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Chapter 28

Chapter 28. Cerebrovascular Accident. Learning Objectives. Discuss the risk factors for cerebrovascular accident (CVA). Identify the two major types of CVA. Describe the pathophysiology, signs and symptoms, and medical treatment for each type of CVA.

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Chapter 28

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  1. Chapter 28 Cerebrovascular Accident

  2. Learning Objectives • Discuss the risk factors for cerebrovascular accident (CVA). • Identify the two major types of CVA. • Describe the pathophysiology, signs and symptoms, and medical treatment for each type of CVA. • Describe the neurologic deficits that may result from CVA. • Explain the tests and procedures used to diagnose a CVA and nursing responsibilities for patients undergoing those tests and procedures.

  3. Learning Objectives • List data to be included in the nursing assessment of the CVA patient. • Assist in developing a nursing care plan for a CVA patient during the acute and rehabilitation phases. • Specify criteria used to evaluate the outcomes of nursing care for the CVA patient. • Identify resources for the CVA patient and family. • Discuss criteria used to identify patients eligible for treatment with rt-PA.

  4. Cerebrum Complex functions: initiation of movements, recognition of sensory input, higher-order thinking, regulating emotional behavior and endocrine and autonomic functions Divided into two halves: hemispheres Each hemisphere controls the opposite side of the body: the right hemisphere controls the left side of the body, and the left hemisphere controls the right side of the body The cortex of each is divided into the parietal, frontal, temporal, and occipital lobes; each has a different area of function

  5. Figure 28-1

  6. Cerebrum Brainstem Includes midbrain, pons, medulla, and part of the reticular activating system Controls vital, basic functions, including respiration, heart rate, and consciousness

  7. Cerebellum Uses information received from the cerebrum, muscles, joints, and inner ear to coordinate movement, balance, and posture Unlike the cerebrum, the right side of the cerebellum controls the right side of the body, and the left side of the cerebellum controls the left side of the body

  8. Circulation Carotid system Begins as one common artery; later divides into the external and internal carotid arteries The external carotid arteries divide to supply blood to the face The internal arteries further divide into the middle cerebral artery and the anterior cerebral artery to supply blood to the brain

  9. Circulation Vertebral arteries Originate from the subclavian artery, travel up the anterior neck to merge and form the basilar artery at the brainstem Second division forms posterior cerebral artery Internal carotid and vertebrobasilar arteries unite to form the circle of Willis

  10. Figure 28-2

  11. Cerebrovascular Accidents

  12. Risk Factors for Stroke Nonmodifiable factors Risk factors that cannot be changed Age, race, gender, and heredity Modifiable factors Those that can be eliminated or controlled

  13. Transient Ischemic Attack Temporary neurologic deficit caused by impairment of cerebral blood flow Blood vessels occluded by spasms, fragments of plaque, or blood clots Important warning signs for the individual experiencing a full stroke

  14. Transient Ischemic Attack Signs and symptoms Dizziness, momentary confusion, loss of speech, loss of balance, tinnitus, visual disturbances, ptosis, dysarthria, dysphagia, drooping mouth, weakness, and tingling or numbness on one side of the body Medical diagnosis Health history, physical examination findings, and results of brain imaging studies Laboratory studies, electrocardiography (ECG), duplex ultrasonography, and cerebral angiography

  15. Transient Ischemic Attack Medical treatment Depends on the location of the narrowed vessel and the degree of narrowing Acetylsalicylic acid (aspirin), ticlopidine hydrochloride (Ticlid), extended-release dipyridamole (Aggrenox), or clopidogrel bisulfate (Plavix) decrease platelet clumping Warfarin (Coumadin) and heparin Carotid endarterectomy and transluminal angioplasty

  16. Figure 28-3

  17. Stroke An abrupt impairment of brain function resulting in a set of neurologic signs and symptoms that are caused by impaired blood flow to the brain and last more than 24 hours

  18. Stroke: Pathophysiology Hemorrhagic stroke Blood vessel in brain ruptures; bleeding into the brain occurs Ischemic stroke Obstruction of blood vessel by atherosclerotic plaque, blood clot, or a combination of the two, or by other debris released into vessel that impedes blood flow to an area of the brain

  19. Figure 28-4

  20. Stroke: Signs and Symptoms Different signs and symptoms, depending on the type, location, and extent of brain injury Hemorrhagic stroke Occurs suddenly; may include severe headache described as “the worst headache of my life” Other symptoms: stiff neck, loss of consciousness, vomiting, and seizures

  21. Stroke: Signs and Symptoms Embolic stroke Appear without warning One or more of the following signs and symptoms: one-sided weakness, numbness, visual problems, confusion and memory lapses, headache, dysphagia, and language problems

  22. Figure 28-5

  23. Stroke: Signs and Symptoms Aphasia A defect in the use of language; speech, reading, writing, or word comprehension Dysarthria The inability to speak clearly Dysphagia Swallowing difficulty Dyspraxia The partial inability to initiate coordinated voluntary motor acts Hemiplegia Defined as paralysis of one side of the body

  24. Figure 28-8

  25. Stroke: Signs and Symptoms Sensory impairment Unable to feel touch, pain, or temperature in affected body parts Unilateral neglect Do not recognize one side of the body as belonging to them Homonymous hemianopsia Perceptual problem: involves loss of one side of field of vision Elimination disturbances Neurogenic bladder Flaccid bladder Bowel incontinence

  26. Medical Diagnosis Blood studies, electrocardiogram (ECG), computed tomography, magnetic resonance imaging, carotid ultrasound studies, cerebral and carotid angiography, electrocardiography, positron-emission tomography, and single-photon emission computed tomography

  27. Complications Constipation, dehydration, contractures, urinary tract infections, thrombophlebitis, decubitus ulcers, and pneumonia Sensory losses put patient at risk for traumatic and thermal injuries Swallowing difficulties place patient at risk for pulmonary complications, such as choking and aspiration pneumonia

  28. Prognosis Prognosis for TIA or stroke increasingly hopeful Critical variables for recovery: patient’s condition before the stroke, time between stroke and diagnosis, treatment and support in acute phase (usually the first 48 hours), severity of patient’s symptoms, and access to rehabilitative therapy Long-term recovery may depend on the care received immediately after the stroke Most recovery takes place in the first 3-6 months, but progress often continues long after that

  29. Medical Treatment in the Acute Phase Begins with the onset of signs and symptoms and continues until vital signs, particularly blood pressure and neurologic condition, stabilize This phase usually lasts 24 to 48 hours Many medical management interventions are directed at minimizing complications and deterioration of the patient’s condition after a stroke

  30. Medical Treatment in the Acute Phase Major focus areas Hypertension Oxygenation Hyperthermia Hyperglycemia Drug therapy Tissue plasminogen activator (rt-PA, alteplase, Activase) Given to dissolve clots in acute ischemic strokes

  31. Medical Treatment in the Acute Phase Other medications Mannitol Nimodipine (Nimotop) Phenytoin (Dilantin) and phenobarbital Acetylsalicylic acid (aspirin), ticlopidine hydrochloride (Ticlid), Aggrenox, and clopidogrel (Plavix)

  32. Medical Treatment in the Acute Phase Surgical intervention An option for some patients with hemorrhagic strokes Decisions about surgery are based on patient’s age, intracranial pressure, and location of the hemorrhage

  33. Medical Treatment in the Acute Phase Fluids and nutrition Intravenous fluids Dietary order based on patient’s nutritional requirements and ability to eat Regular, soft, or pureed Total parenteral nutrition may be ordered for the malnourished patient

  34. Medical Treatment in the Acute Phase Urine elimination Indwelling catheter to manage urinary incontinence Intermittent catheterization: controlling incontinence caused by a flaccid bladder

  35. Nursing Care in the Acute Phase Assessment Evaluate type and extent of the stroke: time of onset, symptoms, other details Cincinnati Pre-hospital Stroke Scale Health history Chief complaint and history of present illness Medical history Family history Review of systems Functional assessment

  36. Nursing Care in the Acute Phase Physical examination Assess patient’s general appearance, responsiveness, and behavior Record restlessness or agitation Measure vital signs; weight and height if possible Inspect the face for symmetry; mouth for moisture and drooling Evaluate the alert patient’s ability to swallow Inspect pupils for size, equality, and reaction to light

  37. Nursing Care in the Acute Phase Physical examination Conduct a gross vision assessment Inspect skin color and palpate for moisture and turgor Assess extremities for muscle tone and strength, sensation, and voluntary movement Record evidence of incontinence or bladder distention Frequently repeat neurologic checks: evaluating level of consciousness, pupil appearance and response to light, the patient’s ability to follow commands, and the movement and sensation of extremities

  38. Nursing Care in the Acute Phase Interventions Ineffective Airway Clearance and Ineffective Breathing Patterns Risk for Injury Deficient Fluid Volume or Excess Fluid Volume Imbalanced Nutrition Disturbed Sensory Perception Ineffective Thermoregulation Disturbed Thought Processes

  39. Nursing Care in the Acute Phase Interventions Impaired Verbal Communication Impaired Physical Mobility Total or Functional Urinary Incontinence Constipation and/or Bowel Incontinence Ineffective Coping Interrupted Family Processes

  40. Nursing Care in the Rehabilitation Phase Assessment Reassess patient’s abilities, expectations, knowledge, motivation, and resources

  41. Nursing Care in the Rehabilitation Phase Interventions Self-Care Deficit Risk for Injury Ineffective Coping Impaired Verbal Communication Imbalanced Nutrition Impaired Physical Mobility Constipation Total and Functional Urinary Incontinence

  42. Figure 28-6

  43. Figure 28-7

  44. Figure 28-9

  45. Discharge Patients may be discharged to home or go to specialized rehabilitation centers for continued therapy Outpatient therapy is an option for some patients When able, patients are transitioned back into the home setting Essential to include family, friends, and significant others in this process

  46. Discharge During and after the rehabilitation phase, patients and families need to be made aware of resources to help them deal with continuing disabilities In rehabilitation, the patient is respectfully challenged to return to the highest level of function possible

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