NCM notes: CVA
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NCM notes: CVA






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NCM notes: CVA NCM notes: CVA Document Transcript

  • M. Bausing- January 20, 2012 2. Lacunar/Small penetrating artery thrombotic stroke (25%)- affect one or more vessels & areCerebrovascular disorder most common type; creates a cavity after the - Is an umbrella term that refers to a functional death of infracted brain tissue deep within abnormality of CNS that occurs when the brain; penumbra normal blood supply to the brain is disrupted - - stroke is the primary CVD in the US 3. Cardiogenic Embolic Stroke (20%)- blood clot from the heart carried in the bloodstream toAna-Physio: the brain; associated with dysrhythmiasLarge arteries: 4. Cryptogenic (30%)- no known causeInternal carotid artery 5. Others (5%)- illicit drug use, coagulopathies,Middle cerebral artery migraineBasilar artery RISK FACTORS:Circle of Willis- anterior and posterior Non-modifiable: - Collateral circulation of blood flow - Advanced age >55 - Gender: menCATEGORIES: - Race- group of African Americans twice as the 1. Hemorrhagic- (15%) extravasation of blood in Caucasian the brain (intracerebral) or subarachnoid space Modifiable: 2. Ischemic- (85%) vascular occlusion and significant hypoperfusion - Hypertension (major) - Differ in etiology, pathophysiology, medical and - Atrial fibrillation surgical management - Hyperlipidemia and obesity - Excessive alcohol consumption and smokingISCHEMIC STROKE - Stress - Brain attack or CVA - Asymptomatic carotid stenosis - 3rd leading cause of death (after heart attack - Transient ischemic attack and cancer) - Diabetes - 1st adult chronic disability Pathophysiology of Ischemic Stroke: - Can happen to anyone at any age - 795, 000 people experience stroke a year in the Risk factors occlusion  ischemia US; 500,000 are new and 200,000 are recurrent (<20ml/100ml/min) formation of penumbra (2009) - Blood clot blocks an artery serving the brain, (A) Aerobic respiration impaired  lactic acid  disrupting blood supply; totally occluded acidosisTypes:  (B) Cell membrane breakdown  neurotoxins released (glutamate, nitrate oxide) 1. Large artery thrombotic stroke (20%)- atherosclerotic plaques (thrombus) in the large (A & B) lead to influx of calcium and sodium  blood vessels cytotoxic edema and cell death
  • CxMx: (ACT FAST) o Unilateral neglect- disorder of attention, ignores the body part and - Face- ask the person to smile. Does one side of may even deny the paralysis the face drop? - Sensory loss - Arms- ask the person to raise both arms. Does o Loss of proprioception- ability to one arm drift downward? perceive the position & motion of body - Speech- ask the person to repeat simple parts sentences. Are the words slurred? Can s/he o Agnosia- inability to recognize familiar repeat the sentence correctly? objects - Time- if the person shows any of these sx, time o Apraxia- inability to perform previously is important—call for help. learned action - During attack: o Cognitive & behavioural changes- o Numbness or weakness of the face, depend on the lobe affected- may arm, or leg (most important sx), change in consciousness from mild usually half part of the body confusion to coma o Confusion or change in mental status o Diplopia- double vision o Trouble speaking or understanding speech Left hemispheric stroke: o Visual disturbances (can’t see half of - Paralysis/weakness on right of the body visual field) o Difficulty in walking, dizziness or loss of - Right visual field deficit balance and coordination - Aphasia o Sudden severe headache - Altered intellectual ability - Motor loss- upper motor neuron lesion results - Slow, cautious behaviour in loss of voluntary control over motor Right hemispheric stroke: movements o Hemiplegia- paralysis of one side of the - Paralysis/weakness on left side of the body body; most common - Left visual field deficit o Hemiparesis- weakness of one side of - Spatial-perceptual deficits the body—flaccidity and spasticity - Inc distractibility o Ataxia- involuntary twitching - Impulsive behavior and poor judgement - Communication loss - Lack of awareness of deficits o Aphasia- defective/loss of speech Dx:  Expressive damage to Broca’s Area- can’t express A. Noncontrast CT Scan  Receptive damage to Wernickes B. MRI Area- can’t understand C. 12 lead ECG & carotid ultrasound  Global or mixed- both D. Transcranial Doppler flow studies o Dysarthria- disturbance in muscular control of speech (difficulty in speaking) Therapeutics: - Perceptual disturbance- inability to interpret, A. Stroke prevention and attend to sensory data - Know your blood pressure o Hemianopsia- loss of the visual field of - Find out if you have atrial fibrillation each eye, temporary or permanent. The - Stop smoking affected side of vision corresponds to - Less alcohol the paralyzed side - Check if cholesterol is high
  • - Low sodium, low fat diet  No prior intracranial- Pharmacologic: hemorrhage, neoplasm, AVM, o ASA (Aspirin) & ticlopidine or aneurysm o Clopidogrel- dec incidence of cerebral  No stroke, serious head injury infarction in the pt who have intracranial surgery within experienced TIA 3months o Simvastatin- FDA included in the  No GIT or urinary bleeding secondary stroke prevention within 21 days.- For acute stroke: - Medical mgt: o Coumadin, Heparin and Enoxaparin a. Cerebral hemodynamics o ACE inhibitor and Thiazide diuretics o Intubation if necessary for patent o Corticosteroids & Mannitol airway- Thrombolytic therapy b. Preventing complications o t-PA (tissue plasminogen activator) o Bleeding (after rt-PA) o rapid dx & initiation within 3hrs o Cerebral edema (large ischemic strokes) decrease in the size of the stroke & an o Stroke recurrence and aspiration overall impact after 3 months c. Rehabilitation o Pt is to weighed to (0.9mg/kg with a d. Interdisciplinary management max dose of 90mg) o Physical, occupational and speech o 10% of the calculated dose is given IV therapy bolus over 1 min o Case management and resources o The remaining by IV over 1hr via - Surgical mgt: infusion pumps a. Carotid endarterectomy- removal of o S/E: Bleeding atheroscloretic plaque or thrombus o Antidote: Aminocaproic Acid from the carotid artery o Recombinant t-PA- is genetically b. Carotid stenting- less invasive engineered for of t-PA substance made procedure that is used at times for naturally by the body severe stenosis o Eligibility criteria for t-PA administration  Age 18yrs or older Nx Dx:  Clinical dx of ischemic stroke 1. Ineffective cerebral tissue perfusion  Time of onset of stroke known - Monitor LOC, cardiac status, & others and is 3 hours or less - Monitor respi status, airway patency esp those  SBP< 185, DBP <110 not intubated  Not a minor stroke or rapidly - Suction as necessary resolving - Place in a side-lying position  No seizure @ onset of stroke - Administer oxygen as prescribed  Not taking warfarin - Accurate I&O  Prothrombin time less than - Monitor for seizures 15sec or INR (international 2. Impaired physical mobility normalized ratio) less than 1- - Unilateral paralysis- correct positioning is 7sec important to prevent contractures; measures  Not receiving heparin during are used to relieve pressure the past 48hrs o Pillow may be placed in the axilla-  Platelet more than 100,000 prevent shoulder adduction
  • o Position fingers so that they are barely - Swallowing difficulties place pt at risk for flexed-palm faces upward- most aspiration, pneumonia, dehydration & functional position malnutrition o If sensation is impaired, amount time - Speech therapist spent on the affected side should be - Taught alternative swallowing techniques (take limited small boluses of food, puree foods) o If possible, place pt in prone position - Sit upright preferably in chair- tuck the chin 15-30 min several times a day- small towards the chest as he swallows pillow is placed under pelvis, extending 7. Urinary incontinence from the level of the umbilicus to the - Transient urinary control due to confusion upper third thigh- promotes - Offer bedpan at patterned schedule hyperextension of the joints and - High fiber diet and adequate fluid intake- unless prevents hip flexion contraindicated3. Acute pain - Regulate time for toileting is scheduled- Never lift the pt by flaccid shoulder movement, - Monitor I&O if with Mannitol or pull the affected arm or shoulder 8. Disturbed though process- Enhancing self-care - Structure a cognitive perceptual retraining, o As long as pt can sit- personal activities visual imagery, reality orientation & cueing are encourage procedures to compensate for loss o Do not neglect the affected side- - Give positive feedbacks and conveys attitude of assistive devices are used confidence and hope o Wide grip utensils- accommodate weak 9. Impaired verbal communication grasp - Speech therapist o Raise toilet seats - Sensitive to pt’s reaction & need o Cane, walkers, wheelchairs, transfer - Respond in an appropriate manner & consider boards and belts pts as adults4. Self-care deficit - Avoid completing the thoughts or sentences- As soon as pt can sit up, personal hygiene is - Communication boards0 pictures of common initiated; ADL’s maybe awkward but this maybe needs and phrases learned by repetition - When talking speak slowly in normal manner &- Nurse must be sure that pt does not neglect the tone affected side - Keep language instruction consistent- one at a- Clothing larger than the normally worn time- Place extremities where pt can see - Use of gestures may enhance comprehension5. Disturbed sensory perception - Talk during care of activities- provides social- Approach pt from the side where the visual contract perception is intact 10. Risk for impaired skin integrity- Pt is taught to turn the head in the direction of - Frequent assessment of the skin-bony the defective visual field to compensate for the prominence loss - Skin must be kept dry and clean, gentle- With homonymous hemianopsia- nurse massage in non-reddened area constantly remind the pt of the other side of 11. Sexual dysfunction the body to maintain alignment of the - Provide relevant info, education, reassurance, extremities, place the extremities where pt can adjustment of medications, counselling see them regarding coping with skills, suggestion of6. Impaired swallowing alternative sexual positions
  • HEMORRHAGIC STROKE A. Medical mgt- primarily supportive - Goals: - When a blood vessel in or around the brain o Allow brain to recover from bleeding bursts, causing a bleed or hemorrhage into the o Prevent and minimize the risk for re- brain tissue, ventricles or subarachnoid space bleeding - Accounts 15-20% of cerebrovascular disorders o Prevent or treat complications - Mortality is as high as 43% & 30 days after the - Bed-rest with sedation to prevent agitation and hemorrhage 25-60% stressCauses: - Manage vasopspasm: fluid volume expanders (albumin), calcium channel blockers 1. Rupture of small vessels due to uncontrolled - Analgesics: acetaminophen HPN (80%) B. Surgical management 2. AV Malformations- congenital, blood vessels are 1. Craniotomy- esp if the hematoma exceeds twitching 3cm and GCS is decreasing 3. Intracranial aneurysm (pouching), neoplasm 2. Prevent bleeding in an unruptured aneurysm 4. Medications- anticoagulants, amphetamines or further bldg in a ruptured aneurysm C. Nursing mgtPathophysio: - Optimize cerebral tissue perfusion- neurologicBleeding presses nearby brain tissue : assessment(A) brain metabolism disrupted - Relieving sensory deprivation and anxiety - Monitoring and managing potential(B) brain tissues exposed to blood (abnormal) complications o Vasopspasm (A&B) inc ICP  dec blood flow  ischemia o Seizure o Hydrocephalus o RebleedingCxMx: o Hyponatremia 1. Conscious pt- severe headache Nx Dx: 2. Vomiting 3. Early sudden change in LOC A. Ineffective cerebral tissue perfusion 4. Focal seizure due to frequent brain stem - Place on immediate and absolute bed rest- involvement anxiety increases BP 5. Nuchal rigidity- meningeal irritation - Low fowler-promote venous drainage and dec 6. Visual disturbances ICP 7. Tinnitus and dizziness, hemiparesis - Exertional activities are contraindicated 8. Coma and death- severe bleeding - Exhale through mouth during voiding and defecationComplications: - No enemas, but stool softeners are indicated - Elastic stockings and sequential compression 1. Cerebral hypoxia and dec blood flow- provide boots (ideal)- prevent DVT O2, HOB elevated - Nurse administer personal care, bathing, 2. Vasopasm feeding 3. Inc ICP - External stimuli are kept at minimum 4. Systemic HPN - Visitor restriction is placed on the door-Therapeutics: explained to family B. Disturbed sensory perception
  • C. AnxietyTRANSIENT ISCHEMIC ATTACK - Stroke ahead - Mini-strokes because they produce stroke-like symptoms but rarely cause lasting damage; lasting less than 24hrs - Resolving less than 1hr - Others seconds-minutes - Manifested by sudden loss of motor, sensory, or visual function- temporary impairment - May serve as a warning of an impending strokeRemember: - T: transient episode that clears in 12-24hrs - I: warning sign of Impending stroke - A: aspirin and anticoagulants to minimize risk of thrombosis