CV Disorders Flashcards
Cerebrovascular disorders =
umbrella term that refers to functional abnormality of the CNS that occurs when the usual blood supply to the brain is disrupted
Stroke/brain attack causes?
caused by blockage or rupture and bleeding into brain tissue
How common is stroke as a cause of death in Canada?
What % made up by each of two kinds of stroke?
•Stroke is 3rd leading cause of death in Canada
o 80% ischemic
o 20% hemorrhagic
What is stenosis?
abnormal narrowing of passage in body
______ is single most importance modifiable risk factor for stroke
HTN
Non-modifiable risk factors for CVA?
Aging: risk doubles each decade after 55
Gender: male
Race: non-caucasian
Modifiable risk factors for CVA?
HTN AFib hyperlipidemia obesity smoking DM carotid stenosis valvular disease periodontal disease excessive alcohol consumption
Signs and symptoms of CVA?
• numbness or weakness (especially on one side of body)
• Confusion or change in mental status
• Trouble speaking or understanding speech
• Visual disturbances
• Difficulty walking, dizziness, or loss of balance and coordination
• Sudden severe headache
- Hemiplegia
- Loss of voluntary control
- Dysarthria
- Aphasia/dysphasia
- Apraxia
- Loss of half of visual field, peripheral vision, diplopia
- paresthesia
- Sensory loss
Etc…
hemiparesis
weakness on one side
Hemiplegia
Paralysis on one side
Ataxia =
unsteady gait
Initial signs of motor loss typically can be:
flaccid paralysis + loss of deep tendon reflexes
Dysarthria =
difficulty forming words, due to paralysis of muscles
3 kinds of aphasia/dysphasia
receptive, expressive, and global [mixed]
Apraxia =
difficulty completing previously learned action
homonymous hemianopsia
loss of half of visual field
paresthesia =
numbness and tingling of extremity
Describe sensory loss in CVA?
may be slight impairment of touch or total loss of proprioception (ability to perceieve position and motion of body parts), diffculty interpreting stimuli; agnosias
agnosias =
= deficits in ability to recognize previously familiar objects
Damage to frontal lobe leads to?
Other possible cognitive impairment and psychological effects of a stroke?
deficits in learning, memory, or other higher intellectual functions
limited attn span, forgetfulness, etc; emotional labiality, frustration + depression
If conscious most hemorrhagic stroke patients report what symptom?
What other symptoms common to some types of hemorrhagic stroke?
severe headache
Loss of consciousness of period of time; pain and rigidity in back of neck (nuchal rigidity) and spine; possible visual distubances, tinnitus, dizziness, and hemiparesis
Symptoms associated with subarachnoid hemorrhage
atypical headache with rapid onset, vomiting, neck stiffness, photophobia, hypertension, and cardiac arrhythmias
In what situation of hemorrhage from a brain vessel might few neurological signs be seen?
Slow bleed…may be stopped by clot
Right sided stroke effects?
Paralysis/weakness of left side Left visual field deficit Spatial-perceptual deficits Increased distractibility Impulsive behavior and poor judgement Lack of awareness of deficits
Left sided stroke effects?
Paralysis/weakness of right side Right visual field deficit Aphasia (expressive, receptive, or global) Altered intellectual ability Slow, cautious behavior
What is the best approach to preventing a TIA?
Primary prevention!
* Healthy lifestyle prevention of occurrence and reoccurrence → reduces risk by ½
• Diet, nutrition, fitness, monitoring BP, adherence to med regimens, smoking cessation, health sleep hygiene practices, access to medical diagnostics, interventions and education
single most important risk factor for TIA?
HTN
Causes of TIA?
HTN is #1 cause, Afib, Diabetes, Family hx, cholesterol, Race (African Americans higher incidence)
What is a TIA?
Does it cause tissue damage?
A transient ischemic attack (TIA) is when blood flow to a part of the brain stops for a brief period of time.
- Manifests as sudden loss of motor, sensory, or visual function
A person will have stroke like symptoms from minutes to a few hours
TIA is like a warning sign to a stroke
TIA – does not cause brain tissue to die.
Measures for TIA prevention other than the usual lifestyle factors?
- 100mg Aspirin every other day shown to be effective
- Treat HTN and manage DM
- Those with AFib: use anticoagulants
Compare main presenting symptoms for ischemia and hemorrhagic stroke?
Ischemic = numbness or weakness of face, arm, or leg, especially on one side of body
Hem: exploding headache, decreased LOC
Ischemic vs hem in terms of recovery?
Ischemic: usually plateaus at 6 months
Hem: slower, usually plateaus at ~18months
Why is early thrombolytic tx important for ischemic strokes?
What is the key timelines for intervention?
Early thrombolytic tx results in fewer symptoms + less LOF
• Rapid response
5 kinds of ischemic strokes based on cause?
1) Large artery thrombotic strokes (plaque and occlusion),
2) small penetrating artery thrombotic strokes (affect more than one vessel, most common type)
3) Cardiogenic embolic strokes: associated with dysrhythmias (usually Afib), valvular heart disease or, or thrombi in left ventricle…start in heart, end up in brain; prevented with use of anticoag tx
4) Cryptogenic strokes – no known cause
5) “other”: illicit drug use, coagulopathies, migraine, etc.
Patho of brain ischemia as result of stroke?
obstruction of blood vessel + consequent initiation of “ischemic cascade”- series of cellular metabolic events; brain cells revert to anaerobic resp; acid build up + lack of ATP production; large calcium influx; cell membrane destruction, free radical production
Penumbra region:
area of low cerebral blow flow around infracted area → infarction spreads to this region as infarction advances
How quickly does damage to the brain occur?
1.9 million neurons lost/minute untreated; brain ages 3.9 years/hour without tx
How does hem stroke differ from ischemic in terms of long term deficits and recovery?
Those who survive acute phase of case usually have more severe deficits and longer recover phase than those with ischemic stroke
What are hem strokes due primarily due to?
Where does bleeding occur into?
Primarily d/t intracranial or subarachnoid hemorrage
bleeding into brain tissue, ventricles, or subarachnoid space
What is a intracerebral hemmorhage?
rupture of small vessels
makes up 80% of hem stroke cases
Subarachnoid hem d/t?
caused by tear in cerebral artery
What % of hem cases are d/t burst aneurysm?
bleeding is result of burst aneurysm
Common cause of hem stroke in elderly?
intracerebal hemorrhage d/t cerebral amyloid angiopathy – protein deposit in small and medium blood vessels
Patho of hem stroke?
Symptoms a result of what here?
symptoms produced when hemorrhage, anerysm, or AVM presses on nearby cranial nerves or brain tissue OR when aneurysm or VM ruptures causing subrarachnoid hemorrhage
Secondary ischemia d/t reduced perfusion pressure and vasospasm that accompany subarachnoid hemorrhage
Intracerebral hemorrhage
What is it?
Most common with what conditions?
(bleeding into brain tissue) most common with HTN and cerebral atherosclerosis – causing rupture
What is a Intracranial (cerebral) aneurysm?
Common location?
dilation of the walls of a cerebral artery that develops as result of weakening of artery walls;
usually occurs at birfucation of larger arteries in circle of Willis
What is the most common cause of stroke in young people?
AVM
Arteriovenous Malformations
AVM = ?
Arteriovenous Malformations = caused by abnormal embryonal development that leads to tangle in arteries and veins in brain that lacks cap bed
Focal neurologic signs and symptoms of stroke (according to pp picture)
- Paralysis
- Sensory Loss
- Language disorder
- Reflex changes
S&S of TIA
according to pp picture
- Confusion
- Vertigo
- Dysarthria
- Transient hemiparesis
- Temporary vision changes
- Syncope
Acute phase of ischemic stroke may last how long?
1 to 3 days
Medical imaging Interventions with ischemic stroke pt?
- CT scan of head
- CT angiography of Cerebral and neck vessels
- ECG & carotid ultrasound standard tests
- MRI?
- Transcranial ultrasound?
What should the initial focus of assessments be for a patient post stroke?
focus on airway patency (may be compromised by loss of gag and cough reflex), cardio status, and gross neurological deficits
will a TIA be seen on medical imaging?
Won’t see any evidence of ischemia
What imaging is typically done first with stroke? Why?
CT scan (of head) usually done first – shows if stroke is I or H
What does a cerebral angiography show?
blood flow through vessels in brain
Nursing interventions for ischemic stroke pt?
- careful hx and complete phyical and neurological exam
• Inc HOB - Very regular monitoring of Vitals and neuro vitals
- Continuous hemodynamic monitoring (BP very important)
• Continued assessment to determine if stroke evolving or other acute complications: bleeding (dec BP), medication-induced bradycardia, etc
Managing complications
o Maintaining airway patency
o O2 admin to minimize ischemia
Pharmacological interventions for ischemic stroke pt?
- Needed for secondary prevention in TIA or stroke
- Afib treated with Warfarin
- Aspirin, plavix, etc. depending on patient
- Statins widely used for prevention
- tPA if person qualifies
- After acute phase, antihypertensives used for secondary prevention (aggressive control of HTN important)
- Thrombolitics if within 3-4.5hrs
When is an interdisciplinary approach initiated for stroke patients
- Multidisciplinary approach initiated immediately
* Nurses, OT, PT, and SLP key to keeping independence in survivors
How are efforts to reduce ICP made pharmacologically in care of stroke patients?
osmotic diuretics
Surgical interventions in carotid for stroke patient?
carotid endarterectomy = removal of atherosclerotic plaque or thrombi’s from carotid artery to prevent stroke
or carotid stent
Important complications to manage in stroke patient?
o Risk for aspiration pneumonia → maintaining adequate gas exchange key!
o Maintaining airway patency
o O2 admin to minimize ischemia
o Other complications = UTI’s, dysrhythmias, and complications of immobility
Why is important to inc HOB with stroke patients?
promote venous drainage (swelling, ICP)
When diagnosing stroke in individual under 40, may do what?
may take toxicology report to look for illicit drug use
Which medical imaging tool is used to confirm diagnosis of intracranial aneurysm or AVM
Cerebral angiography – show location and size of lesion, and provide info about adjoining arteries, veins, adjoining vessels
Possible complications of hem stroke?
rebleeding or hematoma expansion, cerebral vasospasm resulting in ischemia, acute hydrocephalus, and seizures
Medical management of hem stroke?
Goal: to allow brain to recover from initial insult (bleeding), prevent or minimize risk of rebleeding, and to prevent and treat complications
o O2 + ensuring HCt and Hb are at good levels
o IV fluids for adequate hydration to ensure BP remains high enough to keep cerebral blood flow + keep blood viscous
o CSF drainage might be necessary with ICP (disturbed CSF flow possible)
oMay consist of bed rest with sedation to prevent agitations and stress, management of vasospasm, and surgical + medical intervention to prevent rebleeding
o Antiseizure agents often used prophylactically
o manage hyperglycemia
o Surgery
o Stool softeners used to prevent straining
What condition often occurs in early stages of hem stroke?
Hyperglycemia in early stage often occurs – should be managed
Why might a o Hypertonic saline infusion be used with hem stroke patients?
can draw fluids from cerebral tissue by inducing hypernatremic state
→ book seems ambivalent about whether this is effective measure of tx
WHy is mannitol used?
What is it?
may be administered to reduce ICP – draws water from brain tissue by osmosis and reduces total body water by diuresis → important to assess for dehydration and electrolyte imbalances
What sort of neuro assessment abnormalities might you see in a hem stroke patient?
may see altered LOC, sluggish PERLA, headache and nuchal rigidity, motor and sensory dysfx, cranial nerve deficits, speech difficulties, etc
Nursing interventions for hem stroke pt?
- Neuro assessment
- Watch for complications (seizure, vasospasm, hydrocephalis, rebleeding)
- BP, pulse, pupillary response, motor fx checked hourly
- Regulate aneurysm precautions
- Inc HOB
- Low lighting (photophobia common)
- Nurse feeds and baths to prevent all exertion
- Seizure precautions
From an observer, what are common first signs of a hem stroke?
Altered LOC (drowsiness, slurring of speech)
What are aneurysm precautions?
strict bed rest, nonstimulating environment, limited visitors, no straining, acute flexion or rotation of head (restricts bloodflow), smoking
Instruct pt to do what to prevent straining with voiding/defecation?
What other measure might be taken for this?
breath out mouth during voiding and defecation
Stool softeners and mild laxatives – no enemas!
How much should HOB be elevated for stroke patients? Why? WHen might a patient be instructed to lie flat?
HOB elevated 15-30 degrees to promote venous drainage and decrease ICP (or may be told to lie flat to inc cerebral perfusion)
If a seizure occurs, what are the nurses primary goals?
maintain airway + prevent injury
Nursing assessments during the acute phase of a stroke?
- Neurological flow sheet maintained
- Looking for reduced LOC, loss of orientation, dec response to stimulation
- Presence or absence of voluntary and involuntary movements
- Stiffness and flaccidity of neck
- Eye opening, PERLA, dry eyes (d/t loss of blink reflex)
- CWMS
- Quality and rates of resps and pulse, ABG’s, temp
- Ability to speak
- I/O
- Bleeding
- Maintenance of BP
What is recombinant tPA?
When should it be used?
genetically engineer from from t-PA (thrombolytic substance in body) – binds fibrin, converts plasminogen to plasmin, which stimulates fibrinolysis of atherosclerotic lesion
•Intervene with these within 3-4.5hrs to significantly reduce long-term recovery
Why is there a time limit on the use of thrombolytics in stroke?
• Delay in tx means pt no longer elibible for thrombolytic tx b/c revascularization of necrotic tissue (develops at 3-4.5hrs) increase risk of cerebral edema and hemorrhage
How is tPA dose determined? Is everyone eligible? What happens if you are?
- T-PA dose determined based on weight
* Must determine if pt is candidate for tPA tx; once this is intiated, no other anticoag given for 24hrs
Important considerations for giving tPA?
Greatest risk of t-PA is bleeding → delay insertion of nasogastric tubes, urinary catheters, etc
What is given to those who are not qualified for tPA?
anticoag (heparin and LMWH) used; efforts to reduce increased intracranial pressure (ICP) from brain edema incl osmotic diuretics,
What is TPA in body (not recombinant)?
Tissue plasminogen activator (TPA) = natural substance that dissolves already formed clots
How does warfarin work?
works by inhibiting vitamin K syn by bacteria in GI, thus inhibiting production of vitamin-K dependent clottin factors
What condition might you confuse a TIA with?
you might think its Diabetes as it has similar symptoms
What would nursing assessments in recovery of stroke focus on?
Important to know what about pre stroke patient?
Assessments focused on decreased fx in daily activities – closely tied to quality of life
•Important to know how patient was before stroke
When does rehab of stroke begin?
Goals?
- Rehab begins moment of stroke but intensifies during convalescence period
- Most important goals around improving quality of life and minimizing dependence
Main areas of focus for nurses in rehab of stroke patients?
- Improving mobility and preventing joint deformities
- Preparing for ambulation
- Preventing shoulder pain
- Enhancing self-care
- Managing sensory-perceptual Difficulties
- Assisting with nutrition
- Attaining Bowel and Bladder control
- Improving Thought Processes and communication
- Maintaining skin integrity
- Improving family coping
- Helping pt cope with sexual dysfunction
Important considerations for prevention of joint deformities?
- correct positions important for prevention of contractures, prevent compression neuropathies
o May use splint at night to keep extension
o Preventing should adduction: while in bed, place pillow in axilla, arm placed in slightly flexed position with distal joints higher than proximal – helps to prevent edema and joint fibrosis
o Fingers slightly flexed, hand slightly supinated; botox injections possibility
o Change position q2h
o Put pillow between legs when turning to lateral lying
o Time spend on affected side should be minimized if loss of sensation
o Upper thigh should not be acutely flexed when lateral lying to prevent edema and promote venous return
o If possible, place in prone position 15-30mins several times/day; pillow under pelvis to promote hyperextension of hips → this position helps gait, drains bronchial secretions and prevents contractural deformities in shoulders and knees
How do joints tend to contract after stroke?
o When control of voluntary muscles lost, flexor muscles exert control over extensors
o Arms tends to adduct and rotate internally, legs rotate internally, flex at knee
ROM activities how many times per day for rehab?
Long or short sessions better?
o Affected extremities exercised passively through full ROM 4-5 times/day
o Frequent short periods better than prolonged at infrequent intervals
Why is repetition important in rehab?
forms new CNS pathways, encourages new patterns of movement
Why do rehab pt’s need exercise programs?
Enhances circ to prevent venous stasis + thrombi, maintain mobility, etc
o Need daily exercise to improve muscle strength + maintain ROM
What muscles are some of the most important to mobilize first?
Quad + gluteal started first to promote walking – done at least 5 times/day for 10mins
What can be a helpful tool for exercise schedule in rehab patients?
Written schedule can remind pt
General guidelines in helping pt preparing for ambulation
o First will work to balance when sitting, then standing
o Can use tilt table if pt has difficulty balancing when standing (esp good for those with orthostatic htn after prolonged bed rest)
o If needs wheelchair, folding type with hand breaks best because pt involved in manipulating
o Training periods short and frequent
o Parallel bars may be helpful, pronged cane as gains confidence
What kind of pain is especially prevalent in stroke rehab patients?
Shoulder
Why does shoulder pain result in rehab patients?
o 3 situations possible: painful shoulder, subluxation of the shoulder and should-hand syndrome
o If has flaccid shoulder, can easily be overstretching during positioning – ensure never to lift pt by flaccid shoulder
o Subluxation (dislocation) can occur from overstretching and gravity if arm is paralyzed
What is shoulder-hand syndrome?
pain in shoulder with swelling in hand; can cause frozen shoulder and atrophy of subcut tissues – when shoulder becomes stiff, is usually painful
Measures for should pain prevention/treatment?
o Much pain can be prevented with proper positioning and mobility
o When seated, position flaccid arm on table or with pillow
o ROM exercises very important
o May use sling when first mobilizing to prevent dangling of arm
o Avoid overhead pulleys
o Other treatments: analgesia, massage, acupuncture, TENS, should strapping
What can nurse do to enhance self care of pt?
o Set realistic goals, possible add 1 activity each day
o First step: carry out self-care activities on unaffected side
o Use small towel, boxed toilet paper rather than roll
o Get baseline functional abiltity – FIM = Functional Independence Measure
o Keep space uncluttered and organized
o Place clothes on affected side in order need to be put on
o Be present to help with fatigue and encouragement
Nursing considerations for managing sensory-perceptual difficulties (those r/t vision)
o Approach on side where visual perception is intact
o Place all visual stimuli on unaffected side (clock, calendar, etc)
o Have turn head toward affected side to compensate
o Inc lighting, possible glasses
o With homonymous hemianopsia tend to move away from and avoid affected half = amorphosynthesis → imp for nurse to remind of other side of body, position limbs correctly and so within visual field
How to aid with nutrition after stroke?
o Dysphasia possible – risk for pneumonia, dehydration, aspiration, malnutrition
o SLP will evaluate
o Increase HOB, encourage chin tuck to prevent aspiration
o May have feeding tube
Why do post stroke patients experience intermittent incontinence?
d/t confusion, inability to voice needs, impaired motor and postural control
o Bladder may become spastic as deep tendon reflexes and muscle tone inc
What might be used at first after stroke for voiding and why?
Other aids?
Response to bladder filling may be diminished at first – intermittent catheterization used
o Voiding pattern analyzed and bed pan offered at this schedule
o Males aided by upright or standing position
o High fibre, adequate fluids encouraged to prevent constipation
When working to improve thought processes, what should the approach or attitude of the nurse be?
How should exercises be designed?
o Role of nurse = supportive; reviews results of neuropsychological testing, observes performance and progress, gives positive feedback and conveys attitude of confidence and hope
o Exercises designed to capitalize on strengths while improving performance of affected fxs
What part of the brain is the cortical area responsible for integrating the pathways required for comprehension and formulation of language
Broca’s area
Why are speech deficits more likely seen if left hemispheric damage?
Broca’s area very close to left motor area – often affected if also see motor deficits → why foten those paralyzed on right side (damage left side) can’t speak, damage to right less likely to affect speech
What can aphasia result in (regarding mental health). Role of nurse here?
depression → nurse to be supportive of anxiety and frustration
What is a common pitfall of nurses in the care of patients with aphasia?
completing thoughts or sentences of patient → don’t do this!
What simple measure can be helpful for functioning despite deficits?’
Other considerations for those with reduced communication abilities?
Consistent schedule, routines, and repetition
o May be aided by copy of daily schedule, audiotaped list, folder of personal info, checklists, communication board with common needs and phrases
o Give one instruction at a time, speak slowly and clearly, keep language consistent
o Communicating with pt with aphasia – see box on pg. 2059
o Remember to speak with pt during care → important to have this social contact
Tips for improving family coping with stroke pt.
o Encourage to access emotional supports
o Give info about expected outomces
o Teach to not do what pt can do for themself
o Ensure knows recovery from hemiplegia is many months and progress is slow
o Teach to keep interactions positive, focus on remaining abilities
o Prepare family to expect some emotional lability – instruct that crying or laughing may not indicate happiness of sadness, and that lability will improve with time
Possible barriers in post-stroke patients regarding sexual functioning?
Nurse to do what?
physical limitations, discomfort and/or pain which may limit sexual positions, decreased libido/arousal
o Nurse plays key role in speaking with pt about this- should do in-depth assessments of sexual hx and follow with appropriate interventions r/t physical barriers, promotion of intimacy, pleasure, and self-confidence
• Constraint-induced movement therapy =
intensive exercises given to affected limb while unaffected limb is restrained
What to encourage to prevent depression in stroke survivors?
• Encourage to continue hobbies, keep social contact
Considerations for care-givers of stroke patients?
- Caregiver burden associated with inc anxiety, depression – assess for signs of this in caregiver
- Remind caregivers to attend their own needs too – respite care services encouraged
Glasgow Coma Scale
The Glasgow coma scale (GCS) is a reliable and universally comparable way of recording the conscious state of a person. Three types of response are measured, and added together to give an overall score. The lower the score the lower the patient’s conscious state. The GCS is used to help predict the progression of a person’s condition.
13- 15 Mild TBI (traumatic brain injury) symptoms. Concussion?
9 – 12 Moderate disability – LOC?, physical or cognitive impairments
3 – 8 Coma – unconscious state – no meaningful response, no voluntary response
3 categories in GCS?
Eye opening
Verbal
Motor
