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NR202 Test 5 Cerebral ischemia and infarction: CVA


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Controllable risk factors for strokes
1. Hypertension
2. Heart disease-Atrial fibrillation in particular
3. Cigarette smoking
4. Excessive alcohol intake
5. High cholesterol levels
6. Obesity
7. Substance abuse
8. Sedentary life-style
9. Oral contraceptive use
Uncontrollable risk factors for strokes.
1. Increasing age
2. Male sex
3. African American
4. Diabetes
5. Previous stroke/TIA
6. Family history of stroke or TIA
7. Sickle cell disease
Ischemia: Describe Transient ischemic attack
-An episode of cerebrovascular insufficiency

-partial occlusion of an artery

-Symptoms vary with site and degree of occlusion

-sudden loss of motor, sensory, or visual function

-Brief lasting only a few minutes to 24 hours
TIA Treatment-Explain different types and what it treats
1. Treatment of hypertension, hypergylcemia

2. Cessation of smoking

3. Treatment of hyperlipidemia

4. Platelet inhibitor drugs-ASA, ticlid, plavix

5. Persantine (coronary vasodilator)

6. Anticoagulant therapy-coumadin

7. Carotid Endarterectomy
Explain Carotid Endarterectomy
Occluded or stenotic vessel per carotid doppler or angiogram

Removes artherosclerotic plaque

Position on unoperated side c HOB above 30 degrees

Avoid flexing, rotating, or hyperextending the head

Complications-Bleed (tracheal deviation), BP decreases, BP increases, cranial nerve impairment (dysphagia)
Infarction AKA
Cerebrovascular Accident CVA
Brain Attack
Ischemic-Thrombotic and embolic

-A blood vessel supplying the brain is obstructed by a clot

-The area of brain that is affected begins to suffocate and stops functioning

(Thrombus formed in Brain, embolus moved to the brain from something like A-Fib)
Hemorrhagic stroke
Types and explain symptoms
Types: Intracerebral ICH- blood inside the brain
Subarachnoid (SAH)- blood around the brain
Poorly controlled hypertension
Cataclysmic headache
Occur during activity
Most often fatal- LOC, coma, death
Thrombotic CVA's
Occlusion of artery by a clot
Over age 50
Occurs when resting or sleeping
Stroke symptoms and progressively worsens over 1-2 days - stroke in evolution
Completed stroke is after 3 days
Embolic stroke-Explain
Younger than thrombotic patients
While awake and active
Sudden onset-immediate deficits
thrombus particle carried through arterial system to the brain
Source? -A-Fib
State the Symptoms Suggesting a Stroke
The abrupt onset of hemiparesis
Sudden decline in LOC
Cataclysmic headache
Acute dysphasia-slurred speech
Loss of sensation in half of body- Rt side or left side
Sudden loss of vision in one or both eyes or visual field
Double vision
ER assessment to see if one had a stroke-Components
1. Airway-Side lying position, raised head of bed
2. Breathing-pattern
3. Circulation-VS-BP
4. Accucheck-To rule out hypoglycemia (mimics symptoms of stroke)
5. Time of onset of symptoms-Many strokes are thrombolic or embolic-give activase if a person is within 3 hours of onset of symptoms
Gascow coma scale-
-To Speech
-To Pain
-No response

-Obeys commands
-Localizes pain
-Abnormal flexion-Decorticate
-Abnormal extension-Decerebrate

-Inappropriate words
-Incomprehensible sounds
-No response
Neuro check-Abbreviated Neurologic Assessment
Assess level of consciousness
Obtain vital signs
Check pupillary response to light
Assess strength of hand grip and movement of extremities
Determine ability to sense touch/pain in extremities
How is a stroke diagnosed
Glascow Coma scale
Abnormal speech
Arm Drift
Cranial Nerve
Facial droop
Accucheck to rule out hypoglycemia
CT's contrast, MRI-to distinguish type between hemorrhagic and ischemic
Acute medical Treatment
Thrombolytic-only if within 3 hours of onset of symptoms of ischemic CVA
Anticoagulant-Heparin-only if thrombotic stroke and only first 2-3 days
Calcium channel blockers to reduce cerebral vasospasm
Hyperosmolar solutions or diuretics
Anticonvulsants-Cerebyx (metabolizes to dilantin)
Vasodilators-Nipride titrate to specified BP
Cranial nerves
IX-glossopharyngeal and X Vagus
-Control gag and cough reflexes-if impaired at risk for silent aspiration
-Tongue blade to touch the uvula-patient should retch-if uvula only moves up on one side-the patient does not have an adequate gag reflex so watch when feeding

XII--Stick out toungue (midline) and move side to side

II-Optic and III-Oculomotor
-controls pupillary reflex- II sees the light III responds by constricting the pupil

III-Oculomotor and IV-Abducen
-Moves eyes in 4 directions
-"Look at my fingers please." Snap fingers.
-Make sure no white is showing on side looking toward.

V-Trigeminal and VII-Facial
-motor and sensory nerves to the face
-Control the corneal blink reflex
-Sterile cotton ball across cornea-if absent, protect the cornea from foreign bodies, abrasions and dehydration

VIII Auditory-whisper in ear

XI Spinal Accessory (not crucial
-shrug shoulders, turn head
Nursing Diagnoses
Altered cerebral tissue perfusion
Unilateral Neglect
Self Care deficit: Dressing/Grooming
Potential for hyperthermia (if CVA affects hypothalamus)
Impaired verbal communication
Sensory/Perceptual alterations
Risk for fluid volume deficit r/t damage to pituitary
Describe unilateral neglect
Inattention to one side of body.
May occur with some strokes of the middle cerebral artery. Poor hygiene and grooming may be seen in clients with dementing disorders
Abnormal gait is seen in:
Transient ischemic attacks
Parkinson's disease
Emotional swings or changes in personality may be observed with strokes of the _____________
Anterior cerebral artery
Aphasia (Defective or absent language function) may occur in TIAs. Receptive aphasia (inability to understand verbal or writen language) is often noted in strokes of posterior or anterior cerebral artery. Aphasias are seen with damage to the left cerebral cortex. Aphasias are more often seen with strokes of the right hemisphere than the left hemisphere.
(change in the tone of voice)
Is common in strokes of the posterior or inferior cerebral artery. Dysphonia is seen with paralysis of the vocal cords (cranial nerve X)
Dysarthria define/describe
Dysarthria is difficulty speaking which is seen with lesions of upper and lower motor neurons, the cerebellum, and the extrapyramidal tract. It is also seen in strokes of the anterior inferior and superior cerebral arteries
Disorientation to time and place may occur in clients with stroke of the ________ ________ hemisphere
right cerebral hemisphere
Memory deficits are often seen with strokes of the anterior ______ _______ and _____________ _______
Anterior cerebral artery
Vertebralbasilar artery
Perceptual deficits and impaired cognition may be seen in strokes of the ________ ________ ________
middle cerebral artery. Perceptual deficits may occur following brain trauma and dementing disorders.
Impaired cognition also may occur with cerebral trauma and brain tumors.
Anosmia -Define/Describe
Anosmia (inability to smell) may be seen with lesions of the frontal lobe and may also occur with impaired blood flow to the middle cerebral artery
Blindness in one eye may be seen with strokes of the ______ ______ _______
Impaired vision may also bee seen with strokes of the _______ _______ ______
Internal carotid artery or with TIAs.

Impaired vision: anterior cerebral artery and brain tumors
Nystagmus-explain and where is it seen... seen with strokes of the___
Nystagmus (involuntary eye movement)may be seen with strokes of the anterior, inferior, and superior cerebellar arteries.
Ptosis occurs
Ptosis is drooping eyelids
Ptosis occurs with strokes of the posterior inferior cerebellar artery.
Dysphagia (difficulty swallowing) is common with impaired blood flow to the vertebralbasilar arteries and to the posterior inferior, anterior inferior, or superior cerebellar arteries.
1. The client experienced neurologic changes from a transient ischemic attack. Family mambers exhibit an understanding of this condition if they discuss with the nurse that associated deficits from this pathology will be gone within what timeframe?
Several hours

Rationale: Clients who experience a TIA should have resolution of symptoms within several minutes or within a maximum of 24 hours. Reversible ischemic neurologic deficits usually resolve within several days and with an evolving CVA there are usually permenant neurological deficits.
2. In reviewing the client's plan of care, the home care nurse has identified interventions that relate to the client's hemiparesis after the event of an embolic stroke. The nurse would expect to see what documentation by the support staff who had cared
3. Full active or passive range of motion for all extremities.

Rationale: The client with hemiparesis, or weakness on one side of the body, needs exercise for both sides of the body. Active range of motion will be done on the unaffected side and passive range of motion will be done on the affected side to maintain or improve joint or muscle function. The other options may be appropriate for a stroke patient but not in relation to hemiparesis.
A client has damage to the left hemisphere of the brain. This will affect the client's ability to do what?

1. Hearing
2. Speech
3. Motor
4. Thoughts
Decorticate posturing-Define/describe
Decorticate posturing-upper arms are close to the sides; the elbows, wrists, and fingers are flexed; the legs are extended with internal rotation; and the feet are plantar flexed
Decorticate posturing occurs with lesions of the corticospinal tracts
Decerebrate posturing: Define/Describe
Decerebrate posturing is where the neck is extended, with the jaw clenched; the arms are pronated, extended, and close to the sides; the legs are extended straight out; and the feet are plantar flexed.
Decerebrate posturing occurs with lesions of the midbrain, pons, or diencephalon.
A client with a massive cerebral hemorrhage and loss of consciousness is scheduled for an electroencephalogram (EEG). The nurse is discussing the purpose of the test with the family. It would be most accurate for the nurse to tell family members the test
Answer C: activity of the brain
An EEG measures the electrical activity of the brain. Extent of intracranial bleeding and location of the injury site would be determined by computerized tomography or magnetic resonance imaging. Percent of functional brain tissue would be determined by a series of tests.

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