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Care of Patient with CVA. Rita Carey-Nita. Transient Ischemic Attack. Temporary impairment of the cerebral circulation Sudden loss of neurological function is noted due to inadequate perfusion of a portion of the brain

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transient ischemic attack
Transient Ischemic Attack
  • Temporary impairment of the cerebral circulation
  • Sudden loss of neurological function is noted due to inadequate perfusion of a portion of the brain
  • Neurological impairment lasts minutes to hours but does not exceed 24 hours
  • Patient’s who suffer from TIA are at greater risk for developing a CVA
  • Imperative that further evaluation to prevent CVA from occurring
cerebral vascular accident
Cerebral Vascular Accident
  • Infarction of the brain tissue caused by the disruption of blood flow to the brain
  • Neurological deficits are reflective to the area in the brain affected
  • Referred to as brain attack
  • Need immediate intervention
    • Need treatment within 3 hours of symptom onset
pathophysiology
Pathophysiology
  • Pathophysiology
    • Cerebral function is dependent upon oxygen and glucose delivery neurons
    • Impaired blood flow affects the delivery of oxygen and glucose to brain tissue
    • Brain tissue dies
    • Permanent damage is a result without immediate intervention
    • Pneumbra is an area of brain tissue surrounding the damage that may be revived if reperfused quickly
etiology
Etiology
  • Etiology
    • Can be ischemic or hemorrhagic
    • Need MRI or CT Scan to determine which
  • Ischemic Stroke
    • Caused by emboli or thrombosis that decrease perfusion
      • Artherosclerosis narrowing vessels causing occlusion causes thrombotic stroke
      • Emboli breaking off and traveling and lodging in narrowed vessel causes embolic stroke
    • Common vessel is bifurcation of common carotid into internal & external carotid
etiology1
Etiology
  • Emboli
    • Cardiac origin
      • A-fib
      • SA node disorder
      • Acute MI
      • Bacterial endocarditis
      • Cardiac tumors
      • Valve disorder
    • Arterial
      • Severe stenosis of carotid & basilar arteries
      • Severe stenosis of small deep arteries of brain
    • Vasculitis
      • Inflammatory condition involving cerebral blood vessels
      • Causes include:
        • Lupus—meningitis—fungal infections—herpes zoster arteritis
slide7

Hemorrhagic Stroke

    • Caused by the rupture of a cerebral blood vessel
    • Brain tissue beyond vessel does not receive blood supply resulting in tissue death
    • Brain tissue surrounding the hemorrhage is also damage by the released blood
    • Intracerebral hemorrhage (ICH)
      • Most common cause is uncontrolled HTN
      • Ruptured aneurysm is another cause
    • Subarachnoid hemorrhage (SAH)
      • Rupture of blood vessels on surface of brain
      • Slowest recovery
      • Most patient suffer extensive neurological impairment
risk factors
Risk Factors
  • Modifiable
    • Can be changed with treatment
      • Smoking cessation—lifestyle modification—treat hypertension
  • Nonmodifiable risk factors
    • Can not be altered
      • Gender—race—prior stroke—hereditary—age
slide9

Warning Signs

    • Teach warning signs
      • Sudden numbness or weakness of face, arm or leg on one side
      • Sudden confusion, trouble speaking, or comprehending
      • Sudden impaired vision in one or both eyes
      • Sudden dizziness, loss of balance, or coordination
      • Sudden severe headache
acute signs symptoms
Acute Signs & Symptoms

Symptoms result from either hemorrhagic or ischemic

  • Visual disturbances
      • All or part of one eye
      • Affect eye on same side of CVA
      • Horizontal—bitemporal—homonymous—hemianopsia—quandrantic
  • Language disturbances
      • Dysphasia
      • Aphasia
        • Expressive or receptive
      • Global aphasia
        • Both
      • Dysarhtria
        • Motor speech deficit
acute signs symptoms1
Acute Signs & Symptoms
  • Motor disturbance
    • Weakness or paralysis or numbness on one side of body
        • Commonly presents in face and arm
        • Can have complete hemiparesis
    • Unilateral & opposite to area of damage
    • Brainstem or vertebrobasilar stroke affects both side of body
    • Ataxia
    • Dysphagia
  • Specific to Hemorrhagic
    • Rapid deterioration
    • Drowsiness
    • Severe headache
diagnostic tests
Diagnostic Tests
  • CPSS—The Cincinnati Prehospital Stroke Scale
    • Implemented for quick intervention with stroke victims
    • Three components
      • Have patient smile
        • take note of facial droop or uneven symmetry
      • Ask patient to hold out arms in front of them with eyes closed
        • watch for downward drift
      • Ask patient to repeat a phrase
        • did they comprehend
        • repeat phrase exactly
        • is speech slurred
    • If any one of three positive the patient needs immediate treatment
diagnostic tests1
Diagnostic Tests

CT scan

    • Useful in diagnosing hemorrhagic stroke
    • Negative with TIA
    • Ischemic stroke will not be detected early on
  • EKG
  • Echocardiogram
  • CBC
  • Metabolic panel
  • Blood typing
  • PT & INR
  • Serum Pregnancy
  • Stools & emesis for blood
  • Cardiac monitoring
  • Pulse oximetry
  • Dysphagia screening
  • Carotid Doppler
  • Cerebral angiogram
  • NIH Stroke Scale
therapeutic interventions
Therapeutic Interventions

Acute emergent care

  • Think ABC’s
    • Airway—breathing—circulation
    • Oxygen therapy to keep O2 greater than 90%
    • Cardiac monitoring
    • Vital signs
    • Diagnostic test to determine if hemorrhagic or ischemic
    • After results immediate interventions
therapeutic interventions1
Therapeutic Interventions
  • Thrombolytic Therapy
      • Alteplase or Tissue plaminogen activator (t-PA) for ischemic
    • Goal is to break down thrombus that is occluding the vessel
    • Hope to prevent or reverse symptoms
    • Acts by converting plasminogen to plasmin which lysis the clot
    • If successful the patient will have no residual effects from stroke
    • Need treatment within 3 hours of onset of symptoms
      • Stabilize
      • Obtain diagnostic test results promptly
      • If CT scan shows ischemic than angiogram
    • Need to meet specific criteria—not all are canditate
  • Has risk of cerebral hemorrhage
therapeutic interventions2
Therapeutic Interventions

Pharmacological Management

  • Control of blood pressure vital
    • Should not lower too quickly or too far
    • No more than 10% of baseline at one time
    • Can cause more ischemia
    • Monitor BP frequently
    • Some physician do not lower BP because believe higher BP needed for cerebral perfusion in hypertensive patient
  • Prevention of seizure activity
    • Anti-seizure medication
  • In hemorrhagic stroke
    • Prevention of vasospasm with nimodipine--calcium channel blockers relax the smooth muscle of vessel
    • Antifibrinolytic to inhibit plaminogenacitvation reducing rebleeding
therapeutic interventions3
Therapeutic Interventions

Post emergent care

  • Control cause of TIA or CVA
  • If deficits with CVA
    • PT—OT—Speech
  • Antiplatelet therapy within 24 hours
    • Plavix—Aggrenox—aspirin
  • Antidysrhythmic medication with atrial fibrillation
  • Anticoagulants
    • Coumadin—heparin
  • Prevention of aspiration
    • Decreased LOC—dysphagia
slide19

Carotid Stenosis

    • More than 70% blockage requires surgical intervention of carotid endarterectomy
    • Carotid is opened and plaque removed
  • Nursing Interventions
    • Neurological assessment
      • Monitor for deterioration
    • Assess site
      • Bleeding—hematoma
  • Larger hospitals trying balloon angioplasty
prevention
Prevention

Prevention

  • Control
    • HTN—cholesterol—weight—diabetes
  • Smoking cessation
  • Coumadin therapy with chronic atrial fibrillation
  • Aspirin and anti-platelet to prevent abnormal clotting
  • Treat carotid stenosis with endarterectomy
  • Educate
    • Signs & symptoms of stroke
    • Call for help immediately
    • Early intervention & treatment within 3 hours
long term effects
Long Term Effects
  • Impaired motor function
    • Hemiplegia
    • Hemiparesis
    • Contracture
    • Dysphagia
    • Incontinence
    • Sensation impairment
  • Early mobilization imperative to prevent long term complications
  • PT—OT—Speech
long term effects1
Long Term Effects

Aphasia

    • Is infarct is on dominant side of brain speech center affected
    • Expressive—receptive—global
  • Speech therapy may be effective

Emotional Lability

    • Moods swing between happy and sad at any given time

Impaired Judgment

    • Especially seen with right sided injury
      • At risk for injury
    • Frontal lobe
      • Inappropriate behavior
long term effects2
Long Term Effects

Unilateral Neglect

  • Mainly seen in right hemisphere infarcts
  • Do not acknowledge left side
  • Therapy helpful to teach patient to focus on the left

Nursing Interventions

    • Place belonging on right side
    • Call bell on right side of bed
    • Door to patient right
    • Teach patient to assess left side
long term effects3
Long Term Effects

Homonymous Hemianopsia

  • Visual disturbance where patient has vision loss on one side
  • Contributes to unilateral neglect

Other long-term effects

  • Depression—pressure ulcers—DVT—PE—pneumonia