CVA

CVA and Increased Intracranial Pressure

  • Definition and Overview

    • CVA (Cerebrovascular Accident) often results in increased Intracranial Pressure (ICP) due to fluid accumulation.
    • Increased ICP leads to swelling and stress on the brain.
    • This condition is considered a medical emergency that necessitates prompt intervention.

  • Signs and Symptoms of Increased ICP

    • Decreased Level of Consciousness: Initial and crucial sign.
    • Additional Symptoms:
    • Restlessness
    • Irritability
    • Confusion
    • Headache
    • Nausea and Vomiting
    • Changes in speech pattern
    • Change in sensorimotor status
    • Seizures
    • Cushing's Triad:
      • Severe hypertension
      • Widened pulse pressure
      • Bradycardia
    • Posturing: Abnormal postures may be exhibited.

  • Other Complications Associated with Increased ICP

    • Hydrocephalus (accumulation of cerebrospinal fluid)
    • Vaso- and arterial spasms
    • Occurrence of seizures

Blood Pressure Control

  • Ischemic Stroke Management

    • Clients require slightly elevated blood pressure to facilitate circulation around obstructed vessels.
    • Utilize a flat head of the bed to minimize cardiac workload.
    • Use of Pressors:
    • Medications such as Neo-Synephrine may be administered to raise blood pressure.

  • Hemorrhagic Stroke Management

    • Clients necessitate a lowered blood pressure to mitigate further bleeding.
    • Elevate the head of the bed to a position of 30-45° for adequate drainage.
    • Antihypertensives:
    • Nicardipine can be used to effectively reduce blood pressure.

Ongoing Therapy in Stroke Management

  • Post-Ischemic Stroke Therapy

    • Patients are typically prescribed:
    • Antithrombotic/Anticoagulant Medications:
      • Aspirin
      • Antiplatelet Agent: Plavix
      • Warfarin: Used in cases of atrial fibrillation to maintain anticoagulation for cerebral circulation.
    • Antihypertensives: Examples include ACE inhibitors and diuretics (e.g., Hydrochlorothiazide).
    • Stool Softeners: Employed to prevent straining, which can increase ICP.

  • Post-Hemorrhagic Stroke Therapy

    • Key medication includes Nimodipine, a calcium channel blocker that:
    • Effectively crosses the blood-brain barrier.
    • Prevents vaso- and arterial spasms.
    • Stool softeners are also advised to prevent complications.

Types of Ischemic Stroke

  • Thrombotic Stroke:

    • Occurs as a result of a stationary thrombus, typically due to atherosclerosis.
    • Develops slowly, leading to a gradual reduction in oxygen supply.

  • Embolic Stroke:

    • Resulting from a mobile clot that lodges into vessels quickly.
    • Causes an abrupt interruption in cerebral perfusion, creating an immediate medical emergency.

  • Treatment Importance

    • A crucial time-sensitive treatment window exists; "Time is brain tissue":
    • The longer the delay in treatment, the greater the risk of permanent disability due to brain tissue loss.

  • Consequences of Stroke

    • Often leads to contralateral injuries:
    • Right-brain stroke results in left-side weakness or paralysis and vice versa.
    • Brain Edema: Increased intracranial pressure may cause additional secondary injuries.

Tissue Plasminogen Activator (TPA) Administration Guidelines

  • Preparation for TPA Administration:

    • Prior checks include coagulative values to assess the risk of bleeding.
    • Measure the client’s blood pressure:
    • If greater than 180 mmHg, administer IV antihypertensives and closely monitor blood pressure.

  • Administration Protocol for TPA:

    • Do not perform IV push except for the initial 10% bolus given over one minute by an experienced critical care nurse.
    • The remaining dosage is administered over 60 minutes.
    • Transfer clients immediately to a critical care unit with staff trained in TPA management.

  • Monitoring During TPA Therapy:

    • Conduct frequent neurological checks, ideally every 15 minutes to one hour.
    • Discontinue TPA if neurological status declines, indicating a shift from ischemic to hemorrhagic stroke.
    • Continue TPA if the patient's neurological condition improves.
    • After the initiation of TPA, avoid any invasive lines for 24 hours.
    • Refer to the textbook for comprehensive care practices for clients undergoing TPA therapy.