CVA

Question 1

CVA

Answer 1

Also known as a “stroke” or “brain attack”
Results from inadequate blood flow to the brain
4th leading cause of death in the U.S.

Question 2

CVA patho

Answer 2

• Permanent Brain Damage occurs within 3 to 10 minutes when deprived of oxygen
• Type of deficit that results depends on the location and size of the brain area most affected

Question 3

causes of CVA

Answer 3

thrombosis

cerebral embolism

Question 4

CVA- thrombosis

Answer 4

Associated with atherosclerosis and HTN
Occurs most often at bifurcations; branch of vessel
Most common cause (over half of all strokes)
Onset: gradual
May be preceded by TIA (transient ischemic attack)
plaque buildup

Question 5

cerebral embolism

Answer 5

Emboli often arise from the heart (rheumatic heart disease with mitral stenosis; atrial fibrillation)
2nd most common cause of CVA
Middle cerebral artery most commonly involved (MCA)
traveling clot

Question 6

(Ischemic strokes) both thrombotic and embolic strokes may be preceded by warning signs

Answer 6

majority of emboli originate in the heart due to ineffective pumping or dysrhythmias
TIA (Transient Ischemic Attack): transient neurologic dysfunction caused by temporary ischemia
Warning sign of an impending stroke
Lasts

Question 7

hemorrhagic strokes

Answer 7

caused by rupture of blood vessel due to:
Poorly controlled HTN**, trauma, bleeding disorders
Rupture of intracranial aneurysms (abnormal dilation in a cerebral vessel); aneurysm can be congenital, traumatic, arteriosclerotic in origin and usually rupture during activity

Question 8

CVA cerebral vessels most affected

Answer 8

Middle Cerebral Artery (most common)

Internal Carotid Artery (2nd most common)

Question 9

risk factors for CVA

Answer 9

1. African American
2. Increase blood viscosity or clotting
3. Certain meds/drugs
4. Smoking History/Heavy ETOH Use
5. Obesity
6. Sedentary Lifestyle
7. Sickle Cell Anemia
8. Hypertension
9. Hyperlipidemia
10. Diabetes Mellitus
11. Heart Disease
12. Cardiac Disorders (Dysrhythmias, CHF, A-fib)
13. Age
14. Family History
15. Male
16. Periodontal Disease

Question 10

stroke prevention

Answer 10

1. Decrease Risk Factors
2. Control blood pressure (Can reduce risk of stroke up to 30%)
3. Use of blood thinners (inhibit platelet aggregation)
   – ASA (aspirin)
   – Persantine (Dipyridamole)
   – Plavix (Clopidogrel)
   – A-fib (blood thinners): Pradaxa, Xarelto, Coumadin
   – Lipid Lowering Agents: Statins

Question 11

CVA if there are symptoms of a TIA

Answer 11

Suggestive of possible impending ischemic stroke
Assess for significant occlusion of carotids
Ultrasound or Arteriogram of the carotids is done

Question 12

CVA diagnostics

Answer 12

Carotid or Cerebral Arteriogram:
Purpose: used to identify aneurysms. Stenosis, AVMs (arteriovenous malformation)
CT: Differentiates hemorrhagic vs. non-hemorrhagic stroke; can visualize infarcted areas
MRI
ECG: determine dysrhythmias
Lumbar Puncture:

Question 13

carotid endarterectomy (CEA)

Answer 13

Purpose: remove atherosclerotic plaque from the inner lining of artery to restore blood flow
Carries a risk of death or stroke (1-9%)

Question 14

Post-op care for carotid endarterectomy (CEA)

Answer 14

Monitor: for hemorrhage
Monitor: for swelling (which could compromise airway)
Closely monitor neurological status:
1. LOC (level of consciousness), Mental Status
2. Pupil Checks
3. Hand Grips (muscle strength, symmetry)
4. Speech
Frequent vital sign assessment (BP management)

Question 15

assessment findings of thrombotic stroke

Answer 15

Sx may appear over minutes to hours to days

Question 16

assessment findings of hemorrhagic stroke

Answer 16

SX occur suddenly without warning

Question 17

right side brain function

Answer 17

specialized in sensory-perceptual functions, awareness of body space, visual-spatial processing

Question 18

left sided brain function

Answer 18

dominant for language in most persons

Question 19

characteristics of a left CVA

Answer 19

Right sided hemiparesis (weakness)
Right sided hemiplegia (paralysis)
Behavior is cautious, plodding, careful
Increased language problems

Question 20

characteristics of a right CVA

Answer 20

Left sided Hemiparesis (weakness)
Left sided Hemiplegia (paralysis)
Behavior is impatient, impulsive, lack of insight
Greater deficits in function ADL
Often have left sided (unilateral) neglect

Question 21

CVA unilateral neglect

Answer 21

Inability to respond to stimulus on the contralateral side of the cerebral infarction
May not believe arm is part of body, or unaware of position of extremity, or deny that limb is paralyzed

Question 22

Assessment Findings Common to Both Left & Right CVAs

Answer 22

1. Memory loss
2. Early fatigue
3. Visual changes
4. Motor weakness and paralysis
5. Emotional lability (sudden uncontrolled change in emotion or mood)
6. Decreased sensation, esp. temperature and pain

Question 23

CVA aphasia

Answer 23

Defined: impairment of ability to formulate or interpret language symbols
Classified as expressive, receptive, or global (mixed)

Question 24

Expressive aphasia CVA

Answer 24

Also known as: Broca’s or nonfluent (stutter)
Results from: damage in Broca’s area of frontal lobe
Client understands what is said but is unable to communicate verbally; has difficulty in initiating motor speech
Uses: hesitant, slow, labored, single word speech

Question 25

Receptive aphasia CVA

Answer 25

Also known as: Wernicke’s or fluent Results from: damage to the Wernicke’s area in the temporoparietal area Client unable to understand what is spoke or written; comprehension is impaired Client may be able to: talk at a normal rate, but speech makes no sense Client is unaware of: mistakes in speech

Question 26

global aphasia CVA

Answer 26

Also known as: mixed aphasia Occurs with dysfunction in: both areas of expression and reception Reading and writing ability are: equally effected Few language skills

Question 27

dysarthria CVA

Answer 27

Difficulty pronouncing words from cranial nerve dysfunction or from weakness or paralysis of the muscles of the lips, tongue, and larynx

Question 28

visual changes due to CVA

Answer 28

Damage to the optic tract or occipital lobe may result in homonymous hemianopia

Question 29

CVA homonymous hemianopia

Answer 29

1. Blindness in the same side of both sides | 2. Results in loss of half of the visual field

Question 30

CVA depending on area affected homonymous hemianopia

Answer 30

1. Changes may occur in depth perception | 2. Diplopia may occur

Question 31

cognitive changes due to CVA

Answer 31

Depend on area and extent of injury: Changes in attention span, concentration, orientation Changes in judgment, memory, problem solving LOC: ranges from alert to barely arousable, comatos; Use GCS (Glasgow Coma Scale to assess, 3-15) may have agnosia or apraxia

Question 32

agnosia CVA

Answer 32

inability to recognize common objects, people, or sounds

Question 33

apraxia CVA

Answer 33

inability to carry out a previously learned action/activity

Question 34

cranial nerve damage due to CVA

Answer 34

May result in: Dysphagia: Inability to chew (CN V trigeminal) Absent gag reflex (CN X vagus) Impaired tongue movement or deviation (CN XII hypoglossal) Inability to swallow (CN IX glossopharyngeal and X vagus)

Question 35

cranial nerve damage due to CVA may result in

Answer 35

Facial paralysis, weakness with droop, or ptosis (CN VII facial) Position on their unaffected side

Question 36

If stroke is hemorrhagic in nature, signs of meningeal irritation might be present including:

Answer 36

Severe headache, Nuchal rigidity, Irritability, Seizures

Question 37

CVA- Signs of meningeal irritation:

Answer 37

(+) Brudzinski’s: flex neck and pt. flexes hip/knee to relieve tension in their neck

Question 38

CVA nursing diagnoses

Answer 38

Ineffective Tissue Perfusion (Cerebral) R/T interruption of arterial blood flow Many others related to motor, sensory, cognitive deficits:

Question 39

goals post-CVA

Answer 39

Prevent Complications Maintain Function Promote Optimal Functioning

Question 40

to maintain cerebral perfusion (CVA)

Answer 40

Thrombolytic Therapy: (for ischemic strokes) To dissolve the clot and prevent neurologic deficits TPA (Tissue Plasminogen Activator) or other enzyme (Streptokinase or Urokinase) Must be given within three hours of the onset of stroke symptoms to be effective

Question 41

CVA nursing interventions

Answer 41

``` Neuro Assessments (GCS, vital signs) Stabilize BP (Systolic BP directly affects cerebral blood flow) Control Seizures (increased BP and oxygen demands occur with seizures) ```

Question 42

dysphagia is common

Answer 42

1. May need suction equipment if patient unable to handle secretions 2. Position on side if unable to handle secretions (to prevent pooling at the back of the mouth/throat 3. Evaluation by speech therapy “Cookie Swallow” or modified barium swallow to determine if aspiration is occurring 4. Check for “pocketing of food” in cheeks (occurs with decreased sensation)

Question 43

maintain nutritional status CVA

Answer 43

1. Offer frequent oral hygiene 2. Use adaptive devices to promote feeding independence (OT) 3. If dysphagia is severe: TPN or NG enteral feedings short term PEG tube (G-tube) for long term enteral feedings

Question 44

CVA- promote perceptual/sensory function

Answer 44

1. Approach from side of intact vision 2. Teaching patient “scanning” 3. Promote consistent environment 4. Encourage familiar objects from home

Question 45

to promote mobility post CVA

Answer 45

1. Active and Passive ROM- Active achieves muscle strength and tone (movement the individual does on his/her own) 2. Physical therapy- for gait training or gross motor 3. Occupational therapy – for mine motor movement 4. Hand splints, leg braces, slings, etc. may be used to prevent contractures, prevent subluxation of shoulder, etc.

Question 46

promote self-care post CVA

Answer 46

1. Occupational Therapy 2. Emphasize routine and repetition to relearn self care activities 3. Use assist devices to promote independence 4. If aproxia (inability to carry out motor activities on command): use pictures, cues versus just verbal directions 5. Use loose fitting clothing with Velcro closures to easily put on and take off 6. Dress affected side first

Question 47

promote bowel and bladder function post CVA

Answer 47

1. Neurogenic bladder often occurs (bladder empties when it reaches a certain volume without voluntary control; incontinence) due to: cortical damage which affects inhibitory center in the brain 2. Stress regular toileting routines and times rather than waiting for an urge to go 3. Progressively increase the time between voidings to decrease frequency 4. Use fluids and diet to promote bowel irregularity

Question 48

promote efective communication post CVA

Answer 48

1. Speak slowly early 2. Allow sufficient time for response 3. Repeat names of objects used routinely 4. Speech Therapy 5. Use a picture board versus words

Question 49

Avoid Activity Intolerance post CVA

Answer 49

1. Teach energy conservation techniques | 2. Intersperse activity with rest periods

Question 50

Persons with stroke often easily distracted with short attention spans

Answer 50

1. Schedule teaching during peak periods of alertness often early in the day 2. Break tasks into shorter components 3. Use memory aids (pictures, cue cards, etc.)

Question 51

Apathy, depression, emotional lability often present

Answer 51

1. Provide information on support groups, “stroke clubs”

Question 52

CVA morbidity/mortality

Answer 52

Stroke produces significant morbidity in survivors: 31% require assistance with self-care 20% require assistance with ambulation 16% are institutionalized