Transcript Cerebral-vascular Accidents

Cerebral-vascular
Accidents
By: 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 strokes
Ischemic (clots)
Thrombotic & embolic
Hemorrhagic (bleeds)
Subarachnoid hemorrhage (SAH) &
Intracerebral hemorrhage (ICH)
Pathophysiology
 Thrombotic stroke
 Arterial occlusions caused by thrombi formed in
arteries supplying the brain or in the intracranial
vessels (Huether, 2011).
 Embolic stroke
 Fragments 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 stroke
Are caused by occlusion of a single
deep perforating artery that supplies
small penetrating subcortical
vessels, causing ischemic lesions
(Huether, 2011).
Transient ischemic attack
Brief 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 CVAs
Unilateral limb weakness, numbness
Speech difficulties
Headache, visual disturbances
Dizziness, anxiety
Altered level of consciousness
Lippincott. (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 mobility
Related to: weakness on right side
secondary to stroke
As 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 1
A 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-locmeningitis/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. Pulse
b. Respirations
c. Blood pressure
d. Temperature
http://amy47.com/nclex-style-practice-questions/neuro-icp-locmeningitis/cva-stroke/
Question 3
A 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 4
The 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 to
a. 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 speechlanguage 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 6
A 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 evidencebased guide to planning care. (9th ed.). St. Louis,Missouri: Mosby Elsevier.
 American stroke association. (2012). Retrieved from
http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/Type
s-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-43a0-48708a55-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/S1052305708002139/1s2.0-S1052305708002139-main.pdf?_tid=7faabc74-2dc0-11e2-994f00000aacb362&acdnat=1352831737_90780f25910cd0531e4a2c961f0b16ba
 http://quizlet.com/5114986/stroke-flash-cards/
 http://amy47.com/nclex-style-practice-questions/neuro-icp-loc-meningitis/cvastroke/