1. Fill in: 
    Stroke is the _a_ leading cause of deaths in adults in the US, with _b_ people dying each year. _c_ is the best method for decreasing mortality and morbidity.
    • a. 5th
    • b. 800k
    • c. Prevention
  2. Fill in:
    When blood flow or metabolism is stopped in the brain, damage to the brain begins in __a__ minutes, and cellular death occurs in __b__. The main cause of ischemic stroke is __c__.
    • a. 3 minutes
    • b. 5 minutes
    • c. Atherosclerosis (build up of plaque)
  3. 1. What are the 2 major arteries that supply blood to the brain?
    1. Internal carotids (anterior circulation) and Vertebral arteries (posterior circulation)
  4. What is Autoregulation?
    What is the lower limit (MAP) in which autoregulation is still effective?
    What is the upper limit?
    • Autoregulation: automatic adjustment in the diameter of the cerebral blood vessel by the brain to maintain a constant blood flow during changes in arterial BP, to keep it WNL. 
    • The lower limit: of arterial pressure is a MAP of 70 mmHg. Below this, CBF (cerebral blood flow) decreases, and s/s of cerebral ischemia occurs (syncope, blurred vision, etc)
    • The upper limit: is 150mmHg. When pressure exceeds this, the vessels are maximally constricted, and further vasoconstrictor response is lost.
  5. What are the sub types of Ischemic strokes?
    • 1. Ischemic: 
    •  - a. Thrombotic: occurs from injury to a blood vessel and formation of a blood clot or plaque build up. It is the result of narrowing of the blood vessel, accounting for 60% of strokes.
    •  - b. Embolic: occurs when an embolus lodges in and occludes a cerebral artery (typically an emboli from the heart), resulting in an infarction and edema of the area involved. It is the 2nd most common cause of stroke (24%). However, it occurs more rapidly than thrombotic strokes, giving little time to accommodate.
  6. What are the subtypes of Hemorrhagic strokes? What are their n s/s?
    • Hemorrhagic stroke: accounting for 15% of all strokes when blood pools into brain tissue.
    •  a. Intracerebral Hemorrhage: Accounting for 10% of strokes, it is bleeding in the brain caused by a ruptured vessel, where HTN is the most common cause. Patients have a 30-day mortaility rate at 40-80%, where 50% of deaths occur within 48 hours. 
    •  - s/s: severe HA, vomit, inability to walk, dysphagia, dysarthria, and eye movement disturbances.
    •  b. Subarachnoid Hemorrhage (SAH): occurs when there is bleeding into the CSF space between arachnoid and pia mater. It is commonly caused by rupture of a cerbral aneurysm. 
    •  - s/s: SAH is viewed as a "silent killer" as individuals do not have warning signs of an aneurysm until rupture has occured, and about 40% of people die during the first episode. Loss of consciousness may or may not occur.
  7. Define a TIA
    What are signs?
    How long will s/s usually last?
    When will most resolve?
    • TIA: transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia w/out acute infarction of the brain. 
    • s/s: these depend on the blood vessel involved and area of the brain that is ischemic. Carotid system -> temporary loss of vision for example. If it involves vertebrobasilar system -> tinnitus or vertigo.
    • Duration: s/s last <24 hours, typically last <1 hour, sometimes as short as 15 mins. 
    •  - Most will resolve within 3 hours.
  8. List TIA tx, including:
    Minimizing factors
    Antiplatelet meds
    • Prevention of future strokes
    • Minimizing risk factors: controlling HTN, lowering cholesterol and lipid levels, and controlling diabetes.
    • Antiplatelet drugs: Clopidogrel, Ticlopidine, Ticagrelor, -statins
    • Diagnostics: carotid ultrasound (look for atherosclerosis) -> endarterectomy (surgical procedure to remove the atheromatous plaque material or blockage in the lining of an artery)
  9. List clinical manifestations of a stroke that include motor deficits
    • Impaired mobility
    • Respiratory fxn
    • Swallowing
    • Speech
    • Gag reflex
    • Lack of ability to provide self care
  10. List clinical manifestations of a stroke that include Neuro
    • Bladder and bowel elimination
    • Intellectual fxn
    • Spatial-perception alterations
    • Personality
    • Affect
    • Sensation
    • swallowing
    • communication
  11. List diagnostics
    Which one is the single most important?
    Which ones that will look at the heart?
    What labs will you look at?
    • Most important: Non-contrast CT scan, which can differentiate between ischemic and hemorragic stroke.
    • Later: CTA (CT angiography), MRI, MRA
    •  - Carotid Ultrasound, trans-cranial doppler
    • Cardiac: EKG, CXR
    • Labs: CBC, PT/PTT, cardiac markers, BG, lipids, LP
  12. List preventative therapies
    • Healthy diet
    • weight control
    • regular exercise
    • smoking cessation 
    • routine health check-ups
    • Meds: cholesterol and blood thinners
    • Surgical intervention w/ known carotid dz
  13. List actions in order taken during the first 10 minutes at an ED of a suspected adult stroke (8 steps)
    • 1. Assess ABCs, VS
    • 2. Provide O2 if hypoxemic
    • 3. Obtain IV access and perform lab assessments
    • 4. Check BG, treat if needed
    • 5. Neurologic screening assessment
    • 6. Activate stroke team 
    • 7. Order emergent CT scan
    • 8. 12-lead
  14. After the first 10 minutes of a suspected stroke at an ED, what do you do up to the 25 min mark? (3)
    After the initial 25 mins, pt. is ready to go to CT. What is being checked with this test?
    • 1. Review pt. history
    • 2. Establish time of symptom onset or last known normal
    • 3. Perform neurologic examination (NIH stroke scale or Canadian Neurological scale)

    CT: will detect for Hemorrhage. If there is no hemorrhage, it is probably an acute ischemic stroke, and a fibrinolytic therapy will be considered.
  15. How is BP commonly affected by a stroke? 
    What are considerations with an ischemic stroke patient who is going through fibrinolytic therapy (rtPA: dissolves clots), in regards to their BP?
    • After a stroke, BP is commonly elevated. However, a patient not going through fibrinolytic therapy who have a BP >220/120, needs meds to lower it.
    • If a patient is receiving fibrinolytic therapy, their BP needs to be <185/110, and then maintained at or below 180/105 for at least 24 hours. 
    •  - Preferred drugs: Labetalol and Nicardipine
    • **Low BP after a stroke is uncommon, but should be addressed if critically low**
  16. T or F: A patient who is receiving rtPA, a fibrinolytic therapy for ischemic stroke, should receive anticoagulants or antiplatelets in conjunction with the drug in the first 24 hours.
  17. T or F: a patient who is not a candidate for rtPA, fibrinolytic therapy, for ischemic strokes can still receive aspirin to help with blood flow.
  18. List acute care interventions for an Ischemic stroke
    • ABCs
    • Baseline neurologic assessment
    •  - onset of symptom time
    •  - NIH stroke scale
    • BP management
    • Evaluate for tPA candidacy
    • After stabilization, may be treated with platelet inhibitors and anticoagulants
  19. List acute care interventions for a Hemorrhagic stroke (6)
    • 1. ABCs
    • 2. Baseline and frequent neurological assessments 
    • 3. Monitor ICP and prevention of increased ICP
    • 4. Manage BP
    • 5. Evaluate to determine if and what type of surgical intervention is appropriate
    • 6. Seizure precautions
  20. List early s/s of ALOC in an ICP patient
    • irritable, restless
    • confusion
    • lethargy
    • progressive HA
    • change of affect or personality
    • occular changes (pupils sluggish, diplopia, blurred vision)
    • weakness, onset of nausea
  21. What is normal ICP?
    7-15 mm Hg
  22. List worsening signs of LATE ICP
    • stupor, coma
    • Cushing's triad: Increased SBP (wide pulse pressure, bradycardia, irregular resp.
    • Pupils unequal, nonreactive
    • Projectile vomiting
    • Posturing
    • Hypertheramia
    • Loss brainstem reflexes (gag reflex, swallow)
  23. List nursing assessments of a stroke pt (priority)
    • Respiratory system: preventing aspiration and PNA
    • Neurological status
    • Early swallow assessment
    • Communication and language impairment
    • Patient coping skills
    • Homonymous hemianopsia (condition in which a person sees only one side of each eye; can be one or both eyes)
  24. List communication methods for an aphastic patient (loss of ability to understand or express speech)
    • Present ONE thought or idea at a time
    • Yes and No questions
    • Organize day by schedule, not routine
    • Use gestures: show me or point to
    • Use therapeutic touch
    • Be patient, and allow time for response
    • Decrease environmental stimuli
  25. 1. What is the single most modifiable risk factor for stroke?
    2. This can increase chances for a hemorrhagic stroke 4x.
    • 1. HTN
    • 2. Smoking
  26. If a patient who experiences a stroke has a loss of autoregulation control (cerebral blood flow), how will you expect the body to compensate?
    What symptoms will show that will appear as a neurologic emergency?
    • The body attempts to maintain cerebral perfusion by increasing systolic BP.
    • A neurologic emergency is when the patient goes through Cushing's Triad
    •  - systolic HTN w/ a widening pulse pressure
    •  - Bradycardia w/ a full and bounding pulse
    •  - altered respirations
  27. How can abnormal CO2 levels affect blood flow to the brain?
    • CO2 is a vasodilator and plays a significant role in cerebral blood flow. 
    • abnormal levels can increase ICP, and prevent blood from entering the brain
  28. State if this cause can lead to ischemia or hemorrhage type of stroke

    Bleeding disorders:
    Arteriovenous malformations:
    Crack cocaine smokers:
    Intra-nasal cocain users:
    Erythrocyte disorders:
    • Atherosclerosis: ischemia 
    • Thrombosis: ischemia
    • HTN: hemorrhage
    • Emboli: ischemia
    • Aneurysms: Hemorrhage
    • Bleeding disorders: Hemorrhage
    • Arteriovenous malformations: Hemorrhage
    • Smoking: Ischemia
    • Crack cocaine smokers: Ischemia
    • Intra-nasal cocain users: Hemorrhage
    • Erythrocyte disorders: Ischemia
  29. 1. To prevent future strokes and minimize risk factors, you want to make sure the patient lowers these 3 things.
    2. You may also want to start them on this kind of drug.
    3. Why will you want to do an carotid ultrasound?
    • 1. Have them lower their BP if HTN, lipids, and blood sugar if DM.
    • 2. Will go on anti-platelet drugs
    • 3. Carotid ultrasound: to look for atherosclerosis
  30. What is the first signs of Intracerebral Hemorrhage?
    What is the most common cause?
    • Often begins with severe HA and n/v
    • Common: HTN
  31. What is the common cause of Intracerebral Hemo?
    What are common causes of subarachnoid hemo?
    • Intracerebral hemo: HTN
    • Subarachnoid hemo: rupture of cerebral aneurysm, trauma, or drug abuse
  32. Select all that apply of s/s with Right-sided brain dmg:

    • G. Impaired speech and language
    • b. Spatial-perceptual deficits
    • c. Impaired right/left descrimination
    • d. Deny or minimize problems
    • e. Aware of deficits causing depression or anxiety
    • f. Impulsive and impaired judgment
    • g. Impaired time concepts
  33. Select all that apply of left-sided brain damge:

    a. Impaired speech and language
    b. Spatial-perceptual deficits
    c. Impaired right/left descrimination
    d. Deny or minimize problems
    e. Aware of deficits causing depression or f. anxiety
    f. Impulsive and impaired judgment
    g. Impaired time concepts
    h. Impaired comprehension related to language, math
    • a. Impaired speech and language
    • b. Spatial-perceptual deficits
    • c. Impaired right/left descrimination
    • d. Deny or minimize problems
    • e. Aware of deficits causing depression or f. anxiety
    • f. Impulsive and impaired judgment
    • g. Impaired time concepts
    • h. Impaired comprehension related to language, math
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