Cerebrovascular Accident (Stroke) Notes

Cerebrovascular Accident (Stroke)

  • Rapid loss of brain function due to disturbance in blood supply.

  • Persists more than 24 hours with no apparent cause other than vascular origin.

  • Also called "brain attack" or stroke.

Stroke: Blood Clot Mechanism

  1. Blood clot can form during atrial fibrillation.

  2. Blood clot travels in the bloodstream.

  3. Clot blocks an artery in the brain, causing stroke.

Risk Factors of Stroke

Fixed Risk Factors:

  • Age and Gender: Males are more prone than females.

  • Race: Asians are more prone than Europeans.

  • Heredity.

  • Previous vascular event (MI, peripheral embolism).

  • High fibrogen.

Modifiable Risk Factors:

  • High blood pressure.

  • Heart disease.

  • Diabetes mellitus.

  • Hyperlipidemia.

  • Smoking.

  • Excessive alcohol consumption.

  • Oral contraceptives.

  • Social deprivation.

  • Obesity, sedentary lifestyle.

Types of Stroke

  • Ischemic Stroke (85%)

    • Thrombotic

    • Embolic (most common)

  • Hemorrhagic Stroke (15%)

    • Intracerebral hemorrhage

    • Subarachnoid hemorrhage

Ischemic Stroke

  • Blood clot stops blood flow to an area of the brain.

  • Referred to as TIA (transient ischemic attack).

  • Most common form of stroke (85%).

Transient Ischemic Attack (TIA)

  • Area of the brain affected by TIA.

Causes of TIA

  • Large artery atherosclerosis.

  • Cardio-aortic embolism.

  • Small artery occlusion.

Causes of Thrombotic Ischemic Stroke

  • Lacunar stroke: Artery supplying the deeper portion of the brain is blocked.

  • Large vessel thrombosis.

  • Hypercoagulable disorders/thrombophilia.

Causes of Embolic Ischemic Stroke

  • Artery to artery.

  • Carotid bifurcation (divides into external and internal carotid arteries).

  • Aortic arch (section of the aorta between the ascending and descending aorta).

  • Cardioembolic Causes:

    • Atrial fibrillation.

    • MI.

    • Mural thrombosis.

    • Bacterial endocarditis.

    • Mitral stenosis.

Hemorrhagic Stroke

  • Caused by arteries in the brain either leaking blood or bursting open.

  • Rupture can be caused by:

    • Hypertension.

    • Trauma.

    • Blood-thinning medications.

    • Aneurysms (weakness in blood vessel walls).

Types of Hemorrhagic Stroke

  • Intracerebral Hemorrhagic Stroke

    • Most common type.

    • Brain tissue is flooded with blood after an artery in the brain bursts.

  • Subarachnoid Hemorrhagic Stroke

    • Bleeding occurs in the subarachnoid space – the area between the brain and the thin tissues that cover it.

Warning Signs of Stroke

  1. Weakness.

    • Sudden loss of strength or sudden numbness in the face, arm, or leg, even if temporary.

  2. Trouble speaking.

    • Sudden difficulty speaking or understanding or sudden confusion, even if temporary.

  3. Vision Problem.

  4. Headache.

  5. Dizziness.

Symptoms of Stroke

  1. Confusion, including trouble with speaking and understanding.

  2. Headache, possibly with altered consciousness or vomiting.

  3. Numbness of the face, arm, or leg particularly on one side of the body.

  4. Trouble with seeing, in one or both eyes.

  5. Trouble with walking, including dizziness and lack of co-ordination.

  6. Bladder or bowel control problems.

  7. Depression.

  8. Pain in the hands and feet that gets worse with movement and temperature changes.

  9. Paralysis or weakness on one or both sides of the body.

  10. Trouble controlling or expressing emotions.

Diagnostic Evaluation

  • Stroke happens fast and will often occur before an individual can be seen by a doctor for proper diagnosis

  • Acronym F.A.S.T. is a way to remember the signs of stroke and identify the onset more quickly.

F.A.S.T. Assessment

  • Face: Ask the person to smile. Does the face look uneven or does one side droop?

  • Arm: Ask the person to raise both of their arms. Does one arm drift down?

  • Speech: Ask the person to repeat a simple phrase. Does their speech sound strange?

  • Time: If you notice any of these signs, it's time to call 9-1-1!

Stroke Recognition: 3 Steps

  1. Ask the person to smile and stick out tongue.

  2. Ask the person to make a complete sentence.

  3. Ask the person to raise both arms.

  • Contact someone if the person cannot perform these 3

Other Diagnostic Evaluations

  • CT Scan: To determine type of stroke.

  • Physical examination.

  • Blood Test: To find how quickly blood clots, detect infection.

  • MRI scan: To create image of the brain tissue damage.

  • Carotid Ultrasound

  • Cerebral Angiogram

  • Echocardiogram

Management

  • Early Management: With a stroke, time lost is brain lost.

Primary and Secondary Prevention of Stroke

  • A = antiplatelet, anticoagulants

  • B = blood pressure lowering meds

  • C = cholesterol lowering, cessation of smoking

  • D = diet

  • E = exercise

Medical Management

  1. Anti-coagulants:

    • Heparin (IV)

    • Warfarin (oral)

  2. Anti platelets:

    • aspirin (oral)

    • Ticlopidine

    • Clopidogrel

  3. Hyperosmolar Agents:

    • Reduces cerebral edema

    • Mannitol IV

Surgical Management

  1. Craniectomy

    • Removal of a portion of skull to relieve pressure on the brain

  2. Hemispheric decompression

    • Removal of a large flap of the skull to give space for swollen brain to bulge and reduces ICP

Nursing Management

Nursing Assessment

  1. Presence or absence of voluntary or involuntary movements of extremities

  2. Stiffness or flaccidity of the neck

  3. Eye opening, comparative size of pupils, PERRLA

  4. Color of face and extremities; temperature and moisture of skin

  5. Ability to speak

  6. Presence of bleeding

  7. Maintenance of blood pressure

  8. Mental status

  9. Sensation and perception

  10. Motor control

Nursing Diagnosis

  1. Impaired physical mobility

  2. Acute pain

  3. Disturbed sensory perception

  4. Impaired urinary elimination

  5. Disturbed thought processes

  6. Impaired verbal communication

  7. Risk for impaired skin integrity

  8. Interrupted family processes

  9. Sexual dysfunction

Nursing Interventions

  1. Positioning to prevent contractures, relieve pressure, attain good body alignment.

  2. Prevent flexion of extremity

  3. Prevent adduction of shoulder by placing a pillow under the axilla

  4. Prevent edema by elevating affected extremity

  5. Maintain joint mobility by doing ROM exercises

  6. Prevent venous stasis by exercise

  7. Regain balance à sitting and standing

  8. Personal hygiene à encourage

  9. Manage sensory difficulties à approach patient on the side where vision is intact

  10. Visit a speech therapist à assess gag reflexes and assist in teaching swallowing techniques

  11. voiding pattern à schedule voiding and offer urinal

  12. Be consistent in patient’s activities

  13. Assess skin for signs of breakdown

Evaluation

  1. Improved mobility

  2. Absence of shoulder pain

  3. Self – care achieved

  4. Relief of sensory and perceptual deprivation

  5. Prevention of aspiration

  6. Continence of bowel and bladder

  7. Improved thought process

  8. Achieved a form of communication

  9. Maintained skin integrity

  10. Restored family functioning

  11. Improved sexual function

  12. Absence of complications

    • Tissue ischemia

    • Cardiac dysrhythmias