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what is used for prompt pre-hospital care and acute care approach for stroke

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stroke chain of survival-- also known as the 7D's

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The first D is

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detection

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detection is

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detecting the early signs and symptoms of stroke-- this is critical to their outcome

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the second D is

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dispatch

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dispatch is

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telephoning 911

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3rd D is

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delivery

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delivery is

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delivery of a patient to a medical facility -- you want to provide advanced hospital notice so that they are prepared

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4th is

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door

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door is the door to the

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emergency department

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immediately upon arrival what should occur?

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rapid assessment

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5th D is

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data

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data is

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collection of data

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6th D is

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decision

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decision is regarding

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decision about treatment

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7th, and final D is for

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drug

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drug is for

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drug administration as appropriate and post-administration monitoring

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what is another assessment which can be used for stroke?

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FAST

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F stands for

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face

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for face you want to assess to see if

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one side of the face droops

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this can be assessed by

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asking the person to smile

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A stands for

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arms

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when assessing arms you are looking to see

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if one arm is weak or numb

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this can be assessed by

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asking patient to raise both arms

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what are you looking for?

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one arm drifting downward

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S stands for

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Speech

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what are you assessing for when looking at speech?

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to see if the patient has slurred speech

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this can be assessed by asking the patient to

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repeat a simple sentence and see if they can repeat it correctly

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T stands for

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time

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is time very important

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yes!

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time equals

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brain

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if a patient shows any of these symptoms you want to

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call 911 or get to hospital immediately

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acute stroke can be divided into two phases

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1) hyperacute phase 2) phase 2

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hyperacute phase is the

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first 24 hours of care

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phase two is the

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acute care during hospitalization

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when assessing patients for stroke why do want want to obtain a glucose

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we want to make sure is higher than 50

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why do we want to make sure its higher than 50?

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because hypoglycemia can mimic stroke

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if they have low blood sugar and you administer dextrose

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and the symptoms go away you know that it was caused by hypoglycemia

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you want to determine

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when symptoms started

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this is particularly important for which type of stroke

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ischemic

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this is because

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want to make sure its within 3 hours so that TPA can be administered

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if you cannot determine the onset of symptoms you want to

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when the last time the patient was known to be at baseline

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this will become

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default time of onset

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the diagnosis of stroke is made by

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history, neurologic exam, and neuroimaging

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what type of neuroimaging is used to

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CT

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the CT scan will determine if patient is

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having hemorrhagic stroke

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what will not be available on the CT scan if the symptoms started a few hours ago

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ischemia

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but what often is always present?

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bleeding

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CT scans are used to

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rule out hemorrhagic stroke

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if there is bleeding this indicates

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hemorrhagic stroke

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do TIA have the same diagnostic workup?

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yes

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what is a good tool used to quantify stroke severity and assess patient outcome after stroke?

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health stroke scale (NIHSS)

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this scale is based on a point system ranging from

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0-42

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o indicates

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no neurological deficits

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42 indicates

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worst possible score

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this is good because it allows clinicians to

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communicate findings using a standardized assessment tool

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this scale focuses on 6 different major areas

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1) LOC 2) visual function 3) motor function 4) sensation and neglect 5) cerebellar function 6) language

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is the immediate nursing priority in the care of patients presenting with a suspect stroke assessment of motor function?

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no

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what is aways the first/immediate care?

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airway (ABC's are always first)

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the initial diagnostic workup and treatment of an ischemic stroke is driven by

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time-dependnet parameters

question

this is because which medication has to be given within a 3 hour time frame form the onset of symptoms?

answer

TPA

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TPA works by

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binding to fibrin and converting plasinogen to plasmin which is responsible to clot breakdown

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TPA works to

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breakdown the clots

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once hemorrhagic stroke has been ruled out and diagnosis for ischemic stroke has been made what occurs?

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review of eligibility/exclusion criteria

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what are some things which make it so you cannot get TPA?

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hypertension, recent prior stroke, major surgery, serious head injury,

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what does the hypertension criteria look like?

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systolic over 185 or diastolic over 110

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who is responsible for administering TPA?

answer

nurses

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what determines dosage?

answer

patients weight in KG

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what is the TPA dosage?

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.9 mg/kg

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what is the max dose?

answer

90 mg

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ten percent of the calculated dose is administered?

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IV bolus

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the remaining 90% is administered

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over an hour long period via infusion pump

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what is the most common side effect of TPA?

answer

bleeding

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patients are monitored for bleeding in

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stools/urine, gums, IV insertion site and intracrainally through observing LOC

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when monitoring those on TPA for the first 2 hours when are vital taken?

answer

q 15 minutes

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after those 2 hours, for the next 6 hours when are vitals taken?

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Q30 minutes

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after these 6 hours, for the next 16 hours when are vitals taken

answer

Q1 hr

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regardless of the type of stroke or treatment patients will be monitored for

answer

neurologica and hemodynamic status

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what is used for patients who did not receive TPA or who did receive TPA and did not improve?

answer

clot retraction

question

during the hyper acute phase for hemorrhagic strokes focuses on

answer

airway, breathing, and circulation (ABC's)

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what is particularly paid attention to?

answer

LOC

question

immediate complications of a hemorrhage stroke include

answer

increased ICP, acute hydrocephalus, potential for hernia and secondary brain injury

question

if there is evidence of deterioration or ICP what occurs?

answer

immediate report to health care team

question

what is used as part of ongoing assessment?

answer

glawsco coma scale

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if the scale is 8 or less what occurs?

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immediate intubation

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the bed should be elevated?

answer

30 degrees

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should pulse oximetry occur?

answer

yes

question

what may be needed, and the nurse should be prepare for, to decrease ICP?

answer

1) reverse anticoagulation 2) placement of ventricular cath for CSF drainage 3) mannitol 4) hyperventilation

question

do we want to prevent and control hyperthermia (>37.5)

answer

yes

question

this is because it is

answer

associated with poor prognosis

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should patients be kept NPO?

answer

yes until they have been screened for dysphagia

question

surgical evacuation of blood may be required.. what are interventions?

answer

craniotomy and evacuation of hematoma

question

what are used to control bleeding and seizures?

answer

antihypertensives and antiepileptic

question

surgical clipping and endovascular coiling may be required for

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patient who have known ruptured aneurysm or subsequent SAH

question

surgical clipping is when there is

answer

craniotomy and placement of clip in neck of artery to close the rupture site

question

does research show that patients with strokes have better outcome if they are admitted to a dedicated stroke unit?

answer

yes

question

the major goal for the patient and family should include

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all efforts to return the patient to his/her pre-morbid functioning

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There are two types of prevention which is targeted

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1) primordial prevention 2) primary prevention

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primordial prevention targets

answer

the entire population, not just those with high risk factors,

question

examples of primordial prevention is

answer

decrease development of obesity,increase exercise and well balanced diet

question

works to prevent disease risk factors from

answer

developing

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primary prevention refers to treatment of

answer

established disease risk factors but for patients who have not yet had an event

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for patients who have had a stroke risk factor modification is critical part of secondary prevention plan.. identify key risk factors such as

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HTN, diabetes, dyslipidemia, smoking, alcohol consumption, sedentary life style, and obesity

question

some patients will be put on medications such as

answer

1) anti platelet 2) statin 3) antihypertensive

question

if patient has A fib what will be administered?

answer

warfarin or heparin

question

for those patients who have had a hemorrhagic stroke what is critical?

answer

blood pressure control

question

if the patient has TIA or stroke thought to be caused from carotid artery stenosis what may be the recommendation?

answer

carotid edarterectomy (CEA)

question

CEA is the removal of

answer

atherosclerotic plaque or thrombus from internal carotid artery

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what is sometimes recommended for patients who surgery might be risky- they are usually done when hemodynamically stable and within first 2 weeks after event?

answer

carotid angioplasty or stenting

question

we want to educate families and patients on what to

answer

expect at home or rehab

question

what are some comprehensive nursing interventions?

answer

1) improve mobility 2) promote self-care 3)prevent shoulder pain 4) promote nutrition 5) enhance communication 6) prevent aspiration

question

what is very important to preventing skin breakdown and contractors?

answer

positioning in bed

question

what types of exercises might we implement?

answer

passive range of motion

question

what are some signs and symptoms of aspiration?

answer

gaging/chocking/drooling

question

what might occur on the weak side in the mouth of the patient?

answer

pocketing of food.

question

in order to prevent shoulder pain from occurring during recovery of stroke we want to

answer

support patients weak arm on pillow or table

question

patient having slurred speech , this would be documented as

answer

dysarthria

question

what medication is administered within a 3 hour onset of symptom to be effective in lysing a clot?

answer

TPA

question

would a patient have impulsive behavior with left or right sided stroke?

answer

right

question

is the CT used to differentiate between hemorrhagic or ischemic stroke.. is that contrast or non contrast?

answer

will be non-constrast

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