Final Study Guide 1300
Stroke
o Stroke occurs when there is either:
- Ischemia (inadequate blood flow) to the brain
- Hemorrhage into the brain that results in death of brain cells.
o Also known as:
- Brain attack
- Cerebrovascular accident (CVA)
o Loss of function varies according to location & extent of brain tissue involved.
- Blood is responsible for carrying oxygen & glucose to the brain and ridding
waste from the brain.
- Major issue is long term disability social support from family/friends/SO
Risk Factors
Non-Modifiable Modifiable
-Age (65 years or older ↑ risk) -HTN #1 important risk factor
-Gender (men more likely than women) -Heart d/s
-Ethnicity/race (African Americans) -Serum cholesterol
-Heredity/ family hx -Smoking
-Excess alcohol
-Obesity
-Sleep apnea
-Metabolic syndrome
-Lack of physical exercise
-Poor diet
-Drug abuse (cocaine)
o Conditions associated w/ stroke risk:
- Afib
- DM
- Cardiac valve abnormalities (nice to know)
Patho of Stroke
o Blood is supplied to the brain by 2 major pairs of arteries:
- Internal carotid arteries (anterior circulation)
- Vertebral arteries (posterior circulation)
o The brain requires a continuous supply of blood to provide oxygen & glucose that
neurons need to function.
o Intracranial pressure (ICP) also influences cerebral blood flow:
- Increased ICP causes brain compression & reduced cerebral blood flow.
- One major goal when caring for a stroke pt is to reduce secondary injury r/t
increased ICP.
Types of Stroke
Ischemic (Thrombotic) Ischemic (Embolic) Hemorrhagic
,-The process of clot formation -An embolus is a blood clot or -A burst blood vessel may
(thrombosis) results in a other debris circulating in the allow blood to seep into &
narrowing of the lumen, which blood. When it reaches an damage brain tissues until
blocks the passage of the artery in the brain that is too clotting shuts off the leak.
blood through the artery. narrow to pass through, it -Warning signs less common
-Most common lodges there & blocks the flow unless due to HTN
-Preceded by TIA typically of blood.
-2nd most common
-Warning signs less common
Evolution: Evolution: Evolution:
-Intermittent -Abrupt -Usually abrupt
Onset: Onset: Onset:
-Gradual -Sudden -Sudden OR gradual if due to
HTN
Associated factors: Associated factors: Associated factors:
-HTN -Cardiac d/s (afib, MI) -HTN
-Atherosclerosis -Vessel d/o
-DM -Trauma
LOC: LOC: LOC:
-Preserved (awake) -Preserved (awake) -Deepening stupor or coma
Neuro Deficits: Neuro Deficits: Neuro Deficits:
-During first couple weeks -Maximum deficit @ onset -Severe focal deficits
-Confusion -Expressive aphasia
-Slight h/a -Paralysis
-Visual problems
-Speech deficits
No seizures No seizures Seizures
CSF Normal CSF normal CSF bloody
Duration: Duration: Duration:
-Improvement over weeks to -Rapid improvement (after Variable
months (gradual) TPA)
Ischemic Stroke
o Often follows warning signs:
- TIA, also known as “silent stoke”
Brief interruption in cerebral blood flow temporary neurologic dysfunction w/o
acute infarction
- Multiple TIAs indicate a high stroke risk
- Visual, motor, sensory, speech deficits:
, Symptoms typically resolve w/i 30-60min
Visual deficits: blurred vision, tunnel vision, diplopia, blindness, ptosis
(drooping eyelid)
Motor deficits: bilateral or unilateral weakness or numbness, ataxia,
tinnitus
Speech deficits: dysarthria (unclear speech)
Sensory deficits: Vertigo
Right-Sided Brain Damage (stroke on R side) Left-Sided Brain Damage (stroke on L side)
o Paralyzed L side: hemiplegia
o Left-sided neglect o Paralyzed R side: hemiplegia
o Spatial-perceptual deficits (distance in o Impaired speech/language aphasias
space) o Impaired right/left discrimination
o Denies or minimizes problems o Slow performance, cautious
o Rapid performance, short attention o Aware of deficits depression, anxiety
span o Impaired comprehension r/t language,
o Impulsive, safety problems math
o Impaired time concepts
Clinical Manifestations
Motor Communication Affect Intellectual Spatial-Perceptual Elimination
-Impairment of -Aphasia (when -May have -Both memory -R brain stroke -GU & GI
mobility, damage to difficulty & judgment more likely to incontinence
respiratory dominant controlling may be have problems w/ -Occur initially &
function, hemisphere of emotions impaired spatial perception often temporary
swallowing & the brain) -Emotional -L brain stroke orientation -When a stroke
speech, gag reflex, -Receptive responses may more likely to -Incorrect affects 1
& self-care abilities aphasia (loss of be have memory perception of self hemisphere of the
-Akinesia (loss of comprehension) exaggerated or problems & illness brain, the
skilled voluntary -Expressive unpredictable -R brain -Unilateral neglect prognosis of
movement) aphasia -May be stroke more (Can only see 1 normal bladder
-Hemiplegia (inability to magnified by likely to be side, high risk for function is
(paralysis on 1 produce depression, impulsive (bed falls) excellent
side) language) changes in alarms, high -Agnosia (inability -Unable to express
-Hemiparesis -Global aphasia body image, & risk for falls) to interpret their needs to use
(weakness on 1 (total inability loss of -Either type of sensations & the restroom
side) to function stroke may recognize things) causing
-Hypotonia communicate) have difficulty -Apraxia (unable incontinence
(flaccidity) -Dysarthria generalizing to perform tasks
-Hypertonia (slurred speech) (be specific & or movements
(spasticity) -Dysphagia concise, when asked)
-Hyporeflexia interferes w/
-Hyperreflexia learning)
, Diagnostics
CT scan/ MRI MR Cerebral Angiography Lumbar Glasgow coma scale Carotid Duplex
A Puncture scan
-Indicate size & -Shows blood flow thru -If your pt comes in
location of the carotid arteries in neck. -Looks for RBC w/ ↓ LOC or -No smoking 2h
lesion -Detects defects, in the CSF if an comatose before test b/c o
-Differentiates narrowing, or obstruction SAH is -8 or less = constriction, no
between ischemic of arteries or blood vessels suspected but comatose caffeine b/c it
& hemorrhagic in brain CT scan does -9 to 12= moderate can affect result
-CT scan is easy & -Iodine based contrast dye not show head injury
right away is injected into an artery hemorrhage -Greater than 13=
-MRI takes longer during this procedure -Spinal tap minor head trauma
-If pt is -Avoided if pt is
closterphobic & Preprocedure: suspected of E+V+M=GSC
getting an MRI, -No food/fluid 4-6hr prior having an Eye opening (E):
give a benzo. -Assess allergy to shellfish obstruction or 4= Spontaneous
-MRI: no metals or iodine other signs of ↑ 3=to voice
-Any hx of bleeding or ICP b/c of 2=to pain
CT scan w/ anticoag tx requires danger of 1=does not open
contrast or additional herniation of
sedation: considerations/monitoring brain Verbal(V)
-No food/fluid 4hr to ensure clotting after downward 4=coherent &
prior procedure leading to oriented
-Assess for allergy -Asses BUN/creat to pressure on 3=Inappropriate
to shellfish or determine kidney’s ability cardiac & resp. speech
iodine to excrete the dye centers & 2=sounds are made,
-Assess renal -Ensure pt is not wearing potentially but no words
function any jewelry death 1=does not occur
(BUN/creat) -Mild sedative for
relaxation: monitor v/s Preprocedure: Motor(M)
MRI: -Ensure all 6=Commands are
-Remove jewelry Intraprocedure: jewelry is followed
& metals -Head is secured removed 5=Local reaction to
-Catheter is placed into an -have pt void pain occurs
artery (usually groin or prior to 4=general
neck), dye is injected, x-ray procedure withdrawal to pain
is taken -Position pt to 3=Decorticate
-Cather is then removed & stretch spinal posture
arterial device is used or canal or 2=Decerebrate
pressure is held over the “cannonball” posture
artery to control bleeding position 1=Motor response
by thrombus formation does not occur
Intraprocedure:
Postprocedure: -Clean area
-Area closely monitored to prior to
ensure that clotting occurs insertion
-Movements are restricted -INJ local
anesthesia
Stroke
o Stroke occurs when there is either:
- Ischemia (inadequate blood flow) to the brain
- Hemorrhage into the brain that results in death of brain cells.
o Also known as:
- Brain attack
- Cerebrovascular accident (CVA)
o Loss of function varies according to location & extent of brain tissue involved.
- Blood is responsible for carrying oxygen & glucose to the brain and ridding
waste from the brain.
- Major issue is long term disability social support from family/friends/SO
Risk Factors
Non-Modifiable Modifiable
-Age (65 years or older ↑ risk) -HTN #1 important risk factor
-Gender (men more likely than women) -Heart d/s
-Ethnicity/race (African Americans) -Serum cholesterol
-Heredity/ family hx -Smoking
-Excess alcohol
-Obesity
-Sleep apnea
-Metabolic syndrome
-Lack of physical exercise
-Poor diet
-Drug abuse (cocaine)
o Conditions associated w/ stroke risk:
- Afib
- DM
- Cardiac valve abnormalities (nice to know)
Patho of Stroke
o Blood is supplied to the brain by 2 major pairs of arteries:
- Internal carotid arteries (anterior circulation)
- Vertebral arteries (posterior circulation)
o The brain requires a continuous supply of blood to provide oxygen & glucose that
neurons need to function.
o Intracranial pressure (ICP) also influences cerebral blood flow:
- Increased ICP causes brain compression & reduced cerebral blood flow.
- One major goal when caring for a stroke pt is to reduce secondary injury r/t
increased ICP.
Types of Stroke
Ischemic (Thrombotic) Ischemic (Embolic) Hemorrhagic
,-The process of clot formation -An embolus is a blood clot or -A burst blood vessel may
(thrombosis) results in a other debris circulating in the allow blood to seep into &
narrowing of the lumen, which blood. When it reaches an damage brain tissues until
blocks the passage of the artery in the brain that is too clotting shuts off the leak.
blood through the artery. narrow to pass through, it -Warning signs less common
-Most common lodges there & blocks the flow unless due to HTN
-Preceded by TIA typically of blood.
-2nd most common
-Warning signs less common
Evolution: Evolution: Evolution:
-Intermittent -Abrupt -Usually abrupt
Onset: Onset: Onset:
-Gradual -Sudden -Sudden OR gradual if due to
HTN
Associated factors: Associated factors: Associated factors:
-HTN -Cardiac d/s (afib, MI) -HTN
-Atherosclerosis -Vessel d/o
-DM -Trauma
LOC: LOC: LOC:
-Preserved (awake) -Preserved (awake) -Deepening stupor or coma
Neuro Deficits: Neuro Deficits: Neuro Deficits:
-During first couple weeks -Maximum deficit @ onset -Severe focal deficits
-Confusion -Expressive aphasia
-Slight h/a -Paralysis
-Visual problems
-Speech deficits
No seizures No seizures Seizures
CSF Normal CSF normal CSF bloody
Duration: Duration: Duration:
-Improvement over weeks to -Rapid improvement (after Variable
months (gradual) TPA)
Ischemic Stroke
o Often follows warning signs:
- TIA, also known as “silent stoke”
Brief interruption in cerebral blood flow temporary neurologic dysfunction w/o
acute infarction
- Multiple TIAs indicate a high stroke risk
- Visual, motor, sensory, speech deficits:
, Symptoms typically resolve w/i 30-60min
Visual deficits: blurred vision, tunnel vision, diplopia, blindness, ptosis
(drooping eyelid)
Motor deficits: bilateral or unilateral weakness or numbness, ataxia,
tinnitus
Speech deficits: dysarthria (unclear speech)
Sensory deficits: Vertigo
Right-Sided Brain Damage (stroke on R side) Left-Sided Brain Damage (stroke on L side)
o Paralyzed L side: hemiplegia
o Left-sided neglect o Paralyzed R side: hemiplegia
o Spatial-perceptual deficits (distance in o Impaired speech/language aphasias
space) o Impaired right/left discrimination
o Denies or minimizes problems o Slow performance, cautious
o Rapid performance, short attention o Aware of deficits depression, anxiety
span o Impaired comprehension r/t language,
o Impulsive, safety problems math
o Impaired time concepts
Clinical Manifestations
Motor Communication Affect Intellectual Spatial-Perceptual Elimination
-Impairment of -Aphasia (when -May have -Both memory -R brain stroke -GU & GI
mobility, damage to difficulty & judgment more likely to incontinence
respiratory dominant controlling may be have problems w/ -Occur initially &
function, hemisphere of emotions impaired spatial perception often temporary
swallowing & the brain) -Emotional -L brain stroke orientation -When a stroke
speech, gag reflex, -Receptive responses may more likely to -Incorrect affects 1
& self-care abilities aphasia (loss of be have memory perception of self hemisphere of the
-Akinesia (loss of comprehension) exaggerated or problems & illness brain, the
skilled voluntary -Expressive unpredictable -R brain -Unilateral neglect prognosis of
movement) aphasia -May be stroke more (Can only see 1 normal bladder
-Hemiplegia (inability to magnified by likely to be side, high risk for function is
(paralysis on 1 produce depression, impulsive (bed falls) excellent
side) language) changes in alarms, high -Agnosia (inability -Unable to express
-Hemiparesis -Global aphasia body image, & risk for falls) to interpret their needs to use
(weakness on 1 (total inability loss of -Either type of sensations & the restroom
side) to function stroke may recognize things) causing
-Hypotonia communicate) have difficulty -Apraxia (unable incontinence
(flaccidity) -Dysarthria generalizing to perform tasks
-Hypertonia (slurred speech) (be specific & or movements
(spasticity) -Dysphagia concise, when asked)
-Hyporeflexia interferes w/
-Hyperreflexia learning)
, Diagnostics
CT scan/ MRI MR Cerebral Angiography Lumbar Glasgow coma scale Carotid Duplex
A Puncture scan
-Indicate size & -Shows blood flow thru -If your pt comes in
location of the carotid arteries in neck. -Looks for RBC w/ ↓ LOC or -No smoking 2h
lesion -Detects defects, in the CSF if an comatose before test b/c o
-Differentiates narrowing, or obstruction SAH is -8 or less = constriction, no
between ischemic of arteries or blood vessels suspected but comatose caffeine b/c it
& hemorrhagic in brain CT scan does -9 to 12= moderate can affect result
-CT scan is easy & -Iodine based contrast dye not show head injury
right away is injected into an artery hemorrhage -Greater than 13=
-MRI takes longer during this procedure -Spinal tap minor head trauma
-If pt is -Avoided if pt is
closterphobic & Preprocedure: suspected of E+V+M=GSC
getting an MRI, -No food/fluid 4-6hr prior having an Eye opening (E):
give a benzo. -Assess allergy to shellfish obstruction or 4= Spontaneous
-MRI: no metals or iodine other signs of ↑ 3=to voice
-Any hx of bleeding or ICP b/c of 2=to pain
CT scan w/ anticoag tx requires danger of 1=does not open
contrast or additional herniation of
sedation: considerations/monitoring brain Verbal(V)
-No food/fluid 4hr to ensure clotting after downward 4=coherent &
prior procedure leading to oriented
-Assess for allergy -Asses BUN/creat to pressure on 3=Inappropriate
to shellfish or determine kidney’s ability cardiac & resp. speech
iodine to excrete the dye centers & 2=sounds are made,
-Assess renal -Ensure pt is not wearing potentially but no words
function any jewelry death 1=does not occur
(BUN/creat) -Mild sedative for
relaxation: monitor v/s Preprocedure: Motor(M)
MRI: -Ensure all 6=Commands are
-Remove jewelry Intraprocedure: jewelry is followed
& metals -Head is secured removed 5=Local reaction to
-Catheter is placed into an -have pt void pain occurs
artery (usually groin or prior to 4=general
neck), dye is injected, x-ray procedure withdrawal to pain
is taken -Position pt to 3=Decorticate
-Cather is then removed & stretch spinal posture
arterial device is used or canal or 2=Decerebrate
pressure is held over the “cannonball” posture
artery to control bleeding position 1=Motor response
by thrombus formation does not occur
Intraprocedure:
Postprocedure: -Clean area
-Area closely monitored to prior to
ensure that clotting occurs insertion
-Movements are restricted -INJ local
anesthesia
