Cerebral Vascular Accident (CVA)-Stroke

• AVM (arteriovenous malformation): impaired blood flow; Pt suddenly collapse 

• Quicker you act, quicker recovery

  • may just have aphasia (cant speak), or may have paralysis & severe cognitive impairment

Cerebrovascular Accident (CVA) or Stroke

• Brain requires blood to provide the oxygen and glucose

• CVA = interruption of cerebral blood flow

Stroke occurs when

• Functions are lost or impaired –can pt come back if perfusion and oxygen comes back thats why time is crucial

Severity of loss of

• function varies according to the location and extent of the brain involved.

• Time = Brain–cerebral spinal fluid, brain matter, and — the skull cannot take any additional of anything else bc then parts of the brain will start to die off

Risk Factors: Nonmodifiable

• Age (doubles each decade >55 years of age)

• Gender (Male)

• Race (African American)

• Ethnicity

• Heredity/family history of stroke (prior transient ischemic attack, or a prior stroke)

Modifiable risk factors

• HTN and Heart disease

• Metabolic syndrome

• Serum cholesterol→ platelet aggregation on top of cholesterol

• Heavy alcohol consumption and Drug abuse and Smoking

• Poor diet and Obesity

• Sleep apnea

• Physical inactivity

Diabetes→ can be both non-modifiable and modifiable; once Dx you cannot cure

Transient Ischemic Attack (TIA)

• Transient dysfunction

• Not permanent

• High risk for CVA

• Symptoms last <1 hour

Transient Ischemic Attack (TIA): clinical manifestations

• hemiparesis

• inability to speak, diplopia, transient weakness,

• numbness, loss of sensation,

• vertigo and Vision difficulty

• aphasia (understand or express speech),

• dysarthria (impairment of speaking muscles),

• dysphagia (swallowing),

• ataxia (loss of muscle coordination ie. Gait

difference between TIA and stroke

• all these things are seen in a regular stroke except it last less than 1hr and if someone doesn’t rec it they are then at high risk of stroke if TIA goes away, essentially a precursor to a stroke down the road

Transient Ischemic Attack (TIA) tx

• platelet inhibitor (ASA, clopidogrel), anticoagulants

  • Platelet inhibitors return brain back to normal function

Ischemic stroke

• Inadequate blood flow

• May progress in the first 72 hours related to growing edema

• 80% of all strokes are ischemic strokes.

Ischemic stroke: 2 types

• Thrombotic→ plaque in artery and then clot occludes 

• Embolic→ embolism completely occluded

• Small chances for survival and difficult for patient to remain fully functioning (both ischemic and hemorrhagic)

Hemorrhagic stroke

• Bleeding in skull–vessel in the brain broke and blood in places where it should not be, extra blood is destroying other cells and brain matter

• HTN most common cause

• Sudden onset, rapid deterioration

• “Worst headache of my life” blood puts extra pressure on parts of the brain and thus die off

Thrombotic stroke

•  plaque builds up on the side of vessel (narrows) and then everything builds up (causing a partial-complete blockage)

Embolic stroke

• can be vegetative bacteria, A-fib, right atrial clots, DVT

  • Something breaking off, rather than “dam effect” of building up 

Ischemic stroke

• no oxygen or nutrients

nursing assessment

• ABC

• Time of Onset

• Rapid glucose check

• Vitals

• Comprehensive neuro examination

  • Level of consciousness

• Including NIHSS stroke scale–don’tmemorize it just know it’s a part of the assessment

• Glasgow Coma Scale

• Motor abilities and Sensation

• Proprioception (ability to sense movement)

• Cerebellar function–romberg

• Pupil check

Common Deficits Following Stroke: Contralateral

• ex. right brain stroke produces effects on left side (L hemiplegia)

Common Deficits Following Stroke:Hemiparesis→

• weakness on one side

Common Deficits Following Stroke: Hemiplegia→

• the inability to move a group of muscles on one side (paralysis)

  • Pt may or may not know their limb is present

• no movement at all

Akinesia –

loss of skilled voluntary movement

common deficits following stroke: facial droop, ptosis

• ptosis is the eyelid drooping 

Swallowing and speech deficits Following Stroke: Dysphagia→

• impaired muscles of swallowing

• Speech therapy consult and swallowin eval

Swallowing and speech deficits Following Stroke: Diminished Sensation and Gag reflex

• Assessed by speech pathologist; ensure gag reflex before anything PO

• May need to ask them to swallow twice or rinse with water to fully swallow and clear mouth 

Swallowing and speech deficits Following Stroke: Aphasia→

• communication dysfunction

  • Expressive (Broca’s) Aphasia (slow speech, takes effort)

    • Loss of speech production can’t tell you the answer bc it isn’t coming out that way

• Receptive (Wernicke’s) Aphasia

  • Loss of speech comprehension doesn’t understand what youre saying

• Global: Both gestures, communication boards,

Sensory and perceptual deficits following Stroke: Dysarthria

•  impaired muscles of speech. Slurred speech

  • Does NOT affect the comprehension of language/ communication the motor of the mouth doesn’t let em speak

Sensory and perceptual deficits:

• Blindness in same half of each visual field

• Other visual problems

  • Diplopia (double vision)

• Neglect of affected side –usually dt hemianopsia

• Agnosia: inability to recognize objects or stimuli using senses –or name objects in their hands

• Apraxia: inability to perform learned, purposeful movements (know how to do it, but can’t physcially do it)

• Blindness in same half of each visual field

• Known as Homonymous Hemianopsia–can only see from half of their eye and sees the same thing, tell em to turn their head to scan the room 

• Right side stroke-left hemiplegia-left side of both eyes

Emotional and cognitive changes

• Frustration

• Depression

• Anxiety

• Impulsive, Impaired judgement

• Impatient

• Memory problems 

Diagnostic studies

• Noncontrast Cat Scan (CT) the gold standard or MRI

  • Indicate the size and location of the lesion

  • Differentiate between ischemic and hemorrhagic stroke–since both are treated differently, white stuff is blood

    • Ischemic: treatment must be given in <4.5 hrs 

    • Don’t treat ischemic stroke if you don’t know when it started 

  • Done within 25 minutes of ED arrival

initial nursing Interventions

• Ensure patent airway and breathing

• Call Stroke Alert

• Maintain adequate oxygenation

• Obtain IV access (2 IV access), give normal saline

• Obtain CT scan immediately

• Baseline laboratory tests

• Vital signs (high BP is fine, but should be crazy high) 

most important point from patient history is

• Time of onset. About 25% of patients will worsen in the first 24 to 48 hours. 

Maintain BP according to guidelines:

• Elevated BP is common immediately after a stroke.

• Body’s attempt to maintain cerebral perfusion

• Use of drugs to lower BP is recommended only if BP is markedly increased (mean arterial pressure [MAP] greater than 130 mm Hg or systolic pressure greater than 220 mm Hg).

In the case of an acute stroke,

IV antihypertensives such as metoprolol are preferred.

• Although low BP immediately following a stroke is uncommon, hypotension and hypovolemia should be corrected.

The time a suspected stroke patient arrives in the ED to the start of the

thrombolytic infusion (if ischemic stroke) should be 60 minutes or less

Medications

• Antiplatelet drugs.  Aspirin, clopidogrel

• Anticoagulant therapy

  • Platelet inhibitors and anticoagulants are Contraindicated for patients with hemorrhagic stroke 

    • Only for ischemic stroke 

    • Not until after CT scan

• Anticipate thrombolytic therapy for ischemic stroke

• Statins

  • Monitor for SE of meds

• Management of hypertension

• Seizure prophylaxis-specific after  hemorrhagic stroke

Thrombolytics–recombinant tissue plasminogen activator (ends in -ase) 

• Acts directly on clot to cause lysis. Converts plasminogen to plasmin, which digests fibrin and dissolves clot

• *Within 30 minutes of arrival to ED, not usually after 4.5 hours after symptoms (Average 4.5 hours)

• Before tPA→do all invasive procedures (draw labs, start 2 or 3 IV lines, foley)

• Contraindications (Bleeding, BP etc.  See MI PPT)

Role of the RN in rtPA administration 

• Assess for exclusions to therapy

• Monitor baseline coagulation studies

• Insert foley, nasogastric tube and multiple IV’s before rtPA administration

• Monitor level of consciousness (bleeding), for symptoms of cerebral hemorrhage

• May have bleeding gums, IV sites-small amount ok.  Concerns if frank bleeding; change in LOC

After start of rtPA-

no IV starts, IMs, Invasive procedures or foley insertions for 24 hours

• Teach patient about increased risk of bleeding

Ischemic surgical care

• Angioplasty

• Stenting

• Carotid endarterectomy

• Extracranial-intracranial bypass

• Stent retriever

• MERCI

Hemorrhagic stroke surgical care

• Resection (clips off vessels feeding area)

• Clipping of aneurysm

• Coiling

Angioplasty and stenting

–if clot of plaque

Carotid endarterectomy

• In the common carotid artery or internal carotid artery, Endarterectomy is the removal of material on the inside of the artery.

Extracranial-intracranial bypass–

takes vessel from another part of the body and bypasses the clot

• Common vessels used as a graft are the saphenous vein in the leg or the radial or ulnar arteries in the arm

Clot retrievers

• Stent retrievers (Solitaire) 2015–se: if it doesn’t get all the clot it’ll break off a piece and send it somewhere else

MERCI Clot retriever catheter

Treatments for hemorrhagic strokes

• clipping, clipping with bypass, coiling

Nursing management–priority problems

• Risk for ineffective cerebral tissue perfusion– nutrients, glucose

• Ineffective airway clearance

• Impaired physical mobility

• Unilateral neglect

• Safety…fall precautions –hemiplesia

• Impaired verbal communication

• Impaired urinary elimination

• Impaired swallowing…aspiration precautions, swallowing screen

• Mobility, Skin Integrity

• Situational low self-esteem

Nursing management: musculoskeletal: In the acute phase,

• range-of-motion exercises and positioning are important. 1-2x a week

Paralyzed or weak side needs

special attention when positioned.

• To move pt, place chair/wc on strong side–so this way they can do it emselves, pt may have contractures which we can put a brace or a wash cloth/something so the hand won’t close

Nursing management: musculoskeletal 

• Trochanter roll at hip to prevent external rotation

• Hand cones to prevent hand contractures

• Arm supports with slings and lap boards to prevent shoulder displacement

• Avoidance of pulling the patient by the arm to avoid shoulder displacement or hurtin em

• Posterior leg splints, footboards, or high-topped tennis shoes to prevent foot drop

Hand splints to reduce

spasticity but not all the time so they don’t have a contracture

Nursing managements: assistive devices for eating

Nursing management: communication

• Anxiety producing

• Assess patient for both the ability to speak and the ability to understand.

• Yes or No questions

• Gestures may be used to support verbal cues.

• Allow time for thought completion and speech

nurse should speak

• Speak slowly and calmly, using simple words/directions or short sentences.

For pts with aphasia:

look at pt when speaking to them, use simple words and sentences, ask yes or no questions

Nursing management: sensory-perceptual alterations

• Scan

• Exercise

• Eye patch

• Ptosis eye exercises

• Homonymous hemianopsia (food on the left side is not seen)

• Diplopia have an eye patch

Nursing management: coping

• Family members must cope aspects of patient’s behavior.

• Behaviors that may have been reinforced during the early stages of stroke as continued dependency

• Encourage Stroke Support Groups for patient and family resped so the family can take a break from pt

Rehabilitation

• After stroke pt has stabilized for 12 to 24 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning.

• PT, OT, ST

• Patients may be transferred to a rehabilitation unit, outpatient therapy, or home care–based rehabilitation.

• What were his risk factors for a stroke?

  • A 60-year-old male suffered a left cerebral hemispheric stroke involving the middle cerebral artery.

  • Transcranial Doppler ultrasonography demonstrated 80% stenosis bilaterally.

  • He was advised to undergo bilateral carotid endarterectomy.

  • He has a history of hypertension, MI 2 years previous, COPD, and rheumatic arthritis.

  • He has a 40-year history of smoking, hyperglycemia, hypercholesterolemia, and steroid dependency secondary to treatment of RA.

  • 5 days after his stroke, he is discharged from the hospital to recuperate.

• The client is diagnosed with a thrombotic stroke. Over the next 72 hours, you plan care with the knowledge that he

1. is ready for aggressive rehabilitation.

2. will show gradual improvement of the initial neurologic deficits.

3. may show signs of deteriorating neurologic function as cerebral edema increases.

4. should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits.

• The client also has dysphagia. Before allowing him to eat, which action should you take first?

1. Check the patient’s gag reflex.

2. Request a soft diet with no liquids.

3. Place the patient in high-Fowler’s position.

4. Test the patient’s ability to swallow with a small amount of water.

• Which clinical indicator does the nurse identify when assessing a patient with hemiplegia?

1. Paralysis of both lower extremities.

2. Paralysis of one side of the body.

3. Weakness of both upper extremities.

4. Weakness of the upper and lower extremities.

• A patient who has had a CVA is receiving continuous nasogastric tube feedings. Which of the following should the nurse implement to prevent aspiration pneumonia. Select all that apply.

1. HOB up at least 45 degrees at all times

2. Perform oral hygiene at least once a shift

3. Verify tube placement at the beginning of each shift.

4. Offer bedpan every 4 hours.

5. Allow the client to lie on the left side periodically.

• The nurse is caring for a patient with expressive aphasia. Which should the nurse include as part of long-range planning for the patient?

1. Provide positive feedback when the patient uses a word correctly.

2. Suggest that the patient get assistance at home because the disability is permanent.

3. Communicate with “yes” and “no” questions only.

4. Support the family to accept the fact that the patient cannot participate in verbal communication.

• The wife of a patient admitted with a left-sided brain stroke must leave her husband’s bedside for 2 hours to pick up their children. Which nursing action is appropriate to contribute to patient safety while she is gone?

1. Apply restraints to the patient’s wrists.

2. Maintain the bed in a low fowler position.

3. Sit with the patient until his wife returns.

4. Place the call light in the patient’s left hand

• The spouse of a patient brought to the ED states that 6 hours ago her husband began having difficulty finding words. The patient has since become progressively worse. He has right hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position, is drooling, and has been incontinent of urine. Place in order of priority the interventions the nurse should take for this patient at this time?

1. Provide perineal care

2. Assess for gag reflex

3. Elevate the head of bed 45 degrees

4. Perform a linen and gown change

• Can you answer these?

  • The patient from the previous question is admitted to the acute medical unit after 7 hours with a diagnosis of ischemic stroke. His wife asks if her husband will receive IV thrombolytic therapy. What is your best response?

  • Thirty minutes later, the wife asks for a glass of water or juice because her husband is thirsty. What is your best response?