NURS-433: Management of Care 3 (Module 9, Part 2)

What does CVA stand for, and what is another name for it?

Cerebrovascular accident, also known as a "brain attack"

What does TIA stand for, and what is another name for it?

Transient ischemic attack, also known as a "mini stroke"

What percentage of strokes are ischemic versus hemorrhagic?

Approximately 80% are ischemic and 20% are hemorrhagic

Where does stroke rank among leading causes of death in the United States and worldwide?

Fourth in the United States (CDC) and second worldwide (WHO)

What is the difference between an ischemic and hemorrhagic stroke?

An ischemic stroke occurs when a blood vessel becomes blocked, reducing blood flow to the brain; a hemorrhagic stroke occurs when a blood vessel ruptures, causing bleeding within or around the brain

At what level of cerebral blood flow does the ischemic pathophysiology begin?

Less than 25 mL/100 g of brain tissue per minute

What happens to neuronal oxygen supply during an ischemic stroke?

Decreased cerebral blood flow causes neuronal oxygen deprivation

How do mitochondria respond to oxygen deprivation during an ischemic stroke?

They switch to anaerobic respiration, producing large amounts of lactic acid and altering cellular pH

How does oxygen deprivation affect ATP production in neurons?

It prevents neurons from producing sufficient ATP to fuel depolarization processes and maintain normal cellular function

What happens to cell membrane pumps during an ischemic stroke?

They begin to fail, disrupting normal electrolyte balance

How do calcium and glutamate contribute to neuronal injury during an ischemic stroke?

Calcium influx and glutamate release activate damaging cellular pathways

What is the eventual result of prolonged cerebral ischemia?

Neurons cease functioning, cell membranes are destroyed, and brain tissue becomes damaged

What are the nonmodifiable risk factors for ischemic stroke?

Age over 55, male gender, and African-American race

What is the primary modifiable risk factor for ischemic stroke?

Hypertension

What other modifiable risk factors increase the risk of ischemic stroke?

Cardiovascular disease (atrial fibrillation and atherosclerosis), elevated cholesterol or hematocrit, obesity, diabetes, oral contraceptive use, smoking, and drug or alcohol abuse

What are the major causes of ischemic stroke?

Large artery thrombosis, small penetrating artery thrombosis, cardiogenic embolism, cryptogenic causes, and other etiologies

What is a cryptogenic ischemic stroke?

An ischemic stroke with no known cause

What are the common clinical manifestations of a stroke?

Sudden unilateral numbness or weakness, difficulty speaking or understanding speech, difficulty walking, dizziness, impaired coordination, facial drooping, severe headache, perceptual disturbances, and altered mental status

What determines the specific symptoms a patient experiences during a stroke?

The location and size of the affected area of the brain

What functions are associated with the frontal lobe?

Judgment, foresight, voluntary movement, and smell

What is the primary function of the motor cortex?

Controlling voluntary movement

What is the primary function of the sensory cortex?

Processing pain, heat, and other sensations

What is the primary function of Broca's area?

Speech production

What is the primary function of Wernicke's area?

Speech comprehension

What functions are associated with the parietal lobe?

Language comprehension and processing sensory information

What functions are associated with the temporal lobe?

Hearing, intellectual functioning, and emotional functioning

What is the primary function of the occipital lobe?

Visual processing

What is the primary function of the cerebellum?

Coordination of movement

What vital functions are controlled by the brainstem?

Swallowing, breathing, heart rate, wakefulness, and other involuntary functions

What does AIS stand for?

Acute ischemic stroke

What assessment tool is used to evaluate stroke severity, and what is its scoring range?

The National Institutes of Health Stroke Scale (NIHSS), which ranges from 0–42

What diagnostic imaging studies are used to evaluate an acute ischemic stroke?

CT and MRI

What treatment options are available for acute ischemic stroke?

Thrombolytics (tenecteplase [TNKase]/tissue plasminogen activator [tPA]), anticoagulants for patients not eligible for thrombolytics, mannitol for increased intracranial pressure, and surgical clot removal

What are the major considerations associated with thrombolytic therapy?

It carries significant risks, is expensive, and requires strict eligibility criteria

What are the basic eligibility criteria for thrombolytic therapy?

Ischemic stroke causing a measurable neurologic deficit, symptom onset within 3 hours (up to 4.5 hours for selected patients), and age 18 years or older

What neurologic history or symptoms exclude a patient from thrombolytic therapy?

Head trauma or previous stroke within 3 months, suspected subarachnoid hemorrhage, or a history of intracranial hemorrhage

What recent vascular procedure is an exclusion criterion for thrombolytic therapy?

Arterial puncture at a noncompressible site within the previous 7 days

What blood pressure values exclude a patient from thrombolytic therapy?

Systolic blood pressure greater than 185 mmHg or diastolic blood pressure greater than 110 mmHg

What bleeding-related findings exclude a patient from thrombolytic therapy?

Active bleeding, acute bleeding diathesis, or a platelet count below 100,000/mm³

How does recent heparin administration affect thrombolytic eligibility?

Heparin administration within the previous 48 hours is an exclusion if the aPTT exceeds the upper limit of normal

What coagulation values are exclusion criteria for patients taking anticoagulants?

INR greater than 1.7 or PT greater than 15 seconds

What blood glucose level is an exclusion criterion for thrombolytic therapy?

Less than 50 mg/dL

What CT finding excludes a patient from thrombolytic therapy?

Multilobar infarction

What age and NIHSS criteria are exclusions for thrombolytic therapy?

Age greater than 80 years and severe stroke with an NIHSS score greater than 25

What is the major complication associated with thrombolytic therapy?

Intracranial or systemic bleeding

Where are the surgical interventions for ischemic stroke performed?

At select hospitals, typically in the catheterization laboratory by a neurosurgeon

What does MERCI stand for, and how does it work?

Mechanical Embolus Removal in Cerebral Ischemia; a corkscrew-like device snares and removes a cerebral blood clot

What percentage of stroke patients can be safely treated with MERCI?

Approximately 30%

What is a potential limitation of the MERCI device?

It may uncoil and lose the clot during retrieval

What is the purpose of mechanical thrombectomy?

To physically remove a blood clot from a cerebral artery and restore blood flow

What does SHELTER stand for, and how does it work?

Stroke Help using an Endo-Luminal Transcatheter Embolus Retrieval; it is designed to safely trap and extract cerebral blood clots

What does SWIFT stand for, and how does it work?

Solitaire With the Intention For Thrombectomy; it uses a microcatheter to trap and suction out the clot

Where can bleeding occur during a hemorrhagic stroke?

Within brain tissue, the ventricles, or the subarachnoid space

How does blood exposure affect brain metabolism during a hemorrhagic stroke?

It disrupts normal brain metabolism and contributes to neurologic injury

Why does intracranial pressure increase during a hemorrhagic stroke?

Accumulation of blood, particularly in the subarachnoid space, increases intracranial pressure

How does a hemorrhagic stroke cause secondary brain injury?

Compression, reduced cerebral perfusion, and vasoconstriction can produce secondary ischemia and damage brain tissue

What are the major risk factors for hemorrhagic stroke?

Hypertension, cerebral atherosclerosis, certain medications, and increased age

What are the major causes of hemorrhagic stroke?

Spontaneous rupture of small vessels due to hypertension, ruptured cerebral aneurysms, amyloid angiopathy, arteriovenous malformations (AVMs), and intracranial aneurysms

What medications or substances may contribute to intracerebral hemorrhage?

Anticoagulants, amphetamines, and illegal drugs

What are the common clinical manifestations of hemorrhagic stroke?

Sudden thunderclap headache, decreased or altered level of consciousness, vomiting, possible focal seizures, nuchal rigidity, visual disturbances, tinnitus, dizziness, and hemiparesis

What is nuchal rigidity?

Pain and stiffness in the back of the neck

What visual disturbances may occur during a hemorrhagic stroke?

Vision loss, diplopia (double vision), and ptosis (drooping eyelid)

What are the three primary goals of hemorrhagic stroke treatment?

Allow the brain to recover from the initial insult, prevent or minimize rebleeding, and prevent or treat complications

What treatments are implemented for hemorrhagic stroke?

Fresh frozen plasma (FFP), vitamin K, antiepileptic medications, analgesics, sequential compression devices (SCDs), IV insulin for hyperglycemia, and antihypertensive medications

What is the primary focus of post-stroke care?

Managing neurologic deficits, preventing complications, and supporting recovery and rehabilitation

Why is understanding the function of different brain regions important in post-stroke care?

It helps nurses anticipate neurologic deficits based on the location of brain injury

When are NIHSS assessments performed during the stroke admission process?

Initially in the emergency department or field, then again upon arrival to the ICU or stroke unit

Within what timeframe should a diagnostic CT be performed, and why?

Within 45 minutes to evaluate the stroke and determine eligibility for thrombolytic therapy (i.e., tPA administration)

What additional diagnostic studies may be performed after stroke admission?

MRI, carotid ultrasound, echocardiogram, EKG, coagulation panel, lipid panel, and erythrocyte sedimentation rate (ESR)

Which healthcare professionals may be included on the interdisciplinary stroke team?

Primary physician, neurologist, neurosurgeon, GI specialist, nurses, pharmacist, speech therapist, physical therapist, occupational therapist, nutritionist, and case worker

What is the overall focus of collaborative stroke care?

Caring for the whole person, preventing complications, promoting rehabilitation, providing support and encouragement, listening to the patient, and educating the patient and family

What does FAST stand for in stroke recognition?

Face drooping, Arm weakness, Speech difficulty, and Time to seek emergency help

What anticoagulant medications are commonly used in stroke-related care?

Enoxaparin and warfarin

What antiplatelet medications are commonly used in stroke-related care?

Aspirin (ASA) and clopidogrel (Plavix)

What medication classes are used to manage elevated cholesterol and hypertension in stroke-related care?

Antilipemic medications (statins) for elevated cholesterol and antihypertensives for elevated blood pressure

What assessments should nurses perform frequently when caring for stroke patients?

Vital signs and comprehensive neurologic assessments, including level of consciousness, motor symptoms, speech, and eye symptoms

What should nursing care focus on after the acute stroke is complete?

Patient functioning, self-care ability, coping, teaching needs, rehabilitation, and prevention of complications

What body systems and care domains should nurses focus on when assessing stroke patients?

Neurologic, respiratory, gastrointestinal, genitourinary, integumentary, musculoskeletal (gross and fine motor), sensory, and safety

What are the common nursing problems associated with stroke?

Impaired physical mobility, acute pain, self-care deficits, disturbed sensory perception, impaired swallowing, urinary incontinence, disturbed thought processes, impaired verbal communication, risk for impaired skin integrity, interrupted family processes, and sexual dysfunction

Which healthcare professionals should nurses collaborate with when managing nutritional needs after a stroke?

Speech therapy and the nutritionist

What positioning and swallowing strategies may be recommended for patients with dysphagia?

Upright head-of-bed positioning, chin-tuck positioning, avoiding straws, swallowing twice, and taking small bites; follow and teach speech therapy guidelines

What food textures and liquid consistencies may be prescribed for patients with dysphagia?

Regular, mechanical soft, or pureed foods; thin, nectar-thick, or honey-thick liquids

How may medications be administered to patients with swallowing difficulties?

Whole, one at a time, or crushed, depending on individual speech therapy recommendations and medication requirements