Exam 3 foundations: Strokes

Cognition

mental process of acquiring knowledge and understand

What does cognition include?

attention, memory, language, judgement, and reasoning

How is cognition affected?

Affected by neurological conditions like stroke, dementia, and

traumatic brain injury

*Functions of the cerebrum (4)

• Interprets sensory information

• controls involuntary movements

• handles thinking, reasoning, memory, and speech

• regulates personality and emotions

What is the left hemisphere of the cerebrum associated with?

associated with language and analytics

What is the right hemisphere of the cerebrum associated with?

associated with spatial reasoning and creativity

*Functions of the cerebellum (3)

• coordinates movement and posture

• maintains balance and equilibrium

• fine tunes motor skills

*Functions of the brainstem (2)

• Regulates automatic body functions

  • breathing

  • heart rate

  • sleep-wake cycles

• Relays information between the brain and rest of the body

*Cerebral cortex function

outer layer responsible for high-level function

*Frontal lobe function

Responsible for planning, decision-making, and personality

*Parietal lobe function

process sensory information and spatial awareness

• touch

• Temperature

• Pain

*Temporal lobe function

Involved in hearing, memory, and language

*Occipital lobe function

Process visual information

What are the 3 parts of the brainstem?

• Midbrain

• Pons

• Medulla oblongata

*Midbrain function

important for eye movement

*Pons function

Coordinates facial movement, hearing, and balance

*Medulla oblongata function

regulates breathing, BP, and HR

The left side of the brain controls the ___ side of the body, while the right side of the brain controls the ___ side of the body

• right

• left

Lift side of the brain function (4)

• Written + spoken language

• Mathematical equations

• Logical decision making

• Reasoning

Right side of brain function (5)

• Understanding language

• Non-literal thinking

• Spatial awareness

• Imagination

• Facial recognition

Stroke

sudden interruption of BF

Pathophysiology of strokes (3)

• Interruption of cerebral blow flow —> cellular ischemia —> infarction

• Neurons deprived of oxygen and glucose —> excitotoxicity and cell death

• Edema and inflammation contribute to secondary injury

Modifiable risk factors of strokes

• HTN

• diabetes

• smoking

• obesity

• hyperlipidemia

• hormone therapy

Non-modifiable risk factors of strokes (4)

• Age > 55

• Males

• people of color

• family history

Stroke types (3)

• Ischemic stroke

• Hemorrhagic stroke

• Transient ischemic attack (TIA)

*Ischemic stroke

blockage of the cerebral artery

*Thrombotic ischemic stroke

blood clot (thrombus) forms directly within a brain artery

*Cause of thrombotic ischemic strokes

Blood clot forms within the brain artery, gradually narrowing or blocking the vessel

Onset of thrombotic ischemic strokes (timing and when it usually occurs)

slower, occurring at night or in the early morning

Risk factors for thrombotic strokes (6)

• HTN

• hyperlipidemia

• atherosclerosis

• diabetes

• smoking

• any condition that can promote blood clotting or poor perfusion

*Embolic ischemic stroke

blood clot or other debris (embolus) originates somewhere else in the body and travels to the brain, lodging in a smaller artery

Cause of embolic ischemic strokes

Blood clot or other debris travels from elsewhere in the body to the brain artery

• around/near the brain, but not in the brain

Onset of embolic ischemic strokes

Sudden and rapid

Risk factors for embolic strokes

• Afib (irregular heartbeat)

• heart valve issues, heart attack

• conditions that increase the risk of blood clots (DVT)

What is the source of embolic strokes?

Large arteries in the heart

• heart abnormalities can result in a blood clot forming

Severity of ischemic strokes

greater stroke severity and high changes of death compared to thrombotic strokes

Other causes of ischemic strokes

• Global cerebral ischemia

• Hypoglycemia

• Hypercoagulabiliy

• Vasculitis (infl of BVs)

• Arterial dissections (tear in the inner layer of an artery)

Cryptogenic ischemic stroke

unknown cause

• often leads to an excessive cardiac workup to try and identify the cause

*Hemorrhagic stroke

blood vessel in the brain ruptures, causing bleeding into or around the brain tissue

*Intracerebral hemorrhage stroke (ICH)

Bleeding occurs within the brain tissue itself

Causes of ICHs

• HTN

• arteriovenous malformation (cluster of BVs where the arteries connect directly to the veins, bypassing the capillary network — leads to vessel weakening)

• head trauma

Subarachnoid hemorrhage

Bleeding in the between the brain and its surrounding membranes

*Symptoms of subarachnoid hemorrhages

• Sudden, severe headache (“thunderclap" headache)

• neck stiffness

• sensitivity to light.

Transient ischemic attack (TIA) hemorrhage

A temporary, focal cerebral ischemia that results in reversible neurological deficits without acute infarction (imaging doesn’t show infarction)

• “mini-stroke”

Primary signs and symptoms of ischemic strokes

• Weakness on one side of the body

• Aphasia

  • Broca’s aphasia or expressive aphasia

  • Wernicke’s aphasia or receptive aphasia

If the blockage/stroke occurs on the left side of the brain, ____ brain symptoms will manifest. If the blockage/stroke occurs on the right side of the brain, ____ brain symptoms will manifest

• Blockage on left —> left-sided brain symptoms

• Blockage on right —> right-sided brain symptoms

FAST findings

• Face

• Arms

• Speech

• Time

A stroke is first suspected by ____, and it is VERY important to determine when the symptoms started

symptoms

*Knowing when symptoms started is critical, called the “_____”

last known well

*First step of determining the type of stroke

Non-contrast CT

• some people may need more testing (MRI, CT, CT perfusion)

Other methods to diagnose strokes

• Immediate labs (glucose, proponents, coagulation panel, CBC, and BMP)

• Additional investigations: lipid profile, fasting glucose, HbA1c, beta-HCG, liver chemistries, TSH, thrombophilia screening, CNS infection screening, toxicology, ESR/CRP.

• Cardiac evaluation

• EEG (only if concerned for seizures)

First line of treatment for ischemic strokes and 2 types

Reperfusion therapy: restoring BF to tissues that experienced a lack of blood supply

• intravenous thrombolysis — Ateplase (tPA)

• Mechanical thrombectomy

*tPA

given via IV to help dissolve blood clots ideally within 4.5 hours of symptom onset

Mechanical thrombectomy

Physical retrieval of the occluding thrombus via a catheter

Supportive and neuroprotective measures for ischemic strokes (3)

• Targeted temperature management: Maintain normothermia

• Treat glucose to normal range (140-180 if diabetic).

• Allow for permissive hypertension systolic >180, but <220

First consideration of treatment for hemorrhagic strokes

Whether patient needs surgical management

Treatments of hemorrhagic strokes (6, 3 primary)

• Neurosurgical consultation advised for acute ICP management and evacuate hematoma

• Control BP: systolic <140

• Check weather patient is already taking an anti platelet or anticoagulant med

• Work with neurology/neurosurgery to determine whether your patient needs to be started on an anticonvulsant to prevent seizures

• Frequent serial scans: Q6H in the acute period

• Admit to neurocritical unit

Primary methods of management for ischemic strokes (2)

• Encourage a heart-healthy diet and exercise (moderate intensity) for 150 mins/week

• Control BP to a target of <130/80

ischemic vs hemorrhagic stroke to reduce stroke risk

• ischemic strokes use antiplatelet therapy

• hemorrhagic strokes DO NOT use antiplatelet therapy because risk for excess bleeding

*Primary complications of subarachnoid hemorrhages and what can it lead to?

• Vasospasms

• Occurs 3-10 days after the onset of SAH and can lead to an ischemic stroke

How are subrachnoid hemorrhages treated? How does it work?

Nimodipine

• calcium channel blocker used to reduce brain damage after a subarachnoid hemorrhage

• It works by relaxing blood vessels in the brain, increasing blood flow to damaged areas

Neurological manifestations of a transient ischemic attack (TIA)

Acute, transient focal deficits that usually last < 1 hr

• majority of cases resolve in < 15 min

Symptoms may depend on the affected territory and etiology

ABCD2 scoring system

• used to assess the short-term stroke risk

  • Likelihood someone with have a second stroke soon after the first

• Age, BP, Clinical features, and Duration of symptoms

*A higher ABCD2 score indicates…

a higher likelihood of another stroke within 2 days

• *prevention is key

Diagnosis of TIA is identical to that of…

a stroke

Why is it very important to obtain neurovascular imaging after a TIA?

to rule out vessel occlusion

What is the most important method of treatment for TIA’s?

prevention

What treatment should high-risk (ABCD2 >/= 4) TIA patients get?

Consult neurology and start DAPT (aspirin + clopidogrel) for a minimum of 21 days then switch to antiplatelet

Most important nursing interventions for strokes (3)

• Monitor for eligibility and response to tPA

• Frequent neurological checks and vital signs

• Education (stroke preventions and s/s using FAST)

What position should patients with a stroke be in when in bed? Why?

Patients should be put into a position where venous drainage can occur

• this is because inflammation of the brain will increase intercranial pressure and can cause further damage

Glasgow Coma Scale (GCS)

used to assess a persons conciousness

What does a higher GCS score indicate? Lower? What must we do if the GCS is less than 8?

• Higher: more consciousness

• Lower: more unconscious

• > 8 must intubate

Modified Rankin Scale (MRS)

measures the degree or dependence in individuals after a stroke

What does a higher number on the MRS scale mean?

The higher the number, the worse the degree of disability

John’s Hopkins Mobility goal calculator

To record the mobility that a hospitalized patient actually does, not what they are capable of doing

• higher the number the more mobile they are

Mobility

The ability to move freely and independently. Essential for activities of daily living (ADLs), self-care, and overall well-being

Factors that influence mobility

• developmental stage

• Nutritional status

• Lifestyle

• Environmental factors

• Diseases/conditions

• Pain

• Medications

What systems are affected by immobility? (7)

• cardiovascular

• Respiratory

• Musculoskeletal

• Metabolic

• GI

• Urinary

• Integumentary (pressure injuries)

Nursing interventions for mobility (10)

• Early adulation

• ROM exercises (active and passive)

• Positioning

• Assistive devices

• Safe patient handling (e.g. lifting equipment)

• Hydration and nutrition

• Pain management

• Patient and family education

• Psychological support

• Collaboration with healthcare professions

Functional ability

The cognitive, social, physical and emotional ability to carry out normal activities of life

• Activities of daily living (ADLs)

• instrumental ADLs (IADLs)

ADLs vs IADLs

• ADLs are the building blocks of independent living

• IADLs are the skills needed to manage one’s life and environment effectively

ALDLs activities

• bathing/shower

• Dressing

• Eating

• Toileting

• Mobility/transferring

IADLs activities

• meal prep

• Shopping

• Housekeeping

• Laundry

• Med management

• Transportation

• Communication

Nursing interventions for ADL/IADL (9, 1 primary)

• Assess ADL independence on admission and during daily care

• *Encourage patient participation in ADLs to promote independence

• Provide assistive devices: grab bars, walkers, raised toilet seats

• Collaborate with OT/PT as needed

• Assess cognitive and executive function (especially in older adults)

• Monitor for decline in IADLs as an early sign of dementia, depression, or frailty

• Refer to social work or case management for support services

• Involve family or caregivers in education and planning

• Document any decline or improvement

*Why are nursing interventions important?

• Discharge planning: Determines if a patient needs rehab, home health, or long-term care

• Risk identification: Functional decline can predict falls, hospital readmission, or poor outcomes

• Care prioritization: Focuses nursing interventions on what matters most to the patient's independence

*Social worker role

• support well-being, rights and social needs of individuals, families, and populations

• Help people navigate complex life challenges

*Case management role

coordinate and oversees patient’s comprehensive care plan

• Serves as a bridge between healthcare providers, patients, families, and resources.

*Palliative care role

• medical team focused on improving quality life for individuals with serious or life-limiting illnesses.

• Not limited to end-of-life care – it can be provided at any stage of illness and alongside curative treatments.

  • Relieve pain and other distressing symptoms

  • Help address emotion, psychological, and spiritual needs

  • Support patients and families in decision-making.

  • Help coordinate care across settings and specialties

*Role of PT

help individuals of all ages to restore, maintain and promote optional physical function and mobility

*OT role

help people of all ages develop, recover, or maintain the skills needed for daily living and meaningful activities- functioning in everyday life

*Speech therapy/speech language pathology

work with people across the lifespan to help them communicate effectively and swallow food and liquids

*Delirium

An acute neurocognitive disorder characterized by impairments in attention and awareness

Causes of delirium (7)

• Metabolic diseases

• infection

• CNS pathology

• drugs

• toxins

• hypoxemia

• major surgery

What method is used to diagnose delirium? What is it fulfilled by (2)?

CAM (confusion assessment method)

• Fulfilled by:

  • Absence of preexisting dementia, coma, or severely reduced responsiveness

  • Evidence of an organic underlying cause

Patients should meet all of the following to be considered delirious (3)

• Attention and awareness are impaired

• Acute onset over hours or days with waxing and waning severity

• ≥ 1 additional disruption in cognition

Delirium condition fulfills what 2 things?

• Absence of preexisting dementia, coma, or severely reduced responsiveness

• Evidence of an organic underlying cause

Determining the underlying etiology of delirium via what labs? (6)

• CBC

• Glucose

• Electrolytes

• Urinalysis

• Renal function

• Liver chemistries

Delirium vs Dimentia

• Dementia is a major neurocognitive disorder with progressive major cognitive decline over years

• delirium is rapid and fluctuating

Causes of delirium I WATCH DEATH

Infection

Withdrawal

Acute metabolic disorders

Traumas

CNS issues

Hypoxia

Deficiencies (nutritional)

Endocrine issues

Acute vascular

Toxins and drugs

Heavy metals

Delirium nursing interventions — MMORE

• Mobilize as able

• Music as needed

• lights On during the day and Off at night

• frequent Reorientation and cognitive stimulation

• Eyes and Ears - hearing aids and glasses as appropriate