Cerebral Vascular Accident (CVA) and TIA

Definition: A Cerebral Vascular Accident (CVA), commonly referred to as a stroke, is defined as a lack of blood flow to a specific area of the brain.
Primary Classifications:
- Ischemic: Occurs when blood flow is blocked by a clot or narrowing of the vessels.
- Hemorrhagic: Occurs when a blood vessel in the brain ruptures, causing bleeding into the surrounding tissue.

Lifestyle and Substance Use:
- Smoking.
- $ETOH$ (alcohol) use.
- Sedentary lifestyle.
- Obesity.
- Illicit drug use.
Medical Conditions:
- Hypertension (High Blood Pressure).
- Hyperlipidemia (High Cholesterol).
- Hyperglycemia (High Blood Sugar).
- History of Deep Vein Thrombosis ( $DVT$ ).
- Atrial fibrillation ( $A-fib$ ).
Demographics and Medications:
- Age.
- Gender.
- Use of oral contraceptives.

Certain conditions can present with symptoms identical to a stroke and must be ruled out during assessment:
- Hypoglycemia: Low blood sugar can cause focal neurological deficits.
- Medication Adverse Effects: Certain drugs may cause stroke-like symptoms.
- Migraines: Complex or hemiplegic migraines can mimic acute neurological events.

The Immediate Goal: "Get Help ASAP!" to preserve brain tissue.
Diagnostic Imaging: A Head $CT$ scan is the priority to differentiate between ischemic and hemorrhagic stroke and determine the appropriate treatment path.
Pharmacological Intervention:
- tPA (Alteplase): A thrombolytic ("clot-busting") agent.
- Timing: Must be administered within $\mathbf{4}$ hours of the onset of symptoms.
- Nursing Priorities for tPA: Monitor for complications (bleeding), screen for contraindications, and perform routine, frequent neurological assessments.
Surgical and Mechanical Interventions:
- Mechanical Thrombectomy: Physical removal of a clot from a blood vessel.
- Surgical Repair: Necessary for certain hemorrhagic events or vascular abnormalities.
Ongoing Monitoring:
- Close neurological monitoring.
- Assess for risk for seizures.
- Multidisciplinary involvement: Physical Therapy ( $PT$ ), Occupational Therapy ( $OT$ ), and Speech-Language Pathology ( $SLP$ ).
- Care depends heavily on the specific affected areas of the brain.

Dysphagia: Difficulty swallowing.
Dysarthria: Difficulty with the articulation of speech due to muscle weakness.
Aphasia: Loss of ability to understand or express speech.
Apraxia: Inability to perform learned purposeful movements despite having the desire and physical capacity.
Agnosia: Inability to interpret sensory information or recognize objects/people.
Hemiparesis: Weakness on one side of the body.
Hemiplegia: Paralysis on one side of the body.
Ataxia: Lack of muscle coordination during voluntary movements.
Blindness: Visual field deficits or total loss of sight.
Decreased LOC: Lowered Level of Consciousness.

Dysphagia Management:
- Follow a specific dysphagia diet (e.g., Soft foods).
- No thin liquids: Liquids may require thickening to prevent aspiration.
- No straws: Straws can increase the risk of aspiration.
- Positioning: The patient must SIT UP! during and after meals.
Communication Strategies:
- Use simple, clear language.
- Break tasks down: One step at a time.
- Alternative communication: Get creative with tools (e.g., picture boards).
- Be patient!
Mobility and Physical Care:
- For patients with hemiparesis or hemiplegia: Provide care from the strong side and lead with the strong side during transfers.
Cognitive and Processing Concerns:
- Adjust the teaching approach based on the patient's individual processing speed and cognitive deficits.

Common Medications:
- Aspirin (Antiplatelet).
- Blood Pressure (BP) control agents.
- Lipid-lowering agents (e.g., Statins).
- Anticoagulation.
The "Goldilocks Rule" for Medication:
- Too Much: Risk for hemorrhage/bleeding.
- Too Little: Risk for further clotting/stroke.
- Just Right: Therapeutic level.
Warfarin Management:
- Requires regular monitoring of PT/INR.
- Typical Goal: INR of $2-3$ .
- Consistency: Keep dietary intake (especially Vitamin K) and medication timing consistent.
- Drug Interactions: Warfarin has a vast number of interactions with other medications.
- Safety: Implement bleeding precautions (e.g., soft toothbrush, electric razor).

Definition: Often described as a "mini-stroke," a TIA is a temporary interruption of blood flow to the brain.
Characteristics: It causes stroke-like symptoms that usually last only a few minutes. It serves as a critical warning sign for a future full-blown CVA.
Management Strategies (Similar to Stroke):
- Aspirin.
- Anticoagulants.
- Blood pressure control.
Procedures for Carotid Artery Disease:
- Carotid Endarterectomy: A surgical procedure where an incision is made in the neck to remove plaque from the carotid artery.
- Angioplasty and Stenting: A minimally invasive procedure where a balloon is inflated to open the blockage and a stent is placed to restore blood flow.

Case Study Question: When completing the admission assessment, you note that the client is experiencing left-sided upper extremity weakness, slurred speech, poor coordination, and the client is drooling slightly. How should the nurse document these findings?
- Findings Breakdown:
  - Left-sided upper extremity weakness: Hemiparesis.
  - Slurred speech: Dysarthria.
  - Poor coordination: Ataxia.
  - Drooling slightly: Risk for dysphagia.
- Correct Documentation Choice: Hemiparesis, dysarthria, ataxia, risk for dysphagia.

Case Studies: Students should refer to EVOLVE case studies and HESI PN Case Studies specifically regarding Stroke for further mastery.