Neuro Conditions -TIA & Stroke

TIA & Stroke

Objectives

  • Provide safe, patient-centered nursing care using evidence-based practices for patients with sensory, perception, and cognition problems.
  • Identify developmental principles and prevention/early detection strategies for health problems to achieve optimal health for adult and older adult patients with sensory, perception, and cognition problems.
  • Differentiate medications prescribed for patients with common sensory, perception, and cognition problems.
  • Examine caring and professional behaviors required when providing nursing care for patients with sensory, perception, and cognition problems.
  • Examine effective communication (verbal, nonverbal, written, electronic) for the care of patients with sensory, perception, and cognition problems.
  • Use established practice standards and guidelines to ensure quality outcomes for patients with sensory, perception, and cognition problems.
  • Determine collaborative relationships needed to provide and improve care for patients with sensory, perception, and cognition problems.
  • Determine leadership skills required to provide care for patients with sensory, perception, and cognition problems.

Transient Ischemic Attack (TIA)

  • TIA: Temporary neurologic dysfunction from a brief interruption in cerebral blood flow.
  • Often a warning sign for acute ischemic strokes.
  • Symptoms typically resolve within 30-60 minutes but can last up to 24 hours.
  • Causes:
    • Carotid stenosis: Hardening and narrowing of the artery, decreasing blood flow to the brain, often due to atherosclerotic plaque buildup.
    • Atrial fibrillation.
  • ABCD Assessment Tool: Used to determine stroke risk after a TIA.
    • Age: ≥60 years (stroke risk increases with age).
    • Blood Pressure: ≥140/90 mm Hg (either systolic or diastolic).
    • Clinical TIA features: Unilateral weakness increases stroke risk.
    • Duration of symptoms: Longer duration increases stroke risk.
Key Features of TIA
  • Visual Symptoms:
    • Blurred vision
    • Diplopia (double vision)
    • Hemianopsia (vision affected in one or both eyes)
    • Tunnel vision
  • Mobility (Motor) Symptoms:
    • Weakness (facial droop, arm or leg drift, hand grasp)
    • Ataxia (lack of muscle control and coordination affecting gait, balance, and walking)
  • Sensory Perception Symptoms:
    • Numbness (face, hand, arm, or leg)
    • Vertigo (spinning or dizziness)
  • Speech Symptoms:
    • Aphasia (problems with speech and/or language)
    • Dysarthria (slurred speech caused by muscle weakness or paralysis)
Management of TIA
  • Treat the underlying cause.
  • Collaborative Interventions:
    • Surgery (traditional or minimally invasive) to remove atherosclerotic plaque and increase brain perfusion.
    • Carotid angioplasty with stenting to increase brain perfusion.
    • Antiplatelet drugs (aspirin, clopidogrel, or combination) to prevent thrombotic or embolic strokes.
    • Reducing high blood pressure by adjusting medications.
    • Controlling diabetes and maintaining glucose levels within a target range (100-180 mg/dL).
    • Promoting lifestyle changes: Smoking cessation, heart-healthy foods, increased mobility and physical activity.

Stroke

  • Stroke, or brain attack, is a leading cause of death in the United States.
  • A stroke occurs when cerebral circulation is interrupted, resulting in neurological deficits.
  • Ischemia quickly alters cerebral metabolism and causes infarction.
  • Extent of infarction depends on the location and size of the occluded artery and collateral circulation.
  • Anoxia longer than 10 minutes results in tissue infarct and irreversible damage.
Types of Stroke
  • Ischemic Stroke:
    • Occlusion leads to ischemia in brain tissue and edema in surrounding tissue.
    • Caused by cerebral thrombosis (with atherosclerosis as primary cause) or an embolus.
    • Edema may subside, and function may be regained.
  • Hemorrhagic Stroke:
    • Rupture of arteriosclerotic and hypertensive vessels causes bleeding into brain tissue.
    • Intracerebral hemorrhage is often secondary to hypertension and common after age 50.
    • Aneurysms (weakened outpouchings in a vessel wall) can cause hemorrhage.
    • Arteriovenous malformations (AVMs) can rupture, leading to hemorrhagic stroke.
  • A stroke is a medical emergency requiring immediate diagnosis to reduce impairment.
Causes and Risk Factors
  • Hypertension
  • Cardiovascular disease
  • Diabetes Mellitus
  • Anti-coagulation therapy
  • Stress
  • Obesity
  • Oral contraceptives
  • Carotid artery disease
  • Physical inactivity
  • Excessive alcohol intake
  • Smoking
  • High cholesterol
Pathophysiology
  • The brain requires a constant blood flow to function normally.
  • Interruption of blood flow for several minutes leads to tissue death and infarction.
  • Cell death impairs normal brain activities, causing deficits depending on lesion size and location.
Clinical Manifestations of Thrombotic Stroke
  • Symptoms develop slowly over hours to days.
  • Patient remains conscious and has hypertension.
  • Possible symptoms: headache, dizziness, weakness/paralysis, numbness, visual disturbance, difficulty walking.
  • Thrombosis causes narrowing of the artery.
Clinical Manifestations of Hemorrhagic Stroke
  • Occurs while active.
  • Minutes to 1 hour after, hours to days after.
  • Patient may rapidly progress to a coma.
  • Rapid onset of complete hemiplegia, severe headache, and nuchal rigidity.
Clinical Manifestations of Embolic Stroke
  • No time pattern; occurs without warning.
  • 10-30 seconds, hours to days after.
  • Patient remains conscious and is normotensive.
  • An embolus detaches and lodges in a cerebral artery.
Common Clinical Manifestations
  • FACETS:
    • Face drooping
    • Arm weakness
    • Speech difficulty
    • Time to call
  • Hemiparesis (weakness)
  • Hemiplegia (paralysis)
  • Visual disturbances
  • Speech alterations
  • Dysphagia (difficulty swallowing)
  • Musculoskeletal deficits
  • Agnosia (inability to recognize objects)
  • Unilateral neglect
Specific Clinical Manifestations
  • Hemiparesis/Hemiplegia: Weakness or paralysis on one side of the body.
  • Apraxia: Difficulty with skilled movements; inability to perform purposeful movements despite having the physical ability.
  • Vision Loss/Alteration: Impaired visual acuity, diplopia, depth perception, and perception of horizontal and vertical planes.
  • Homonymous Hemianopia: Visual loss in the same half of the visual field in each eye; patient sees clearly on one side but not the other; they must turn their head to see the other side.
  • Aphasia: Inability to communicate.
    • Expressive Aphasia: Difficulty using words and sentences.
    • Receptive Aphasia: Problems understanding others.
    • Global Aphasia: Affects both speech comprehension and production.
  • Dysphagia: Difficulty swallowing.
    • Assess cranial nerves for gag reflex; aspiration risk; keep NPO (nothing by mouth).
  • Agnosia: Inability to recognize familiar objects through the senses (visual or auditory).
  • Unilateral Neglect: Inability to respond to stimuli on the contralateral side of the infarction.
    • Teach patient to turn their head to scan the environment.
Labs and Diagnostics
  • ECG (Electrocardiogram)
  • CT (Computerized Tomography) scan of the brain
  • MRI (Magnetic Resonance Imaging) scan
  • Carotid Duplex Ultrasonography: To check for carotid stenosis
  • Angiogram of the head: To reveal blocked or bleeding vessels
  • CBC (Complete Blood Count)
  • PT/INR/PTT (Prothrombin Time/International Normalized Ratio/Partial Thromboplastin Time): Blood clotting tests
  • Serum Cholesterol
  • Glucose
  • Spinal Fluid Analysis (Spinal Tap)
Therapeutic Management
  • Management depends on whether the stroke is ischemic (blood clot) or hemorrhagic (bleeding in the brain).
  • Treatment focuses on restoring blood flow for ischemic stroke and controlling bleeding/cranial pressure for hemorrhagic stroke.
  • Controlling blood pressure is another goal.
  • Medications:
    • Tissue Plasminogen Activator (tPA)
    • Anticoagulant therapy
    • Antiplatelets
    • Calcium channel blocker
    • Stool softeners
    • Analgesics
    • Antianxiety medications
Tissue Plasminogen Activator (tPA)
  • tPA dissolves blood clots (clot buster).
  • Thrombolytic agents dissolve the thrombus or embolus blocking cerebral blood flow.
  • Crucial factor: time between symptom onset and arrival at the stroke center (3-4.5 hour window).
  • IV alteplase is the only drug approved for acute ischemic stroke.
  • Routine lab tests (PT, INR, aPTT) are needed before fibrinolytic or anticoagulation therapy.
  • tPA cannot be given to patients with hemorrhagic stroke.
Nursing Interventions During and After IV Alteplase Administration
  • Explain the procedure and obtain consent.
  • Administer IV alteplase (90 mg) over 60 minutes.
  • Monitor LOC (Level of Consciousness), vital signs every 10-15 minutes during and every 30 minutes after for 6 hours.
  • Maintain BP below 185/110 mm Hg using IV labetalol (beta-blocker) only if BP exceeds this limit.
  • Avoid arterial punctures, NG tube insertions, rectal thermometers/medications for 24 hours after infusion.
  • Discontinue infusion and notify PCP immediately if patient has severe headache, severe hypertension, bleeding, nausea, or vomiting.
  • Maintain bed rest for 24 hours after completion of the infusion.
  • Obtain a follow-up CTA scan after therapy and before starting antiplatelet or anticoagulant drugs.
Medical/Surgical Management of Ischemic Stroke
  • Immediate Treatment:
    • Intravenous injection of tissue plasminogen activator (tPA) within a 4.5-hour window.
  • Surgical Interventions:
    • Embolectomy
    • Carotid artery angioplasty
  • Aspirin to reduce the likelihood of another stroke.
Additional Therapeutic Management
  • Assess and maintain blood pressure as close to normal as possible.
  • Maintain normothermia to reduce cerebral glucose and oxygen consumption.
  • Organize nursing activities to decrease patient stimuli.
  • Keep the head of the bed at 30 degrees to reduce cerebral edema.
  • Maintain the patient's head in a neutral position to improve venous drainage.
  • Implement nursing interventions for preventing skin breakdown and contractures.
  • Medications:
    • Anticoagulants (heparin, warfarin) for atrial fibrillation (AF) to prevent micro clots.
    • Aspirin (low dose) and other antiplatelets for acute ischemic strokes and future prevention.
    • Calcium channel blockers to prevent further vasospasms after subarachnoid hemorrhages.
    • Stool softeners, analgesics, and antianxiety medications as needed.
Surgical Management of Hemorrhagic Stroke
  • Ligation of the vessel
  • Clips to stop the bleeding
  • Mesh to direct blood flow away from malformed vessel
Nursing Care and Patient Teaching
  • Nursing Care:
    • Outcome goals
    • Physical assessment
    • Health history
    • Neurological assessment
    • Patient/family teaching
  • Patient Teaching:
    • Lifestyle changes
    • Medication management
    • Therapy management
    • Self-management
    • Health care services
Assessment
  • Physical assessment and health history: Determine when symptoms started, what the patient was doing, and if symptoms are still present; inquire about medications and head injuries.
  • Assess blood pressure and check carotid arteries for a bruit.
  • During the initial stroke: Assess unstable patients every 15 minutes, stable patients every 2-4 hours.
  • Analyze data for trends and notify the PCP if the patient is deteriorating neurologically.
    • Manifestations of progressive deterioration: decreasing LOC, changes in motor or sensory function, pupillary changes, respiratory difficulty, visual or perceptual defects, or aphasia.
  • For hemorrhagic stroke: Monitor for increased pressure on the brain (ICP), such as restlessness, confusion, difficulty following commands, and headache.
  • Implement nursing measures to prevent straining during bowel movements, excessive coughing, vomiting, or lifting.
Speech Therapy
  • Evaluate the patient for dysphagia and aspiration risk; prescribe a dysphagia diet if necessary.
  • Position patient in Fowler’s position to eat.
  • Avoid straws and un-thickened liquids.
  • Alternate liquids with solids to prevent food from being left in the mouth.
  • Place food in the unaffected side of the mouth and have the patient chew each bite thoroughly.
  • After swallowing, check for food on the affected side by turning the head to the unaffected side and sweeping the mouth with the tongue.
  • Minimize distractions during meals.
  • Include a dietician as part of the care team.
Physical Therapy
  • Assess the patient and develop a plan of care.
  • Help the patient out of bed as soon as medically stable.
  • Provide assistance due to potential balance issues from hemiplegia.
  • Raise the head of the bed slowly to reduce orthostatic hypotension.
  • Monitor for balance and safety awareness when assisting the patient to sit up.
  • Follow guidelines for transferring patients and for wheelchair transfers.
Occupational Therapy
  • Assist the patient with self-care issues.
  • Reorient disoriented patients frequently.
  • Use glasses and hearing aids to maintain environmental awareness and improve thought processes.
  • Schedule activities like sitting up in a chair for meals to improve LOC and orientation.
  • Position a calendar and a clock where the patient can see them.
  • Address altered behavioral patterns, including confusion, memory loss, and emotional lability.
  • Explain all nursing activities to decrease agitation.
  • Avoid sensory overload.
Unilateral Neglect Interventions
  • Greet the patient upon entering the room and position the bed to view the doorway.
  • Keep personal care items, bedside chair, and commode on the unaffected side; set up the food tray toward the unaffected side.
  • Correctly align the patient’s extremities.
  • Gradually focus the patient's attention to the affected side by moving personal items, bedside chair, and commode to the affected side.
  • Assist the patient from the affected side and have them groom the affected side first.
  • Cue the patient to scan the entire environment and remind them to keep track of the affected extremities.
Address Psychosocial Aspects
  • Acknowledge the feelings of profound suffering related to stroke-related changes.
  • Be understanding and kind.
  • Offer supportive statements, such as “I am sure it's hard for you not to be able to dress alone.”
  • Ensure the patient feels listened to and cared about.
  • Consider transfer to a rehabilitation center for ongoing therapy once medically stable.
Potential Complications
  • Permanent disability
  • Inability to care for self
  • Institutional placement
  • Further occurrence of strokes
  • Death