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    Cva Cva Presentation Transcript

    • Brain Attack NR-75DDiana Diaz RN, MS
    • Objectives Define “stroke” Discuss incidence & risk factors Review Cerebral flow and factors that affect it Discuss pathophysiology of CVA Correlate clinical manifestations of stroke with the pathophysiology.
    • History of Stroke Hippocrates-2,400 yrs ago Names for Stroke Most commonly known today  Brain Attack
    • Definition Ischemia is inadequate blood flow Brain attack (Stroke) occurs when there is ischemia to a part of the brain that results in death of brain cells
    • Incidence 3rd Cause of death in US and Canada  Statistics 2/3 in people >65 = in men and women Higher incidence and death rates among African-Americans, Hispanics, Native-American, Asian Americans
    • Risk FactorsNon Modifiable Age Gender Race Heredity
    • Risk FactorsModifiable  Asymptomatic Obesity carotid stenosis HTN  Diabetes mellitus Smoking  Heart disease, atrial Heavy alcohol fibrillation consumption  Oral contraceptives Hypercoagulability  Physical inactivity Hyperlipidemia  Sickle cell disease
    • Review of Cerebral Circulation
    • Blood supply by arteries Blood is supplied to the brain by two major pairs of arteries  Internal carotid arteries  Vertebral arteries
    • Blood supply by arteries Carotid arteries branch to supply most of the  Frontal, parietal, and temporal lobes  Basal ganglia  Part of the diencephalon  Thalamus  Hypothalamus
    • Blood supply by arteries Vertebral arteries join to form the basilar artery, which supply the  Middle and lower temporal lobes  Occipital lobes  Cerebellum  Brainstem  Part of the diencephalon
    • “Brain Attack” means: Blood flow to the brain is totally interrupted
    • Etiology Atherosclerosis – Disease of the arteries; hardening and thickening of the arterial wall because of soft deposits of intraarterial fat and fibrin that harden over time.
    • Common sites for thedevelopment of Atherosclerosis
    • Transient Ischemic Attack (TIA) Transient ischemic attack (TIA) is a temporary focal loss of neurologic function caused by ischemia Most TIAs resolve within 3 hours TIAs are a warning sign of progressive cerebrovascular disease
    • Types of Stroke Strokes are classified based on the underlying pathophysiologic findings  Ischemic  Hemorrhagic
    • Ischemic vs. Hemorrhagic
    • Ischemic Stroke Ischemic strokes result from inadequate blood flow to the brain from partial or complete occlusion of an artery 85% of all strokes are ischemic strokes
    • Ischemic Stroke Thrombotic or Embolic Most patients with ischemic stroke do not have a decreased level of consciousness in the first 24 hours May progress in the first 72 hours
    • Thrombotic stroke Thrombosis occurs in relation to injury to a blood vessel wall and formation of a blood clot Result of thrombosis or narrowing of the blood vessel Most common cause of stroke
    • Embolic stroke Occur when an embolus lodges in and occludes a cerebral artery Results in infarction and edema of the area supplied by the involved vessel Second most common cause of stroke
    • Embolic stroke Majority of emboli originate in the inside layer of the heart, with plaque breaking off from the endocardium and entering the circulation Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms
    • Hemorrhagic Stroke Account for approximately 15% of all strokes Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles
    • Hemorrhagic Stroke Intracerebral hemorrhage  Bleeding within the brain caused by a rupture of a vessel  Hypertension is the most important cause  Hemorrhage commonly occurs during periods of activity
    • Hemorrhagic Stroke Intracerebral hemorrhage  Manifestations include neurologic deficits, headache, nausea, vomiting, decreased levels of consciousness, and hypertension
    • Hemorrhagic Stroke Subarachnoid hemorrhage  Occurs when there is intracranial bleeding into cerebrospinal fluid-filled space between the arachnoid and pia mater  Commonly caused by rupture of a cerebral aneurysm
    • Clinical Manifestations Affects many body functions  Motor activity  Elimination  Intellectual function  Spatial-perceptual alterations  Personality  Affect  Sensation  Communication
    • Clinical Manifestations Brain attack  Term increasingly being used to describe stroke and communicate urgency of recognizing stroke symptoms and treating their onset as a medical emergency
    • Clinical ManifestationsMotor Function Most obvious effect of stroke Include impairment of  Mobility  Respiratory function  Swallowing and speech  Gag reflex  Self-care abilities
    • Clinical ManifestationsMotor Function An initial period of flaccidity may last from days to several weeks and is related to nerve damage Spasticity of the muscles follows the flaccid stage and is related to interruption of upper motor neuron influence
    • Clinical ManifestationsCommunication Patient may experience aphasia when a stroke damages the dominant hemisphere of the brain  Aphasia is a total loss of comprehension and use of language
    • Clinical ManifestationsCommunication Dysphasia refers to difficulty related to the comprehension or use of language and is due to partial disruption or loss Dysphasia can be classified as nonfluent or fluent
    • Clinical ManifestationsCommunication Dysarthria does not affect the meaning of communication or the comprehension of language It does affect the mechanics of speech
    • Clinical ManifestationsAffect Patients who suffer a stroke may have difficulty controlling their emotions Emotional responses may be exaggerated or unpredictable
    • Clinical ManifestationsIntellectual Function Both memory and judgment may be impaired as a result of stroke A left-brain stroke is more likely to result in memory problems related to language
    • Clinical ManifestationsSpatial-Perceptual Alterations Stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation However, this may occur with left- brain stroke
    • Clinical ManifestationsSpatial-Perceptual Alterations Spatial-perceptual problems may be divided into four categories 1. Incorrect perception of self and illness 2. Erroneous perception of self in space
    • Clinical ManifestationsSpatial-Perceptual Alterations 1. Inability to recognize an object by sight, touch, or hearing 2. Inability to carry out learned sequential movements on command
    • Clinical ManifestationsElimination Most problems with urinary and bowel elimination occur initially and are temporary When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is excellent
    • Diagnostic Studies When symptoms of a stroke occur, diagnostic studies are done to  Confirm that it is a stroke  Identify the likely cause of the stroke CT is the primary diagnostic test used after a stroke
    • Diagnostic Studies Additional studies  Complete blood count  Platelets, prothrombin time, activated partial thromboplastin time  Electrolytes, blood glucose  Renal and hepatic studies  Lipid profile
    • Collaborative CarePrevention Goals of stroke prevention include  Health management for the well individual  Education and management of modifiable risk factors to prevent a stroke
    • Collaborative CarePrevention Antiplatelet drugs are usually the chosen treatment to prevent further stroke in patients who have had a TIA Aspirin is the most frequently used antiplatelet drug
    • Collaborative CarePrevention Surgical interventions for the patient with TIAs from carotid disease include  Carotid endarterectomy  Transluminal angioplasty  Stenting  Extracranial-intracranial bypass
    • Collaborative CareAcute Care Assessment findings  Altered level of consciousness  Weakness, numbness, or paralysis  Speech or visual disturbances  Severe headache  ↑ or ↓ heart rate  Respiratory distress  Unequal pupils
    • Collaborative CareAcute Care Interventions – Initial  Ensure patient airway  Remove dentures  Perform pulse oximetry  Maintain adequate oxygenation  IV access with normal saline  Maintain BP according to guidelines
    • Collaborative CareAcute Care Interventions – Initial  Remove clothing  Obtain CT scan immediately  Perform baseline laboratory tests  Position head midline  Elevate head of bed 30 degrees if no symptoms of shock or injury
    • Collaborative CareAcute Care Interventions – Ongoing  Monitor vital signs and neurologic status  Level of consciousness  Motor and sensory function  Pupil size and reactivity  O2 saturation  Cardiac rhythm
    • Collaborative CareAcute Care Recombinant tissue plasminogen activator (tPA) is used to  Reestablish blood flow through a blocked artery to prevent cell death in patients with acute onset of ischemic stroke symptoms
    • Collaborative CareAcute Care Thrombolytic therapy given within 3 hours of the onset of symptoms  ↓ disability  But at the expense of ↑ in deaths within the first 7 to 10 days and ↑ in intracranial hemorrhage
    • Collaborative CareAcute Care Surgical interventions for stroke include immediate evacuation of  Aneurysm-induced hematomas  Cerebellar hematomas (>3 cm)
    • Collaborative CareRehabilitation Care After the stroke has stabilized for 12-24 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning Patient may be transferred to a rehabilitation unit
    • Nursing ManagementNursing Implementation Respiratory System  Management of the respiratory system is a nursing priority  Risk for aspiration pneumonia  Risks for airway obstruction  May require endotracheal intubation and mechanical ventilation
    • Nursing ManagementNursing Implementation Neurologic System  Monitor closely to detect changes suggesting  Extension of the stroke  ↑ ICP  Vasospasm  Recovery from stroke symptoms
    • Nursing ManagementNursing Implementation Cardiovascular System  Monitoring vital signs frequently  Monitoring cardiac rhythms  Calculating intake and output, noting imbalances  Regulating IV infusions
    • Nursing Management Nursing Implementation Cardiovascular System  Adjusting fluid intake to the individual needs of the patient  Monitoring lung sounds for crackles and rhonchi (pulmonary congestion)  Monitoring heart sounds for murmurs or for S3 or S4 heart sounds
    • Nursing Management Nursing Implementation Musculoskeletal System  Trochanter roll at hip to prevent external rotation  Hand cones to prevent hand contractures  Arm supports with slings and lap boards to prevent shoulder displacement
    • Nursing ManagementNursing Implementation Integumentary System  Skin of the patient is susceptible to breakdown related to loss of sensation, ↓ circulation, and immobility  Compounded by patient age, poor nutrition, dehydration, edema, and incontinence
    • Nursing Management Nursing Implementation Integumentary System  Pressure relief by position changes, special mattresses, or wheelchair cushions  Good skin hygiene  Emollients applied to dry skin
    • Nursing Management Nursing Implementation Integumentary System  Early mobility  Position patient on the weak or paralyzed side for only 30 minutes
    • Nursing ManagementNursing Implementation Gastrointestinal System  After careful assessment of swallowing, chewing, gag reflex, and pocketing, oral feedings can be initiated  Feedings must be followed by scrupulous oral hygiene
    • Nursing ManagementNursing Implementation Communication  Nurse’s role in meeting psychologic needs of the patient is primarily supportive  Patient is assessed both for the ability to speak and the ability to understand  Speak slowly and calmly, using simple words or sentences
    • Nursing ManagementNursing Implementation Sensory-Perceptual Alterations  Blindness in the same half of each visual field is a common problem after stroke  Other visual problems may include diplopia (double vision), loss of the corneal reflex, and ptosis (drooping eyelid)
    • Nursing ManagementNursing Implementation Ambulatory and Home Care  The rehabilitation nurse assesses the patient and family with  Rehabilitation potential of the patient  Physical status of all body systems  Presence of complications caused by the stroke or other chronic conditions  Cognitive status of the patient
    • Nursing ManagementNursing Implementation Ambulatory and Home Care  The patient is usually discharged from the acute care setting to home, an intermediate or long-term care facility, or a rehabilitation facility
    • Nursing ManagementNursing Implementation Ambulatory and Home Care  Nurses have an excellent opportunity to prepare the patient and family for discharge through  Education  Demonstration  Practice  Evaluation of self-care skills