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Lisa Randall, RN, MSN, ACNS-BC RNSG 2432. Cerebrovascular Accident “Brain Attack”. Objectives. Define cerebrovascular accident and associated terminology Discuss related pathophysiology and presentation of various types of stroke

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objectives
Objectives
  • Define cerebrovascular accident and associated terminology
  • Discuss related pathophysiology and presentation of various types of stroke
  • Discuss etiology, risk factors, diagnostics, management, and outcomes of stroke
  • Review case studies and nursing diagnoses, interventions, and goals
definition
Definition
  • Stroke or “brain attack” is an acute CNS injury that results in neurologic S/S brought on by a reduction or absence of perfusion to a territory of the brain. The disruption in flow is from either an occlusion (ischemic) or rupture (hemorrhagic) of the blood vessel.
incidence prevalence
Incidence & Prevalence
  • Third leading cause of death in the USA
    • 750,000+ people/year
    • 175,000 die within one year (25%)
  • Leading cause of long-term disabilities
    • 5.5 million survivors (USA)
    • 15 to 30 % live with permanent disability
definitions
Definitions
  • Cerebrovascular Accident
    • Ischemic Stroke
      • Thrombotic
      • Embolic
      • Lacunar infarct
      • TIA
    • Hemorrhagic Stroke
      • ICH
      • SAH
stroke emergency care
Stroke: Emergency Care
  • http://youtu.be/-d8__FkW-nU
thrombotic stroke
Thrombotic Stroke
  • Occlusion of large cerebral vessel
  • Older population
  • Sleeping/resting
  • Rapid event, but slow progression (usually reach max deficit in 3 days)
embolic stroke
Embolic Stroke
  • Embolus becomes lodged in vessel and causes occlusion
  • Bifurcations are most common site
  • Sudden onset with immediate deficits
    • Embolysis
    • Hemorrhagic Transformation
lacunar strokes 20 of all stokes
Lacunar Strokes - 20% of all stokes
  • Minor deficits
    • Paralysis and sensory loss
  • Lacune
  • Small, deep penetrating arteries
  • High incidence:
    • Chronic hypertension
    • Elderly
    • DIC
transient ischemic attack
Transient Ischemic Attack
  • Warning sign for stroke
  • Brief localized ischemia
  • Common manifestations:
    • Contralateral numbness/

weakness of hand, forearm, corner of mouth

    • Aphasia
    • Visual disturbances- blurring
  • Deficits last less than 24 hours (usually less than 1 or 2 hrs)
  • Can occur due to:
    • Inflammatory artery disorders
    • Sickle cell anemia
    • Atherosclerotic changes
hemorrhagic stroke definitions
Hemorrhagic Stroke Definitions
  • Intracerebral hemorrhage
  • Intracranial hemorrhage
  • Parenchymal hemorrhage
  • Intraparenchymal hematoma
  • Contusion
  • Subarachnoid hemorrhage
hemorrhagic stroke
Hemorrhagic Stroke
  • Rupture of vessel
  • Sudden
  • Active
  • Fatal
  • HTN
  • Trauma
  • Varied manifestations
hemorrhagic stroke1
Hemorrhagic Stroke
  • Intracerebral

Hemorrhage

  • Subarachnoid

Hemorrhage

pathophysiology hemorrhagic stroke
PathophysiologyHemorrhagic Stroke
  • Changes in vasculature
  • Tear or rupture
  • Hemorrhage
  • Decreased perfusion
  • Clotting
  • Edema
  • Increased intracranial pressure
  • Cortical irritation
slide17

Legs

Mom: Bowel/bladder Reasoning/judgment Long term memory

Voluntary Motor

Sensations Pain & Touch Taste

Arms

Head

Vision & visual memory

Hearing/association & Smell & taste Short term Memory

Balance, Coordination of each muscle group

CN 5,6,7,8 P,R, B/P

CN 9,10,11,12 Tracks cross over Coordinate movement, HR,B/P

physiology normal cerebral blood flow
PhysiologyNormal Cerebral Blood Flow
  • Oxygen
  • Glucose
  • 20% of Cardiac Output / oxygen
  • Arterial supply to the brain:
    • Internal carotid (anteriorly)
    • Vertebral arteries (posteriorly)
  • Venous drainage
    • 2 sets of veins - venous plexuses
      • Dural sinuses to internal jugular veins
      • Sagittal sinus to vertebral veins
    • No valves, depend on gravity and venous pressure gradient for flow
risk factors
Risk Factors

NON-MODIFIABLE

MODIFIABLE

  • Age
    • 2/3 over 65
  • Gender
    • M=F
    • Female>fatality
  • Race
    • AA > hispanics, NA
    • Asians > hem
  • Heredity
    • Family history
    • Previous TIA/CVA
  • Hypertension
  • Diabetes mellitus
  • Heart disease
  • A-fib
  • Asymptomatic carotid stenosis
  • Hyperlipidemia
  • Obesity
  • Oral contraceptive use
  • Heavy alcohol use
  • Physical inactivity
  • Sickle cell disease
  • Smoking
  • Procedure precautions
etiology ischemic stroke
EtiologyIschemic Stroke

Embolism

Prothrombotic states

  • Atrial fib
  • Sinoatrial D/O
  • Recent MI
  • Endocarditis
  • Cardiac tumors
  • Valvular D/O
  • Patent foramen ovale
  • Carotid/basilar artery stenosis
  • Atherosclerotic lesions
  • Vasculitis
  • Hemostatic regulatory protein abnormalities
  • Antiphospholipid antibodies
  • Hep cofactor II
etiology hemorrhagic stroke
Etiology Hemorrhagic Stroke
  • Chronic HTN**
  • Cerebral AmyloidAngiopathy*
  • Anticoagulation*
  • AVM
  • Ruptured aneurysm (usually subarachnoid)
  • Tumor
  • Sympathomimetics
  • Infection
  • Trauma
  • Transformation of ischemic stroke
  • Physical exertion, Pregnancy
  • Post-operative
aneurysm
Aneurysm
  • Localized dilation of arterial lumen
  • Degenerative vascular disease
  • Bifurcations of circle of Willis
    • 85% anterior
    • 15% posterior
aneurysm subarachnoid hemorrhage
AneurysmSubarachnoid Hemorrhage
  • SAH
  • Mortality 70%
  • 97% HA
  • Nuchal rigidity
  • Fever
  • Photophobia
  • Lethargy
  • Nausea
  • Vomiting
aneurysm sah
Aneurysm/SAH
  • Complications
    • HCP
    • Vasospasm
  • Triple H Therapy
    • HTN
    • Hemodilution
    • Hypervolemia
  • Surgical treatment
    • Clip
    • Coil
    • INR
nursing management
Nursing Management
  • Assessment
  • Monitoring
    • BP
    • TCDs
    • CBC
  • Preventing complications
    • Bowel program
    • DVT prophylaxis
    • Siezure prophylaxis
    • Psychological support
    • Discharge planning
arteriovenous malformations
Arteriovenous malformations
  • AVM
    • Tangled mass of arteries and veins
    • Seizure or ICH
treatment avm
Treatment AVM
  • Endovascular
  • Neurosurgery
  • Radiosurgery
presentation
Presentation
  • Sudden onset
  • Focal neurological deficit
  • Progresses over minutes to hours
  • HA, N/V, <<LOC, HTN
  • Depends on location
stroke symptoms include
Stroke Symptoms include:
  • SUDDEN numbness or weakness of face, arm or leg
  • SUDDEN confusion, trouble speaking or understanding.
  • SUDDEN trouble with vison.
  • SUDDEN trouble walking, dizziness, loss of balance or coordination.
  • SUDDEN severe HA.
manifestations by vessel
Manifestationsby Vessel
  • Vertebral Artery
    • Pain in face, nose, or eye
    • Numbness and weakness of face (involved side)
    • Gait disturbances
    • Dysphagia
    • Dysarthria (motor speech)
manifestations by vessel1
Manifestationsby Vessel
  • Internal carotid artery
    • Contralateral paralysis (arm, leg, face)
    • Contralateral sensory deficits
    • Aphasia (dominant hemisphere involvement)
    • Apraxia (motor task),
    • Agnosia (obj. recognition),
    • Unilateral neglect (non-dominant hemisphere involvement)
    • Homonymous hemianopia
manifestations complications by body system
Manifestations & Complications by Body System
  • Neurological
    • Hyperthermia
    • Neglect syndrome
    • Seizures
    • Agnosias (familiar obj)
  • Communication deficits
    • Aphasia (expressive, receptive, global)
    • Agraphia
  • Visual deficits
    • Homonymous hemianopia
    • Diplopia
    • Decreased acuity
    • Decreased blink reflex
manifestations complications by body system1
Manifestations & Complications by Body System
  • Neurological (cont.)
    • Cognitive changes
      • Memory loss
      • Short attention span
      • Poor judgment
      • Disorientation
      • Poor problem-solving ability
  • Behavioral changes
    • Emotional lability
    • Loss of inhibitions
    • Fear
    • Hostility
manifestations complications by body system2
Manifestations & Complications by Body System
  • Musculoskeletal
    • Hemiplegia or hemiparesis
    • Contractures
    • Bony ankylosis
    • Disuse atrophy
    • Dysarthria - word formation
    • Dysphagia – swallow
    • Apraxia – complex movements
    • Flaccidity/spasticity
  • GU
    • Incontinence
    • Frequency
    • Urgency
    • Urinary retention
    • Renal calculi
manifestations complications by body system3
Manifestations & Complications by Body System
  • Integument
    • Pressure ulcers
  • Respiratory
    • Respiratory center damage
    • Airway obstruction
    • Decreased cough ability
  • GI
    • Dysphagia
    • Constipation
    • Stool impaction
initial stroke assessment interventions
Initial Stroke Assessment/Interventions
  • Neurological assessment & NIH assessment
  • Call “Stroke Alert” Code
  • Ensure patient airway
  • VS
  • IV access
  • Maintain BP within parameters
  • Position head midline
  • HOB 30 (if no shock/injury)
  • CT, blood work, data collection/NIH Stroke Scale
  • Anticipate thrombolytic therapy for ischemic stroke
nih stroke scale score
NIH Stroke Scale Score
  • Standardized method
    • measures degree of stroke r/t impairment and change in a patient over time.
  • Helps determine if degree of disability merits treatment with tPA.
    • As of 2008 stroke patients scoring greater than 4 points can be treated with tPA.
  • Standardized research tool to compare efficacy stroke treatments and rehabilitation interventions.
  • Measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language not measured by Glasgow coma scale.
  • Current NIH Stroke Score guidelines for measuring stroke severity:

Points are given for each impairment.

    • 0= no stroke
    • 1-4= minor stroke
    • 5-15= moderate stroke
    • 15-20= moderate/severe stroke
    • 21-42= severe stroke
    • A maximal score of 42 represents the most severe and devastating stroke.
question
Question
  • The neurologic functions that are affected by a stroke are primarily related to
    • A. the amount of tissue area involved.
    • B. the rapidity of the onset of symptoms.
    • C. the brain area perfused by the affected artery.
    • D. the presence or absence of collateral circulation.
question1
Question
  • A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipated that the health care provider will request a
    • A. CT scan.
    • B. lumbar puncture.
    • C. cerebral angiogram.
    • D. PET scan.
diagnostics
Diagnostics

Tests for the Emergent Evaluation of the Patient with Acute Ischemic Stroke

  • CT head (-)
  • Electrocardiogram
  • Chest x-ray
  • Hematologic studies (complete blood count, platelet count, prothrombin time, partial thromboplastin time)
  • Serum electrolytes
  • Blood glucose
  • Renal and hepatic chemical analyses
  • National Institute of Health Scale (NIHSS) score
diagnostics1
Diagnostics

Ischemic Stroke

Hemorrhagic Stoke

medical management
BP

MAP

CPP

Factor VII, Vit K, FFP

ICP

HOB

Sedation

Osmotherapy

Hyperventilation

Paralytics

Fluid management

euvolemia

Seizure prophylaxis

Keppra

Dilantin

Sedation

Body temperature

PT/OT/ST

DVT prophylaxis

Medical Management
treatment
Treatment

Ischemic

Hemorrhagic

  • Medical management
  • TpA
  • Endovascular
    • Carotid endarectomy
    • Merci clot removal
      • http://youtu.be/P2TNz-TniIA
  • Medical management
  • Decompression
    • Craniotomy
    • Craniectomy

PT/OT/ST

REHABILITATION

medications
Medications
    • Anti-coagulants – A fib & TIA
  • Antithrombotics
    • Calcium channel blockers – Nimotop (nimodipine)
    • Corticosteroids ???
    • Diuretics – Mannitol, Lasix (Furosemide)
    • Anticonvulsants – Dilantin (phenytoin) or Cerebyx (Fosphenytoin Sodium Injection)
    • Thrombolytics - tPA (recombinant tissue plasminogen activator)
medications1
Medications
  • Thrombolytics Recombinant Alteplase (rtPA) Activase, Tissue plasminogen activator
    • Treatment must be initiated promptly after CT to R/O bleed
      • Systemic within 3 hours of onset of symptoms
      • Intra-arterial within 6 hours of symptoms
    • Some exclusions:
      • Seizure at onset
      • Subarachnoid hemorrhage
      • Trauma within 3 months
      • History of prior intracranial hemorrhage
      • AV malformation or aneurysm
      • Surgery 14 days, pregnancy,
      • Cardiac cath. 7 days
neurosurgical management
Neurosurgical Management
  • Craniotomy
  • Craniectomy
  • EVD placement
  • ICP monitor placement
recommendations for surgical treatment of ich
Nonsurgical candidates

Small hemorrhage

Minimal deficit

GCS </= 4 (unless brain stem compression)

Loss of brainstem fxn

Severe coagulopathy

Basal ganglion or thalamic

Surgical candidates

>3cm

Neuro deficit

Brain stem compression

MLS, HCP

Aneurysm, AVM, cavernous hemangioma

Young c mod/large lobar hemorrhage c clinical deterioration

Recommendations for Surgical Treatment of ICH
question2
Question
  • A carotid endarectomy is being considered as treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery
    • A. is used to restore blood circulation to the brain following an obstruction of a cerebral artery.
    • B. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery.
    • C. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke.
    • D. is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation.
standing orders
Standing Orders
  • Per facility policy
nursing concerns
Medical management!

Post-op care

Mobilization

Nutrition

Constipation

Skin

Infection

Patient/family teaching

Follow-up

Medications

Resources available

Nursing Concerns
question3
Question
  • An essential intervention in the emergency management of the patient with a stroke is
    • A. intravenous fluid replacement.
    • B. administration of osmotic diuretics to reduce cerebral edema.
    • C. initiation of hypothermia to decrease oxygen needs of the brain.
    • D. maintenance of respiratory function with a patent airway and oxygen administration.
overview
Overview

http://youtu.be/-d8__FkW-nU

nclex
NCLEX
  • A patient comes to the ED immediately after experiencing numbness of the face and inability to speak, but while the patient awaits examination, the symptoms disappear and the patient requests discharge. The RN stresses that it is important for the patient to be evaluated, primarily because
    • A. the patient has probably experienced an asymptomatic lacunar stroke.
    • B. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours.
    • C. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off.
    • D. the patient has probably experienced a TIA that is a sign of progressive vascular disease.
nursing diagnosis
Nursing Diagnosis
  • Ineffective cerebral tissue perfusion
  • Impaired mobility
  • Self-care deficit
  • Impaired verbal communication
  • Impaired swallowing
nursing diagnoses interventions
Nursing Diagnoses/Interventions
  • Ineffective Tissue Perfusion
    • Goal is to maintain cerebral perfusion
      • Monitor respiratory status
      • Auscultate, monitor lung sounds
      • Suction as needed – increases ICP
      • Place in side-lying position (secretions)
      • O2 as needed/prescribed
      • Assess LoC, other neuro vital signs
      • NIH Stroke Scale
      • Glasgow Coma Scale – Eyes, Verbal, & Motor
nursing diagnoses interventions1
Nursing Diagnoses/Interventions
  • Ineffective Tissue Perfusion (cont)
      • Monitor strength/reflexes
      • Assess for HA, sluggish pupils, posturing
      • Monitor cardiac status
      • Monitor I&O’s
        • Can get DI as result of pituitary gland damage
      • Monitor seizure activity
nursing diagnoses interventions2
Nursing Diagnoses/Interventions
  • Impaired Physical Mobility
    • Goal is to maintain and improve functioning
      • Active ROM for unaffected extremities
      • Passive ROM for affected extremities
      • Q2 hr turns
      • Assess for thrombophlebitis
      • Confer with PT for movement and positioning techniques for each stage of rehab
nursing diagnoses interventions3
Nursing Diagnoses/Interventions
  • Impaired Physical Mobility

Flaccidity & spasticity

Meds used to treat spasticity:

Kemstro or Lioresal (baclofen)

Valium (diazepam)

Dantrium (dantrolene sodium)

Zanaflex (tizanidine hydrochloride)

New drugs being tried –

        • Neurontin (Gabapentin) & Botox (botulinum toxin)
nursing diagnoses interventions4
Nursing Diagnoses/Interventions
  • Self-Care Deficit
    • Goals are to promote functional ability, increase independence, improve self-esteem
      • Encourage use of unaffected arm in ADLs
      • Self-dressing (using unaffected side to dress affected side first)
      • Sling or support for affected arm
      • Confer with OT for techniques to promote return to independence
nursing diagnoses interventions5
Nursing Diagnoses/Interventions
  • Impaired Verbal Communication
    • Goal is to increase communication
      • Speak in normal tones unless there is a documented hearing impairment
      • Allow adequate time for responses
      • Face center client when speaking, speak simply and enunciate words
      • If you don’t understand what the client is saying, let them know, and have them try again
nursing diagnoses interventions6
Nursing Diagnoses/Interventions
  • Impaired Verbal Communication (cont)
      • Try alternate method of communication if needed
        • Writing, computerized boards, etc
      • Allow client anger and frustration at loss of previous functioning
      • Allow client to touch (hands, arms), may be the only way of expressing (comfort, etc)
      • If client has visual disturbances:
        • During initial phase of recovery, position where client can easily see you; in later stages, client can be directed to adjust position for visual contact
nursing diagnoses interventions7
Nursing Diagnoses/Interventions
  • Impaired Swallowing
    • Goal is safety, adequate nutrition, and hydration
      • Position client upright, using **pureed – less often ** or finely chopped soft foods
      • Hot or cold food or thickened liquids
      • Teach client to put food behind teeth on unaffected side and tilt head backwards
      • Check for food pockets, especially on affected side
      • Have suctioning equipment at bedside
      • Minimize distractions while eating
      • Never leave client with food etc. in mouth
question4
Question
  • A patient with a right hemisphere stroke has a nursing diagnosis of unilateral neglect R/T sensory-perceptual deficits. During the patient’s rehabilatation, it is important for the nurse to
    • A. avoid positioning the patient on the affected side.
    • B. place all objects for care on the patient’s unaffected side.
    • C. teach the patient to care consciously for the affected side.
    • D. protect the affected side from injury with pillows and supports.
complications
Complications
  • Increased intracranial pressure
  • Rebleeding
  • Vasospasm
  • HCP
  • Death
outcomes
Age

Size, volume

Location

HCP, IVH

Deficit, LOC, MAP

Duration

Co-morbidities

44% mortality

Outcomes
evaluation
Evaluation
  • Reduce mortality and morbidity
  • Baseline neurological function
  • Outcomes
  • Evidenced based practice
patient family education
Patient/Family Education
  • PREVENTION is key
    • Smoking cessation
    • Physical activity
      • Weight reduction
    • Diet
      • Plavix
    • LDL chol reduction
      • Statins
      • > HDL
  • BP normilization
    • ACE inhibitos
    • ARB
    • Thiazide diuretics
  • Antiplatelet agents
    • ASA
  • DM
  • ETOH
  • Homocysteine reduction
  • http://youtu.be/awtFZQkoBPc
legal ethical concerns
Legal/Ethical Concerns
  • Advanced directives
    • MPOA
  • Category status
  • Code status
  • Withdrawal of care
  • Palliative care
  • Placement
slide76

Resources

www.stroke.org -- National Stroke Association (800-787-6537)

www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke (800-352-9424)

www.naric.com -- National Rehabilitation Information Center (8003462742)

www.aphasia.org -- National Aphasia Association (800-922-4622)

www.aan.com -- American Academy of Neurology

www.dynamic-living.com -- Daily living products

www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf -- NIH stroke scoring system

www.strokecenter.org/trials -- Find a clinical trial on stroke

case study 1

A

BRACKENRIDGE

Jackson, William J

A

BRACKENRIDGE

CT Head w/o Contrast

J^3172551

CT Head w/o Contrast

1/12/1975

Head W/O ST.

1/12/1975

Head W/O ST.

34 YEAR

12/3/2009 6:43:15 AM

34 YEAR

12/3/2009 6:43:15 AM

M

3725860

M

3725860

---

---

LOC: -111.80

LOC: -111.80

THK: 4.80

THK: 4.80

HFS

HFS

R

L

R

L

512x512

512x512

RD: 250

RD: 250

Tilt: -10

Tilt: -10

KVp: 120

KVp: 120

mA: 460

C: 35

mA: 460

C: 35

eff. mAs: 460

W: 80

eff. mAs: 460

W: 80

Acq No: 4

---

Compressed 11:1

Acq No: 4

---

Compressed 11:1

---

IM: 14 SE: 2

---

IM: 14 SE: 2

Page: 14 of 36

P

Page: 14 of 36

P

cm

cm

Case Study #1
  • 34 yo AAM
  • R temporoparietal ICH c IVH, HCP
  • h/o L MCA ischemic
  • Sentis protocol
  • Coumadin (INR 13)
  • Factor VII, Vit K
  • Craniotomy
  • ICP
  • EVD x 2
question5
Question
  • The incidence of ischemic stroke in pateints with TIAs and other risk factors is reduced with the administration of
    • A. furosemide (Lasix).
    • B. lovastatin (Mevacor).
    • C. daily low-dose aspirin (ASA).
    • D. nimodipine (Nimotop).
question6
Question
  • A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include

a. hyperventilation therapy.

b. surgical clipping of the aneurysm.

c. administration of hypersomotic agents.

d. administration of thrombolytic therapy.

question7
Question
  • A nursing intervention that is indicated for the patient with hemiplegia is
    • A. the use of a footboard to prevent plantar flexion.
    • B. immobilization of the affected arm against the chest with a sling.
    • C. positioning the patient in bed with each joint lower that the joint proximal to it.
    • D. having the patient perform passive ROM of the affected limb with the unaffected limb.
question8
Question
  • The nurse can assist the patient and the family in coping with the long-term effects of a stroke by
    • A. informing the family members that the patient will need assistance with almost all ADLs.
    • B. explaining that the patient’s prestroke behavior will return as improvement progresses.
    • C. encouraging the patient and family members to seek assistance from family therapy or stroke support group.
    • D. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning.
references
References
  • AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St.
  • Broderick, J., et. al. (1999) Guidelines for the management of spontaneous intracerebral hemorrhage. AHA.
  • El-Mitwali, A., Malkoff, M. (2001) Intracerebral hemorrhage. The Internet Journal of Neurosurgery. 1.1.
  • Greenberg, Mark. (2006). Handbook of

Neurosurgery. Greenberg Graphics,

Tampa, Florida.