Cerebrovascular Disorders

Question 1

Identify the risk factors leading to the development of stroke.

Answer 1

Nonmodifiable:
- Age > 55
- Male
- African-American

Modifiable:
- HTN
- Cardiovascular disease
- Elevated cholesterol
- Obesity
- Diabetes
- Smoking, drug, alcohol abuse
- Sleep apnea, migraines, oral contraceptive use

Question 2

Ischemic Stroke: S/Sx

Answer 2

Depends on location & size of affected area
- Numbness or weakness of face, arm, leg (one side)
- Confusion, change in mental status
- Trouble speaking or understanding speech
- Difficulty walking, dizziness, loss of balance/coordination
- Sudden, severe headache
- Perceptual disturbances

Question 3

Ischemic Stroke: Treatment (Anticoagulants)

Answer 3

• Anticoagulants
  
  • Heparin, warfarin
  • Direct thrombin inhibitors (dabigatran, argatroban, bivalirudin, desirudin)
  • Direct factor Xa inhibitors (rivaroxaban, apixaban, edoxaban)
  • Antiplatelets (clopidogrel, adenosine, aspirin)

Question 4

Ischemic Stroke: Treatment (Medications)

Answer 4

• Platelet-inhibiting (aspirin, dipyridamole)
• Thrombolytics: dissolve clot (tPA) - alteplase, tenecteplase, urokinase
• HMG-CoA reductase inhibitors: decrease cholesterol production (-statin)
• Antidotes (aminocaproic acid - tPa; TXA - fibronolytic, protamine sulfate - heparin, vitamin K - warfarin)

Question 5

Ischemic Stroke: Treatment (Antihypertensives)

Answer 5

• ACE inhibitor (-pril)
• ARBs (-sartan)
• Calcium channel blockers (amlodipine, diltiazem, verapamil, -pines)
• Beta-blockers (-lol)
• Diuretics
• Antiadrenergics (-zosin)
• Alpha-agonists (clonidine, methyldopa)
• Direct renin inhibitors (aliskiren)

Question 6

Hemorrhagic Stroke: S/Sx

Answer 6

Similar to ischemic stroke
- Severe headache
- Early & sudden changes in LOC
- Vomiting

Question 7

Hemorrhagic Stroke: Treatment

Answer 7

• Control HTN
• CT scan, cerebral angiography
• Bed rest with sedation
• Oxygen
• Treat vasospasm, increased ICP, HTN, seizures, prevent further bleeding

Question 8

Hemorrhagic Stroke: Nursing Management

Answer 8

• Frequent neuro assessments
• Monitor respiratory status & oxygenation
• Monitor ICP, potential complications
• Monitor fluid balance & labs
  All changes reported immediately

Question 9

Identify nursing management for a CVA patient including rehabilitation, emotional & nutritional support.

Answer 9

Rehab:
- Passive or active ROM
- Exercise affected side (do not neglect), establish regular exercise routine
- Help patient achieve balance, ambulation training
- Encourage personal hygiene

Emotional:
- Address them on strong side
- Socialization, support groups

Nutrition:
- Speech therapy
- Patient sit upright, preferably out of bed, to eat
- Chin tuck when swallowing
- Thickened liquids or pureed diet

Question 10

TPA (Alteplase): Eligibility Criteria

Answer 10

• Age >= 18 yrs
• Ischemic stroke diagnosis
• Systolic <= 185, diastolic <= 110
• PT <= 15 s, INR <= 1.7, Plt >= 100,000
• No previous complications of bleeding or surgeries (infective endocarditis, hemorrhage, serious head trauma, intracranial surgery, GI bleeding, LMW heparin past 24 hrs)

Question 11

TPA: Contraindications

Answer 11

• Uncontrolled, severe HTN
• Aneurysm
• Internal bleeding, surgery, trauma
• Caution in pts 65-80. Not recommended over 80

(Heparin & osmotic diuretic given if ineligible for tPa)

Question 12

Identify complications that may occur after a stroke.

Answer 12

Ischemic:
- Decreased cerebral perfusion
- Risk for aspiration
- Immobility, weakness

Hemorrhagic:
- Increased ICP
- Cerebral hypoxia
- Vasospasms
- Further bleeding, seizures

Question 13

List precautions for a patient with an aneurysm.

Answer 13

• Bed rest
• Elevate HOB to promote venous drainage to increase cerebral perfusion
• Avoid activity that may increase ICP or BP
• Valsalva maneuver
• Exhale through mouth when voiding to decrease strain, prevent constipation
• Nurse provides all personal care & hygiene
• Non-stimulating, non-stressful environment