MedSurg II - Stroke

olanjones's version from 2017-03-18 02:45

Stroke Types & Diagnostics

Question Answer
Ischemic: Thromboticmen>women, oldest median age; Warning: TIA(30%-50% of cases) Onset: Often during or after sleep
Prognosis: Stepwise progression, signs and symptoms develop slowly, usually some improvement, recurrence in 20%-25% of survivors
Ischemic: Emboticmen>women, Warning: TIA (uncommon) Onset: Lack of relationship to activity, sudden onset
Prognosis: Single event, signs and symptoms develop quickly, usually some improvement, recurrence common without aggressive treatment of underlying disease
Hemorrhagic: Intercerebralwomen slightly>men, Warning: Headache (25% of cases) Onset: Activity (often)
Prognosis: Progression over 24 hr. Poor prognosis, fatality more likely with presence of coma
Hemorrhagic: Subarachnoidwomen slightly>men, youngest median age, Warning: Headache (common) Onset: Activity (often), sudden onset, most commonly related to head trauma
Prognosis: usu single sudden event, fatality more likely w/ presence of coma
Warning Signs of Stroke-Sudden numbness, weakness, paralysis of the face, arm, or leg, especially on one side of the body
-Sudden confusion, trouble speaking or understanding; Slurred speech
-Sudden trouble seeing in one or both eyes; Sudden trouble walking, dizziness, loss of balance or coordination
-Sudden, severe headache with no known cause
Cerebral ImagingComputed tomography (CT) scan, CT angiography (CTA), Magnetic resonance imaging (MRI), Magnetic resonance angiography (MRA), CT/MRI perfusion and diffusion imaging
Cerebral Blood FlowCerebral angiography, Carotid angiography, Digital subtraction angiography, Transcranial Doppler ultrasonography, Carotid duplex scanning
Cardiac AssessmentElectrocardiogram, Chest x-ray, Cardiac markers (troponin, creatine kinase-MB), Echocardiography (transthoracic, transesophageal)
Additional Lab StudiesCBC +platelets, Coag (PT, aPTT), Electrolytes, Glucose, Renal & Hepatic, Lipids, CFS analysis

Stroke S/S

Question Answer
Anterior cerebral arteryMotor and/or sensory deficit (contralateral), sucking or rooting reflex, rigidity, gait problems, loss of proprioception and fine touch
Middle cerebral arteryDominant side: Aphasia, motor and sensory deficit, hemianopsia
Nondominant side: Neglect, motor and sensory deficit, hemianopsia
Posterior arteryHemianopsia, visual hallucination, spontaneous pain, motor deficit
VertebralCranial nerve deficits, diplopia, dizziness, nausea, vomiting, dysarthria, dysphagia, and/or coma
Right-brain damageParalyzed left side: hemiplegia, Left-sided neglect, Spatial-perceptual deficits, Tends to deny or minimize problems; Rapid performance, short attention span; Impulsive, safety problems; Impaired judgment; Impaired time concepts
Left-brain damageParalyzed right side: hemiplegia; Impaired speech/language aphasias; Impaired right/left discrimination; Slow performance, cautious; Aware of deficits: depression, anxiety; Impaired comprehension r/t language, math
Broca’s aphasia (nonfluent)Damage to frontal lobe of brain; Frequently speak in short phrases that make sense but are produced with great effort
Often omit small words such as “is,” “and,” and“the”; May say, “Walk dog,” meaning, “I will take the dog for a walk,” or “book book two table,” for “There are two books on the table”
Typically understand speech of others fairly well; Often aware of their difficulties and can become easily frustrated
Wernicke’s aphasia (fluent)Damage occurs in left temporal lobe, although it can result from damage to right lobe
May speak in long sentences that have no meaning, add unnecessary words, and even create made-up words; May say, “You know that smoodle pinkered and that I want to get him round and take care of him like you want before”
Often difficult to follow what person is trying to say; Usually have great difficulty understanding speech, Often unaware of their mistakes
Global aphasia (nonfluent)Results from damage to extensive portions of language areas of brain
Have severe communication difficulties; May be extremely limited in ability to speak or comprehend language
Other aphasiaResults from damage to different language areas in brain; Some people may have difficulty repeating words/sentences even though they can speak & understand the meaning of the word/sentence
Others may have difficulty naming objects even though they know what the object is & what its use is

Nursing Assess & Tx

Question Answer
SubjectiveConfirm past health history, medications, sensations (numbness/tingling), HA, visual disturbance
Objective-General: emotional lability, lethargy, apathy/combative, fever
-Respiratory: irreg (tachypnea, apnea, labored), loss/delayed cough reflex
-Cardio: HTN, tachycardia, carotid bruit
-GI: loss of gag reflex, decreased motility, bowel incontinence
-Urinary: frequency, urgency, incontinence
-Neuro: motor & sensory deficits, altered LOC, changes in reflex patterns/strength/balance, personality changes
Preventative txControl of DM, HTH; Tx underlying cardiac prob, NO SMOKING, limit ETOH
-Drug tx: platelet inhibitors, anticoag (for afib)
-Surgical tx: Carotid endarterectomy, Stenting of carotid artery, Transluminal angioplasty, Extracranial-intracranial bypass, Surgical interventions for aneurysms at risk of bleeding
Acute CareMaintain airway, Fluid tx, tx cerebral edema, Prevent secondary inj (edema, impaired blood flow, etc)
-Ischemic: tPA IV or intraarterial (must be admin w/in 3 - 4 1/2 hours of onset of clinical s/s), Stent rertreivers, MERCI retriever
-Hemorrhagic: Surgical decompression, Clipping or coiling of anerusym
Rehab txFocus on helping patient achieve independence and functional recovery
NIH Stroke Scale15-item neurologic exam to evaluate the effect of an acute stroke; rates patient’s ability to answer questions & perform activities. Ratings for each item are scored, if an item is untested, a detailed explanation must be written on the form
NIHSS Items-LOC, LOC questions, LOC commands
-Best gaze, Visual, Facial palsy
-Motor & drift, Limb ataxia, Sensory
-Best language, Dysarthria (slurred speech), Extinction/inattention, Distal motor function

Care Plans

Question Answer
Cerebral Perfusion Promotion-Maintain hemodynamic parameters (per PCP), Monitor neurologic status to detect changes
-Calculate/monitor CPP, Monitor respiratory status, Monitor patient’s ICP & neurologic responses to care activities
-Monitor determinants of tissue oxygen delivery, Administer/titrate vasoactive drugs, Avoid neck flexion/extreme hip/knee flexion
Aspiration PrecautionsMonitor LOC, cough/gag reflex/swallowing ability; Avoid liquids/use thickening agent; Feed in small amounts; Offer food/liquids that can form bolus before swallowing
Airway Management-Auscultate breath sounds, Remove secretions (by cough/suction)
-Encourage slow, deep breathing; turning; and coughing to increase airway clearance without increasing ICP
-Assist with incentive spirometer, Keep pt NPO until swallow eval
Exercise Therapy: Muscle Control-Collaborate w/ PT, OT, and recreational therapists in developing and executing exercise program; Determine patient’s readiness to engage in activity or exercise protocol
-Apply splints to achieve stability of proximal joints involved with fine motor skills; Encourage patient to practice exercises independently
-Reinforce instructions provided to patient about the proper way to perform exercises; Provide restful environment for patient after periods of exercise
Communication Enhancement: Speech Deficit-Listen attentively; Provide positive reinforcement/praise; Use simple words/ short sentences
-Perform prescriptive speech-language therapies during informal interactions with patient, Provide verbal prompts/reminders
-Treat pt as adult; Use normal volume/tone; Present one idea/thought at a time; Decrease environmental stimuli
-Keep questions simple (yes/no answers); Allow time for response; Do not pretend to understand if you don't - encourage non-verbal communication
-Do not push communication if the person is tired or upset; Aphasia worsens with fatigue and anxiety
Unilateral Neglect Management-Monitor for abnormal responses to three types of stimuli: sensory, visual, and auditory; Instruct patient to scan from left to right
-Position bed so patient is approached/care given on unaffected side; Rearrange environment to use unaffected visual field; position items/tv/reading materials w/in view on unaffected side
-Touch unaffected shoulder when initiating conversation; Gradually move personal items & activity to affected side as patient demonstrates an ability to compensate for neglect
-Include caregivers in rehabilitation process
Urinary Habit Training-Keep a continence specification record for 3 days; Establish interval of initial toileting schedule (based on voiding pattern/usual routine)
-Assist patient to toilet and prompt to void at prescribed intervals, Teach patient to consciously hold urine until the scheduled toileting time
-Discuss daily record of continence with staff; Give positive feedback/reinforcement to patient when he/she voids at scheduled toileting times (make no comment when incontinent)
Swallowing Therapy-Collaborate with other members of health care team (e.g., OT/SP/dietitian)
-Assist patient to sit in an erect position for feeding/exercise; Assist patient to “chin tuck” in prep for swallowing; Assist patient to maintain sitting position for 30 min after meal
-Instruct patient or caregiver on emergency measures for choking; Check mouth for pocketing of food after eating
-Provide mouth care as needed; Monitor body weight
Self-Esteem Enhancement-Monitor patient’s statements of self-worth; Encourage patient to identify strengths; Assist in setting realistic goals
-Reward or praise patient’s progress toward reaching goals; Encourage increased responsibility for self; Monitor levels of self-esteem over time


Question Answer
RNAssess clinical manifestations of stroke and determine when clinical manifestations started; Assess neurologic status, including ICP
RNScreen patient for contraindications for tPA tx; Infuse tPA for patients with ischemic stroke who meet the criteria;
RNMonitor cardiovascular status, including hemodynamic monitoring if needed; Assess patient’s ability to swallow (in conj. w. ST)
LPNAdminister scheduled anticoagulant & antiplatelet medications
CNAObtain/report vital signs frequently; Measure & record urine output
CNAAssist with positioning patient and turning patient at least every 2 hr; Perform passive/active range-of-motion exercises
CNAPlace equipment needed for seizure precautions in patient room

Cranial Nerves

Question Answer
CN mnemonic neuominc (Sensory/Motor)?Some Say Marry Money But My Brother Says Big Boobs Matter More (S=sensory, M=Motor, B=Both)
CN I OlfactorySensory: smell; Client closes eyes & ID's different aromas
CN II OpticSensory: vision & vision fields; Client reads Snellen-type chart
CN III Oculomtor (mixed nerve)Motor: extraocular eye movement (EOM) & parasympathetic pupil constriction
CN IV TrochlearMotor: EOM: moves eyeballs down & laterally; penlight & Snellen chart utilized
CN V TrigeminalBoth: motor→muscles of mastication & sensory→face, scalp, mouth, nose
CN VI AbducensMotor: moves eyes laterally
CN VII FacialBoth: facial expression; taste (anterior 2/3 of tongue); Ask client to smile, raise eyebrows, frown, puff out cheeks, close eyes tightly; ID various tatstes
VIII AuditorySensory: hearing (tuning fork) & equilibrium (Romberg test)
IX GlossopharyngealBoth: (gag reflex) swallowing ability, tongue movement (move tongue side-side, up & down), taste (posterior, apply tastes to that area of tongue to ID)
X VagusBoth: swallowing/gag reflex; sensation from carotid body, carotid sinus & pharynx (assess speech for hoarseness)
XI AccessoryMotor: head movement; shrugging of shoulders (turn head side to side) utilize trapezius & sternomastoid muscles
XII HypoglossalMotor: movement of tongue; protrusion of tongue & move it side to side
Mnemonic for CN: On Occasion Our Trusty Truck Acts Funny Very Good Vehicle Any HowOlfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear Glossopharyngeal Vagus Accessory Hypoglossal

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