Cerebral-vascular Accidents

1. Cerebral-vascular Accidents By: Emma Fleck

2. Objectives • Pathophysiology/types/signs • Relevance to population: age, gender, congenital • Current treatment and modalities • Diagnostic tests/labs • Medications • Prognosis/outcome • Nursing diagnosis • NCLEX questions

3. Pathophysiology • A stroke is a sudden, nonconvulsive focal neurologic deficit (Huether, 2011). • The interruption deprives the brain of blood and oxygen, thereby causing brain cells to die (Kerr,2012). • Normal functions may become impaired or lost, causing paralysis, speech and language problems, memory and reasoning deficits, coma, and possibly death (Kerr,2012).

4. Pathophysiology • CVAs are the leading cause of disability and the third cause of death in the United States (Huether, 2011). • About 75% of CVAs occur among those older than 65 years (Huether, 2011). • Person’s with both hypertension and type 2 diabetes mellitus have a increase in stroke incidence (Huether, 2011). • More common in men at younger ages (Huether, 2011). • Smoking, being overweight, having a high alcohol intake, and having high blood pressure can increase a person’s risk for a stroke to occur (Huether, 2011).

5. Pathophysiology • Two main types of strokes • Ischemic (clots) • Thrombotic & embolic • Hemorrhagic (bleeds) • Subarachnoid hemorrhage (SAH) & Intracerebral hemorrhage (ICH)

6. Pathophysiology • Thrombotic stroke • Arterial occlusions caused by thrombi formed in arteries supplying the brain or in the intracranial vessels (Huether, 2011). • Embolic stroke • Fragments that break from a thrombus formed outside the brain (Huether, 2011). • In persons who experienced an embolic stroke, a second stroke usually follows because the source of emboli continues to exist ("American stroke association," 2012)

7. Pathophysiology • Lacunar stroke • Are caused by occlusion of a single deep perforating artery that supplies small penetrating subcortical vessels, causing ischemic lesions (Huether, 2011). • Transient ischemic attack • Brief episode of neurologic dysfunction, stroke symptoms (Huether, 2011).

9. Pathophysiology • Hemorrhagic stroke • Results from a weakened vessel that ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue (Huether, 2011). • Subarachnoid hemorrhage (SAH) -bleeds into the space between the brain and the skull ("American stroke association," 2012) • Intracerebral hemorrhage (ICH) occurs when a blood vessel bleeds into the tissue deep within the brain. ("American stroke association," 2012)

10. Pathophysiology • Common signs and symptoms of CVAs • Unilateral limb weakness, numbness • Speech difficulties • Headache, visual disturbances • Dizziness, anxiety • Altered level of consciousness • Lippincott. (2010) • Signs and symptoms differ depending on the region of the brain effected..

11. Medical & Nursing Interventions and Care Guidelines • “The Stroke Association (2011) described stroke rehabilitation as ‘the process of overcoming or learning to cope with the damage a stroke has caused.” (Kerr, 2012) • Key elements of nursing rehabilitation roles: • Assessment. • Communication. • Technical and physical care. • Therapy integration • Therapy carry on (therapy that is initiated by other health professionals but carried out by nurses). • Emotional support for patients and their families. (Kerr, 2012)

12. Medical & Nursing Interventions and Care Guidelines • Nurses often work closely with patients who have survived a stroke to encourage behavior change in areas such as diet, physical activity, smoking, weight management and medication concordance (Kerr, 2012) • identifying, initiating and maintaining lifestyle change. For example, blood pressure management necessitates knowledge of the specific medication used, its mode of action and potential side effects, as well as physiological monitoring and reporting on the effectiveness of any medication (Kerr, 2012) • Discharge planning draws on skills of communication, delegation and resource management, frequently requiring nursing liaison and co-ordination with another multidisciplinary (Kerr, 2012)

14. Patient Case Scenario • The patient is a 81 year-old white female who was found unresponsive by staff at a nursing home around 7:30 AM on October 22-2012. • The patient presented characteristics of high blood pressure, right sided weakness, unable to follow commands, awake, and had abnormal speech. • Patient has a history of: high cholesterol, smoked for about 40 years, has diabetes type 2, and has high blood pressure

15. What was done in the hospital • When patient arrived to the hospital, CT scans and a chest X-ray were given. • CT scan shows that patient suffered from a left frontal lacunar stroke and chest x-rays gives the impression of patchy bibasilar opacitites due to infiltrate or atelectasis. • The patient continued her stay for stroke monitoring and medications for her type 2 diabetes and heparin/aspirin to reduce clotting. Interventions were to have full liquid diet due to difficulty swallowing, to get a speech therapist, and physical therapist. • On 10-24-12, the patient states that she is not in any pain and that she wants to leave the hospital, however there is still some slight right sided weakness due to unbalanced gait.

16. Test/labs • XR chest (10/22 0954): Impression: Patchy bibasilar opacitites may be due to infiltrate or atelectasis (this shows that patient has pneumonia) • CT Head/Brain WO Contrast STRO (10/22 0939): Impression: hypodensity consistent with infarct in the • Left frontal region medially adjacent to the anterior portion of the left lateral ventricle. Age indeterminate, appears old, but can be subacute, correlate with symptoms. Age appropriate atrophy

17. Test/labs

18. Test/labs • How does a CT scan work? • Bone absorbs the most X-rays, so the skull appears white on the image. • Water (in the cerebral ventricles or fluid-filled cavities in the middle of the brain) absorbs little, and appears black. • The brain has intermediate density and appears grey. • Most ischemic strokes are less dense (darker) than normal brain • whereas blood in hemorrhage is denser and looks white on CT. • ("CT Scan," 2011)

19. Medications • Patient was prescribed aspirin and heparin to stop the blood from clotting. • “For people who have an ischemic stroke, the goal of treatment is to restore blood flow to the affected area of the brain as quickly as possible. (Sweileh,2009). • For hemorrhagic strokes, antihypertensive medications are used to lower blood pressure. • If anticoagulant medications, such as warfarin or heparin, are the cause, they are immediately discontinued and other drugs may be given to increase blood coagulation. (Sweileh,2009).

20. Prognosis/Outcome • People often begin to recover within hours or days after a lacunar stroke (Bethesda, 2011) • Patient will be able to perform self care (bathe herself) and be able to demonstrate using a walker for impaired gait, and increase activity to right side (Ackley & Ladwig, 2011).

21. Nursing Diagnosis • Impaired mobility • Related to: weakness on right side secondary to stroke • As evidence by: unbalanced gait and patient not being able to perform ADL (Ackley & Ladwig, 2011)

22. If you think someone is having a stroke.. Act F.A.S.T • Face • Arms • Speech • Time http://www.youtube.com/watch?v=jxxsdrhu7T0

23. Question 1 A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? • Prepare to administer recombinant tissue plasminogen activator (rt-PA). • Discuss the precipitating factors that caused the symptoms. • Schedule for A STAT computer tomography (CT) scan of the head. • Notify the speech pathologist for an emergency consult. http://amy47.com/nclex-style-practice-questions/neuro-icp-loc-meningitis/cva-stroke/

24. Question 2 During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s: a. Pulse b. Respirations c. Blood pressure d. Temperature http://amy47.com/nclex-style-practice-questions/neuro-icp-loc-meningitis/cva-stroke/

25. Question 3 A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important the nurse assess the patient's • a. ability to follow commands. • b. visual fields. • c. right-sided reflexes. • d. emotional state http://quizlet.com/5114986/stroke-flash-cards/

26. Question 4 The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. ask simple questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice facial and tongue exercises to improve motor control necessary for speech. d. prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner http://quizlet.com/5114986/stroke-flash-cards/

27. Question 5 A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. impaired verbal communication related to speech-language deficits. c. risk for injury related to denial of deficits and impulsiveness. d. ineffective coping related to depression and distress about disability. http://quizlet.com/5114986/stroke-flash-cards/

28. Question 6 A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take? • a. Document that the aspirin was refused by the patient. • b. Call the health care provider to clarify the medication order. • c. Tell the patient that the aspirin is used to prevent aches. • d. Explain that the aspirin is ordered to decrease stroke risk. http://quizlet.com/5114986/stroke-flash-cards/

29. References • Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidence-based guide to planning care. (9th ed.). St. Louis,Missouri: Mosby Elsevier. • American stroke association. (2012). Retrieved from http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/Types-of-Stroke_UCM_308531_SubHomePage.jsp • Bethesda. (2011). Lacunar stroke guide. Retrieved from http://www.drugs.com/health-guide/lacunar-stroke.html • Ct scan. (2011, November 19). Retrieved from http://www.strokecenter.org/patients/stroke-diagnosis/imaging-tests/ct-scan/ • Huether, S. E., & McCance, K. L. (2011). Understanding pathophysiology. (5th ed.). St. Louis: Mosby. • Kerr, P. (2012). Stroke rehabilitation and discharge planning. Nursing Standard, 27(1), 35-39. Retrieved from http://ehis.ebscohost.com/eds/pdfviewer/pdfviewer?sid=379653bb-43a0-4870-8a55-cc8bd7ed2568@sessionmgr104&vid=2&hid=120 • Lippincott. (2010). Atlas of pathophysiology. (third ed.). • Sweileh, W. (2009). Discharge medications among ischemic stroke survivors. 18(2), 97-102. Retrieved from http://ac.els-cdn.com/S1052305708002139/1-s2.0-S1052305708002139-main.pdf?_tid=7faabc74-2dc0-11e2-994f-00000aacb362&acdnat=1352831737_90780f25910cd0531e4a2c961f0b16ba • http://quizlet.com/5114986/stroke-flash-cards/ • http://amy47.com/nclex-style-practice-questions/neuro-icp-loc-meningitis/cva-stroke/