AMS1

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Author:
alyn217
ID:
165224
Filename:
AMS1
Updated:
2012-08-13 23:19:33
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AMS1T4 Stroke
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Description:
Neuro: Stroke
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  1. Risk factors for stroke
    • Age
    • Gender
    • Race
    • Heredity
    • Modifiable: 
    • Hypertension
    • asymptomatic carotic stenosis
    • heart disease (afib)
    • DM
    • alcohol
    • smoking
    • hypercoagulability
    • hyperlipidemia
    • obesity
    • oral congraceptives
    • sickle cell
    • physical inactivity
    • migrane
    • patent foramen ovale (PFO)
    • Coacain
    • Methamphetamine
  2. Pathophys of stroke
    • Blood is suppied to the brain by two majro pair of arteries:
    • internal carotic
    • vertebral
  3. TIA
    • tempr cessation of blood flow
    • experience transient symptoms
    • symptoms typically last <1hr, up to 24 hr
    • pt should seek med care
    • Event should be seen as an "early warning system," which will probably-->Rx asprin or other prophylactic treatment for stroke, diet education, etc. 
  4. TIA SnSs
    • Carotid symptoms
    • tempt vison loss
    • transient hemiparesis (one-sided weakness)
    • numbness/loss of sensation
    • aphasia (diff/inability to speak)
    • Vertebrobasilar symptoms:
    • tinnitus
    • dysphagia
    • vertigo
    • ptosis
    • ataxia
    • dysarthria (slurred speech)
    • blurred vission
    • unilateral or bilateral numbness/weakness
  5. Management for TIA
    • Diagnostics:
    • CT (gold standard, but only good after 24 hours. Ischemic stroke only, will be good immediately for hemorrhagenous stroke)
    • MRI
    • Cardiac monitor (check for afib)
    • ECHO
    • Carotid NIVA
    • Lipid panel
    • coag panel
    • Hgb A1C
    • Rx:
    • Antihypertensives
    • Antiplatelet
    • Surgery:
    • Carotid endarterectomy
  6. TIA vs Stroke
    • Transient
    • resolve
    • ischemia to brain
    • no infarction
    • no damage to brain on mri
    • warning sign for future stroke
    • short hospital stay
  7. hemorrhagic stroke
    • subarachnoid hemorrhage
    • intracerebral hemorrhage
    • ateriovenous malformation (congenital abnormality
    • coag disorder
    • anticoage/thrombotic (reverse)
    • trauma
    • brain tumor
    • reptured aneurysm
    • Intervensions:
    • stat CT head
    • Risk=HTN
    • SnSs: Headache, n/v, v LOC, neuro deficits
  8. Hemorrhagic Stroke
    • 40% mortality rate
    • caused by: ruptured aneurysm, trauma, drug use.
    • complications:
    • vasospasm
    • rebleeding
    • hydrocephalus
    • seizure
    • EKG
    • SnSs:
    • Neuro deficits
    • meningeal s/sx (stiff neck, bad headache, light sensitive)
    • n/v
    • vision issues
  9. Ischemic stroke
    • Infarction vs ischemia
    • thrombotic: progressive SnSs 
    • Embolic: rapid onset (afib)
    • small artery occlusive disease
    • Cryptogenic (unknown source)
  10. SnSs of Ischemic stroke
    • weakness/paralysis to face/arm/leg, often one side but can be bilat
    • numbness
    • sudden confusion, trouble speaking or understanding
    • slurred speech
    • vission problems
    • dizziness/loss of balance/coord/ataxic
    • diff swalling (npo)
    • sudden severe headache, n/v
  11. Time is Brain
    • FAST
    • Face: smile will droop on one side
    • Arm: both arms raised, should be symetrical bilat
    • Speech: speak simple sentence, slurred? unable?
    • Time: When was last time pt was normal? 3 hr clock starts then. 
  12. Stroke: rt vs lt side
    • rt side: Rt brain, lt body
    • spatial perceptial deficits
    • tend to deny or minimize problems
    • rapid performance, short attention span
    • impulsive, saftey problems
    • impaired judment
    • impaired time conception
    • lt side: lt brain, right body
    • impaired speech/language
    • impaired rt/left discrimination
    • slow performance, cautious
    • aware of deficits, depression, anxiety
    • impaired comprehension related to language math. 

    Both will have physical deficits on opposite side of body.
  13. Classic stroke symptoms
    motor defictis (pronator drift)
    • Mobility: 
    • --Hemiparalysis/paresis
    • --Flaccid/spastic tonicity
    • --Hypo/hyperreactive reflexes
    • --Gait, balance, posture
    • Respiratory
    • --aspiration? Intubate
    • Swallowing:
    • --Dysphagia
    • Speech:
    • --Dysphasia/arthria
    • Selfcare:
    • --Diminished ADLs
  14. Stroke symptoms
    Dysphasia
    • print slide 31
    • Aphasia
    • --broca's: expressive. Diff talking
    • --Wernicke's: receptive (cannot hear/understand language)
    • --Global: all of the above. Do not rehab well and usually causes premanent deficits. 
    • Dysarthria: slurred speech
  15. Classic Stroke SnSs
    affective
    • Emotions exaggerated or upredictable
    • --depression?
    • --Mood lability (mood swings)?
  16. Classic stroke SnSs
    Cognition
    • Left-sided:
    • --impaired memory
    • --cautious
    • Right-sided
    • --Impaired judgment
    • --impulsive
  17. Spatial perceptual issues
    • more common with Rt side stroke
    • four categories
    • --lack of insight
    • --neglect (extinction
    • ----homonymous hemianopsia
    • --agnosia (object recognition
    • --apraxia (unable to do learned taskes)
  18. Classic stroke symptoms
    elimination issues
    • temporary
    • related to inablity to communicate or express need
    • urinary (usually incontinence)
    • bowels (constipation)
  19. Ct diagnostics
    • noncontrast ct head
    • --CTA: angiogram
    • --CTV: venogram
    • --CTP: perfusion
    • Cerebral angiogram (with contrast
    • MRI/MRA (takes longer than CT; 45min vs 10.)
    • Transcranial doppler: used to find vasospasm
    • Lumbar puncture (test material) fetal side line position. Look for clear liquid at base of spine after procedure.
  20. How do we treat ischemic stroke?
    Test
    • TPA: tissue plasminogen activator
    • --intravenous: 3 hour limit
    • --intraarterial: 6 hour limit
    • Intervential radiology-clot retrieval/stents
    • antiplatelet: aspirin plavix, aggrenox, ticlid
    • lipid lowering agent, ie statins
    • coumadin: afib or clotting disorder
    • surgical: carotid endarterectomy (CEA)
    • maintain airway/monitor blood pressure
    • rehab: pt/ot/st
  21. Carotid Endarterectomy
    Post procedure monitor for any snss of neuro change that could signify a stroke!
  22. thrombolytics-tPA
    • for ischemic stroke
    • Must be administered within 3 to 4.5 hours from onset
    • increased risk of bleeding
    •  must meet set criteria
    • NIH stroke scale:
    • --LOC
    • --motor: face/arm/leg
    • --speech
    • --sensory
    • --vision
    • --ataxia
    • --extinction
  23. acture care of ischemic cva
    • neuro, resp, cardiac
    • --risk of herniation peaks 72 hrs post cva
    • antithrombolitics
    • fluid balance, e-lytes
    • normothermia (fever exacerbates ischemia), give tylenol
    • maintain normal blood sugar
    • assess for seizure
    • dvt prophylaxis
  24. Collaborative care
    prevention
    test
    • Risk factors
    • --modifiable: 
    • ----HTN
    • ----smoking
    • ----ETOH
    • ----diet
    • ----exercise
    • ----weight
    • --Nonmodifiable?
    • Antiplatelet drugs, ie ASA plavix-->assess for bleeding
    • lipid lowering agents, ie statins
    • Surgical interventions
    • --interventional procedures
    • --carotid endarterectomy
  25. Collaborative care
    Acute Care
    • Initial Interventions
    • --perform baseline lab tests
    • --position head midline
    • --elevate bed 30d if no SnSs of shock/symptoms
    • --seizure precautions
    • anticipate thrombolytic therapy for ischemic stroke
    • --ensure patent airway and O2
    • --Obtain CT scan immediately
    • --remove denture
    • --IV access with normal saline
    • --maintian BP according to guidelines
    • ----permissive HTN (ischemic)
    • ----avoid hypotension-->hypoperfusion
  26. post stroke assessment and care
    • Vs and neuro checks
    • NIHSS frequently
    • LOC
    • CN I-XII
    • motor and sensory fucntion
    • cerebellar fnxn
    • pupil size and reactivity
    • O2 sat
    • Cardiac rhythm
  27. Nursing amangement
    • Coping
    • --stroke is often a family disease, ie emotionally, financially, 
    • ambulatory and home care
    • --home
    • --LTAC?
    • et al

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