cerebrovascular accident “brain attack”
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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 - PowerPoint PPT PresentationTRANSCRIPT
Lisa Randall, RN, MSN, ACNS-BCRNSG 2432
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
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
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
Cerebrovascular Accident Ischemic Stroke
Thrombotic Embolic Lacunar infarct TIA
Hemorrhagic Stroke ICH SAH
Stroke: Emergency Care
http://youtu.be/-d8__FkW-nU
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
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 Minor deficits
Paralysis and sensory loss Lacune Small, deep penetrating
arteries High incidence:
Chronic hypertension Elderly DIC
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
Intracerebral hemorrhage Intracranial hemorrhage Parenchymal hemorrhage Intraparenchymal hematoma Contusion Subarachnoid hemorrhage
Hemorrhagic Stroke
Rupture of vessel Sudden Active Fatal HTN Trauma Varied
manifestations
Hemorrhagic Stroke
Intracerebral Hemorrhage
Subarachnoid Hemorrhage
PathophysiologyHemorrhagic Stroke
Changes in vasculature Tear or rupture Hemorrhage Decreased perfusion Clotting Edema Increased intracranial pressure Cortical irritation
Hearing/association & Smell & taste Short term Memory
Voluntary Motor
Sensations Pain & Touch Taste
Balance, Coordination of each muscle group
Arms
Head
LegsMom: Bowel/bladder Reasoning/judgment Long term memory
Vision & visual memory
CN 5,6,7,8 P,R, B/P CN 9,10,11,12
Tracks cross over Coordinate movement, HR,B/P
Vessels of the Brain
Vessels of the Brain
Right Side
Circle of Willis
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
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
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 Chronic HTN** Cerebral Amyloid Angiopathy* Anticoagulation* AVM Ruptured aneurysm (usually subarachnoid) Tumor Sympathomimetics Infection Trauma Transformation of ischemic stroke Physical exertion, Pregnancy Post-operative
Aneurysm
Localized dilation of arterial lumen Degenerative vascular disease Bifurcations of circle of Willis
85% anterior 15% posterior
AneurysmSubarachnoid Hemorrhage
SAH Mortality 70% 97% HA Nuchal rigidity Fever Photophobia Lethargy Nausea Vomiting
Aneurysm/SAH
Complications HCP Vasospasm
Triple H Therapy HTN Hemodilution Hypervolemia
Surgical treatment Clip Coil INR
Nursing Management
Assessment Monitoring
BP TCDs CBC
Preventing complications Bowel program DVT prophylaxis Siezure prophylaxis Psychological support Discharge planning
Arteriovenous malformations AVM
Tangled mass of arteries and veins Seizure or ICH
Treatment AVM Endovascular Neurosurgery Radiosurgery
Presentation
Sudden onset Focal neurological deficit Progresses over minutes to hours HA, N/V, <<LOC, HTN Depends on location
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.
Manifestationsby Vessel
Vertebral Artery Pain in face, nose, or eye Numbness and weakness of face (involved
side) Gait disturbances Dysphagia Dysarthria (motor speech)
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 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 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 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 System Integument
Pressure ulcers Respiratory
Respiratory center damage Airway obstruction Decreased cough ability
GI Dysphagia Constipation Stool impaction
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
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.
Comic Relief
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.
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
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
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
Treatment
Ischemic Hemorrhagic
Medical management TpA Endovascular
Carotid endarectomy Merci clot removal
http://youtu.be/P2TNz-TniIA
Medical management Decompression
Craniotomy Craniectomy
PT/OT/STREHABILITATION
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)
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
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
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
Per facility policy
Nursing Concerns
Medical management!
Post-op care Mobilization Nutrition Constipation Skin
Infection Patient/family
teaching Follow-up Medications Resources available
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
http://youtu.be/-d8__FkW-nU
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
Ineffective cerebral tissue perfusion Impaired mobility Self-care deficit Impaired verbal communication Impaired swallowing
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/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/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/Interventions
Impaired Physical MobilityFlaccidity & 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/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/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/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/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
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
Increased intracranial pressure Rebleeding Vasospasm HCP Death
Outcomes
Age Size, volume Location HCP, IVH Deficit, LOC, MAP Duration Co-morbidities
44% mortality
Evaluation
Reduce mortality and morbidity Baseline neurological function Outcomes Evidenced based practice
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
Advanced directives MPOA
Category status Code status Withdrawal of care Palliative care Placement
Resourceswww.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
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
Jackson, William JJ^31725511/12/19751/12/197534 YEAR34 YEARMM
Page: 14 of 36Page: 14 of 36------Acq No: 4Acq No: 4eff. mAs: 460eff. mAs: 460mA: 460mA: 460KVp: 120KVp: 120Tilt: -10Tilt: -10RD: 250RD: 250512x512512x512
BRACKENRIDGE BRACKENRIDGECT Head w/o ContrastCT Head w/o Contrast
Head W/O ST.Head W/O ST. 12/3/2009 6:43:15 AM 12/3/2009 6:43:15 AM
37258603725860------
LOC: -111.80LOC: -111.80THK: 4.80THK: 4.80
HFSHFS
IM: 14 SE: 2IM: 14 SE: 2Compressed 11:1Compressed 11:1
W: 80W: 80C: 35C: 35
RR LL
AA
PP
------
cm cm
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).
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 includea. hyperventilation therapy.b. surgical clipping of the aneurysm.c. administration of hypersomotic agents.d. administration of thrombolytic therapy.
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.
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
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.