Chapter 66 - Management of Patients with CVA

*Ischemic CVA*: (1) Thrombotic: (a) Define (b) Causes 1. 2. ____ ***

(1) (a) clot forms within a cerebral vessel (b) 1. Atherosclerosis plaques in cerebral artery 2. Carotid Artery Stenosis***

(1) Expressive Aphasia = ____ Area (2) Receptive Aphasia = ____ Area

(1) Broca's (2) Wernicke's

*Cerebral Angiography (Angiogram)*: (1) Uses catheter, X-ray imaging and an injection of contrast material (2) To examine ______ - Vessels used: Carotid, Brachial, or Femoral (3) Before: _____ , ______ , _____ , ______ , ____ (4) After: ____ , ____ , _____

(2) blood vessels in the brain (3) assess allergies, use of anticoagulants / bleeding risk, may be NPO after 12:00, empty bladder (may take 1-3hrs) (4) Increase oral fluids to remove contrast, consider injection site pain, assess for bleeding

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms? A. cardiac disease B. migraine headaches C. hypertension D. impaired cerebral circulation

D

*CVA*: (1) stands for (2) aka

(1) Cerebrovascular Accident (2) Stroke

*Receptive Aphasia: Wernicke's Area* (1) Damage to ____*** (2) Difficulty _____ and _____*** (3) Difficulty _____ (4) Unaware of ______

(1) LEFT TEMPORAL LOBE*** (2) understanding written & spoken language*** (3) following directions (4) speech issues

*Ischemic CVA*: (2) Embolic: (a) Define (b) Causes: 1. __*** 2. (3) Other = _____ ; _____ >>> ____

(2) (a) clot forms in a proximal site, then travels to brain (b) 1. Atrial fibrillation*** or valvular heart disease 2. Fat emboli from fractures of long bone (ex: femur) (3) cocain; migraine >>> vasospasm

TIA = - aka

Transient Ischemic Attack - mini strokes (NOT a stroke BUT it's a precursor to a stroke)

*CVA*: (1) Ischemic: (a) (b) (2) Hemorrhagic (a) (b) (c) (d)

(1) (a) Thrombus (b) Embolus (2) (a) Intracerebral Bleed (ICB) (b) Subarachnoid Hemorrhage (SAH) (c) Arteriovenous Malformation (AVM) (d) Cerebral Aneurysm

*CVA*: (1) TIME = BRAIN*** (a) The longer we take to do something, the more _______ occurs (2) The human brain has 22 billion neurons -> each minute after a stroke, 1.9 million neurons are destroyed. (3) _____ --> _____ --> _____ -->

(1) (a) damage to brain tissue (3) Cerebral Ischemia --> Cerebral Infarction --> Permanent loss of neuron function

*CVA: Symptoms* (1) Hemiplegia = (2) Hemiparesis = (3) Dysphasia = (4) Aphasia = - (5) Dysphagia = (6) Ataxia = (7) Hemianopia =

(1) 1 sided paralysis (2) 1 sided weakness (3) impaired speech (4) inability to express self or understand others - expressive or receptive or mixed (both) (5) trouble swallowing (6) unsteady gait, staggering gait, trouble walking, loss of balance or coordination, dizziness -> think of someone who's drunk (same gait, manneurisms) (7) loss of 1/2 of visual field

*Cerebrovascular Accident (CVA) (Stroke)*: (1) Ischemic = (2) Hemorrhagic =

(1) vascular occlusion (>85%) >> blood clot is stuck in an important artery in the brain (2) Extravasation of blood into brain

*Hemorrhagic CVA*: (4) Cerebral Aneurysm (a) Define (b) Due to _____ (c) Usually occurs at _______ (5) AVM (Arterior Venous Malformation) (a) is it congenital? (b) Define (c) Leads to _______ (d) Common cause of hemorrhagic stroke in _____ patients *** (e) MOST COMMON CAUSE = ____***

(4) (a) Dilation of cerebral artery (b) weakness of arterial wall (c) bifurcation of Circle of Willis (5) (a) yes (b) tangling of arteries / veins (c) dilation of cerebral arteries / veins that rupture (d) younger patients *** (e) HTN ***

After having a stroke, a patient has cognitive deficits. Which deficits are likely to occur as result of the stroke? Select all that apply. A. poor abstract reasoning B. decreased attention span C. short and/or long-term memory loss D. difficulty swallowing E. parasthesias

A, B, C

The nurse is preparing the patient for an MRI to evaluate a new onset stroke. Which finding in the patient's history would prompt the nurse to notify the health care provider? A. allergy to IV contrast B. chronic indwelling foley catheter C. removal of the gallbladder 3 weeks ago D. placement of a pacemaker 6 months ago

D

◦Client admitted to the medical unit with a diagnosis of CVA after "feeling funny" at work and falling ◦Medical history: hypertension, high cholesterol, and gastric ulcers ◦Surgical history: left knee replacement and appendectomy ◦Client is alert and oriented x 3, with slurred speech ◦Exhibits left hemiparesis and facial droop ◦BP 162/90, HR 72, RR 18, Temp 98.8 F, O2 saturation 98% on room air ◦Client made comfortable in bed, spouse visiting with client Where will you place t

On the right side of the patient

*Hemorrhagic CVA*: (1) Define (2) More common in patients with ______ >> _____ (3) Caused by: (a) (b)

(1) BLEEDING into brain tissue (intracerebral) or subarachnoid space (2) HTN >> Rupture of blood vessel (3) (a) Cerebral Aneurysm (b) AVM (Arterior Venous Malformation)

*CVA*: FAST** (1) B = (2) E = (3) F = (4) A = (5) S = (6) T =

(1) Balance - Does the person have a sudden loss of balance? (2) Eyes - Has the person lost vision in one or both eyes? (3) Face - does the face look uneven? - ask them to smile (4) Arm - does one arm drift down? - ask them to raise both arms (5) Speech - Does their speech sound strange? - Ask them to repeat a phrase (6) Time - EVERY SECOND brain cells die. Call 911 at ANY of these signs

*Cerebrovascular Accident (CVA) (Stroke)*: (1) Define = (2) 2 Major Causes: 1. 2.

(1) Blood supply to brain is disrupted (2) 1. Ischemic 2. Hemorrhagic

*Ischemic CVA: Diagnostic Studies* (1) FIRST - ______ *** (a) Ideally within _____ (or less) of arrival - fast results - If IV contrast used, will take longer to perform (2) NEXT... _______*** (a) 12 lead EKG -> (b) Echocardiogram and/or TEE -> (c) Carotid US -> (d) MRI / MRA -> (e) Cerebral angiography may also be necessary (f) ALSO, test patient for illicit drug use if suspected***

(1) CT Scan without IV Contrast*** (2) Identify the source of clot*** (a) atrial fibrillation (b) valve issue or cardiac thrombus (c) carotid stenosis (d) vessel pathology, tumor

*Ischemic Stroke: Invasive Treatment* (1) Surgical Intervention >> ______ (a) Usually done if ________ OR _______

(1) Carotid Endarectomy (a) Carotid artery stenosis 70%; OR 50-69% with significant risk factors

*CVA: TIME = BRAIN* (1) Cerebral Ischemia = (2) Cerebral Infarction = (3) Permanent loss of neuron function =

(1) Diminished cerebral perfusion (blood flow) > no blood supply, death of tissue (2) Cell death due to diminished perfusion (3) Irreversible

State whether the client / spouse understands or requires further teaching: (1) Client places right arm in shirt sleeve first when getting dressed (2) Spouse states: "It will help my wife's vision if I approach her from the right side" (3) Spouse states: I will talk to the home care aides when they come, to be sure they get all of the care done within the first hour" (4) Client turns head to the right and then to the left before activity or ambulation (5) Client states: I know that I need to call for help when I have to go to the potty (6) Client states: I can skip the stool softener pill if I have a bowel movement each day (7) Client picks up a washcloth with the left hand to wash face

(1) Requires further teaching (2) Understood (3) Requires further teaching (4) Understood (5) Understood (6) Requires Further Teaching (7) Requires Further Teaching

*CVA*: (1) Ischemic is a _____ , while Hemorrhagic is a _____

(1) clot; bleed

*Left Sided Neglect* (1) ____ Neglect* (2) Disorder of ______ (3) Difficulty ____ , ___ & _____ on the _____

(1) Hemispatial (2) attention (3) noticing, attending to & responding to stimuli on the left side of the body

*Expressive Aphasia: Broca's Area* (1) Damage to _____** (2) _____ speech (3) Omit words, trouble finding the correct words (4) Understand speech of others but ______*** (5) Often aware of difficulties can be frustrated

(1) LEFT FRONTAL LOBE** (2) Short phrase (4) cannot adequately express themselves***

*Magnetic Resonance Angiography: MRA* (1) Type of ____ (2) Looks specifically at ____ (3) Is it invasive?

(1) MRI (2) blood vessels (3) non-invasive

*Ischemic Stroke: Invasive Treatment* (1) Endovascular Therapy >> _____- (a) ______ device (b) (c)

(1) Mechanical Embolectomy (a) Penumbra Device (b) Trevo (c) MERCI Retriever

*Transient Ischemic Attack (TIA)*: (1) Define = (2) Symptoms lasting _____*** (3) Sudden loss of ____ , ___ , or _____ function (4) Oddly enough ... brain imaging (MRI or CT Scan) usually shows NO ischemia (5) Often serves as a WARNING SIGN of _____*** (6) TIA preceeds 15% of ischemic strokes

(1) Neurologic Ischemia that is temporary ("transient") (2) <60 mins*** (3) motor, sensory, or visual function (5) IMPENDING STROKE***

*Assessment: Hemorrhagic Stroke* (1) Refer to ____

(1) NIH Stroke Scale

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. acute pain B. sepsis C. bleeding D. seizures

C