Cva- brain

8/11/2019 Cva- brain

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Brain Attack

NR-75D

Diana Diaz RN, MS


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Objectives Define stroke

Discuss incidence & risk factors

Review Cerebral flow and factors thataffect it

Discuss pathophysiology of CVA

Correlate clinical manifestations ofstroke with the pathophysiology.


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History of Stroke Hippocrates-2,400 yrs ago

Names for Stroke

Most commonly known today

Brain Attack


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Incidence 3rdCause of death in US and Canada

Statistics

2/3 in people >65

= in men and women

Higher incidence and death ratesamong African-Americans, Hispanics,Native-American, Asian Americans


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Risk FactorsNon Modifiable

Age

Gender

Race

Heredity


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Risk FactorsModifiable

Obesity

HTN

Smoking

Heavy alcohol

consumption Hypercoagulability

Hyperlipidemia

Asymptomaticcarotid stenosis

Diabetes mellitus Heart disease, atrial

fibrillation

Oral contraceptives Physical inactivity

Sickle cell disease


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Review of Cerebral Circulation


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Blood supply by arteries Blood is supplied to the brain by two

major pairs of arteries Internal carotid arteries

Vertebral arteries


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Blood supply by arteries Carotid arteries branch to supply most

of the

Frontal, parietal, and temporal lobes

Basal ganglia

Part of the diencephalon

Thalamus Hypothalamus


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Blood supply by arteriesVertebral arteries join to form the

basilar artery, which supply the

Middle and lower temporal lobes

Occipital lobes

Cerebellum

Brainstem Part of the diencephalon


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Brain Attack means:

Blood flow to the brain istotally interrupted


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EtiologyAtherosclerosisDisease of the

arteries; hardening and thickening of

the arterial wall because of softdeposits of intraarterial fat and fibrinthat harden over time.


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Common sites for thedevelopment of Atherosclerosis


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Transient Ischemic Attack

(TIA) Transient ischemic attack (TIA) is a

temporary focal loss of neurologic

function caused by ischemia Most TIAs resolve within 3 hours

TIAs are a warning sign of progressive

cerebrovascular disease


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Types of Stroke

Strokes are classified based on theunderlying pathophysiologic findings

Ischemic

Hemorrhagic


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Ischemic vs. Hemorrhagic


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Ischemic Stroke

Thrombotic or Embolic

Most patients with ischemicstroke do not have a decreasedlevel of consciousness in thefirst 24 hours

May progress in the first 72hours


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Thrombotic stroke

Thrombosis occurs in relation to injury to a

blood vessel wall and formation of a bloodclot

Result of thrombosis or narrowing of the

blood vessel Most common cause of stroke


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Embolic stroke

Occur when an embolus lodges in and

occludes a cerebral artery Results in infarction and edema of the area

supplied by the involved vessel

Second most common cause of stroke


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Embolic stroke

Majority of emboli originate in the insidelayer of the heart, with plaque breaking off

from the endocardium and entering thecirculation

Patient with an embolic stroke commonlyhas a rapid occurrence of severe clinical

symptoms


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Hemorrhagic Stroke

Account for approximately 15% of allstrokes

Result from bleeding into the braintissue itself or into the subarachnoidspace or ventricles


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Hemorrhagic Stroke

Intracerebral hemorrhage

Bleeding within the brain caused by a

rupture of a vessel Hypertension is the most important cause

Hemorrhage commonly occurs during

periods of activity


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Hemorrhagic Stroke

Intracerebral hemorrhage

Manifestations include neurologic deficits,

headache, nausea, vomiting, decreasedlevels of consciousness, and hypertension


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Hemorrhagic Stroke

Subarachnoid hemorrhage

Occurs when there is intracranial bleeding

into cerebrospinal fluid-filled spacebetween the arachnoid and pia mater

Commonly caused by rupture of acerebral aneurysm


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Clinical Manifestations

Affects many body functions Motor activity

Elimination Intellectual function

Spatial-perceptual alterations

Personality

Affect Sensation

Communication


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Clinical Manifestations

Brain attack Term increasingly being used to describe

stroke and communicate urgency ofrecognizing stroke symptoms and treatingtheir onset as a medical emergency


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Clinical ManifestationsMotor Function

Most obvious effect of stroke

Include impairment of

Mobility

Respiratory function

Swallowing and speech

Gag reflex

Self-care abilities


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Clinical ManifestationsMotor Function

An initial period of flaccidity may lastfrom days to several weeks and is

related to nerve damage Spasticity of the muscles follows the

flaccid stage and is related to

interruption of upper motor neuroninfluence


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Clinical ManifestationsCommunication

Patient may experience aphasia whena stroke damages the dominant

hemisphere of the brainAphasia is a total loss of

comprehension and use of language


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Dysphasia refers to difficulty related tothe comprehension or use of language

and is due to partial disruption or loss Dysphasia can be classified as

nonfluent or fluent


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Dysarthria does not affect themeaning of communication or the

comprehension of language It does affect the mechanics of speech


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Clinical ManifestationsAffect

Patients who suffer a stroke may havedifficulty controlling their emotions

Emotional responses may beexaggerated or unpredictable


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Clinical ManifestationsIntellectual Function

Both memory and judgment may beimpaired as a result of stroke

A left-brain stroke is more likely toresult in memory problems related tolanguage


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Clinical ManifestationsSpatial-Perceptual Alterations

Spatial-perceptual problems may bedivided into four categories

1. Incorrect perception of self andillness

2. Erroneous perception of self in space


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Clinical ManifestationsSpatial-Perceptual Alterations

3. Inability to recognize an objectby sight, touch, or hearing

4. Inability to carry out learnedsequential movements oncommand


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Diagnostic Studies

When symptoms of a stroke occur,diagnostic studies are done to

Confirm that it is a stroke Identify the likely cause of the stroke

CT is the primary diagnostic test used

after a stroke


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Diagnostic Studies

Additional studies

Complete blood count

Platelets, prothrombin time, activatedpartial thromboplastin time

Electrolytes, blood glucose

Renal and hepatic studies Lipid profile


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Collaborative CarePrevention

Goals of stroke prevention include

Health management for the well individual

Education and management of modifiablerisk factors to prevent a stroke


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Antiplatelet drugs are usually thechosen treatment to prevent further

stroke in patients who have had a TIAAspirin is the most frequently used

antiplatelet drug


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Surgical interventions for the patientwith TIAs from carotid disease include

Carotid endarterectomy Transluminal angioplasty

Stenting

Extracranial-intracranial bypass


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Collaborative CareAcute Care

Assessment findingsAltered level of consciousness

Weakness, numbness, or paralysis Speech or visual disturbances

Severe headache

or heart rate

Respiratory distress

Unequal pupils


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InterventionsInitial

Ensure patient airway

Remove dentures Perform pulse oximetry

Maintain adequate oxygenation

IV access with normal saline Maintain BP according to guidelines


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InterventionsInitial

Remove clothing

Obtain CT scan immediately Perform baseline laboratory tests

Position head midline

Elevate head of bed 30 degrees if nosymptoms of shock or injury


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InterventionsOngoing

Monitor vital signs and neurologic status

Level of consciousness Motor and sensory function

Pupil size and reactivity

O2saturation

Cardiac rhythm


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Recombinant tissue plasminogenactivator (tPA) is used to

Reestablish blood flow through a blockedartery to prevent cell death in patientswith acute onset of ischemic strokesymptoms


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Thrombolytic therapy given within 3hours of the onset of symptoms

disability But at the expense of in deaths within

the first 7 to 10 days and in intracranial

hemorrhage


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Surgical interventions for stroke

include immediate evacuation ofAneurysm-induced hematomas

Cerebellar hematomas (>3 cm)


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Collaborative CareRehabilitation Care

After the stroke has stabilized for 12-24 hours, collaborative care shifts from

preserving life to lessening disabilityand attaining optimal functioning

Patient may be transferred to a

rehabilitation unit


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Nursing ManagementNursing Implementation

Respiratory System

Management of the respiratory system is a

nursing priority Risk for aspiration pneumonia

Risks for airway obstruction

May require endotracheal intubation andmechanical ventilation

N i M


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Neurologic System

Monitor closely to detect changes

suggesting Extension of the stroke

ICP

Vasospasm

Recovery from stroke symptoms

N i M


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Cardiovascular System

Monitoring vital signs frequently

Monitoring cardiac rhythms Calculating intake and output, noting

imbalances

Regulating IV infusions

N i M t


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Cardiovascular System

Adjusting fluid intake to the individual

needs of the patient Monitoring lung sounds for crackles and

rhonchi (pulmonary congestion)

Monitoring heart sounds for murmurs orfor S3or S4heart sounds

N i M t


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Musculoskeletal System Trochanter roll at hip to prevent external

rotation

Hand cones to prevent hand contractures

Arm supports with slings and lap boardsto prevent shoulder displacement


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N i M t


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Integumentary System

Pressure relief by position changes,

special mattresses, or wheelchaircushions

Good skin hygiene

Emollients applied to dry skin

N i M t


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Integumentary System

Early mobility

Position patient on the weak or paralyzedside for only 30 minutes

N i M t


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Gastrointestinal System

After careful assessment of swallowing,

chewing, gag reflex, and pocketing, oralfeedings can be initiated

Feedings must be followed by scrupulousoral hygiene

N i M t


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Communication Nurses role in meeting psychologic needs

of the patient is primarily supportive Patient is assessed both for the ability to

speak and the ability to understand

Speak slowly and calmly, using simple

words or sentences

N i M t


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Sensory-Perceptual Alterations Blindness in the same half of each visual

field is a common problem after stroke Other visual problems may include diplopia

(double vision), loss of the corneal reflex,and ptosis (drooping eyelid)

N i M t


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Ambulatory and Home Care The rehabilitation nurse assesses the

patient and family with Rehabilitation potential of the patient

Physical status of all body systems

Presence of complications caused by the strokeor other chronic conditions

Cognitive status of the patient


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N i M t


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Ambulatory and Home Care Nurses have an excellent opportunity to

prepare the patient and family fordischarge through Education

Demonstration

Practice Evaluation of self-care skills

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