Cerebral Vascular Accident Flashcards
Other names for a “Stroke”
Cerebral Vascular Accident (CVA)
Brain Attack
Name the subtypes of “ischemic strokes”
& Subtypes of “hemorrhagic strokes”
Ischemic Stroke-Thrombotic and Embolic
Hemorrhagic Stroke-Aneurysm, Hypertension and Arteriovenous malformation
Most common type of stroke?
Thrombotic stroke-It’s commonly associated with atherosclerosis
Where is the usual source of the embolic stroke?
The heart
Most common cause of hemorrhagic stroke?
HTN
Explain how long before the signs and symptoms begin with Thrombotic, Embolic and Hemorrhagic strokes
Thrombotic-Usually evolve over minutes to hours
Embolic- Sudden development and rapid occurrence of neurologic deficits
Hemorrhagic-Sudden onset; progression over minutes to hours
What’s the second most common type of stroke?
Embolic stroke
True or False: A poorer prognosis is seen with hemorrhagic strokes
True
Modifiable risk factors for Stroke:
Hypertension Heart disease Diabetes Smoking Obesity Sleep apnea Metabolic syndrome Alcohol/drug abuse Poor diet Lack of physical exercise
Fill in the blank: A TIA (Transient ischemic attack) is to ______ as angina is to MI (myocardium infarction)
stroke
Define TIA:
A transient episode of neurological dysfunction caused by ischemia, w/ no acute infarction of the brain
▪ Symptoms usually last < 1 hour
Can one predict the outcome of a TIA?
There is no way to predict outcome:
▪ 1/3 = do not have another event
▪ 1/3 = have more TIAs
▪ 1/3 = progress to stroke
Motor function impairments of a Stroke: Clinical Manifestations (Cues)
-Motor function impairs: ▪ Mobility ▪ Respiratory function ▪ Swallowing/speech ▪ Gag reflex ▪ Self-care abilities -Akinesia (loss of voluntary movement) -Changes in muscle tone (initial flaccidity – followed by spasticity) -Altered reflexes (changes from hyporeflexia to hyperreflexia)
Communication impairs of a Stroke: Clinical Manifestations (Cues)
-Communication:
▪ Aphasia:
▪ Receptive (loss of comprehension)
▪ Expressive (inability to produce language)
▪ Global (total inability to communicate)
-“Dysphasia” (impaired ability to communicate; used interchangeably with aphasia)
-Dysarthria:
▪ Garbled speech
Visual, emotional and elimination impairs of a Stroke: Clinical Manifestations (Cues)
-Affect:
▪ Hard time controlling their emotions (exaggerated or unpredictable)
-Intellectual Function:
▪ Impair memory & judgment
-Spatial-Perceptual Problems:
▪ Homonymous hemianopsia (blindness occurs in same half of visual fields of eye)
▪ May not recognize their body parts
▪ Agnosia (Loss of the ability to identify objects using one or more senses)
▪ Apraxia (The inability to perform learned (familiar) movements on command, even though the command is familiar & there is willingness to perform the movement)
-Elimination:
▪ Bowel & bladder alterations are usually temporary
Define Homonymous Hemianopsia:
Blindness occurs in same half of visual fields of eye. They may not recognize all of their body parts or surroundings
Define agnosia
Loss of the ability to identify objects using one or more senses
Define apraxia
The inability to perform learned (familiar) movements on command, even though the command is familiar & there is willingness to perform the movement
Interprofessional Care for Stroke
Health Promotion:
▪ Management of modifiable risk factors ▪ Healthy diet ▪ Weight control ▪ Regular exercise ▪ No smoking ▪ Limiting alcohol consumption ▪ BP management ▪ Routine health assessments
Preventive Drug Therapy for Stroke:
▪ Measures to prevent development of a thrombus or
embolus is used in patients at risk for stroke
▪ Antiplatelet drugs are used in patients who have had a TIA
▪ Aspirin, 81 mg/day is most often used antiplatelet agent
Stroke/TIA surgical Intervention options:
Surgical interventions for patient with TIAs due to carotid
disease include:
▪ Carotid endarterectomy (remove plaque within carotid lining)
▪ Stenting
▪ Transluminal angioplasty
True or False? Most strokes are treatable
True! Stroke unit care — Evidence suggests that patients with acute stroke have better outcomes when admitted to a hospital unit that is specialized for the care of patients with all types of acute stroke
Stroke Interventions
TIME is of the essence for stroke interventions!!
▪ IV fibrinolytic therapy (“clot busters”)
▪ Endovascular interventions
What is the only drug approved at this time for treatment of acute ischemic strokes?
IV alteplase is the only drug approved at this time for tx of acute ischemic strokes
What is the administration time for IV fibrinolytic therapy for stroke treatment?
FDA approves administration of if within 3 hours of stroke onset (American Stroke
Association endorses extension to 4.5 hours, under certain criteria)
Stroke endovascular interventions for perfusion:
▪ Mechanical embolectomy w/ stent placement
▪ Carotid artery angioplasty w/ stent placement
Ischemic stroke Interprofessional Goals for care:
▪ Preserving life
▪ Preventing further brain damage
▪ Reducing disability
▪ Time of onset of symptoms is critical information
▪ Begins with managing:
▪ Circulation
▪ Airway
▪ Breathing
Acute Care: Ischemic Stroke=
▪ Baseline neurologic assessment
▪ Monitor closely for:
▪ Signs of increasing neurologic deficit
▪ Many patients worsen in the first 24 to 48 hours
▪ Elevated BP is common immediately after a stroke
(It may be a protective response to maintain cerebral perfusion)
▪ Control fluid and electrolyte balance
▪ Adequately hydrate to: ▪ Promote perfusion ▪ Decrease further brain injury ▪ Manage intracranial pressure (ICP) ▪ Use interventions that improve venous drainage
True or false? Decreased BP is common immediately following a stroke.
False. Increased BP is common immediately after a stroke. It may be a protective response to maintain cerebral perfusion.
Acute Care: Ischemic Stroke-Medications:
▪ Recombinant tissue plasminogen activator (tPA)
-Given to reestablish blood flow through a blocked artery to prevent cell
death
-Must be started within 4.5 hours of onset of clinical signs of ischemic stroke
-Patients are carefully screened
▪ After the patient has stabilized and to prevent further clot formation,
patients with strokes caused by thrombi and emboli may be treated
with anticoagulants and platelet inhibitors
-ASA, ticlopidine, clopidogrel, dipyridamole
▪ Use of statins is effective after ischemic stroke
Define Endovascular/Mechanical
Thrombectomy:
We use “Stent retrievers”…
▪ A way of managing ischemic stroke
▪ Catheter used to guide the small stent into affected artery in brain
▪ Stent expands interior walls of artery and allows blood to flow to brain
▪ Clot seeps into mesh of stent
▪ Stent and clot removed together
Acute Care: Hemorrhagic
Stroke=
▪ Interprofessional Goals for care:
▪ Preserving life
▪ Preventing further brain damage
▪ Reducing disability
▪ Goals are the same as for the patient with ischemic stroke ▪ Manage: ▪ Airway ▪ Breathing ▪ Circulation ▪ Intracranial pressure
Surgical Therapy for Hemorrhagic
Stroke:
▪ Surgical interventions used to treat hemorrhagic strokes include:
▪ Evacuation of hematomas
▪ Resection and/or radiosurgery
▪ Clipping or coiling of an aneurysm
- Procedure is chosen based on cause of stroke
What happens during Aneurysm clipping-surgical?
A surgical clip is used to clip off the berry aneurysm; cuts off the blood supply to the aneurysm and decreases the likelihood of rupture due to decreased pressure.
Stroke: Guglielmi Detachable Coil
“Coil”
A) A coil is used to occlude an aneurysm. Coils are made
of soft, springlike platinum. The softness of the platinum
allows the coil to assume the shape of irregularly shaped
aneurysms while posing little threat of rupture of the
aneurysm.
B) A catheter is inserted through an introducer (small
tube) in an artery in the leg. The catheter is threaded up
to the cerebral blood vessels.
C) Platinum coils attached to a thin wire are inserted into
the catheter and then placed in the aneurysm until the
aneurysm is filled with coils. Packing the aneurysm with
coils prevents the blood from circulating through the
aneurysm, reducing the risk of rupture.
Where does aneurysm coiling procedures take place?
Interventional radiology
STROKE - Acute Care –
Nursing Assessment:
-Primary assessment focuses on:
▪ Cardiac status
▪ Respiratory status
▪ Neurologic assessment
-If patient is stable, obtain:
▪ Description of current illness
▪ With attention to symptom onset and duration, nature, and changes
-Also, If the patient is stable, obtain:
▪ History of similar having had similar symptoms previously
▪ Current medications
▪ History of risk factors and other illnesses
▪ Family history of stroke, aneurysm or cardiovascular disease
What’s included in the secondary assessment for Strokes?
Comprehensive neurologic exam: ▪ Level of consciousness ▪ NIH Stroke Scale (NIHSS) ▪ Cognition ▪ Motor abilities
▪Also, Comprehensive neurologic exam includes:
▪ Cranial nerve function
▪ Sensation
▪ Proprioception (awareness of position/movement of body)
▪ Cerebellar function (motor control)
▪ Deep tendon reflexes
Stroke Acute Care: Related Nursing
Care (Respiratory, Neurologic and Cardiovascular systems)
Respiratory system:
▪ Risk for atelectasis – may be intubated/ICU
Neurologic system:
▪ Monitor for extension of stroke, increased intracranial pressure/ICP, vasospasm, recovery from stroke s/s
Cardiovascular system:
▪ V.S., cardiac rhythms, I&O’s, regulating IVFs
▪ Risk for VTE – monitor accordingly
Stroke Acute Care: Related Nursing
Care Musculoskeletal system:
▪ Prevent joint contractures/atrophy
▪ In acute phase, ROM & positioning are important (especially affected side)
▪ Trochanter roll at hip to prevent external rotation
▪ Hand cones to prevent hand contractures
▪ Avoid pulling patient by arm to avoid shoulder displacement
▪ Prevent footdrop w/ footboards/high-top tennis shoes
Stroke Acute Care: Related Nursing
Care Integumentary system:
▪ Measures to prevent skin breakdown
▪ Regular pressure relief by position changes:
▪ Place no longer than 30 minutes on weak side
What is the purpose of a trochanter roll?
The trochanter roll should reach from above the hip to just above the knee. Helps prevent external rotation of the hips, which in turn prevents potential contractures
Stroke Acute Care: Related Nursing
Care GI and Urinary system:
GI system:
▪ Constipation most common bowel problem
Urinary system:
▪ In acute stage, often poor bladder control
▪ Avoid use of indwelling catheters
▪ Bladder retraining program
Stroke Acute Care: Related Nursing
Care Nutrition:
▪ IVFs; keep NPO until speech therapist performs a swallowing eval
-Once approved, proceed w/ feeding:
▪ Foods should be easy to swallow, with enough texture, temp & flavor to stimulate
swallow reflex
Assistive Devices for
Eating:
1) The rounded plate helps keep food on the plate. Special grips and weighted handles are helpful for some persons. The cup shape allows drinking without having to tilt the head
2) Knives with rounded blades are
rocked back and forth to cut food. The
person does not need a fork in one hand
and a knife in the other.
3) Plate guards help keep food on the
plate.
4) Cup with special handles promotes
independence.
Stroke Acute Care: Related Nursing
Care Communication:
Communication:
▪ Nurse’s role is primarily supportive
▪ Speak slowly & calmly, using simple words or sentences
▪ Gestures may be used to support verbal cues
▪ Speech, comprehension & language deficits are most difficulty problem for patient & family
▪ Speech therapist instrumental in care
Stroke Acute Care: Related Nursing
Care-Sensory-perceptual problems:
Visual may include: ▪ Diplopia (Double vision) ▪ Loss of corneal reflex (May not close the eyes when something gets in them) ▪ Ptosis (Droopy eyelid) ▪ Homonymous hemianopsia
Stroke Patient: Ambulatory Care
Patient is usually discharged from acute care setting to:
▪ Home
▪ Intermediate or long-term care facility
▪ Rehabilitation facility
Rehabilitation (targeting physical, mental & social well-being):
▪ Include patient, family, nurse, stroke/rehab team
▪ Musculoskeletal: Focus = preventing additional loss & balance training
▪ Coping strategies – for both patient & family
▪ Stroke support groups
Describe an embolic stroke:
An embolus is a blood clot or other debris circulating in the blood. When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks the flow of blood.
Describe a hemorrhagic stroke:
A burst blood vessel may allow blood to seep into and damage brain tissues until clotting shuts off the leak.
Describe a thrombotic stroke:
The process of clot formation (thrombosis) results in a narrowing of the lumen, which blocks the passage of the blood through the artery.
Are stroke clinical manifestations based on the location of the stroke or the type of stroke?
Clinical manifestations of strokes are related to the LOCATION of the stroke, not whether it is ischemic or hemorrhagic
