Transcript Dee Behrens` and Betty Berls` - AANN Northern Illinois Chapter

Testing your Stroke
Knowledge
AANN Northern Illinois Chapter Symposium
March 14, 2015
Presented By:
Dee Behrens, RN, BSN, CNRN, SCRN
Betty Berls, RN,BSN, CNRN
Objectives
• Identify the anatomical location in the brain that
correlates with specific stroke symptoms
• Review neurological assessment in the stroke patient
• Discuss nursing interventions in the care of ischemic
and hemorrhagic patients
• Recognize stroke risk factors
Course Content
• Questions and answer format
• Case Studies
A patient with Wernicke’s aphasia would have which
one of the following findings on examination?
A. Slow, non-fluent speech
B. Inability to repeat words or sentences
C. Telegraphic speech
D. Inability to follow a command
Correct Answer is D
Patients with Wernicke’s or receptive aphasia cannot
understand what is being said to them. The speech may
be fluent but has no meaning.
Dysfunction with cranial nerve IX and X increases risk
for:
A. Aspiration
B. Hemi-inattention
C. Respiratory arrest
D. Infection
Answer is A
A patient is being discharged from the stroke unit who
underwent an aneurysm clipping. The patient asks the
nurse if the clip will be removed in the future. The
correct response by the nurse is
A.
B.
C.
D.
In 3 months
When all symptoms resolve
Never
In 10 years
Correct Answer C
Aneurysm clips can vary in size, shape and design but they
are all placed with the intention of being permanent. Coils
and stents are also intended to remain in place
permanently but occasionally migrate or become loosened,
requiring removal and/or replacement.
The MOST sensitive and specific imaging technique to
demonstrate acute infarction is
A. Non-contrast CT
B. CT Perfusion Study
C. CTA
D. MR diffusion-weighted imaging
Correct Answer: D
MR diffusion weighted imaging is the most sensitive to
identifying the early stage of an acute ischemic stroke. It
detects small restrictions in the movement of water
molecules within the injured areas.
The NIHSS provides information on:
A.
B.
C.
D.
Medical History
Glascow Coma scale scores
Neurological deficits
NIHSS provides little information
Correct Answer: C
NIHSS (National Institutes of Health Stroke Scale) is a tool
utilized to score the severity of stroke symptoms.
• Composed of 11 items
• Each one scores a specific ability between 0-4
• Score of 0 in each category typically indicates normal
function
• Total score is a sum of all 11 items
• Minimum score is a 0 while maximum is 42
SCORE
STROKE SEVERITY
0
No Stroke Symptoms
1-4
Minor Stroke
5-15
Moderate Stroke
16-20
Moderate to Severe Stroke
21-42
Severe Stroke
An acute ischemic patient is being discharged with a
new diagnosis of A-fib and will be going home on
Warfarin. Discharge instructions include drug-food
interactions. Which food item is the patient instructed
to avoid:
A.
B.
C.
D.
Green Beans
Acorn Squash
Broccoli
Tomatoes
Correct Answer: C
Patients taking warfarin should be taught to avoid foods
high in Vitamin K. Most leafy green vegetables-collard
greens, broccoli, avocados, brussel sprouts, cabbage,
green onions. Also beef and pork liver, canola oil,
margarine, mayonnaise, soybean oil
A 64yo African American male presents to the
emergency room with c/o sudden onset of left leg
weakness and numbness. Identify which blocked artery
could cause these symptoms:
A.
B.
C.
D.
Posterior cerebellar artery
Left anterior cerebral artery
Basilar
Right anterior cerebral artery
Correct Answer: D
Occlusion of the right anterior cerebral artery
produces contralateral sensorimotor deficits
mainly involving the lower extremity sparing the
face and hands
A stroke in which area of the brain would be
most devastating to a classical pianist?
A.
B.
C.
D.
Left cerebral hemisphere
Cerebellum
Right cerebral hemisphere
Brain stem
Correct Answer: C
Functions of the right cerebellar hemisphere:
• Controls left side of the body
• Art Awareness
• Creativity
• Imagination
• Intuition
• Music Awareness
• 3-D forms
An example of apraxia would be demonstrated
by your patient presenting with which
symptom?
A.
B.
C.
D.
Inability to name colors
Difficulty pronouncing multi-syllable words
Inability to show he can cut with imaginary scissors
Difficulty understanding the emotional and affective
component of what is being said
Correct Answer: C
Apraxia is the inability to perform a purposeful motor act on
command. It can be seen with lesions of the dominant
parietal lobe.
Right homonymous hemianopsia is described as:
A.
B.
C.
D.
Inability to see the left visual field in both eyes
Loss of vision in the right eye
Inability to see the right visual field in both eyes
Loss of vision in the left eye
Correct Answer: C
Homonymous Hemianopsia is visual deficit affecting the
same side (right or left) of each visual field. The patient
must turn their head from side to side to compensate for
the deficit.
A patient in his third day of admission since suffering a
left MCA infarct becomes more aphasic with increased
weakness of the right arm and leg. Repeat Stat head CT
demonstrates increased vasogenic edema. Mannitol
25mg IV is ordered every 3 hours. What are the
nurrsing considerations for this patient?
A. Need for hypertensive management, sedation and
analgesia
B. Serum osmolarity, CPP goals and fluid balance
C. Hypotonic fluids, head of bed position, and arterial line
D. Venous thrombus protection, head of bed position, and
pulmonary toilet
Correct Answer: B
Mannitol is an osmotic diuretic. It works by increasing the amount of
fluid excreted by the kidneys and helps the body decrease pressure in
the brain and eyes.
Drug Class: Osmotic Diuretic
A patient just arrived in the ICU after receiving tPA. The
nurse assigned to this patient knows post infusion vital
signs and neurological status needs to be checked:
A.
B.
C.
D.
15 min x1 hr, q30 min x 2 hrs, then qhr x 16hrs, then every 4hrs
15 min x2 hrs, q30min x 4hrs, q1hr x 16 hrs and then q 2-4 hrs
15 min x 2 hrs, q30 min x 6 hrs, q 1hr x 16 hrs, and then q 2-4 hrs
15 min x 2 hrs, q 30 min x 8 hrs, q 1hr x 16 hrs and then q 4hrs
Correct Answer: C
Once tPA is administered the blood pressure should be
maintained below 180/105 to decrease the risk of ICH.
Avoid hypotension to maintain perfusion to the damaged
area of the brain.
Rapid neurological deterioration can indicate an ICH post
infusion leading to the necessity of frequent neuro checks
A patient is admitted for observation following a mild
subarachnoid hemorrhage. Throughout the night, the
patient becomes increasingly confused and difficult to
arouse but exhibits no focal neurological deficits.
Which of the following is the most likely cause of this
patient’s change in status?
A.
B.
C.
D.
Recurrent subarachnoid hemorrhage
New onset vasospasm
Subclinical seizures
Communicating hydrocephalus
Correct Answer: D
Cerebrospinal fluid (CSF) is normally produced in the
ventricles by the choroid plexus at a rate of 20-25 ml/hr and
is reabsorbed in the subarachnoid space by the arachnoid
villi at the same rate. In the SAH patient, blood
accumulation in the subarachnoid space limits the ability of
the reabsorption of CHF, which leads to hydrocephalus.
Symptoms of progressive communicating
hydrocephalusinclude aslowly declining level of
consciousness, without focal deficits.
An ischemic stroke patient is being given discharge instructions.
The nurse knows that further instructions are needed when the
patient makes the following statement “I will aim to keep my …
A.
B.
C.
D.
LDL cholesterol level greater than 130mg/dl
Blood pressure less than 120/80
Body mass index no greater than 25
HDL cholesterol level greater than 40mg/dl
Correct Answer: A
Levels of LDL (low-density lipoprotein) cholesterol greater
than 130mg/dl are linked to an increased risk for ischemic
stroke.
The American Heart/ StrokeAssociation recommended that
LDL cholesterol levels be maintained at less than 100
mg/dl.
Answer the next 4 questions based on this scenario
•
•
•
•
•
•
•
•
A 75-year-old Caucasian female was found on the floor of her kitchen by her
daughter at 10:00am. Her daughter called an ambulance and the woman was taken
to the emergency room. In the ER the daughter states she talked to her mom on the
phone at 08:15 and she was feeling fine. The patient presents with the following
symptoms:
- paralysis of the right arm and leg
-inability to answer questions but ability to understand what was said to her
VS are 178/100, 88, 20, 37.0
Blood sugar: 100
Pulse ox: 98%
PMHX: Hypertension, Dyslipidemia, Arthritis
Home Medications include: Lopressor 50 mg/dly, Zocor 20 mg every evening
Head CT was completed and was negative for any hemorrhage
ER nurse documents the Last Known Normal as:
A.
B.
C.
D.
10:00 am
08:15 pm
06:00 am
10:00 pm
Correct Answer: B
To determine a patient’s eligibility for Tissue Plasminogen Activator (tPA) the
time the patient was LAST KNOWN NORMAL time must be established. The
window for most people is 3 hours. In some cases the window can be
expanded to 4.5 hours.
Patient is determined a candidate for tPA. The
nurse knows the dosage for tPA in an ischemic
stroke is:
A. 0.5mg/kg administered over 2 hours
B. 0.9mg/kg with 10% bolus given first over 1 minute with
the remainder administered over 24 hours
C. 0.9mg/kg with 10% bolus given over 1 minute with
remainder administered over 1 hour
D. 0.3 mg/kg administered over 24 hours
Correct Answer: C
• 0.9 mg/kg with 10% bolus given over 1
minute and then the remainder over 1 hour
The nurse knows that post tPA infusion B/P
needs to remain below:
A.
B.
C.
D.
130/80
185/110
190/100
180/105
Correct Answer: D
• Pre infusion B/P should be maintained below
185/110
• Post infusion B/P needs o be maintained at
or below 180/105
This patient is admitted to the ICU for the next 24 hours
the nurse expects which of the following tests to be
ordered as part of the stroke work-up:
A.
B.
C.
D.
Renal Ultrasound
Carotid Ultrasound
MRI of Cervical Spine
CTA of Chest
Correct Answer: B
• The primary purpose of a carotid ultrasound is to test for
narrowed carotid arteries.
• This is completed to not only help determine the cause
of this stroke but define secondary stroke prevention.
A subarachnoid hemorrhage patient has been admitted
to the ICU and has a documented Hunt- Hess score of
grade 5 and a Fisher grade of 4. The nurse knows the
patients prognosis for recovery is:
A.
B.
C.
D.
Excellent
Poor
Good
Fair
Correct Answer: B
]
Hunt and Hess Grading System
Grade 1: Asymptomatic or mild headache
Grade 2: Cranial nerve palsy or moderate to severe
headache/nuchal rigidity
Grade 3: Mild focal deficit, lethargy, or confusion
Grade 4: Stupor and/or hemiparesis
Grade 5: Deep coma, decerebrate posturing, moribund
appearance
The Fisher Grade (grades I-IV) assesses how much blood is
on a CT scan. With both grading systems the higher the
grade the poorer the prognisis
Lacunar strokes are characterized by:
A.
B.
C.
D.
Atherosclerotic plaque rupture in a cerebral vessel
Microthromboembolic vascular occlusion
Infarction of deep, small, penetrating arteries
Vascular leak in the circle of willis
Correct Answer: C
20% of strokes are the result of lacunar infactions which
are small occlusions of tiny cerebral vessels in the deeper
areas of the brain.
Multiple tiny infarcts are common
Frequently occur in persons with chronic hypertension and
diabetes
Thank- you
&
Questions