Cerebrovascular Accident (CVA)

Question 1

What is a transient ischemic attack (TIA)?

Answer 1

• temporary focal loss of neurological function
• temporary loss in vision, change in speech, unilateral motor and/or sensory symptoms
• symptoms last up to 24 hours (average is 15 minutes to 3 hours)
• no lasting effects

Question 2

What is an ischemic stroke?

Answer 2

85% of all strokes

Thrombotic:

1. caused by atheromatous plaques that occlude cerebral arteries
2. narrowing of artery with fat deposits; build up enough to cause a blockage
3. TIA in 30-50% of causes; occur during of after sleep
4. develops slowly over time; symptoms get worse with progression

Embolic:

1. dislodged thrombi (emboli) that occludes cerebral arteries
2. TIA is uncommon; sudden onset, no relationship to activity
3. recurrence is common if underlying disease is untreated

Hemorrhagic:

1. cerebral arterial wall rupture; bleed in brain tissue, ventricles, or subarachnoid space
2. associated with severe headache before stroke. No TPA if hemorrhagic stroke

Question 3

What are the managment recommendations for ischemic stroke?

Answer 3

1. Treat the CVA as an emergency. Call 911, NOT MD when symptoms are first noticed.
2. Change name to BRAIN ATTACK so people will associate it with an emergency
3. Treatment with thrombolytic agent tPA, must be started within THREE HOURS of onset of symptoms (may be as long as 6 hours for ischemic CVA only). TPA leads to fewer deaths and fewer disabilities.

Question 4

What are symptoms of an ischemic stroke?

Answer 4

Symptoms include change in mental status, LOC, abnormal speech, facial droop, UE or LE weakness on same side of the body

Question 5

What do you do in the first ten minutes with a stroke patient?

Answer 5

1. Assess ABCs (airway first)
2. Maintain NPO (risk for aspiration until swallow eval
3. provide O2, insert 2 large bore IV lines, infuse at 0.9% NS
4. draw labs/BG - stroke or are they hypoglycemic?
5. 12 lead EKG, complete neuro assessment (baseline)
6. alert stroke team with time of arrival

Question 6

What do you do within the first 25 minutes with a stroke patient?

Answer 6

1. review medical/nursing history
2. establish time of stroke onset
3. GCS, NIHSS (more specific)
4. complete physical assessment
5. STAT non-contrast CT read within 45 minutes of arrival to ED

Question 7

What are the three causes of stroke?

Answer 7

thrombus

embolus

hemorrhage

Question 8

What are modifiable risk factors for stroke?

Answer 8

1. Smoking
2. Obesity
3. Inactivity
4. Poor diet
5. Hyperlipidemia
6. Elicit drug use
7. Sickle cell crisis
8. Meds (birth control, NSAIDs, anti-coagulants)
9. Alcohol intake

Question 9

What are non-modifiable risk factors for stroke?

Answer 9

1. age risk doubles each decade after age 55
2. family history
3. genders equal, but women more likely to die
4. race: africian american males, hispanic, asian/indian american

Question 10

What are the diagnostic studeis for stroke?

Answer 10

PT/INR, CBC (esp hct, hgb, platelets), BG/chem 8 to rule out hypoglycemia and electrolyte imbalances. CT non-contrast scan or cerebral angiogram.

Question 11

What does the location of stroke have to do with the effect on the body?

Answer 11

1. Symptoms above nose: same side of the brain
2. Symptoms below nose: opposite side of the brain
3. Symptoms are contra lateral to lesion in the brain

Question 12

What are the TNIs in the acute phase of stroke?

Answer 12

prevent secondary brain injury by providing general body system support and preventing complications. rehabilitation begins upon admission. first hours: assess neurological status

Question 13

Risk for altered tissue perfusion

Answer 13

maintain BP and CPP WNL without increased ICP, provide fluids, monitor I/O. Goal: BP high enough to keep CPP normal

Question 14

ROM/Ambulation

Answer 14

patient has risk of DVTs (check Homan’s sign) and PE. Prevention: SCD/TEDs, promote hydration, monitor I/O, encourage ambulation/ROM as appropriate.

Question 15

Risk for injury

Answer 15

initially, muscles on the affected side are flaccid but within a few days they become spastic (increased muscle tone). TNIs:

1. pt. positioning in bed can prevent contractures/long-term complications
2. Intermittent use of splinets may be needed
3. risk for shoulder subluxation - don’t pull pt. up by arms for position changes. In bed, support affected arm on pillow. In sitting position, firm surface to support the affected arm

Question 16

Risk for Aspiration

Answer 16

assess swallowing ability, conservation of energy, modified diet, positioning upright during and after meals. TNIs to prevent aspiration:

1. check placement and control of food in mouth
2. rest before all meals (common risk factor for aspiration is fatigue)
3. have patient concentrate on chewing and swallowing
4. HOB up 90 degrees or upright in chair, upright position for 30-45 minutes after meals
5. May need to add salt/sugar (makes food easier to swallow)
6. avoid peanut butter (sticky) and milk products (increase secretions)
7. put food on unaffected side of mouth; teach pt how to do mouth sweep
8. liquids can be dangerous (increased risk of aspiration), NO STRAWS
9. aspiration precautions sign at HOB
10. visual field deficit may become obvious during mealtime; the RN should teach the client to scan the environment

Question 17

Impaired Verbal Communication

Answer 17

1. expressive aphasia: can’t produce speech but can understand speech
2. receptive speech: can’t understand speech
3. global aphasia: can’t produce or understand speech

TNIs:

1. speak clearly in a normal tone of voice
2. consider alternate means of communication (ie hand squeezes); speech consult
3. simple communication: yes or no questions or one word answers; one thought at a time
4. decrease environmental stimulation
5. give them time to try to express themselves
6. use gestures/demonstrations
7. don’t pretend you understand if you don’t
8. make sure they’re well rested - anxiety and fatigue will worsen aphasia

Question 18

Self-care deficit

Answer 18

Focus on compensation for deficits with use of adaptive equipment; collaborate with PT and OT.

TNIs:

1. with visual field deficit: teach pt. to scan the environment
2. approach patient from the unaffected side first
3. keep room uncluttered
4. keep things where they can reach they and don’t move them
5. rehab phase: place objects for ADLs on affected side; pt will learn to scan environment

Question 19

Impaired mobility

Answer 19

deficits range from weakness to hemi- or tetraplegia. Start with sitting balance then bed to chair/commode followed by walking, first with assistance then more independently.

TNIs:

1. ROM: passive, active, and assisted
2. positioning: use lift sheet for boosts, don’t pull up underarms
3. splints to avoid contractures; boot instead of footboard to prevent footdrop
4. trocanter rolls to prevent external rotation of hips
5. before getting client OOB, assess strength, ability to follow commands, BP, and LOC; use lifts to get patient back into bed if exhausted (put sling in the chair first); position patients with pillows in chair

Question 20

Urinary incontinence

Answer 20

urge incontinence is common and so is uninhibited neurogenic bladder so that incontinence occurs as soon as urge is received by the brain (hyperactive detrusor muscle)

TNIs:

1. plan scheduled voids to empty bladder before it gets full enough to stimulate urge
2. monitor fluid intake, limit fluids at night
3. intermittent catheterization can be used for patients who can’t void or have high residuals
4. every effort should be made to avoid indwelling catheters
5. bladder scanner for post-void residual
6. urinary/bladder regimen
7. clothes that are easy to remove and pull back up

Question 21

Bowel incontinence

Answer 21

less common but constipation occurs due to a decrease in food and fluid intake as well as immobility. Use bedside commode and/or raised toilet seat

Question 22

Discharge plans

Answer 22

include a prescription for new onset a-fib to decrease risk of another stroke. patient will go to a stroke rehab facility first and then will probably be discharged to home

Question 23

What are the TNIs for intracerebral hemorrhage?

Answer 23

1. bed rest, quiet room, HOB 0-10 degrees to decrease ICP
2. limit activities that can increase ICP (ie. suction only when needed, space out activities)
3. same surgical TNIs if client had cranial surgery