NUA 451 - Ch. 47

What are the main presenting and additional symptoms of a hemorrhagic stroke?

-"Exploding headache", decreased LOC -Nausea, vomiting, visual changes, seizure

What are arteriovenous malformations (AVMs) caused by?

-Abnormality during embryonal development that leads to a tangle of arteries and veins in the brain that lacks a capillary bed -Absence of cap bed causes higher pressure within the arterioles to be transmitted directly to the veins leading to dilation of arteries and veins and possible rupture

What does a Primary Stroke Center have?

-Acute stroke team -Dedicated stroke unit -Written care protocols -Supporting lab and imaging services -Mandatory continuing education related to strokes

How is blood pressure managed during the acute vs recovery stroke phase?

-Acute: generally liberalized to allow for improved cerebral blood flow -Recovery: normotension, defined as less than 140/90

What are small, penetrating artery thrombosis strokes typically caused be?

-Aka lacunar strokes or lacunes -Longstanding hypertension, hyperlipidemia, diabetes

What can cause cerebral aneurysms?

-Atherosclerosis -Congenital defect in vessel wall -Hypertensive vascular disease -Head trauma -Advanced age

What causes cardio embolic strokes?

-Cardiac arrhythmias (a fib) -Valvular heart disease -Left ventricular thrombus

What are other major causes of stroke?

-Diabetes -Atrial fibrillation -Obstructive sleep apena

What are other-cause strokes usually caused by?

-Drug-use -Coagulopathies -Migraine -Spontaneous dissection of the carotid or vertebral arteries

What should a nurse do with a patient experiencing an acute hemorrhagic stroke?

-Elevate HOB 30 degrees -Monitor sedation -Prevent and control fever -Prepare to either: 1. use anticoag reversal agent 2. hyperventilate (causes vasoconstriction) 3. place ventricular catheter for CSF drainge 4. administer mannitol --all to reduce CSF

What do hemorrhagic strokes cause and why?

-Increased ICP, secondary hemorrhage, and further ischemia -Because the blood outside of the vasculature forms a mass that compresses adjacent brain tissue

What is a intraparenchymal and subarachnoid hemmhorage?

-Intra: blood within the brain tissue -Sub: blood occupying the subarachnoid space

What are the 4 subtypes of hemorrhagic stroke?

-Intracerebral hemorrhage -Subarachnoid hemorrhage -Cerebral aneurysm -Arteriovenous malformation

What are the two types of stroke?

-Ischemic stroke: occluded artery that deprives blood flow to part of brain supplied by that blood vessel -Hemorrhagic stroke: ruptured artery resulting in bleeding in or around the brain

What are the 6 areas the NIHSS looks at?

-LOC -Visual function -Motor function -Sensation and neglect (failure to pay attention to stimuli on one side of the body) -Cerebellar function -Language

What are the 5 subtypes/causes of ischemic stroke?

-Large-artery thrombotic strokes -Small, penetrating artery thrombotic strokes -Cardio embolic strokes -Cryptogenic strokes -Other

What are primary symptoms of a patient who has experienced a right-sided stroke?

-Left-sided weakness -Impulsiveness -Poor judgment -Left visual field deficit

What are main presenting and additional symptoms of an ischemic stroke?

-Numbness or weakness of the face, arm, leg, especially on one side of the body -Slurred speech, difficulty finding words or comprehension

What are strategies designed to decrease the development of disease risk factors?

-Primordial prevention -Such as efforts to decrease development of obesity, increase exercise, and provide a well-balanced diet -Encompasses entire population and is not limited to individuals with recognized risk factors for stroke or other cardiovascular diseases

What are the most common symptoms of stroke?

-Sudden numbness or weakness in the face, arm, leg, esp on one side of body -Sudden trouble speaking or understanding speech -Sudden visual disturbances -Difficulty walking, dizziness, or loss of balance or coordination -Sudden, severe headache

What treatments can be used to reduce the risk of bleeding associated with SAH?

-Surgical clipping - craniotomy with placement of clip at neck of artery to close rupture site -Endovascular coiling - coils inserted into aneurysm to promote clotting and closing

What are additional symptoms of stroke?

-Vomiting -Slow or sudden change in LOC -Focal seizures

The nurse understands the urgency of timely intervention for an ischemic stroke. Based on her knowledge of cerebral blood flow (normal CBF = 50 to 55 mL/100 g/min) and obstruction, she is aware that neurons will no longer maintain aerobic respiration at which level of CBF?

15 to 20 mL/100 g/min

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is higher than:

185 mm Hg/110 mm Hg

A patient has had an ischemic stroke and has been admitted to the unit. The nurse knows the importance of the principles of body alignment and correct positioning to stroke victims. How should the nurse position the patient to prevent joint deformities?

A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the chest.

What is a common cause of stroke in younger patients?

AVM

What is failure to recognize familiar objects by the senses?

Agnosia

What is the inability to recognize previously familiar objects perceived by one or more of the senses?

Agnosias

What are disturbances in writing intelligible words?

Agraphia

What is the earliest sign of deterioration in a patient with a hemorrhagic stroke?

Alteration in level of consciousness (LOC) - mild drowsiness, slight slurring of speech, and sluggish papillary reaction.

What is partial or complete impairment of language resulting from brain injury affecting spoken language and comprehension?

Aphasia or dysphasia

What is inability to put sounds and syllables together in the correct order to form words, to produce speech?

Apraxia

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?

Apraxia

If warfarin is contraindicated as a treatment for stroke, which medication is the best option?

Aspirin is the best option, although other medications may be used if both are contraindicated.

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?

Auditory agnosia -Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes.

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?

Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. The nurse administers prescribed medications such as an anticonvulsant phenytoin, like Dilantin, to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation is omitted.

What are non-modifiable risks for stroke?

Blacks and Hispanics have a higher incidence of both ischemic and hemorrhagic stroke, and contributing factors may be the higher incidence of diabetes and hypertension in these groups

Which of the following is the most common side effect of tissue plasminogen activator (tPA)?

Bleeding

What is a condition in which amyloid (fibrous) protein deposits accumulate inside the walls of arteries int he brain, causing vessel wall breakdown that can predispose patients to stroke?

Cerebral amyloid angiopathy

Which is indicative of a right hemisphere stroke?

Clients with right hemisphere stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body.

What is cell death at the site of occlusion?

Core infarct

What is difficulty in articulating speech, caused by paralysis of the muscles responsible for producing speech?

Dysarthria, or slurred speech

What is a common complication after stroke that can lead to aspiration pneumonia, dehydration, and poor nutrition?

Dysphagia

Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage?

First 2 to 12 hours

A patient had a stroke is experiencing memory loss, impaired learning capacity, forgetfulness, and lack of motivation. What part of the brain did the stroke likely take place in?

Frontal

What is a combination of expressive and receptive aphasia when a patient can't form words that are understandable?

Global aphasia

What is the most common motor dysfunction resulting from stroke?

Hemiparesis - weakness of one side of the body

An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem?

Hemorrhage

What is known as bleeding into the brain tissue (parenchyma), the ventricles, or subarachnoid space?

Hemorrhagic stroke

What occurs when brain tissue is subjected to increased pressure and moves across structures within the skull?

Herniation

What is the most important risk factor for both types of stroke?

Hypertension

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client?

Impaired Swallowing

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke?

Intracerebral hemorrhage

What type of stroke includes bleeding into any of the spaces within the cranium, including subarachnoid, epidural, and subdural spaces?

Intracerebral hemorrhage

What is a dilation of the wall of a cerebral artery?

Intracranial (cerebral) aneurysm

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA.

What is a complex series of circulatory and metabolic events that occur as result of an ischemic stroke, disruption of blood flow in or to the brain due to an obstructed blood vessel?

Ischemic cascade

What is the area surrounding the core infarct in which blood flow has been reduced?

Ischemic penumbra

Where is the majority of the language center in the brain?

Left hemisphere

What diagnostic tools are used in stroke diagnosis?

MRI and CT to indicate type, size, location, swelling, blood, hydrocephalus

What is a 42 point assessment scale used to quantify stroke severity?

National Institutes of Health Stroke Scale (NIHSS)

Which of the following is the initial diagnostic in suspected stroke?

Noncontrast computed tomography (CT) An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

What is responsible for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension?

Primary ICH

What is a heterogeneous syndrome characterized by the onset of one or more focal neurologic deficits (corresponding to the affected area of the brain) caused by reduced cerebral blood flow that leads to brain cell death and functional disability?

Stroke

What is one of the most common neuro emergencies seen?

Stroke

What type of stroke is bleeding into the subarachnoid space and is associated primarily with hemorrhage due to intracranial aneurysm, trauma, or arteriovenous malformations (AVMs)?

Subarachnoid hemorrhage

What are patients diagnosed with TIA at higher risk for?

Subsequent stroke

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

What IV treatment is used for acute ischemic stroke?

Tissue plasminogen activator (tPA)

What is a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour and without evidence of acute infarction?

Transient ischemic attack (TIA)

What cranial nerves are involved in swallowing?

Trigeminal (5) Facial (7) Glossopharyngeal (8) Vagus (10) Spinal accessory (11) Hypoglossal (12)

What are cryptogenic strokes caused be?

Unknown

What is the most common visual impairment after stroke?

Visual field loss or homonymous hemianopsia (loss of half of the visual field)

What are caused by disturbances in the primary sensory pathways between the eyes and visual cortex?

Visual-perceptive dysfunctions

Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

Weakness on one side of the body and difficulty with speech

When might ischemic penumbra be salvageable?

With early treatment - tPa or clot retrieval

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?

cardio embolic

What are s/s of Korsakoff syndrome?

psychosis, disorientation, delirium, insomnia, hallucinations, personality changes