CVA/Stroke Study Notes

CEREBROVASCULAR ACCIDENT (CVA)/STROKE

  • Types of Strokes

    • Ischemic Stroke (Most Common - 83%)

    • Causes:

      • Thrombus (stationary blood clot)
      • Embolus (a moving clot)
      • Hypoperfusion (reduced blood flow)

    • Blood Flow Blockage:

      • Blocked for > 24 hours

    • Onset:

      • Thrombotic = Slow (occurs during sleep)
      • Related to atherosclerosis
      • Embolic = Sudden (originates from the heart)
      • Often due to Atrial Fibrillation (A-Fib)

    • Assessment Findings:

      • Embolic is characterized by focal/neuro deficits
      • Often patients experience a Transient Ischemic Attack (TIA) prior
      • Major risk factor: A-Fib as an embolus source

    • Management:

      • t-PA (tissue Plasminogen Activator) if eligible
      • Anticoagulants and antiplatelets may be administered
      • Ischemic stroke treatment involves clot management via tPA

    • Diagnostics:

      • FAST examination
      • CT scan to rule out hemorrhage
      • MRI and Angiogram as additional diagnostic tools

    • Hemorrhagic Stroke

    • Cause:

      • Ruptured blood vessel leading to immediate decline
      • Major risk factors include hypertension (HTN), aneurysm, and arteriovenous malformation (AVM)

    • Leads to:

      • Increased Intracranial Pressure (ICP)
      • Severe headache (often described as “the worst headache of my life”)
      • Rapid cognitive and physical decline
      • Symptoms include photophobia, nausea/vomiting (N/V)

    • Assessment Findings:

      • Uncontrolled HTN is a critical risk factor
      • Common causes are aneurysm rupture and arteriovenous malformations
      • Ruptures often occur during physical activity
      • If bleeding is suspected, tPA is contraindicated

    • Diagnostics:

      • CT scan, MRI, and angiogram are essential

    • Key Notes:

      • tPA is contraindicated as it may worsen bleeding
      • Aneurysm precautions include:
      • Bedrest with the head of the bed elevated to 30 degrees
      • Maintain a quiet darkroom environment, avoiding stimuli
      • Avoid caffeine and hot/cold fluids to prevent ICP/rebleeding

TRANSIENT ISCHEMIC ATTACK (TIA)

  • Definition:
    • A warning sign indicating a potential stroke is imminent
    • Symptoms typically resolve in less than 24 hours
  • Assessment Findings:
    • Temporary focal deficits
  • Common Causes:
    • Carotid stenosis and A-Fib
  • Management:
    • Administer statins (to lower cholesterol), antihypertensives, and anti-platelet medications
    • Encourage smoking cessation
    • Managing blood pressure, diabetes, and diet is crucial
  • Diagnostics:
    • Carotid ultrasound is used for assessing risk for CVA
    • >70% stenosis may require endarterectomy
  • Key Notes:
    • TIA should be treated like an emergency due to high stroke risk
    • Priority Actions:
    • CT scan should be the first step to rule out bleeding
    • Determine the last known well time
    • Always check glucose levels first to rule out stroke mimics
    • Confirm swallow ability before feeding as a priority
    • Time equals brain: Prompt action is critical
    • Avoid clustering care: This practice is contraindicated
  • Stroke Symptoms (FAST):
    • F = Face drooping
    • A = Arm weakness
    • S = Speech difficulty
    • T = Time to call 911
    • Additional symptoms to note:
    • Sudden loss of vision
    • Sudden confusion
    • Sudden severe headache (indicative of hemorrhagic stroke)
    • Loss of balance

tPA (ALTEPLASE)

  • Purpose:
    • To dissolve blood clots in ischemic strokes
  • Requirements for Administration:
    • Administered within 3-4.5 hours of stroke onset
    • Ensures no evidence of bleeding is present on CT
    • Blood pressure must be controlled (<185 mmHg)
    • Laboratory values must be within normal limits (INR, platelets, glucose)
  • Post Administration Instructions:
    • No anticoagulants should be given within 24 hours following tPA
    • Continuous monitoring for bleeding is necessary
    • Frequent neurological checks should be performed every 1-2 hours

POST-STROKE PRIORITIES

  • Physical Considerations:
    • Assess for hemiplegia or hemiparesis
    • Aspirational risk remains the most critical consideration
    • Prevention of pressure injuries due to immobility is essential
    • Monitor for deep vein thrombosis (DVT) and skin breakdown
    • Be aware of false weakness or neglect due to hemiparesis
    • Risk of seizures may increase following a stroke
  • Nursing Considerations:
    • Maintain the head of the bed at 30 degrees
    • Prioritize airway management
    • Continue to perform neurological checks
    • Conduct swallowing assessments before allowing food or drink
  • Psychosocial Concerns:
    • Depression is commonly seen post-stroke
    • Patients may experience frustration due to loss of independence
    • Aphasia can create significant communication barriers, leading to social isolation

REHABILITATION

  • Goals and Services:
    • Early mobilization is crucial for preventing complications
    • Collaboration with physiotherapy (PT), occupational therapy (OT), and speech therapy is encouraged
    • The primary goal is maximizing patient independence in activities of daily living (ADLs)

DYSPHASIA AND DYSPHAGIA

  • DYSPHASIA:
    • Language impairment where the patient struggles to understand or express words
    • Types:
      • Expressive Dysphasia:
      • Patient can understand language but struggles to speak
      • Receptive Dysphasia:
      • Patient can speak but struggles to understand others
  • DYSPHAGIA:
    • Signs:
    • Drooling
    • Weak cough
    • Gag reflex issues
    • Interventions:
    • Maintain an upright position during meals
    • Thickened liquids may be necessary
    • Consultation with speech therapy is advised
    • Utilize the chin tuck technique while swallowing
    • Avoid PO (oral) intakes until cleared by a professional
    • Complications:
    • Aspiration pneumonia remains the biggest risk
    • Risks for malnutrition and dehydration are prevalent

COMMON NEUROLOGICAL DEFICITS

  • Assessment:
    • Aphasia: A communication disorder affecting speech
    • Dysarthria: Characterized by slurred speech
    • Hemianopsia: Patient experiences vision loss in half of the visual field
    • Interventions:
      • Teach patients to scan their environment
      • Position objects on the unaffected side initially; encourage turning the head side to side
    • Unilateral Neglect:
    • Patients may ignore one side of their body
      • Interventions:
      • Place items on the affected side to encourage use
      • Remind patients regularly to look toward the affected side
      • Protect affected extremities
    • Neurogenic Bladder: May lead to incontinence

MINI MEMORY TRICKS

  • Surgical Notes:
    • If a bleeding event occurs, remember: Bleed = No need for tPA
    • Fast assessment for stroke: FAST = Stroke Last Chance
    • A-Fib = A Flying Clot - significance of A-Fib as a source for emboli leading to stroke
  • Critical Signs:
    • The most important sign of increased ICP is a declining level of consciousness (LOC)

CAROTID DISEASE: DIAGNOSTICS

  • First Line Diagnostic:
    • Carotid ultrasound
  • Additional Diagnostic Tools:
    • CT angiography and MRI
  • Surgical Intervention:
    • Carotid endarterectomy, which removes plaque from carotid arteries
    • Preoperative Assessment:
      • Establish a baseline neurological status
      • Check antiplatelet medications
    • Postoperative Care:
      • Frequent neurological checks to monitor recovery
      • Maintain blood pressure within normal limits to avoid rupture risk
      • Check the patient for stroke signs post-op
      • Monitor for neck swelling, swallowing difficulties, and potential airway obstruction (emergency situation)

ATRIAL FIBRILLATION (A-FIB)

  • Key Feature:
    • Irregularly irregular rhythm
    • Absence of atrial kick leading to decreased cardiac output and increased risk for clot formation
  • ECG Findings:
    • No P waves present
    • Irregular rhythm noted
    • PR interval is not measurable
    • Displays chaotic atrial activity
  • Symptoms of Decreased Cardiac Output:
    • Shortness of breath (SOB)
    • Dizziness
    • Fatigue
    • Hypotension
  • Additional Symptoms:
    • Palpitations
    • Weakness or exercise intolerance
    • Syncope (severe cases)
    • Altered LOC (due to decreased perfusion which is a bad sign)
  • Management of Stable Patients:
    • If awake and perfusing; may present with mild symptoms such as fatigue, shortness of breath, and palpitations
    • Focus on rate control using beta blockers, calcium channel blockers, or digoxin
  • Management of Unstable Patients:
    • Patients displaying hypotension, chest pain, syncope, altered LOC, shock, or signs of pulmonary edema require immediate action
    • Synchronized cardioversion (timed on the R wave) is indicated
  • Purpose of Cardioversion:
    • To restore normal rhythm and maintain synchronization with the R wave to prevent ventricular fibrillation
    • Sedation is required for the procedure
    • If A-Fib has persisted for > 48 hours or is of unknown duration, perform a transesophageal echocardiogram (TEE) or administer anticoagulation before cardioversion due to risk of clot formation leading to a stroke post-procedure
  • Postoperative Monitoring:
    • Ethical implications include monitoring for arrhythmias, embolism signs (stroke), and skin care at pad sites

ANTICOAGULATION FOR A-FIB

  • Medications:
    • Warfarin
    • Rivaroxaban (direct oral anticoagulant - DOAC)
    • Prevents stroke due to clots forming in the atria
  • Nursing Responsibilities:
    • Monitor for signs of bleeding
    • Educate patients on medication adherence
  • Ablation Procedure:
    • Burns abnormal electrical pathways in the heart
  • Post-Ablation Care:
    • Monitor for bleeding and dysrhythmias post-procedure
    • Bed rest is advised to facilitate site healing
  • Priority Assessment for A-Fib:
    • Check pulse for irregularity
    • Assess blood pressure (often low)
    • Evaluate perfusion status (LOC, urine output, skin condition)
    • Monitor for stroke signs (big risk)
  • Complications Related to A-Fib:
    • Stroke (most significant risk factor)
    • Pulmonary embolism
    • Heart failure
    • Tachycardia-induced cardiomyopathy

EXTRA HIGH-YIELD INFORMATION

  • Pathophysiology of A-Fib:
    • A-Fib leads to blood pooling in the atria, causing clots to form, which can then travel to the brain resulting in a stroke
    • The absence of anticoagulation in A-Fib significantly increases stroke risk
  • Common Causes of A-Fib:
    • Alcohol consumption
    • Hyperthyroidism
    • Heart disease (valve diseases and coronary artery disease - CAD)
    • Older age
  • Management Strategies:
    • Unstable patients (needs immediate intervention) should be cardioverted swiftly
    • Stable patients should receive medical therapies first
  • Atrial Fibrillation Indicators:
    • No P waves indicate an underlying problem in the atria
    • Irregularity with absence of P waves is indicative of A-Fib
    • Always consider prevention of stroke as a top priority
  • Memory Tricks for A-Fib:
    • A-Fib = A mess of fibers (chaotic rhythm)
    • Absence of P = Atria problem
    • Clot leading to stroke is the most significant threat

HEART FAILURE: LEFT VS RIGHT SIDED

  • LEFT-SIDED HEART FAILURE:
    • Symptoms:
    • Shortness of breath (SOB)
    • Crackles in the lungs
    • Orthopnea (difficulty breathing while lying flat)
  • RIGHT-SIDED HEART FAILURE (Cor Pulmonale):
    • Symptoms:**
    • Fatigue
    • Peripheral venous pressure elevation
    • Ascites
    • Weight gain due to fluid retention
  • Priority Teaching for Patients with Heart Failure:
    • Daily weight monitoring is essential (same time daily, same scale, same clothing) as an indicator of fluid status
    • Advised to maintain low sodium intake (<2g/day) and implement fluid restrictions
    • Report any sudden weight changes (≥2 lbs overnight or ≥5 lbs within a week) to a healthcare provider immediately

EXACERBATION (ACUTE) MANAGEMENT

  • UNLOAD FAST:
    • Maintain an upright position
    • Administer oxygen
    • Utilize diuretics (e.g., Lasix) and nitrates as needed
    • Recognize causes such as high sodium intake, fluid overload, medication noncompliance, infections, and dysrhythmias (like A-Fib)

DVT (DEEP VEIN THROMBOSIS): SIGNS AND SYMPTOMS

  • Key indicators include unilateral swelling of the leg, pain, warmth, redness, and discomfort in the calf/leg

VIRCHOW’S TRIAD

  • Components:
    • Hypercoagulability
    • Venous stasis
    • Vascular damage

RISK FACTORS FOR DVT

  • Immobility (bed rest/surgery)
  • Cancer
  • Trauma
  • Dehydration
  • Presence of heart failure
  • Clotting disorders

INTERVENTIONS

  • Preventive Measures:
    • Anticoagulants should be used
    • Avoid massaging the affected area (risk of dislodging a clot leading to pulmonary embolism)
    • Promote early ambulation and use compression devices/stockings as appropriate
    • Adequate hydration is crucial

MEDICATIONS FOR DVT

  • Examples:
    • Heparin (monitor with protamine sulfate)
    • Enoxaparin
    • Warfarin (relationship with vitamin K)
    • Rivaroxaban (DOAC)
  • Monitoring:
    • Close monitoring of platelets with Heparin and INR with Warfarin

NURSING CARE FOR DVT

  • Implement bleeding precautions
  • Measure leg circumference daily
  • Monitor signs of clot progression

DIAGNOSTICS FOR DVT

  • D-Dimer Test:
    • Elevated levels indicate clot presence but are not specific
  • Ultrasound:
    • Used for confirmation of DVT presence

COMPLICATIONS OF DVT

  • Pulmonary Embolism:
    • Recognized by signs of sudden shortness of breath, chest pain, tachycardia, and hypoxia

PERIPHERAL VASCULAR DISEASE (PVD)

  • Differentiation Between Arterial and Venous Conditions:
    • Arterial: Problematic with blood flow down to the extremities
    • Characteristics: Cold, pale skin, claudication (pain with walking relieved by rest), weak or absent pulses, ulcers on toes (painful)
    • Venous: Difficulty with blood returning to towards the heart
    • Characteristics: Warm, swollen with brown discoloration, aching, and irregular border ulcers (found on ankles)

KEY DIFFERENCE

  • Pain during movement and relief at rest signals arterial issues
  • Venous conditions often present with edema and stasis features

6 P’s OF ACUTE ARTERIAL EMERGENCY

  • Pain
  • Pallor
  • Pulselessness
  • Paresthesia
  • Paralysis
  • Poikilothermia (cool temperature)

TEACHING FOR ARTERIAL/VENOUS CONDITIONS

  • Arterial:
    • No elevation, encourage leg dangling
    • Avoid exposure to cold conditions
    • Emphasis on smoking cessation
  • Venous:
    • Elevate legs
    • Utilize compression stockings
    • Avoid prolonged standing/sitting, encourage frequent walking

NURSING PRIORITIES FOR PVD

  • Conduct thorough assessments of pulses, color, and temperature
  • Provide foot and skin care to prevent ulcers
  • Promote ambulation, particularly for venous conditions

MEDICATIONS FOR PVD

  • For Arterial (PAD):
    • Antiplatelets (e.g., aspirin, clopidogrel) to prevent clots
    • Lipid-lowering medications
    • ACE inhibitors (monitor for cough, angioedema, and potassium levels)
    • Beta-blockers (hold if HR < 60)
  • For Venous (DVT):
    • Anticoagulants (such as warfarin)
    • Loop diuretics (e.g., Lasix; monitor for hypokalemia and ototoxicity)

INTERMITTENT CLAUDICATION

  • Defined as pain experienced during walking which is relieved upon resting
  • Symptoms are reproducible and attributed to decreased blood flow

COMPLICATIONS OF PVD

  • Arterial Issues: May lead to tissue death or amputation
  • Venous Issues: Can result in ulcers and chronic swelling

SURGICAL INTERVENTIONS

  • Options:
    • Revascularization or bypass procedures
    • Postoperative care requires frequent pulse assessments and monitoring for the 6 P’s (pain, pallor, numbness, coolness)
    • Immediate reporting of any of the 6 P’s to prevent further complications
    • Avoid smoking and adhere to prescribed medications

EYE DISORDERS

CATARACTS

  • Definition: Cloudy lens leading to gradual vision changes
  • Symptoms:
    • Cloudy vision, halos, gradual painless vision loss
    • Risk factors include aging, diabetes, smoking, long-term steroid use, UV exposure
  • Pre-operative Instructions:
    • Extensive eye drops (antibiotic) may be required before surgery
    • Patients typically must remain NPO prior to the procedure
  • Post-operative Instructions:
    • Avoid bending/straining/coughing
    • Maintain head elevation
    • Usage of an eye shield is imperative
    • Rest on nonoperative side and participate in no driving until cleared
  • Complications:
    • Severe pain, sudden decreased vision, flashes/floaters, redness/drainage need to be evaluated

GLAUCOMA

  • Overview: Pressure build-up can kill optic nerve
  • Signs: Increased intraocular pressure (IOP) leading to blindness; normal IOP values range from 10-21 mmHg
  • Types of Glaucoma:
    • Open-angle (chronic): Gradual peripheral vision loss, often asymptomatic early on
    • Closed-angle (emergency): Presents with sudden severe eye pain, headache, nausea/vomiting, halos, and sudden vision loss
  • Medications:
    • Beta-blockers (timolol) reduce IOP, but monitor for bradycardia and hypotension
    • Prostaglandins increase outflow of aqueous humor
    • Carbonic anhydrase inhibitors - monitor for electrolyte imbalances
  • Nursing Responsibilities:
    • Lifelong adherence to eye drop regimen is necessary
    • Punctal occlusion technique can decrease systemic effects
    • Avoid eye dropper contact with the eye surface
  • Screening Recommendations:
    • Regular eye exams should begin at age 40 for those at risk (diabetics, family history)
    • Untreated glaucoma may lead to permanent blindness

RETINAL DETACHMENT

  • Symptoms:
    • Characterized by sensation of a 'curtain' over vision, floaters, flashes, and sudden painless vision loss
  • Interventions:
    • Classified as a medical emergency requiring activity limitation to avoid sudden movements
    • Immediate surgical referral is necessary, precise positioning is critical if gas bubbles are used post-surgery

MACULAR DEGENERATION

  • Overview: Characterized by loss of central vision
  • Symptoms: Straight lines appearing wavy
  • Types:
    • Dry: Slow progression
    • Wet: Rapid and severe progression
  • Teaching:
    • Use of an Amsler grid for monitoring vision changes
    • Emphasize dietary inclusion of leafy greens (lutein) and antioxidants (vitamins C, E, zinc); smoking cessation encouraged

HEARING LOSS DUE TO OTOTOXIC DRUGS

  • Common Agents:
    • Aminoglycosides, loop diuretics, salicylates, chemotherapy agents
  • Nursing Priorities:
    • Monitor for hearing changes early (tinnitus, reduced hearing) for potential reversibility
    • Recognize tinnitus as an early sign of ototoxicity

COMMUNICATION STRATEGIES FOR HEARING IMPAIRMENT

  • Techniques:
    • Face the patient directly
    • Speak clearly in lower pitch (do not shout)
    • Minimize background noise
    • Verify patient understanding using short simple phrases and written cues as needed

HEARING AID CARE

  • Maintenance Tips:
    • Keep hearing aids clean and dry
    • Ensure secure storage and turn off when not in use
    • Address issues of whistling (indicates poor fit)
    • Regularly check batteries and ensure proper insertion
    • Remove for bathing and store safely
    • Ensure device is on before assuming patient confusion at sounds

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) & ASTHMA

COPD: TYPES AND OVERVIEW

  • Types:
    • Chronic Bronchitis (described as Blue Bloater):
    • Characterized by excessive mucus production and productive cough
    • Commonly results in cyanosis, frequent infections and increased risk for right-sided heart failure
    • Emphysema (represented by Pink Puffer):
    • Air trapping, leading to thin body frame and dyspnea
    • Symptoms include barrel chest and accessory muscle use
  • Priority Education:
    • Smoking cessation is paramount
    • Educate on oxygen safety precautions (NO smoking)
    • Vaccinate against flu and pneumococcal pneumonia
    • Introduce pulmonary rehabilitation programs as they improve quality of life

OXYGEN ALERT

  • Considerations for COPD Patients:
    • These patients often rely on low oxygen drive; thus, oxygen should be administered cautiously at low levels (2-3 L via nasal cannula)
    • Excessive oxygen can lead to CO2 retention and respiratory failure

ASTHMA

  • Overview: Asthma presents as reversible airway constriction
  • Severity Classification:
    • Mild intermittent: Symptoms <2x/week
    • Severe chronic: Symptoms appear continuously
  • Triggers:
    • Dust, smoke, pollen, cold air, exercise, infections, and strong odors
  • Exacerbation Management:
    • Employ high Fowler's position or tripod for relief
    • Administer bronchodilators (first-line treatment)
    • Provide oxygen and steroid therapy as needed

SILENT CHEST / ASTHMATICUS (EMERGENCY STATUS)

  • Indicators:
    • Absence of relief from inhalers
    • Severe shortness of breath, potential need for intubation

MODIFIABLE & NON-MODIFIABLE ASTHMA CAUSES

  • Modifiable:
    • Smoking (the primary modifiable risk)
    • Pollution and occupational exposures
  • Non-modifiable:
    • Age
    • Genetic predisposition (alpha-1 antitrypsin deficiency)

WHEN TO SEEK HELP

  • Patient should seek help if unable to speak full sentences, demonstrates cyanosis, does not experience relief after the rescue inhaler, or experiences severe shortness of breath

PULMONARY REHABILITATION PROGRAM

  • Components:
    • Exercise, breathing training, nutrition, and improving functional capacity without curing underlying disease
  • Medications for Blood Pressure Management:
    • ACE Inhibitors: e.g., Captopril/Enalapril - prevent conversion of angiotensin I to angiotensin II; indications include hypertension, heart failure, post-myocardial infarction, and nephropathy
    • Monitor for side effects such as dry cough, angioedema, hyperkalemia, hypotension, and assess renal function including BUN/Creatinine levels
  • ARB (Angiotensin Receptor Blockers): e.g., Telmisartan - for hypertension and heart failure with fewer side effects than ACE inhibitors

MEDICATION CLASSES

  • Antihypertensives: Monitor for the same parameters as ACE inhibitors
  • Beta Blockers: e.g., Metoprolol - affect heart rate and contractility, used for several conditions including hypertension, and src asthmatic models
  • Aldosterone Antagonists: e.g., Spironolactone - monitor for potassium levels and manage risks like gynecomastia
  • Diuretics: e.g., Furosemide - monitor electrolytes and fluid balance
  • Anticoagulants: used to prevent clots in conditions such as stroke, A-Fib, and PVD. Key examples include Warfarin and Rivaroxaban
  • Monitor necessary labs and ensure adherence to education on drug interactions and side effects.