Cerebral-vascular AccidentsBy: Emma Fleck

Objectives

Pathophysiology/types/signs Relevance to population: age, gender,

congenital Current treatment and modalities Diagnostic tests/labs Medications Prognosis/outcome Nursing diagnosis NCLEX questions

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).

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).

Pathophysiology

Two main types of strokesIschemic (clots)

Thrombotic & embolicHemorrhagic (bleeds)

Subarachnoid hemorrhage (SAH) & Intracerebral hemorrhage (ICH)

Pathophysiology

Thrombotic strokeArterial occlusions caused by thrombi formed in

arteries supplying the brain or in the intracranial vessels (Huether, 2011).

Embolic strokeFragments 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)

Pathophysiology

Lacunar strokeAre caused by occlusion of a single

deep perforating artery that supplies small penetrating subcortical vessels, causing ischemic lesions (Huether, 2011).

Transient ischemic attackBrief episode of neurologic dysfunction,

stroke symptoms (Huether, 2011).

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)

Pathophysiology

Common signs and symptoms of CVAsUnilateral limb weakness, numbnessSpeech difficultiesHeadache, visual disturbancesDizziness, anxietyAltered level of consciousnessLippincott. (2010)

Signs and symptoms differ depending on the region of the brain effected..

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)

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)

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

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.

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

Test/labs

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)

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).

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).

Nursing Diagnosis

Impaired mobilityRelated to: weakness on right side

secondary to strokeAs evidence by: unbalanced gait and

patient not being able to perform ADL

(Ackley & Ladwig, 2011)

If you think someone is having a stroke..

Act F.A.S.T Face Arms Speech Time

http://www.youtube.com/watch?v=jxxsdrhu7T0

Question 1A 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?a. Prepare to administer recombinant tissue

plasminogen activator (rt-PA).b.Discuss the precipitating factors that caused the

symptoms.c. Schedule for A STAT computer tomography (CT)

scan of the head.d. Notify the speech pathologist for an emergency

consult.http://amy47.com/nclex-style-practice-questions/neuro-icp-loc-meningitis/cva-stroke/

Question 2

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s:a. Pulseb. Respirationsc. Blood pressured. Temperature

http://amy47.com/nclex-style-practice-questions/neuro-icp-loc-meningitis/cva-stroke/

Question 3A 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/

Question 4The 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 toa. 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/

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/

Question 6A 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/

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/