Lisa Randall, RN, MSN, ACNS-BCRNSG 2432

Objectives

Define cerebrovascular accident and associated terminology

Discuss related pathophysiology and presentation of various types of stroke

Discuss etiology, risk factors, diagnostics, management, and outcomes of stroke

Review case studies and nursing diagnoses, interventions, and goals

Definition

Stroke or “brain attack” is an acute CNS injury that results in neurologic S/S brought on by a reduction or absence of perfusion to a territory of the brain. The disruption in flow is from either an occlusion (ischemic) or rupture (hemorrhagic) of the blood vessel.

Incidence & Prevalence

Third leading cause of death in the USA 750,000+ people/year 175,000 die within one year (25%)

Leading cause of long-term disabilities 5.5 million survivors (USA) 15 to 30 % live with permanent disability

Definitions

Cerebrovascular Accident Ischemic Stroke

Thrombotic Embolic Lacunar infarct TIA

Hemorrhagic Stroke ICH SAH

Stroke: Emergency Care

http://youtu.be/-d8__FkW-nU

Thrombotic Stroke

Occlusion of large cerebral vessel

Older population Sleeping/resting Rapid event, but slow

progression (usually reach max deficit in 3 days)

Embolic Stroke

Embolus becomes lodged in vessel and causes occlusion

Bifurcations are most common site

Sudden onset with immediate deficits Embolysis

Hemorrhagic Transformation

Lacunar Strokes - 20% of all stokes Minor deficits

Paralysis and sensory loss Lacune Small, deep penetrating

arteries High incidence:

Chronic hypertension Elderly DIC

Transient Ischemic Attack

Warning sign for stroke Brief localized ischemia Common

manifestations: Contralateral numbness/

weakness of hand, forearm, corner of mouth

Aphasia Visual disturbances-

blurring

Deficits last less than 24 hours (usually less than 1 or 2 hrs)

Can occur due to: Inflammatory artery

disorders Sickle cell anemia Atherosclerotic

changes

Hemorrhagic Stroke Definitions

Intracerebral hemorrhage Intracranial hemorrhage Parenchymal hemorrhage Intraparenchymal hematoma Contusion Subarachnoid hemorrhage

Hemorrhagic Stroke

Rupture of vessel Sudden Active Fatal HTN Trauma Varied

manifestations

Hemorrhagic Stroke

Intracerebral Hemorrhage

Subarachnoid Hemorrhage

PathophysiologyHemorrhagic Stroke

Changes in vasculature Tear or rupture Hemorrhage Decreased perfusion Clotting Edema Increased intracranial pressure Cortical irritation

Hearing/association & Smell & taste Short term Memory

Voluntary Motor

Sensations Pain & Touch Taste

Balance, Coordination of each muscle group

Arms

Head

LegsMom: Bowel/bladder Reasoning/judgment Long term memory

Vision & visual memory

CN 5,6,7,8 P,R, B/P CN 9,10,11,12

Tracks cross over Coordinate movement, HR,B/P

Vessels of the Brain

Vessels of the Brain

Right Side

Circle of Willis

PhysiologyNormal Cerebral Blood Flow Oxygen Glucose 20% of Cardiac Output / oxygen Arterial supply to the brain:

Internal carotid (anteriorly) Vertebral arteries (posteriorly)

Venous drainage 2 sets of veins - venous plexuses

Dural sinuses to internal jugular veins Sagittal sinus to vertebral veins

No valves, depend on gravity and venous pressure gradient for flow

Risk Factors

NON-MODIFIABLE MODIFIABLE

Age 2/3 over 65

Gender M=F Female>fatality

Race AA > hispanics, NA Asians > hem

Heredity Family history Previous TIA/CVA

Hypertension Diabetes mellitus Heart disease A-fib Asymptomatic carotid stenosis Hyperlipidemia Obesity Oral contraceptive use Heavy alcohol use Physical inactivity Sickle cell disease Smoking Procedure precautions

EtiologyIschemic Stroke Embolism Prothrombotic states Atrial fib Sinoatrial D/O Recent MI Endocarditis Cardiac tumors Valvular D/O Patent foramen ovale Carotid/basilar artery

stenosis Atherosclerotic lesions Vasculitis

Hemostatic regulatory protein abnormalities

Antiphospholipid antibodies

Hep cofactor II

Etiology Hemorrhagic Stroke Chronic HTN** Cerebral Amyloid Angiopathy* Anticoagulation* AVM Ruptured aneurysm (usually subarachnoid) Tumor Sympathomimetics Infection Trauma Transformation of ischemic stroke Physical exertion, Pregnancy Post-operative

Aneurysm

Localized dilation of arterial lumen Degenerative vascular disease Bifurcations of circle of Willis

85% anterior 15% posterior

AneurysmSubarachnoid Hemorrhage

SAH Mortality 70% 97% HA Nuchal rigidity Fever Photophobia Lethargy Nausea Vomiting

Aneurysm/SAH

Complications HCP Vasospasm

Triple H Therapy HTN Hemodilution Hypervolemia

Surgical treatment Clip Coil INR

Nursing Management

Assessment Monitoring

BP TCDs CBC

Preventing complications Bowel program DVT prophylaxis Siezure prophylaxis Psychological support Discharge planning

Arteriovenous malformations AVM

Tangled mass of arteries and veins Seizure or ICH

Treatment AVM Endovascular Neurosurgery Radiosurgery

Presentation

Sudden onset Focal neurological deficit Progresses over minutes to hours HA, N/V, <<LOC, HTN Depends on location

Stroke Symptoms include: 

SUDDEN numbness or weakness of face, arm or leg

SUDDEN confusion, trouble speaking or understanding.

SUDDEN trouble with vison.

SUDDEN trouble walking, dizziness, loss of balance or coordination.

SUDDEN severe HA.

Manifestationsby Vessel

Vertebral Artery Pain in face, nose, or eye Numbness and weakness of face (involved

side) Gait disturbances Dysphagia Dysarthria (motor speech)

Manifestationsby Vessel

Internal carotid artery Contralateral paralysis (arm, leg, face) Contralateral sensory deficits Aphasia (dominant hemisphere

involvement) Apraxia (motor task), Agnosia (obj. recognition), Unilateral neglect (non-dominant

hemisphere involvement) Homonymous hemianopia

Manifestations & Complications by Body System Neurological

Hyperthermia Neglect syndrome Seizures Agnosias (familiar

obj)

Communication deficits Aphasia (expressive,

receptive, global) Agraphia

Visual deficits Homonymous

hemianopia Diplopia Decreased acuity Decreased blink reflex

Manifestations & Complications by Body System Neurological (cont.)

Cognitive changes Memory loss Short attention

span Poor judgment Disorientation Poor problem-

solving ability

Behavioral changes Emotional

lability Loss of

inhibitions Fear Hostility

Manifestations & Complications by Body System Musculoskeletal

Hemiplegia or hemiparesis

Contractures Bony ankylosis Disuse atrophy Dysarthria - word

formation Dysphagia –

swallow Apraxia – complex

movements Flaccidity/spasticity

GU Incontinence Frequency Urgency Urinary retention Renal calculi

Manifestations & Complications by Body System Integument

Pressure ulcers Respiratory

Respiratory center damage Airway obstruction Decreased cough ability

GI Dysphagia Constipation Stool impaction

Initial Stroke Assessment/Interventions

Neurological assessment & NIH assessment Call “Stroke Alert” Code Ensure patient airway VS IV access Maintain BP within parameters Position head midline HOB 30 (if no shock/injury) CT, blood work, data collection/NIH Stroke

Scale Anticipate thrombolytic therapy for ischemic

stroke

NIH Stroke Scale Score

Standardized method measures degree of stroke r/t impairment and change in a patient over time.

Helps determine if degree of disability merits treatment with tPA. As of 2008 stroke patients scoring greater than 4 points can be treated with

tPA.

Standardized research tool to compare efficacy stroke treatments and rehabilitation interventions.

Measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language not measured by Glasgow coma scale.

Current NIH Stroke Score guidelines for measuring stroke severity: Points are given for each impairment.

0= no stroke 1-4= minor stroke 5-15= moderate stroke 15-20= moderate/severe stroke 21-42= severe stroke A maximal score of 42 represents the most severe and devastating stroke.

Comic Relief

Question

The neurologic functions that are affected by a stroke are primarily related to A. the amount of tissue area involved. B. the rapidity of the onset of symptoms. C. the brain area perfused by the

affected artery. D. the presence or absence of collateral

circulation.

Question

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipated that the health care provider will request a A. CT scan. B. lumbar puncture. C. cerebral angiogram. D. PET scan.

Diagnostics

Tests for the Emergent Evaluation of the Patient with Acute Ischemic Stroke

CT head (-) Electrocardiogram Chest x-ray Hematologic studies (complete blood count,

platelet count, prothrombin time, partial thromboplastin time)

Serum electrolytes Blood glucose Renal and hepatic chemical analyses National Institute of Health Scale (NIHSS) score

Diagnostics

Ischemic Stroke Hemorrhagic Stoke

Medical Management

BP MAP CPP

Factor VII, Vit K, FFP ICP

HOB Sedation Osmotherapy Hyperventilation Paralytics

Fluid management euvolemia

Seizure prophylaxis Keppra Dilantin

Sedation Body temperature PT/OT/ST DVT prophylaxis

Treatment

Ischemic Hemorrhagic

Medical management TpA Endovascular

Carotid endarectomy Merci clot removal

http://youtu.be/P2TNz-TniIA

Medical management Decompression

Craniotomy Craniectomy

PT/OT/STREHABILITATION

Medications

Anti-coagulants – A fib & TIA Antithrombotics Calcium channel blockers – Nimotop

(nimodipine) Corticosteroids ??? Diuretics – Mannitol, Lasix (Furosemide) Anticonvulsants – Dilantin (phenytoin) or

Cerebyx (Fosphenytoin Sodium Injection) Thrombolytics - tPA (recombinant tissue

plasminogen activator)

Medications

Thrombolytics Recombinant Alteplase (rtPA) Activase, Tissue plasminogen activator Treatment must be initiated promptly after CT to

R/O bleed Systemic within 3 hours of onset of symptoms Intra-arterial within 6 hours of symptoms

Some exclusions: Seizure at onset Subarachnoid hemorrhage Trauma within 3 months History of prior intracranial hemorrhage AV malformation or aneurysm Surgery 14 days, pregnancy, Cardiac cath. 7 days

Neurosurgical Management

Craniotomy Craniectomy EVD placement ICP monitor placement

Recommendations for Surgical Treatment of ICH Nonsurgical

candidates Small hemorrhage Minimal deficit GCS </= 4 (unless

brain stem compression)

Loss of brainstem fxn Severe coagulopathy Basal ganglion or

thalamic

Surgical candidates >3cm

Neuro deficit Brain stem

compression MLS, HCP

Aneurysm, AVM, cavernous hemangioma

Young c mod/large lobar hemorrhage c clinical deterioration

Question

A carotid endarectomy is being considered as treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery A. is used to restore blood circulation to the brain

following an obstruction of a cerebral artery. B. involves intracranial surgery to join a superficial

extracranial artery to an intracranial artery. C. involves removing an atherosclerotic plaque in

the carotid artery to prevent an impending stroke. D. is used to open a stenosis in a carotid artery

with a balloon and stent to restore cerebral circulation.

Standing Orders

Per facility policy

Nursing Concerns

Medical management!

Post-op care Mobilization Nutrition Constipation Skin

Infection Patient/family

teaching Follow-up Medications Resources available

Question

An essential intervention in the emergency management of the patient with a stroke is A. intravenous fluid replacement. B. administration of osmotic diuretics to

reduce cerebral edema. C. initiation of hypothermia to decrease

oxygen needs of the brain. D. maintenance of respiratory function with

a patent airway and oxygen administration.

Overview

http://youtu.be/-d8__FkW-nU

NCLEX

A patient comes to the ED immediately after experiencing numbness of the face and inability to speak, but while the patient awaits examination, the symptoms disappear and the patient requests discharge. The RN stresses that it is important for the patient to be evaluated, primarily because A. the patient has probably experienced an

asymptomatic lacunar stroke. B. the symptoms are likely to return and progress

to worsening neurologic deficit in the next 24 hours.

C. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off.

D. the patient has probably experienced a TIA that is a sign of progressive vascular disease.

Nursing Diagnosis

Ineffective cerebral tissue perfusion Impaired mobility Self-care deficit Impaired verbal communication Impaired swallowing

Nursing Diagnoses/Interventions

Ineffective Tissue Perfusion Goal is to maintain cerebral perfusion

Monitor respiratory status Auscultate, monitor lung sounds Suction as needed – increases ICP Place in side-lying position (secretions) O2 as needed/prescribed Assess LoC, other neuro vital signs NIH Stroke Scale Glasgow Coma Scale – Eyes, Verbal, & Motor

Nursing Diagnoses/Interventions

Ineffective Tissue Perfusion (cont)

Monitor strength/reflexes Assess for HA, sluggish pupils, posturing Monitor cardiac status Monitor I&O’s

Can get DI as result of pituitary gland damage Monitor seizure activity

Nursing Diagnoses/Interventions

Impaired Physical Mobility Goal is to maintain and improve functioning

Active ROM for unaffected extremities Passive ROM for affected extremities Q2 hr turns Assess for thrombophlebitis Confer with PT for movement and positioning

techniques for each stage of rehab

Nursing Diagnoses/Interventions

Impaired Physical MobilityFlaccidity & spasticity Meds used to treat spasticity:

Kemstro or Lioresal (baclofen) Valium (diazepam) Dantrium (dantrolene sodium) Zanaflex (tizanidine

hydrochloride) New drugs being tried –

Neurontin (Gabapentin) & Botox (botulinum toxin)

Nursing Diagnoses/Interventions Self-Care Deficit

Goals are to promote functional ability, increase independence, improve self-esteem Encourage use of unaffected arm in ADLs Self-dressing (using unaffected side to

dress affected side first) Sling or support for affected arm Confer with OT for techniques to promote

return to independence

Nursing Diagnoses/Interventions Impaired Verbal Communication

Goal is to increase communication Speak in normal tones unless there is a

documented hearing impairment Allow adequate time for responses Face center client when speaking, speak simply

and enunciate words If you don’t understand what the client is saying,

let them know, and have them try again

Nursing Diagnoses/Interventions Impaired Verbal Communication (cont)

Try alternate method of communication if needed Writing, computerized boards, etc

Allow client anger and frustration at loss of previous functioning

Allow client to touch (hands, arms), may be the only way of expressing (comfort, etc)

If client has visual disturbances: During initial phase of recovery, position where

client can easily see you; in later stages, client can be directed to adjust position for visual contact

Nursing Diagnoses/Interventions

Impaired Swallowing Goal is safety, adequate nutrition, and

hydration Position client upright, using **pureed – less

often ** or finely chopped soft foods Hot or cold food or thickened liquids Teach client to put food behind teeth on

unaffected side and tilt head backwards Check for food pockets, especially on affected

side Have suctioning equipment at bedside Minimize distractions while eating Never leave client with food etc. in mouth

Question

A patient with a right hemisphere stroke has a nursing diagnosis of unilateral neglect R/T sensory-perceptual deficits. During the patient’s rehabilatation, it is important for the nurse to A. avoid positioning the patient on the affected

side. B. place all objects for care on the patient’s

unaffected side. C. teach the patient to care consciously for the

affected side. D. protect the affected side from injury with

pillows and supports.

Complications

Increased intracranial pressure Rebleeding Vasospasm HCP Death

Outcomes

Age Size, volume Location HCP, IVH Deficit, LOC, MAP Duration Co-morbidities

44% mortality

Evaluation

Reduce mortality and morbidity Baseline neurological function Outcomes Evidenced based practice

Patient/Family Education

PREVENTION is key Smoking cessation Physical activity

Weight reduction Diet

Plavix LDL chol reduction

Statins > HDL

BP normilization ACE inhibitos ARB Thiazide diuretics

Antiplatelet agents ASA

DM ETOH Homocysteine

reduction

http://youtu.be/awtFZQkoBPc

Legal/Ethical Concerns

Advanced directives MPOA

Category status Code status Withdrawal of care Palliative care Placement

Resourceswww.stroke.org -- National Stroke Association (800-787-6537) www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke (800-352-9424) www.naric.com -- National Rehabilitation Information Center (8003462742) www.aphasia.org -- National Aphasia Association (800-922-4622) www.aan.com -- American Academy of Neurology www.dynamic-living.com -- Daily living products www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf -- NIH stroke scoring system www.strokecenter.org/trials -- Find a clinical trial on stroke

Case Study #1

34 yo AAM R temporoparietal

ICH c IVH, HCP h/o L MCA ischemic Sentis protocol Coumadin (INR 13) Factor VII, Vit K Craniotomy ICP EVD x 2

Jackson, William JJ^31725511/12/19751/12/197534 YEAR34 YEARMM

Page: 14 of 36Page: 14 of 36------Acq No: 4Acq No: 4eff. mAs: 460eff. mAs: 460mA: 460mA: 460KVp: 120KVp: 120Tilt: -10Tilt: -10RD: 250RD: 250512x512512x512

BRACKENRIDGE BRACKENRIDGECT Head w/o ContrastCT Head w/o Contrast

Head W/O ST.Head W/O ST. 12/3/2009 6:43:15 AM 12/3/2009 6:43:15 AM

37258603725860------

LOC: -111.80LOC: -111.80THK: 4.80THK: 4.80

HFSHFS

IM: 14 SE: 2IM: 14 SE: 2Compressed 11:1Compressed 11:1

W: 80W: 80C: 35C: 35

RR LL

AA

PP

------

cm cm

Question

The incidence of ischemic stroke in pateints with TIAs and other risk factors is reduced with the administration of A. furosemide (Lasix). B. lovastatin (Mevacor). C. daily low-dose aspirin (ASA). D. nimodipine (Nimotop).

Question

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient includea. hyperventilation therapy.b. surgical clipping of the aneurysm.c. administration of hypersomotic agents.d. administration of thrombolytic therapy.

Question

A nursing intervention that is indicated for the patient with hemiplegia is A. the use of a footboard to prevent plantar

flexion. B. immobilization of the affected arm

against the chest with a sling. C. positioning the patient in bed with each

joint lower that the joint proximal to it. D. having the patient perform passive ROM

of the affected limb with the unaffected limb.

Question

The nurse can assist the patient and the family in coping with the long-term effects of a stroke by A. informing the family members that the patient

will need assistance with almost all ADLs. B. explaining that the patient’s prestroke

behavior will return as improvement progresses. C. encouraging the patient and family members

to seek assistance from family therapy or stroke support group.

D. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning.

References

AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St.

Broderick, J., et. al. (1999) Guidelines for the management of spontaneous intracerebral hemorrhage. AHA.

El-Mitwali, A., Malkoff, M. (2001) Intracerebral hemorrhage. The Internet Journal of Neurosurgery. 1.1.

Greenberg, Mark. (2006). Handbook of Neurosurgery. Greenberg Graphics,

Tampa, Florida.