2.9 Neurological and Sensory Motor STROKE Flashcards
Stroke What it is
Emergency! “time is brain”
Sudden decrease of blood flow (oxygen & nutrients) to an area of the brain.
The symptoms experienced depend on the area of the brain impacted
Can result in severe disability or death
Process evolves over hrs: primary cell death, secondary cell death, inflammation/immune response
Stroke
Causes:
A leak
Causes:
A leak – hemorrhagic stroke
-Most fatal
-Blood vessel ruptures and leaks into brain tissues surrounding the vessel –compression injury to tissue + anoxia etc
-2 types:
1. Intracerebral hemorrhage and subarachnoid hemorrhage aneurysm
2. arteriovenous malformation (AVM)
-Congenital vessel problems: aneurysm, AVM
Stroke
Causes: A plug
A plug – ischemic stroke
- Most common
- Blood supply to an area of the brain is interrupted = ischemia & death of tissue
- Thrombotic: “grows there” stenosis, plaque rupture & clot formation
- Embolic: “flows there” (often cardiogenic due to afib) lodges in a vessel too small to pass thru, bifurcations
Stroke Primary cell death
Primary cell death – anoxia & Lack of nutrients, free radical release, edema = burst, infarction & necrosis 4-5 min thru a few hours
Stroke Secondary cell death
Secondary cell death- exposure to products of cell death & inflammation, surrounding cells have enough blood supply to remain open a few hours PENUMBRA
As secondary cell death occurs the inflammatory/immune reaction causes further damage
Stroke Aneurysm
Aneurysm; congenital weakness, outpouching of the vessel wall, most common cause of hemorrhagic stroke
AVM (arteriovenous malformation): tangled collection of arteries and veins that bypass normal circulation, shunting increases pressure in venous system leads to bleeding
Stroke
Intracerebral hemorrhage
Subarachnoid hemorrhage
Intracerebral hemorrhage: The bleeding occurs inside of the brain. This is the most common type of hemorrhagic stroke.
Subarachnoid hemorrhage: The bleeding occurs between the brain and the membranes that cover it.
Transient Ischemic attack (TIA) what is it
“mini stroke”
Brief period of localized cerebral ischemia that causes neurologic deficits lasting for less than 24 hours.
warning sign for ischemic stroke
effects vary according to location and size of the vessel involved
Transient Ischemic attack (TIA)
Deficits include
Deficits include: contralateral numbness or weakness of the leg, hand, forearm, and corner of the mouth; aphasia; and visual disturbances such as blurring or amaurosis fugax(a fleeting blindness of one eye)
Transient Ischemic attack (TIA) Risk factors
Previous TIA or stroke
Hypertension = overdistention of cerebral vessels, ↥ plaque development
Atherosclerosis/hyperlipidemia = plaque accumulation, rupture, brittle vessel walls
Smoking, substance use, ETOH abuse
Low physical activity
Transient Ischemic attack (TIA)
Other disease processes
Other disease processes:
DM, sickle cell, sleep apnea, obesity, afib, autoimmune diseases, clotting disorders
Stress
Women: oral contraceptives, pregnancy, childbirth, menopause, migraines, long term hormone replacement therapy.
Unmodifiable: age, gender, race, heredity
Transient Ischemic attack (TIA)
Clinical manifestations
Depend on the area of the brain area involved Sudden onset Transient or permanent Can impact any brain function Usually one-sided; focal
Transient Ischemic attack (TIA)
Contralateral deficits
Contralateral deficits: motor pathways cross at the junction of the medulla & spinal cord so the loss/impaired sensorimotor function appears on the side opposite the injury (example: a CVA in the right side of the brain will result in paralysis on the left side of the body)
ACT F.A.S.T.
ACT F.A.S.T.
F – face ask the person to smile; look for drooping
A – ask the person to lift both arms; look for unilateral drift down
S – ask the person to repeat a simple sentence; listen for slurred or strange speech
T- time; get the patient to the hospital ASAP
Transient Ischemic attack (TIA) Possible effects/complications:
Sensory-perceptual deficits
Possible effects/complications:
Sensory-perceptual deficits
-impaired ability to integrate, interpret, attend to sensory data
-can impact any sense & increase risk of injury significantly
-pain, numbness, strange sensations
Examples:
hemianopia– loss of half the visual field
agnosia- loss of recognition (can be visual, tactile (touching), or auditory)
apraxia- loss of ability to carry out motor pattern = impact on ADLs
hemineglect syndrome- ignores input from the affected side
Transient Ischemic attack (TIA) Possible effects/complications
Cognitive and behavior changes
Cognitive and behavior changes
Altered LOC
Behavior: emotional lability, loss of self-control, ↧ stress tolerance
Intellectual changes: memory, judgment, attention, & reasoning problems
Transient Ischemic attack (TIA) Possible effects/complications
Communication disorders
Communication disorders
Result from damage to dominant hemisphere (usually left side)
Impact speech (mechanical, motor process of forming words) -Dysarthria
Impact language (formation of ideas to communicate meaning & thoughts)
Complex process: oral, written, auditory, and reading elements
- Aphasia: inability to use or understand language
- Expressive: can not find the words to communication what needs to be said but can understand the language, can not associate words and meaning
- Receptive: can’t understand the language.
- Mixed (global): combination of both receiving and expression
Transient Ischemic attack (TIA) Possible effects/complications
Motor deficits
Motor deficits (body movement is complex function)
- Weakness, paralysis, spasticity with damage in some areas of the brain
- Hemiplegia – paralysis on one half of the body
- Hemiparesis – weakness on one half of the body
- Flaccidity- loss of muscle tone
- Spasticity – excessive muscle tone = weakness, rotation, contractures
- Dysphagia- can’t swallow
- Secondary complications of immobility
Transient Ischemic attack (TIA) Possible effects/complications
Elimination problems
Elimination problems
Sensory loss: frequency, urgency, incontinence
Secondary problems: due to cognitive dysfunction, altered intake or immobility
Comparison of right vs left CVA:
RIGHT
RIGHT
Affects left side of the body
Difficulty with perception
Vision loss
Impulsiveness & ↓ attention span
Problems with decision making
Difficulty with time concepts
Neglect syndrome more common
Short term memory problems
Comparison of right vs left CVA: LEFT
LEFT
Affects right side of the body
Difficulty with speech/language
Slow careful movement
Depression
Math ability impaired
Dysphagia
Stroke Nursing interventions (acute phase):
Focus of care is to maintain cerebral perfusion to minimize brain injury
Certified stroke centers
Nursing interventions (acute phase): Assessment:
Assessment:
- History : time of onset of symptoms is CRITICAL
- Physical exam: airway, VS, cardiac rhythms, temperature regulation, seizures, risk of IICP (increased intercranial pressure)
-NIH Stroke scale:
standardized systematic stroke assessment tool that quantifies stroke-related deficits scoring is key to determining eligibility for lytic therapy and evaluating effectiveness of therapy
Imaging tests: CT, arteriogram, MRI/MRA, PET, and SPECT
Interprofessional Treatment
Interprofessional Treatment: Surgery: Prevention: carotid endarterectomy Repair & revascularization Clot evacuation Hemorrhagic stroke: repair of aneurysm or AVM to prevent/treat bleeding
NIH: standardized stroke assessment
NIH: standardized stroke assessment (LOC, vision, facial paralysis, motor ability, ataxia, sensation, language, and attention)
Medications for CVA Prevention
Prevention:
antiplatelet agents
Control HTN, DM, lipids
Medications for CVA Acute ischemic stroke
Acute ischemic stroke:
- Fibrinolytics (tPA) to lyse the clot – must be given within a few hours of onset of manifestations, protocols animation:
https: //www.youtube.com/watch?v=dClu6nC2qNs
strict criteria due to bleeding risk: R/O correct BS, BP, lytes prevent bleeding & other injuries like falls
Anticoagulants to prevent extension of the clot
Blood pressure management
Nursing care:
Airway/breathing: Sats, lung sounds, suction prn, oxygen therapy, manage aspiration risk
Circulation: vitals, cardiac rhythm monitoring
Neuros: mental status, LOC, pain, change in motor or sensory functions, reflexes, S/S IICP
Maintain body temp
Accurate I & O’s (diabetes insipidus = excessive urination = dehydration)
Seizure precautions
Promote Mobility: ROM, turning, DVT risk
Promote self-care: appropriate to cognitive function, encourage independent ADLs
Communication: treat like an adult, allow time, face pt/speak slowly, honest, use short simple sentences, yes/no if needed, accept frustration, alternate methods
Elimination: bladder training, constipation management, bowel training
Nutrition & aspiration risk: dysphagia, swallow studies, lung sounds
Emotional support, coping, grieving & anxiety in acute phase
SAFETY CONCERNS: aspiration, falls, pressure ulcer prevention
Interdisciplinary collaboration: PT, OT, ST
Rehab stage of stroke patient
Physical therapy
Physical therapy may help prevent contractures and improve muscle strength and coordination.
Physical therapists teach exercises to enable the patient to relearn how to walk, sit, lie down, and change from one type of movement to another.
**Rehab can be a prolonged process!
Rehab stage of stroke patient
Occupational therapy
Occupational therapy provides assistive devices and a plan for regaining lost motor skills that greatly improve quality of life after a stroke. These skills include eating, drinking, bathing, cooking, reading, writing, and toileting.
**Rehab can be a prolonged process!
Rehab stage of stroke patient
Speech therapy
Speech therapy is provided to help the patient improve swallowing as well as how to relearn language and communication skills.
**Rehab can be a prolonged process!
