NCM notes: CVA


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NCM notes: CVA

  1. 1. 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
  2. 2. 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
  3. 3. - 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
  4. 4. 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
  5. 5. 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
  6. 6. 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