RNSG 2432 - CVA / Brain aneurysm

Computed tomography of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. Which of the following is a nursing priority intervention in the emergency department? A. Maintenance of the patient's airway B. Positioning to promote cerebral perfusion C. Control of fluid and electrolyte imbalances D. Administration of tissue plasminogen activator (tPA)

A) Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke, and supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which of the following medications might the nurse expect to provide discharge instructions (select all that apply)? A. Clopidogrel (Plavix) B. Enoxaparin (Lovenox) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) E. Tissue plasminogen activator (tPA)

A, D Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke, not prevent TIAs.

When communicating with a client who has aphasia, which of the following are helpful? Select all that apply: A. Present one thought at a time B. Avoid writing messages C. Speak with normal volume D. Make use of gestures E. Encourage pointing to the needed object

A,C,D,E

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: A. Have a preference for foods high in salt B. Eat food on only half of the plate C. Forget the names of foods D. No be able to swallow liquids

B

What is the priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

B

The nurse would expect to find which of the following clinical manifestations in a patient admitted with a left-brain stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span

B) Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language aphasias, impaired right/left discrimination, and slow and cautious performance. The other options are all manifestations of right-sided brain damage.

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

C

Which of the following sensory-perceptual deficits is associated with left-brain stroke (right hemiplegia)? A. Overestimation of physical abilities B. Difficulty judging position and distance C. Slow and possibly fearful performance of tasks D. Impulsivity and impatience at performing tasks

C) Patients with a left-brain stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-brain stroke.

Which of the following nursing interventions is most appropriate when communicating with a patient suffering from aphasia poststroke? A. Present several thoughts at once so that the patient can connect the ideas. B. Ask open-ended questions to provide the patient the opportunity to speak. C. Use simple, short sentences accompanied by visual cues to enhance comprehension. D. Finish the patient's sentences so as to minimize frustration associated with slow speech.

C) When communicating with a patient with aphasia, the nurse should present one thought or idea at a time; ask questions that can be answered with a "yes," "no," or simple word; use visual cues; and allot time for the individual to comprehend and respond to conversation.

Info provided by a patient that would help differentiate a hemorrhage stroke from a thrombotic stroke includes: a) sensory disturbance b) history of hypertension c) presence of motor weakness d) sudden onset of severe headache

D)

F (face) = Ask the person to smile. Does one side of the face droop? A (arms) = Ask the person to raise both arms. Does one arm drift downward? S (speech) = Ask the person to repeat a simple phrase. Is their speech slurred or strange? T (time) = If you observe any of these signs, call 911 immediately.

Describe "Act FAST" and how it describes the warning signs of stroke.

Bleeding within brain d/t rupture of vessel (10% of all strokes) -- *Prognosis is poor *; 50% of deaths occur in first 48 hrs * HTN = most common cause * Other causes: vascular malformations, coag disorders, anticoag & thrombolytic, trauma , ruptured aneurysms S&S = Commonly occurs during periods of activity; Sudden onset of SS; progression of SS over min to hrs. Initially-SEVERE HA w/ N&V * Other SS: neurological deficits (weakness, vision changes, slurred speech, loss of balance, dilated pupils, etc.), decreased LOC, HTN, coma

Describe ICH. What causes it? What symptoms would the patient present with?

Intracranial bleeding into the cerebrospinal fluid-filled space = *Commonly d/t rupture of a cerebral aneurysm* Other causes: cocaine, trauma S&S = *Severe headache*, LOC may or may not occur (can range from alert to comatose), N&V, seizures, stiff neck - *prognosis = poor *

Describe SAH. What is the most common cause? What are S&S?

Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but w/o acute infarction of the brain --- Symptoms typically last <1 - 2 hrs, sometimes longer but always <24 hrs - * Warning sign for stroke* - brief localized ischemia probable d/t microemboli that temporarily block the blood flow

Describe TIA.

*Treatment must be initiated promptly after screening CT to r/o hemorrhagic stroke * -- Reestablish blood flow through blocked artery -- Other fibrinolytic agents cannot be substituted for t-PA *IV t-PA MUST be administered within 3 to 4.5 hours of symptom onset.* May be given intraarterial (up to 6 hours) -- insert a foley, NG tube & multiple IVs before administration -- Control of BP is critical! --*Timing is the most important factor here!!*

Describe Thrombolytic Recombinant Alteplase (tPA) therapy.

Dysarthria

Difficulty with articulation or muscular control for speech; sound like they have mashed potatoes in their mouth

Largest cerebral artery (most common occlusion site for ischemic stroke) - branches off internal carotid artery - provides blood flow to frontal, temporal, parietal lobes & basal ganglia Mostly affects: Facial symmetry (droopiness) Arm weakness Speech deficits

Discuss the middle cerebral artery (MCA) and clinical manifestations you would expect on a patient if this area was affected by a stroke?

nimodipine (Nimotop) given w/in 24 hours of admission, do not want vasoconstriction cuz that could lead to ischemia, leading to an ischemic stroke on top of the hemorrhagic stroke What will we assess before giving this medication? Apical pulse-hold <60 BP-hold if syst <90

How do you prevent vasospasms? (in hemorrhagic strokes only)

Agnosia

Inability of the senses to perceive stimuli that were previously familiar; may be any of the senses and in varying degrees

NIH stroke scale.

Measures degree of stroke r/t impairment and change in a patient over time. - *Helps determine if degree of disability merits treatment with tPA* (as of 2008 stroke patients scoring greater than 4 points and less than 20 points can be treated with tPA) Points are given for each impairment: 0= no stroke 1-4= minor stroke 5-15= moderate stroke 15-20= moderate/severe stroke 21-42= severe stroke ** A maximal score of 42 represents the most severe and devastating stroke.

thrombotic

Type of ischemic stroke; *Most common cause of "brain attack"* - Injury to vessel wall; formation of blood clot - May be preceded by a TIA. *Rapid event, but slow progression (usually reach max deficit in 3 days)

lacunar infarct

Type of ischemic stroke; Occlusion of a small penetrating artery (form of thrombotic stroke) - Small, deep penetrating arteries = *Commonly occurs in: Thalamus, Basal ganglia, Pons *Usually asymptomatic; If symptoms are present: contralateral loss of sensory modalities, pure motor hemiplegia, contralateral leg & face weakness, arm & leg ataxia

embolic

Type of ischemic stroke; embolus becomes lodged in artery and causes occlusion. Results in infarction & edema. Bifurcations are most common site - Sudden onset with immediate deficits - Other causes *AFIB*, MI, IE, valvular prostheses, rheumatic heart disease - Patient remains conscious; may complain of headache (Recurrence is common)

Complications = re-bleeding before surgery & vasospasm (6-10 days after initial bleed)

What are 2 complications of SAH?

abnormal tangle of arteries & veins in the brain (frequently in middle cerebral artery) - Can cause a seizure or ICH; Genetic Tx: 1. Endovascular surgery 2. Neurosurgery 3. Radiosurgery (if a person has an AVM and experiences a hemorrhagic stroke d/t rupture of the AVM, the tx may be surgical resection and or radiosurgery (ie gamma knife) - This may be preceded by neuroradiology to embolize the blood vessels that supply the AVM

What are AV malformations? What is treatment?

Subarachnoid hemorrhage Trauma within 3 months History of prior intracranial hemorrhage AV malformation or aneurysm Surgery within 14 days, pregnancy, cardiac cath within 7 days

What are the contraindications for tPA?

Non-modifiable: age, gender, ethnicity, race, family hx of stroke or prior TIA. Modifiable: *HTN = most important*, heart disease, smoking, high cholesterol, excessive alcohol consumption, obesity, sleep apnea, poor diet, DM, drug abuse

What are the major non-modifiable & modifiable risk factors for stroke? What is the single most important modifiable risk factor?

primary goal = Prevention of increased ICP Do not position patient on the operative side. Observe the dressing for color, odor & amount of drainage. Notify surgeon immediately of excessive bleeding or clear drainage. Check drains for placement & assess the site. Once dressing is removed, use an antiseptic soap for washing the scalp.

What are the priority nursing considerations for a post-operative patient who has undergone a craniectomy?

VTE prophylaxis Discharged on antithrombotic therapy (ASA) Anticoagulation therapy for a-fib/flutter (Coumadin) Thrombolytic therapy (tPA) Antithrombotic therapy by end of hospital day 2 Discharged on *STATIN* medication Stroke education provided Assessed for rehabilitation

What are the quality measures for stroke put in place by the Joint Commission?

The internal carotid divides into two large branches, the middle and anterior cerebral arteries, and symptoms arise from disruption of blood flow to the areas they supply. Contralateral paralysis (arm, leg, face) Contralateral sensory deficits Aphasia (dominant hemisphere involvement) Apraxia (motor task) Agnosia (obj. recognition) Unilateral neglect (non-dominant hemisphere involvement) Homonymous hemianopia (vision loss in 1/2 of both eyes)

What clinical manifestations would be present if the internal carotid artery was affected?

Pain in face, nose, or eye Affected side numbness, weakness of face Ataxia Dysphagia Dysarthria (difficulty controlling speech)

What clinical manifestations would be present if the vertebral artery was affected?

1)* CT = single most important dx tool*- Can rapidly distinguish between hemorrhagic & ischemic stroke 2) CT angiography (CTA) - visualization of cerebral blood vessels & estimation of perfusion 3) MRI- determine extent of brain injury 4) Magnetic resonance angiography (MRA)- can detect vascular lesions & blockages 5) Cerebral angiography- Identify source of SAH *Risks = lodging embolus, vasospasm, inducing further hemorrhage, allergic reaction to contrast media* 6) Transcranial Doppler - Measures velocity of blood flow in cerebral arteries 7) Lumbar Puncture -Look for evidence of RBC's in cerebrospinal fluid (contraindicated if signs of IICP) Additional Dx: CBC, Electrolytes, Renal & hepatic profiles, Blood glucose , Lipid profile, CSF analysis ,Coag studies , EKG

What diagnostic tests would be ordered for a patient with a potential stroke?

Motor Function = [*A lesion on one side of the brain affects motor function on the contralateral side *] = Depressed reflexes, spasticity of muscles, weakness to upper extremities Communication = aphasia, dysphasia, dysarthria, dysphagia Affect = depression, difficulty controlling emotions Intellectual Function = impaired memory and judgment Spatial-Perceptual Alterations= incorrect perception of self and illness Elimination = constipation, frequency, urgency, incontinence

What general clinical manifestations would you expect to find in patient with a CVA? (motor function, communication, affect, elimination)

*Ensure patent airway!* Call "Stroke Alert" Code Remove dentures, keep patient NPO Obtain pulse oximetry Maintain adequate Sa02 ( > than 95%) ; O2 if necessary Maintain BP within parameters (check MAP) *Obtain CT scan, immediately!* Obtain baseline labs (ex: glucose), Obtain IV access Position head midline; HOB 30 (if no shock/injury, or cervical damage) Institute seizure precautions-suction, pad rails NIH Stroke Scale, Glasgow Coma Scale *Anticipate thrombolytic therapy for ischemic stroke*

What is involved in the initial stroke assessment/ intervention?

(3-7) severe coma (9-12) Moderate (13-14) Mild

What is the Glascow Coma Scale

Primary: (stoke quality measures - see prior slide) Get With the Guidelines (American Stroke Association) The Joint Commission CT scan and/or MRI available 24 hours/day and available for stroke patients within 25 minutes of being ordered Access to neurosurgical team Lab tests for stroke patients completed within 45 minutes Protocols exist Stroke team available 24 hours/day Designated stroke unit Comprehensive: NIHSS score performed for ischemic stroke patients Modified Rankin Score Severity measurement performed for SAH & ICH Procoagulant reversal agent (INR >1.4 with ischemic) Hemorrhagic transformation Nimodipine treatment administered Median time to revascularization Thrombolysis in cerebral infarction

What is the difference between a Primary Stroke Center and a Comprehensive Stroke Center measures?

Anti-platelets: decrease platelet aggregation & prevent thrombus formation - ex: Aspirin, Plavix, Effient Anti-coagulants: prevent coagulation (clotting) of the blood - ex: Heparin, Lovenox

What is the difference between anti-platelet and anticoagulant medications? Give the name of an anti-platelet medication? Give the name of an anticoagulant medication?

Coiling - Used to occlude aneurysm Metal coil is inserted into the lumen of aneurysm Prevents blood from circulating through the aneurysm, reducing risk of rupture Clipping- Reduces blood pulsations to aneurysm Eventually, thrombus forms within aneurysm Aneurysm becomes sealed off

What is the difference between coiling & clipping of an aneurysm?

IV tPA - MUST be administered within 3 to 4.5 hours of symptom onset (all ischemic strokes EXCEPT TIA) [After pt stabilized, to prevent further clot formation] Antiplatelets =Aspirin Blood thinner = Plavix Anticoagulants =Coumadin, Lovenox - Statins have been shown effective treatment for the patient with an ischemic stroke SURGERY: 1) Carotid endarectomy = Removing an atherosclerotic plaque in the carotid artery to prevent impending stroke (esp if the pt has had several TIA's) 2) MERCI clot removal

What is treatment (medications/ surgical) for TIA (ischemic strokes)?

1) Anti-hypertensives: *maintain normal BP (SBP <160)* 2) Seizure Prophylaxis: phenytoin (Dilantin), levetiracetam (Keppra), lamotrigine (Lamictal) - seizure activity may result in further neuronal injury & contribute to coma 3) Aneurysm precautions (decrease external and internal stimuli) -- mainly for SAH 4) Meds for aneurysms (aneurysm precautions; stool softeners, antiemetic, for headache, to sedate) 5) Meds that prevent re-bleed: Aminacproic Acid (Ammicar) fibrolysis inhibitor to prevent lysis of the formed clot/ prevent rebleed -- mainly SAH 6) Meds to prevent vasospasms (SAH): - *before surgery*: (Calcium Channel blocker) Nimodipine, minimize cerebral damage - *after surgery*: 'Triple H therapy' (hypertension, hypervolemia and hemodilution)-- vasodilators (Isuprel); induced arterial hypertension (Dopamine); hypervolemic hemodilution (Albumin) Surgical: 1) Immediate evacuation of aneurysm-induced hematomas, or cerebellar hematomas > than 3 cm - Use of clipping or coiling of the aneurysm; prevents rebleeding (ex: GDC coil) - used mainly for SAH 3) Craniotomy 4) Craniectomy

What is treatment for a hemorrhagic stroke (ICH & SAH)?

Left = paralyzed RIGHT side, impaired speech/ language aphasias, impaired right/ left discrimination, slow performance/ cautious, aware of deficits (depression/ anxiety can occur), impaired comprehension r/t language & math

What manifestations would you expect to find in a patient with left-sided brain damage (stroke on left side)?

Right = paralyzed LEFT side (hemiplegia), LEFT-sided neglect, spatial-perceptual deficits, tends to deny or minimize problems, rapid performance/ short attention span, impulsive/ safety problems, impaired judgment, impaired time concept

What manifestations would you expect to find in a patient with right-sided brain damage (stroke on right side)?

TPA, anticoag, antithrombolytic

What meds are contraindicated in patients with hemorrhagic strokes?

S&S = depend on blood vessel involved Carotid System: amaurosis fugax (temp loss of vision in one eye), transient hemiparesis, numbness or loss of sensation, sudden inability to speak Vertebrobasilar System: tinnitus, vertigo, darkened or blurred vision, diplopia, ptosis, dysphagia, ataxia (lack of voluntary coordination of muscles)

What symptoms are usually present for TIA?

A client arrives in the emergency department with an ischemic stroke. The nurse should first:  A. Ask what medications the client is taking B. Complete a history and health assessment C. Identify the time and onset of the stroke D. Determine if the client is scheduled for any surgical procedures

c

The incidence of ischemic stroke in patients with TIA's and other risk factors is reduced with the administration of: A. furosemide (Lasix) B. lovastatin (Mevacor) C. daily low-dose aspirin (ASA) D. nimodipine (Nimotop)

c

A patient with right-sided hemiplegia & aphasia resulting from a stroke most likely has involvement of the: a) brainstem b) vertebral artery c) left middle cerebral artery d) right middle cerebral artery

c)

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the: a) amount of cardiac output b) oxygen content of the blood c) degree of collateral circulation d) level of carbon dioxide in the blood

c)

Hemianopsia

decreased vision or blindness in half the visual field of one or both eyes, usually on one side of the vertical midline

Dysphasia

impaired ability to communicate

Apraxia

inability to carry out purposeful tasks in the absence of paralysis, or the individual carries out the task inappropriately (ex: tries to comb hair w/ toothbrush)

Hemorrhagic stroke

occurs during activity, has a rapid onset, possible LOC, poorer prognosis than occlusive. - Intracranial hemorrhage (ICH) = caused by a ruptured artery in the brain - Subarachnoid hemorrhage (SAH) = bleeding into the subarchnoid space from intracranial hemorrhage, a berry (sacular) aneurysm or AV malformation

Aphasia

total loss of comprehension & use of language or total inability to communicate

ischemic or occlusive stroke

type of stroke; caused by occlusion of the artery; no LOC, better prognosis than hemorrhagic, & may have TIA's before their stroke - Thrombosis - Embolic - Lacunar infarct - TIA