowering BP There is no contraindication to giving a thrombolytic with high BP. But we work on dropping BP at same time

If dysphagia suspected, you should do a first check gag reflex (and screening), what is that?

offer sip of water and see how patient does. If pt. does not pass screen they are referred to OT or speech therapy, follow guidelines if they need thickening liquids

Platelet inhibitors and anticoagulants are contraindicated in what type of stroke patient?

patients with hemorrhagic stroke (DUH- think about it!)

What is an ischemic stroke?

stroke that results from inadequate blood flow to the brain from partial or complete occlusion of the artery. 2 types of ischemic stroke: -thrombotic -embolic

What is recommended as a routine screen for post-stoke patients?

structured depression inventory to screen for post stroke depression -Patients diagnosed with poststroke depression should be treated with antidepressants in the absence of contraindications and closely monitored to verify effectiveness

What does rehabilitation mean for a stoke patient?

the process of maximizing the patient's capabilities and resources to promote optimal functioning

What is non-fluent dysphasia?

tone is off, speech is flat

What is aphasia?

total loss of comprehension and use of language

Platelet inhibitors and anticoagulants are used in what type of stroke patients?

used in thrombus and embolus stroke patients after stabilization