Adult Medical-Surgical Adult Medical-Surgical Nursing Nursing

Neurology Module: Neurology Module:

Cerebrovascular Disease I (TIA)Cerebrovascular Disease I (TIA)

Cerebrovascular Disease: Cerebrovascular Disease: DescriptionDescription

Dysfunction of the Central Nervous Dysfunction of the Central Nervous System related to impaired cerebral System related to impaired cerebral circulation: the normal blood supply to circulation: the normal blood supply to brain tissue is disruptedbrain tissue is disrupted

This impairment leads to:This impairment leads to:

Transient Ischaemic Attack (TIA)Transient Ischaemic Attack (TIA)

Stroke Stroke

Cerebrovascular Disease: Cerebrovascular Disease: AetiologyAetiology

Impairment of the cerebral circulation occurs Impairment of the cerebral circulation occurs through:through:A thrombus or embolus partially or totally A thrombus or embolus partially or totally occluding a vesseloccluding a vesselHaemorrhage from a ruptured vesselHaemorrhage from a ruptured vesselAtherosclerosis narrowing the arterial Atherosclerosis narrowing the arterial lumen, reducing blood flow. This lumen, reducing blood flow. This progressively leads to ischaemia (transient progressively leads to ischaemia (transient with no lasting damage) then to infarctionwith no lasting damage) then to infarctionMost Most ischaemicischaemic strokes are strokes are carotid-relatedcarotid-related

Cerebrovascular Disease: Cerebrovascular Disease: Risk Factors for TIA and StrokeRisk Factors for TIA and StrokeHypertension*Hypertension*DM (accelerated atherosclerosis)DM (accelerated atherosclerosis)Cardiovascular disease (atherosclerosis)Cardiovascular disease (atherosclerosis)Cardiac dysrhythmia (atrial fibrillation)Cardiac dysrhythmia (atrial fibrillation)Family historyFamily historyHigh cholesterolHigh cholesterolSmoking; AlcoholismSmoking; AlcoholismObesity Obesity Oral contraceptives Oral contraceptives

Transient Ischaemic Attack (TIA)Transient Ischaemic Attack (TIA)

A A temporarytemporary episode of neurological episode of neurological dysfunction:dysfunction:

Sudden loss of motor, sensory or visual Sudden loss of motor, sensory or visual function function

Lasts from a few seconds up to 24 hoursLasts from a few seconds up to 24 hours

May precede strokeMay precede stroke

Warning of impending stroke (sooner or Warning of impending stroke (sooner or later) later)

TIA: Clinical ManifestattionsTIA: Clinical Manifestattions

Sudden, temporary:Sudden, temporary:DysphagiaDysphagiaDysphasia, speech difficultyDysphasia, speech difficultyParesisParesisNumbnessNumbnessAtaxiaAtaxiaReduced visual fieldReduced visual fieldLoss of vision one eyeLoss of vision one eye

TIA: DiagnosisTIA: Diagnosis

Patient history and clinical picturePatient history and clinical picture

Physical/ neurological assessment Physical/ neurological assessment reveals:reveals:

Weak carotid pulseWeak carotid pulse

Carotid bruit on auscultation indicates Carotid bruit on auscultation indicates interference with normal blood flowinterference with normal blood flow

Carotid Doppler or angiography (to assess Carotid Doppler or angiography (to assess circulation to the brain)circulation to the brain)

TIA: Medical ManagementTIA: Medical Management

Anticoagulant therapy (IV Heparin pump or Anticoagulant therapy (IV Heparin pump or Klexane)Klexane)

Platelet aggregation inhibitors (Asprin, Platelet aggregation inhibitors (Asprin, Plavix) longtermPlavix) longterm

Surgery (next slide)Surgery (next slide)

Longterm management of hypertension, Longterm management of hypertension, hyperglycaemia, hyperlipidaemiahyperglycaemia, hyperlipidaemia

Encourage appropriate lifestyle changesEncourage appropriate lifestyle changes

TIA: SurgeryTIA: Surgery

Carotid Endarterectomy: removal of Carotid Endarterectomy: removal of plaque or thrombus from carotid arteryplaque or thrombus from carotid arteryCarotid Angioplasty: procedure via Carotid Angioplasty: procedure via angiogram, balloon to press plaque angiogram, balloon to press plaque against arterial wallagainst arterial wallCarotid Stent: to accompany either of the Carotid Stent: to accompany either of the above to ensure patency of lumen (foreign above to ensure patency of lumen (foreign body therefore requires antiplatelet body therefore requires antiplatelet aggregation cover for first months post-op)aggregation cover for first months post-op)

TIA: Nursing Post-SurgeryTIA: Nursing Post-Surgery

Neurological observationsNeurological observationsMaintain adequate BP: (Hypotension → Maintain adequate BP: (Hypotension → ischaemia and thrombosis; hypertension ischaemia and thrombosis; hypertension → cerebral haemorrhage)→ cerebral haemorrhage)(Nitroprusside: a vasodilator ↓ BP and (Nitroprusside: a vasodilator ↓ BP and promotes carotid blood flow) promotes carotid blood flow) Cardiac monitoringCardiac monitoringObserve for haematoma in neck disrupting Observe for haematoma in neck disrupting breathing (tracheostomy set available)breathing (tracheostomy set available)

TIA: Other Nursing ConsiderationsTIA: Other Nursing Considerations

Careful monitoring on admission to assess Careful monitoring on admission to assess that the that the initialinitial condition is not developing condition is not developing to stroketo strokePost-surgical care Post-surgical care Encourage patient awareness and Encourage patient awareness and preventive lifestyle changes: ↓ smoking, preventive lifestyle changes: ↓ smoking, dietary changes to reduce cholesterol, dietary changes to reduce cholesterol, weight reduction, modest exercise to weight reduction, modest exercise to develop collateral circulationdevelop collateral circulation