Stroke/CVA

Right Brain Injury

Left sided paralysis Spatial/perceptial defects Short attention span Impaired judgement Impulsive Safety risk

Cultural/Ethnic Disparities of Strokes

--African-Americans have higher incidence than whites --First strokes are 2x more common in African-Americans than whites --African Americans 3x more likely to have ischemic and 4x more likely to have hemorrhagic strokes than whites --Higher rates of HTN, Diabetes, sickle cell anemia, smoking and obesity in African Americans - all of which increase stroke risks --African Americans are 2x more likely to die from a stroke than whites --Hispanics, Native Americans and Asians also have higher incidence of strokes than whites

Lacunar Stroke

A stroke from occlusion of a small penetrating artery which then develops a cavity in the place of the infected brain tissue. Most commonly occurs in basal ganglia, thalamus, internal capsule or pons. May be asymptomatic or full on stroke s/s.

Hemorrhagic Stroke

Account for 15% of all strokes. Result of bleeding into the brain tissue itself (intracerebral or intraparenchymal) or into subarachnoid space or ventricles (subarachnoid or intraventricular). The ruptured blood vessel will allow blood into brain tissue until clotting plugs the leak.

Rehabilitation Care for Stroke Patients

After the patient has stabilized for 12-24 hours, care shifts from preserving life to lessening disability and attaining optimal function. Patients may be transferred to a rehabilitation facility or outpatient or home care-based rehab services offered.

Nonmodifiable Risk Factors for a Stroke

Age (risk increases with age) Gender (more common in men) Ethnicity/Race (African Americans have higher risk) Family History

Drug Therapy for Hemorrhagic Strokes

Anticoagulants and platelet inhibitors are CONTRAINDICATED in patients with hemorrhagic strokes. The main treatment is the treatment of HTN. Oral and IV agents may be used to maintain BP within a normal to high-normal range (systolic less than 160 but higher than 90). Seizure prophylaxis is also recommended

Drug Therapy for Stroke Prevention

Antiplatelets (aspirin) used to prevent strokes in patients who have had a TIA. Also used: ticlopidine (Ticlid) clopidogrel (Plavix) dipyridamole (Persantine) dipyridamole & aspirin (Aggrenox) warfarin (Coumadin) for patients with afib who have had TIAs Statins (simvastatin [Zocor], lovastatin [Mevacor]) are also effective for patients who have had a TIA in the past With antiplatelets Ticlid and Plavix notify all doctors and dentists especially before surgery or major dental procedures. May need to discontinue for 10-14 days before surgery. Plavix increases risk for bleeding, especially GI bleeding so patient should report any signs of bleeding (bloody stools).

When to Call RRT

Being worried about a patient Having a gut feeling Acute changes such as: -HR <40 or >130 -BP <90 AND symptomatic -Respirations <6 or >30 -Changes in neuro status -Pulse ox <90% despite oxygen -New onset or repeated seizure activity -New onset of chest pain or symptoms of stroke (FAST)

Intracerebral Hemorrhage

Bleeding within the brain caused by a ruptured vessel. Accounts for 10% of all strokes. Poor prognosis with 30-day mortality rate of 40-80% and 50% of deaths within first 48 hours. HTN most common cause. Usually occurs during activity. Sudden onset of symptoms with progression over minutes to hours. S/S: neurologic deficits, HA, N/V, decreased level of consciousness (in 1/2 of patients), HTN.

Cerebral Circulation

Blood supply to brain from 2 main pairs of arteries: -Left and Right internal carotids (anterior circulation) -Left and Right vertebral arteries (posterior circulation) Anterior and posterior circulation is connected at the Circle of Willis by communicating arteries.

Intellectual Function affected by Stroke

Both memory and judgement can be impaired with a stroke on either side of the brain. Both sides cause patients to have difficulty making generalizations which can interfere with the ability to learn. Left-brain strokes are more likely to result in memory problems related to language. Left strokes often cause a patient to be very cautious with decisions. Right-brain strokes often leave patients impulsive and they tend to move quickly.

Types of Aphasia

Broca's - nonfluent, damage to frontal lobes, short phrases that make sense but takes great effort to produce, often omit small words, understands speech of others well, aware of their difficulties so can become easily frustrated. Wernicke's - fluent aphasia, damage to left temporal lobe (typically), may speak in long sentences that have no meaning with unnecessary or made-up words, difficult to follow what they're saying, usually have great difficulty understanding speech, unaware of their mistakes Global - nonfluent, damage to extensive portions of language areas of brain, severe communication difficulties, extremely limited in ability to speak or comprehend language Other - results from damage to different language areas, some people may have difficulty repeating words and sentences even though they can speak and understand the meaning of words or sentences, others may have trouble naming objects even when they know what it is and what its use is.

Factors affecting blood flow to the brain

CO2 is a potent vasodilator so increases in CO2 content in arterial blood increase cerebral blood flow and vice versa. Low arterial O2 levels also increase cerebral blood flow. Systemic BP, cardiac output and blood viscosity also affect blood flow to the brain. ICP also influences blood flow to the brain. High ICP causes reduced blood flow. So a major concern with stroke patients is to keep the ICP low to prevent secondary damage.

Surgical Therapy for Hemorrhagic Strokes

Can include the immediate evacuation of aneurysm-induced hematomas or cerebellar hematomas larger than 3cm. Those patients with arteriovenous malformation (AVM) may have the AVM rupture and cause a hemorrhagic stroke so treatment is surgical resection. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm. Treatment of the aneurysm includes clipping or coiling the aneurysm to prevent rebleeding. After clipping or coiling, hemodilution-induced HTN using phenylephrine or dopamine and hypervolemia may be used to increase mean arterial pressure and increase cerebral perfusion. Hypervolemia is achieved using IV crystalloid or colloid solutions. Nimodipine (Nimotop) a CCB is used to decrease vasospasms. Before administering it you should check BP and apical and hold if apical is <60 or systolic BP is <90

Surgical Therapy for Stroke Prevention

Carotid endarterectomy (CEA), transluminal angioplasty, stenting or extracranial-intracranial (EC-IC) bypass may be used for patients with TIAs from carotid disease

Circle of Willis

Connects left and right sides of brain blood flow. Provides a redundancy in the event of a blockage.

Possible Nursing Diagnoses for Stroke Patients

Decreased intracranial adaptive capacity r/t decreased cerebral perfusion and sustained increased ICP Ineffective airway clearance r/t decreased LOC Impaired physical mobility Impaired verbal communication Unilateral neglect Impaired urinary elimination Impaired swallowing Situational low self-esteem

Emergency Interventions for All Strokes

Ensure patent airway-ABCs first! Remove dentures Monitor pulse oximetry Give supplemental O2 if needed Establish IV access with NS Maintain BP according to guidelines Remove clothing Obtain CT scan immediately Perform baseline tests including blood glucose and treat for hypoglycemia if present Position head midline Elevate HOB 30 degrees if no shock or injury Institute seizure precautions Anticipate tPA if ischemic stroke Keep patient NPO until swallow reflex is evaluated Monitor vitals and neuro status

Cincinnati Stroke Scale

Face Arms Speech If any 1 of the 3 signs are abnormal, the probability of a stroke is 72% Good tool for the public and pre-hospital teaching

FAST

Face Arms Speech Time

Modifiable Risk Factors for a Stroke

HTN (single most important modifiable risk) Heart Disease (afib, MI, cardiomyopathy, valve issues & congenital defects) Diabetes (5x higher risk of stroke) Smoking (nearly doubles risk factor) Increased cholesterol levels Excessive alcohol consumption Obesity (especially abdominal obesity) Sleep Apnea Metabolic Syndrome Lack of Physical Exercise Poor Diet Drug Abuse (especially cocaine) Older birth control pills and newer ones if she smokes Migraine HAs Inflammatory conditions Hyperhomocystinemia Sickle-cell disease

Hemianopsia

Half of the visual field is affected

Athlerosclerosis

Hardening and thickening of the arteries. A major cause of stroke. Lipids accumulate into a fatty streak on the interior of the artery then becomes a plaque (often happens at bifurcation of an artery). These calcified, brittle plaques can then rupture which causes an inflammatory response to send platelets and fibrin to fix the ruptured areas. All this accumulation then narrows or occludes the artery, or parts can break off and clog smaller vessels causing an infarction.

Motor Functions Affected by Stroke

Impairment of mobility, respiratory functions, swallowing and speech, gag reflex and self-care abilities from destruction of motor neurons. Initial hyporeflexia progresses to hyperreflexia for most patients. Lesions on one side of the brain affect the opposite side of the body (contralateral). Arms and legs on affected side may be weakened or paralyzed. Shoulders tend to rotate internally while hips tend to rotate externally. Affected foot is plantar flexed and inverted. Initially flaccid for days to several weeks then turns spastic.

Subarachnoid Hemorrhage

Intracranial bleeding into the cerebrospinal fluid-filled space between arachnoid and pia mater membranes on the surface of the brain. Commonly caused by rupture of cerebral aneurysm. Also caused by trauma or cocaine abuse. 40% die with first episode, 15% die from subsequent bleeding. Incidence increases with age and higher in women than men. May have warning signs if ballooning artery applies pressure to surrounding tissue, but typically known as silent killer. Sudden onset of a severe HA different from previous HAs and described as "worst headache of my life" is characteristic of a ruptured aneurysm. LOC may range from alert to comatose. At risk for further bleeding and DVT/VTE due to minimal activity.

Types of Stroke

Ischemic (blood flow blockage) --TIA --Thrombotic --Embolic Hemorrhagic (bleeding) --Intracerbral Hemorrhage --Subarachnoid Hemorrhage

Surgical Therapy for Ischemic Strokes

Mechanical embolus removal in cerebral ischemia (MERCI) retriever goes into the artery that is blocked and pulls the clot out. The retriever goes from femoral artery to the clot, where a balloon is inflated just past the clot and the MERCI retriever pulls the clot out while the balloon stays inflated to prevent the clot from breaking off.

Elimination Problems after a Stroke

Most problems occur initially and are temporary. Initially may experience frequency, urgency and incontinence and typically constipation. If urinary incontinence remains, a bladder schedule should be initiated. Constipation is usually a result of immobility, weak abdominal muscles, dehydration and diminished response to defecation reflex.

Clinical Manifestations of a Stroke

Neurologic symptoms don't differ significantly between ischemic and hemorrhagic strokes. General manifestations include motor activity, bladder and bowel elimination, intellectual function, spatial-perceptual alterations, personality, affect, sensation, swallowing and communication. Functions affected are directly related to the artery involved and the area of the brain it supplies for example, posterior cerebral artery occlusion typically results in visual deficits. Aphasia occurs with middle cerebral artery occlusion and cognitive deficits and changes in judgement are typical of anterior cerebral artery occlusion.

Diagnostic Studies for Strokes

Non-contrast CT is single most important test & should be done first. It can quickly identify if it's an ischemic or hemorrhagic stroke and help determine size and location of stroke. CTA (CT angiography) can also be performed after or during CT to visualize cerebral blood vessels. MRI is used to determine extent of brain injury. MRA (magnetic resonance angiography) can detect vascular lesions and blockages similar to CTA. Angiography can identify cervical and cerebrovascular occlusions, atherosclerotic plaques, and malformation of vessels. Cerebral angiography is the definitive study to find the source of subarachnoid hemorrhage. Risks include dislodging embolus, vasospasms, inducing further hemorrhage or allergic reaction to the contrast. DSA removes bones in xray image so you only see the blood vessels Transcranial Doppler (TCD) is noninvasive and measures velocity of blood flow in major cerebral arteries. Can detect microemboli and vasospasm and ideal for patients suspected of a subarachnoid hemorrhage. Also used to determine amount of carotid stenosis. Lumbar puncture can detect RBCs in CSF if subarachnoid hemorrhage is suspected but not found on CT

Thrombotic Stroke

Occurs from injury to the vessel wall and formation of a blood clot. Typically the inside of the vessel is narrowed from plaque and a clot blocks the small opening leading to infarction. Most common cause, accounts for 60% of strokes. 30-50% of patients had a TIA previously. Extent of damage depends on rapidity of onset, size of lesion, and presence of collateral circulation. Most patients don't have a decreased level of consciousness in first 24 hours unless it is due to brain stem stroke or other conditions (seizures, increased ICP, or hemorrhage). Symptoms may progress in first 72 hours as infarction and cerebral edema increase.

Ischemic Strokes

Result from inadequate blood flow to the brain from blockage (partial or complete) of an artery. Accounts for nearly 80% of all strokes. Divided into thrombotic or embolic and a TIA is usually a precursor to ischemic strokes

Embolic Stroke

Occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema or the area supplied by that vessel. Second most common cause of stroke (24% of all strokes) Most emboli originate in inside layer of heart with plaque breaking off and entering circulation. Emboli travels upward and lodges in narrowed blood vessel or at a bifurcation. Afib, MI, infective endocarditis, rheumatic heart disease, valve prostheses and atrial septal defects all are risk factors for embolus formation. Can also occur from air emboli or fat emboli (fracture of long bones). Typically a rapid occurrence of severe symptoms. Less warning signs than thrombotic strokes. Patient usually remains conscious, but have a HA. Prognosis related to amount of brain tissue deprived of blood supply. Recurrence is common unless underlying cause is aggressively treated

Affect affected by Stroke

Patients may have difficulty controlling their emotions. Emotional responses may be exaggerated or unpredictable. Depression and feelings associated with changes in body images and loss of function can make this even worse. Frustration and depression are common in the first year following a stroke.

Other nursing interventions for stroke patients

Preventing DVTs Preventing contractures and muscular atrophy Preventing skin breakdown Maintain nutritional status Assessing gag reflex and swallowing ability before feeding

Preventative Therapy for Strokes

Prevention is best way to treat a stroke! Goals include managing modifiable risk factors: -healthy diet (reduce salt and sodium, low saturated fats, total fats and cholesterol and high in fruits & veggies) -weight control -regular exercise -no smoking -limiting alcohol consumption -routine health assessments (maintain BP)

Drug Therapy for Ischemic Strokes

Recombinant tissue plasminogen activator (tPA) is administered IV to reestablish blood flow in ischemic strokes. tPA must be administered within 3-4.5 hours of the onset of symptoms. Screening for tPA includes CT or MRI to rule out hemorrhagic strokes, blood tests for coagulation disorders, screening for recent history of GI bleed, stroke or head trauma within past 3 months or surgery within last 14 days. If tPA is to be used patient will need foley, NG tube, and multiple IVs. Vitals and neuro status are monitored closely during treatment and control of BP is critical during treatment and for next 24 hours.

Left Brain Injury

Right sided paralysis Depression/Anxiety/Poor emotional control More cautious-less of a safety risk Poor language and math comprehension Impaired speech/aphasia

What is a stroke?

Stroke occurs when there's inadequate blood flow (ischemia) to part of the brain. No blood flow = no oxygen and glucose to brain cells which can lead to cell death. Also known as a "brain attack". Leading cause of serious, long-term disability.

Spatial-Perceptual Alterations affected by Stroke

Strokes on right side of brain are more likely to cause problems in spatial-perceptual orientation, but can also occur in left-side strokes. 4 categories: incorrect perception of self or illness erroneous perception of self in space agnosia (inability to recognize an object by sight, touch or hearing) apraxia (inability to carry out learned sequential movements on command)

Regulation of Cerebral Blood Flow

The brain must have a continuous supply of blood to provide the oxygen and glucose for the neurons to function. Blood flow must be 750-1000 mL/min (20% of total cardiac output). If blood flow is totally interrupted (cardiac arrest) cellular death occurs in just 5 minutes. In response to mean systemic arterial blood pressures of 50-150 mm Hg, the diameter of cerebral blood vessels change to allow constant blood flow to the brain. This is called cerebral autoregulation.

Communication affected by stroke

The left side of the brain is dominant for language skills in right-handed persons and in most left-handed persons. Stroke patients may experience aphasia (total loss of comprehension and use of language or total inability to communicate). Dysphasia refers to impaired ability to communicate. Different types of aphasia exist based on the different portions of the brain affected: --Nonfluent - minimal speech activity with slow speech that requires obvious effort --Fluent - speech is present but contains little meaningful communication. Most types are mixed with impairment in both expression and understanding. Dysarthria is a disturbance in the muscular control of speech. Impairments may involve pronunciation, articulation, and phonation. Does not affect the meaning or comprehension of language, but it affects the mechanics of speech.

Acute Care for Ischemic Strokes

Time of onset is the single most important thing to obtain! Acute care starts with ABCs-give O2, artificial airway, intubation or mechanical ventilation all may be needed. Baseline and subsequent neuro status evaluated. Elevated BP is common immediately after a stroke and may be protective to maintain cerebral perfusion. BP lowering drugs are only used if BP is very high and then IV metoprolol (Lopressor) and nicardipine (Cardene) are preferred. Fluid and electrolyte balance should be carefully monitored, monitor urine output. Too much fluids can lead to increased ICP and hyponatremia. Hyperthermia is common needs to be controlled - aspirin or acetaminophen (Tylenol) or cooling blankets can be used. Antiseizure drugs such as phenytoin (Dilantin) or levetiracetam (Keppra) can be used if seizures occur. Pain management, avoidance of hypervolemia and management of constipation. Mannitol (Osmitrol) and furosemide (Lasix) can be given to decrease cerebral edema & ICP

Transient Ischemic Attack (TIA)

Transient episode of neurologic dysfunction cause by focal brain, spinal cord or retinal ischemia but without acute infarction of the brain. Symptoms last less than 1 hour. Most TIAs resolve but 1/3 don't have another one, 1/3 will have another one and 1/3 will go on to have a stroke. TIAs are a warning sign of progressive cerebrovascular disease. S/S depend on what blood vessel is affected: --carotid system-temporary loss of vision in 1 eye, hemiparesis, numbness or loss of sensation, or sudden inability to speak --vertebrobasilar system-tinnitus, vertigo, darkened or blurred vision, diplopia, ptosis, dysarthria, dysphagia, ataxia, bilateral or unilateral numbness or weakness Treatment after TIA may include antiplatelets (aspirin) to prevent stroke