Stroke
what group of medications are helpful in combating vasoconstriction? swelling in the pituitary area causes what symptoms?
Calcium channel blockers such as Nimodipine and Nicardipine are helpful in combating vasoconstriction. There is also risk of SIADH, hyponatremia, or Diabetes Insipidus due to swelling in the pituitary area causing fluid and electrolyte imbalance.
what are other conditions that mimic stroke?
Other conditions that mimic stroke are Intracranial mass, seizures, migraine, head trauma, infections, hypoglycemia, hyponatremia and alcohol or drug ingestion
how does a transcranial doppler show vasospasm? how is vasospasm treated? how is bp in vasospasm?
Transcranial Doppler (TCD) can show vasospasm by measuring blood velocity in the brain. Vasospasm can be treated with angioplasty to dilate the vessel(s). In vasospasm the BP is actually kept high to increase perfusion
do coils and clips work with MRI? what are the complications? what is the most serious consequence?
Coils and clips are MRI compatible so future MRIs are possible. Complications include rupture of the aneurysm, surrounding vessel occlusion and thromboembolism. Death also remains the most serious consequence.
hydrocephalus can occur how? how is it treated? what is considered another danger for an sah patient?
These conditions will be discussed more in the endocrine section. Hydrocephalus can develop due to problems with normal reabsorption of CSF. The patient may need an external ventricular drain (EVD) temporarily. The patient may need a permanent shunt if CSF reabsorption does not return to normal. As expected, IICP is another danger in the SAH patient and close observation is required.
what are the two types of brain hemorrhage?
Two types of brain hemorrhage are Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH).
what is subarachnoid hemorrhage? sah occurs from what usually? what are the risk factors? the majority of patients will complain of whay?
.SAH is bleeding in the subarachnoid space. Approximately 75% of SAH occur from ruptured aneurysms and 5% occur from arteriovenous malformation (AVM). Risk factors include females in fifties and sixties, genetic disorders, such as polycystic kidney disease, smoking, alcohol abuse, diabetes and familial history. The majority of patients will complain of the 'worst headache of my life' and many will have had headaches in the previous weeks.
how can a stroke patient regain bowel and bladder control?
A stroke patient may be incontinent and require bladder and bowel training. A set toileting plan can help a patient regain bowel and bladder control.
what is a tia? hemorrhagic stroke vs tia occurence? what is the primary cause of hemorrhagic stroke? what are other causes?
A trans ischemic attack (TIA) is a brief interruption or occlusion of blood flow to the brain and resolves within 24 hours Hemorrhagic strokes are much less common than ischemic strokes at approximately 12% of strokes. Hypertension is the primary cause of hemorrhagic stroke.. Other causes are trauma, aneurysm, and arteriovenous malformation (AVM).
after coiling procedure what should be monitored? when coiling is not an option what may be necessary?
After the procedure, monitor vital and neuro signs, catheter insertion site, and femoral and pedal pulses to ensure there is no bleeding or hematoma. When coiling is not an option craniotomy may be necessary and the aneurysm will be clipped, not allowing blood flow to the aneurysm thus preventing rupture.
all suspected stroke pts get what evaluation prior to any oral intake? if the pt cannot swallow who is consulted? what must be at bedside?
All suspected stroke patients get a dysphagia evaluation by the nurse prior to any oral intake. If the patient cannot swallow, a consult to speech therapy for evaluation is required. Suction equipment must be at the bedside.
SAH; ominous sign; symptoms; mortality rate is similar to what? survivors quality of life; why must neuro status be constantly observed?
An ominous sign is Cushing's Triad as previously discussed which involves elevated BP with widening pulse pressure, Cheyne Stokes respirations and bradycardia. The mortality rate is similar to ICH. Of those patients who survive, over 2/3 will not return to their normal quality of life. The SAH patient has a 15-20% risk of rebleed within 14 days so neuro status must to constantly observed.
approximately half of arteriovenous malformations are identified when? what are other symptoms of avm? what are the diagnostics? what diagnostic is considered gold standard?
Approximately half of cases are identified when the patients presents with signs of intracerebral hemorrhage (ICH). Other symptoms may include seizures, headache or neurologic deficits. A CT scan will be done initially but cerebral angiogram is the gold standard for diagnosis.
what is the window of time to improve patient outcome; stroke; assessment; interpretation of ct scan; initiation of clot busters
Assessment by a stoke team/MD within 10 minutes of arrival. CT scan performed within 25 minutes of arrival. Interpretation of CT scan within 45 minutes of ED arrival. Initiation of fibrinolytic therapy, if appropriate, within 1 hour of hospital arrival and 3 hours from onset of symptoms. The time window up to 4.5 hrs. for low risk patients is done on an individual basis. Door-toadmission time of 3 hours in all patients
what is the quickest and easiest way to identify ICH? first priority in nursing care? what may warrant immediate intubation for this pt?
CT scan is the quickest and easiest way to identify ICH. Patients with ICH are admitted to the ICU. The first priority of nursing and medical management will be maintenance of the airway. If the patient is stuporous or comatose they need immediate intubation.
the cause of ischemic stroke has different etiologies; lacunar or small penetrating artery disease; these are usually associated with what
Deep stroke from small vessel disease. Although small, they can cause devastating damage in the brain. These are usually associated with hypertension.
depending on the severity, what may be done to treat an aneurysm? what is coiling? what does it do to the aneurysm?
Depending on severity, the patient may have the aneurysm clipped or coiled. Coiling involves putting platinum coils into the aneurysm and applying electric current to induce thrombus formation. The aneurysm then is no longer able to fill with blood and rupture.
echocardiogram or TEE are done to look for what? they are also used to assess what? routine lab work is done why?
Echocardiogram or transesophageal echocardiogram (TEE) are done to look at chambers of heart, valves, and performance of heart (ejection fraction). They are also used to assess emboli as etiology of stroke due to vegetation in heart valves. Routine lab work is done to assess for baseline and abnormal values and help determine if a patient has any contraindications for tPA
ischemic stroke; elevated glucose levels; how does this effect the stroke?
Elevated glucose levels can worsen outcomes, and may lead to larger infarct size, poorer long-term recovery, and greater risk of hemorrhage.
stroke; scd and importance
Explain the importance of SCD and subcutaneous anticoagulant treatment to the patient and the family. SCDs should be worn at all times unless the patient is ambulating.
what can be given to lower BP, then clot busted given? what is also contraindicated for thrombolytics? what needs to be ruled out? what are high risk bleeding complications?
IV antihypertensives such as Hydralizine or Nipride may be given to lower BP, then tPA may be given. Recent surgery or previous cerebral bleed are also contraindicated. Causes that mimic stroke need to be ruled out. Recent major surgery or procedures within 3 months can cause high risk for bleeding complications. A previous brain bleed would also be contraindicated. There are other considerations such as age, health history, seizure or pregnancy which are reviewed on a patient by patient basis.
ischemic stroke; large artery disease
Large artery disease: Disease of the carotid or vertebrobasilar arteries or proximal middle cerebral artery
ischemic stroke; what happens when you lower blood pressure too much in pts with acute stroke? why is temp monitored? reduction of fever does what?
Lowering blood pressure too much in patients with acute stroke can adversely affect their outcome. Monitor temperature closely. Fever worsens stroke outcome and increases cerebral metabolism. Reduction of fever decreases the size of the infarct over time.
ischemic stroke; what is considered a controversial issue; patients will often present with what in an acute stroke?
Management of blood pressure is a controversial issue. Patients will often present with systemic hypertension in acute stroke.
what are SAH precautions? what may decrease anxiety and agitation?
SAH precautions include avoiding fluctuations of BP, quiet dark environment, pain medication, limitation of visitors, and family education. Again, a supportive family member to sit with the patient can help decrease anxiety and agitation.
use of coumadin for a stroke? when will it be started? what will the nurse monitor? what is a goal INR for stroke? when will the heparin drip be discontinued?
Warfarin (Coumadin) is for long-term follow-up and management of cardioembolic stroke. Warfarin will be started while the patient is on Heparin. The nurse will monitor the PT and INR carefully. Goal is in stroke is an INR between 2-3.5. Once the INR is therapeutic, the Heparin drip will be discontinued.
Whether or not a patient has had tPA what is the goal? why may aspirin be given? what is the usual dose? ticlid; what should be monitored
Whether or not a patient has had tPA the goal is to prevent progression of occlusion. Clumping of the platelets can become large enough to occlude the vessel and impede blood flow so antiplatelet therapy may include Aspirin (ASA) which inhibits platelet aggregation. Usual dose 80-325 mg every day. Ticlopidine (Ticlid) is not used often but if it is nurses need to monitor blood work as Ticlid may cause neutropenia and thrombocytopenia.
what is the main focus within the first 24 hours of an ischemic stroke? what should be observed? monitor for what symptoms?
Within the first 24 hours of an ischemic stroke, the main focus is to monitor for tissue perfusion. Observe for deterioration in neurologic status such as weakness, dysphagia, aphasia, visual field cuts. Monitor for increase in intracranial pressure especially change in level of consciousness,
how does an ICH (intracerebral hemorrhage) occur? what does this result in? ICH vs SAH occurrence? most common in what demographics? what can contribute? symptoms?
an intracerebral hemorrhage (ICH )occurs when blood is forced into the surrounding cerebral parenchyma (brain tissue) from the blood vessels. The resulting compression of tissue causes ischemia and cerebral edema, resulting in increased intracranial pressure. ICH is twice as common as SAH. It is most common in males, the elderly and those with hypertension. Alcohol and drug abuse can be contributory. Headache, nausea and vomiting and decrease in LOC are the most common symptoms.
how is tpa dosage calculated? how is it administered? what is important to anticipate prior to thrombolytics?
tPA dosage is calculated by weight (maximum dose is 90mg) and then 10% given as an IV push bolus then the remainder is administered over one hour. It is important to anticipate any invasive procedures such lab draws, foley catheter, IV because they must be done prior to the thrombolytic as the patient will be a high risk for bleeding from any orifice.
how does tpa work? how does this effect the stroke? post tpa monitoring; what can indicate brain hemorrhage?
tPA works by dissolving the clot and improving blood flow to the part of the brain being deprived of blood flow. The stroke may be reversed or damage kept to a lesser level. Post tPA monitoring is done in the ICU with frequent VS. Even subtle changes must be reported. Neurological deterioration can indicate brain hemorrhage.
the cause of ischemic stroke has different etiologies; cryptogenic
. Cryptogenic: Stroke occurring without a known cause
what is an arteriovenous malformation? the tissue does what? when do avm's present? they are at risk for hemorrhage when? when do symptoms occur?
An arteriovenous malformation (AVM) is a system of dilated vessels that shunt arterial blood directly into the venous system without the capillary network which increases risk of rupture and hemorrhage This tissue often displaces normal tissue. AVMs are present at birth and risk for hemorrhage increases every year with symptoms sometimes arising in a persons in their twenties but usually after age thirty.
stroke; angiography is done why? carotid doppler purpose? what can it detect? eeg? ekg is used to do what?
Angiography is done only if aneurysm or arteriovenous malformation (AVM) is suspected and may be done as a possible treatment option for stenosis for stenting. Carotid Doppler ultrasound is a noninvasive and painless test to scan carotid arteries with sound waves. Can detect degree of stenosis, thrombus. . EEG may be done if seizure activity is suspected. EKG is used to evaluate for dysrhythmia, such as atrial fibrillation.
ct scan will be done initially to rule out what? MRI is used later on for what?
CT scan will be done initially to rule out cerebral bleed as previously depicted. Magnetic resonance imaging (MRI) is more detailed may be used for stroke work-up at a later time to determine small areas of damage.
ischemic stroke; cardio embolic; people with what comorbidities are at high risk for stroke?
Cardio embolic: Stroke resulting from a source of the heart. People with atrial fibrillation, congestive heart failure (CHF),or decreased ejection fraction are at high risk for stroke
what are the complications of SAH? coils and clips may occlude what vessels? when cerebral blood flow is decreased what can occur? the pt will show what symptoms?
Complications of SAH include rupture of the aneurysm during endovascular or surgical procedure. Parent vessels, their branches, or perforating vessels may be occluded by coils or clips. When cerebral blood flow is decreased vasospasm can occur. This occurs in a majority of SAH patients. The patient will show speech or motor deficits or altered LOC.
dipyridamole plus aspirin contains what dosage? plavix usual dose; what medications should be avoided when taking aspirin?
Dipyridamole plus aspirin (Aggrenox) contains 200 mg dipyridamole and 25 mg ASA. Clopidogrel (Plavix): Prevents platelets from clumping together. Usual dose is 75 mg daily. Avoid taking with aspirin (unless ordered by MD), antiinflammatory medications, and Coumadin.
heparin infusion may be used if the stroke is from what source? what is heparin used to prevent? how does heparin work? what must nurses monitor?
Heparin infusion may be used if the stroke is from a cardioembolic source. It is used to prevent recurrent embolus and halt progression of thrombus. Heparin does not break up existing clots like tPA does. It interferes with the clotting cascade by preventing conversion of prothrombin to thrombin. Nurses must monitor the PTT and adjust the Heparin either per a protocol or MD order.
ICP should be maintained at what level? cerebral perfusion pressure? what is the pt started on to prevent seizures? DVT prevention
ICP should be maintained less than 20 mm Hg with cerebral perfusion pressure (CPP) greater than 70. The patient is usually started on phosphenytoin (Cerebryx) or phenytoin (Dilantin) to prevent seizures. DVT prevention with TED hose, SCD and heparin as soon as it is safe to do so because DVTs remain a common problem during recovery from ICH.
If the patient shows an ICH along with neurologic decline what is required? gcs that indicates comfort care? overall mortality rate for ich within 30 days?
If the Glasgow Coma Score (GCS) is less than 4, the prognosis is grim and discussion regarding comfort care may be instituted. The overall mortality rate for ICH within 30 days is over 40%. Give the family information and emotional support. If the patient is agitated a composed family member at the bedside can be helpful.
In the long term patients with ICH will need extensive therapies; what is used if ventilation is needed for more than 10-14 days? what may be required for nutrition?
In the long term patients with ICH will need extensive therapies. A tracheostomy will be placed if ventilation is needed for more than 10-14 days. A PEG may be required for nutrition.
what is a stroke? what can it be caused by? risk factors for stroke are similar to what disease?
It is a sudden neurologic deficit due to interruption of blood flow to the brain. It can be caused by thrombosis, embolism or hemorrhage. Stroke continues to be the leading cause of adult disability with often devastating consequences related to function. Risk factors for stroke are similar to risk factors for myocardial infarction
what meds are used for severe elevated BP? why is an external ventricular drain placed?
Nitroprusside and Nicardipine are commonly used medications for severe elevated BP. An external ventricular drain (EVD) is placed because ICP is a common problem in ICH
nursing management of the patient with unruptured avm? the pt should receive what medications?
Nursing management of the patient with unruptured AVM includes ongoing monitoring of neuro status. Assess for hypertension, which places these patients at greater risk for rupture and monitor for headache, because of this population's risk for ICH, administer analgesics and observe for signs of seizure activity. The patient should receive AEDs.
Once a hemorrhagic stroke is ruled out and ischemic stroke verified, the main goal is to do what? what is the only clot buster drug approved for ischemic stroke at this time?
Once a hemorrhagic stroke is ruled out and ischemic stroke verified, the main goal is to reestablish blood flow. t-PA (Activase) is the only thrombolytic (clot buster) drug approved for ischemic stroke at this time.
Once evaluated the patient may need special assistance to eat to prevent aspiration or possibly require tube feeding; why should the nurse feed the patient initially
Once evaluated the patient may need special assistance to eat to prevent aspiration or possibly require tube feeding. A nurse should feed the patient initially until risk for aspiration is decreased.
percentage of ischemic stroke patients on thrombolytics? reason for that percentage; criteria that needs to be met for thrombolytic therapy?
Only about 4%-6% of all ischemic stroke patients receive thrombolytic therapy. Many patients arrive to the hospital outside the 3-hour treatment window, which rules out most for thrombolytic therapy. Also, certain criteria must be met. Blood pressure must be below a SBP of185 and DBP of 110.
Post hospital management of all types of strokes depends on what?
Post hospital management of all types of strokes depends on the severity of the stroke and the deficits displayed. The social worker or case manager will work with the patient and family to determine the need for rehabilation, skilled nursing care, long term acute care or home care follow up
nursing considerations for post op hematoma or blood evacuation? what requires a call to the MD? hob degrees? monitor for signs of what?
Post operative craniotomy for hematoma or blood evacuation will involve neuro checks hourly or as needed. Even subtle changes should be reported to the surgeon. Strict I&O, pain medication and antiemetics may be needed as nausea is common. Some blood on the head dressing is usual but continuous bleeding requires a call to the MD. Monitor for hypoxia and urinary output. Keep the head of bed (HOB) according to MD order. Usually this will be 30 degrees. Space care (suctioning, turning, trach care etc. ) over time to reduce the risk of IICP. Perform ROM. If the patient is able have them use the incentive spirometer hourly and monitor for signs of pneumonia.
ich; why are stool softeners given? gi ulcers; medications; how is temp controlled?
Stool softeners are given to promote regular bowel movements and prevent acute rises in ICP due to straining. Patients are at greater risk for GI ulcers during this time and require preventative proton pump inhibitors or H2 blockers . Temperature should be kept in normal limits using acetaminophen and a cooling blanket because fever increases brain metabolism, thereby elevating ICP.
SAH; headache may have precipitation factors such as what? what are other complaints? when examined the patient will have what symptoms?
The headache may have precipitating factors such as strenuous activity or emotional stress. Other complaints are transient loss of consciousness, nausea, vomiting, blurred vision, photophobia, and seizure. When examined the patient will have nuchal rigidity and may have change in mental status, and cranial nerve changes especially those involving pupil reaction and eye movement.
why is CT scan the standard diagnostic tool? if there is no blood the stroke is determined to be what? what med is considered? hemorrhage appears how on a CT?
The standard diagnostic tool is the CT scan which is able to differentiate between ischemic and hemorrhagic stroke A CT scan can be done quickly to determine the presence or absence of blood. If there is no blood, the stroke is determined to be ischemic and administration of tPA (transplasminogen activator, 'clot buster') is considered. Hemorrhage is the white area seen on the CT on the right.
symptoms of a stroke occur how? why is treatment often delayed? what symptoms should be identified as a stroke until other causes can be ruled out?
The symptoms of stroke occur suddenly and symptoms vary according to severity and location of the stroke. Treatment is often delayed because people often do not believe they are having a stroke. Sudden unilateral weakness or numbness Sudden confusion, trouble speaking or understanding Sudden severe headache, vision changes in one or both eyes Sudden trouble walking, dizziness, or loss of balance These symptoms should be identified as a stroke until other causes can be ruled out.
treatment of avm will involve what? if the avm is unruptured?
Treatment will involve stereotactic radiosurgery or embolization. If the AVM is unruptured surgery is elective. If the patient has had hemorrhage, surgery is done but delayed for weeks to allow the brain to heal. Other options are stereotactic radiosurgery and embolization.`