Transcript Chapter 34

Chapter 28
Cerebrovascular
Accident
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Learning Objectives
• Discuss the risk factors for cerebrovascular accident
(CVA).
• Identify the two major types of CVA.
• Describe the pathophysiology, signs and symptoms,
and medical treatment for each type of CVA.
• Describe the neurologic deficits that may result from
CVA.
• Explain the tests and procedures used to diagnose
a CVA and nursing responsibilities for patients undergoing those
tests and procedures.
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Learning Objectives
• List data to be included in the nursing assessment of
the CVA patient.
• Assist in developing a nursing care plan for a CVA
patient during the acute and rehabilitation phases.
• Specify criteria used to evaluate the outcomes of
nursing care for the CVA patient.
• Identify resources for the CVA patient and family.
• Discuss criteria used to identify patients eligible for
treatment with rt-PA.
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Cerebrum
• Complex functions: initiation of movements,
recognition of sensory input, higher-order
thinking, regulating emotional behavior and
endocrine and autonomic functions
• Divided into two halves: hemispheres
• Each hemisphere controls the opposite side of the
body: the right hemisphere controls the left side of
the body, and the left hemisphere controls the right
side of the body
• The cortex of each is divided into the parietal, frontal,
temporal, and occipital lobes; each has a different
area of function
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Figure 28-1
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Cerebrum
• Brainstem
• Includes midbrain, pons, medulla, and part of the
reticular activating system
• Controls vital, basic functions, including respiration,
heart rate, and consciousness
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Cerebellum
• Uses information received from the cerebrum, muscles,
joints, and inner ear to coordinate movement, balance,
and posture
• Unlike the cerebrum, the right side of the cerebellum
controls the right side of the body, and the left side of
the cerebellum controls the left side of the body
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Circulation
• Carotid system
• Begins as one common artery; later divides into the
external and internal carotid arteries
• The external carotid arteries divide to supply blood to the
face
• The internal arteries further divide into the middle cerebral
artery and the anterior cerebral artery to supply blood to
the brain
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Circulation
• Vertebral arteries
• Originate from the subclavian artery, travel up the
anterior neck to merge and form the basilar artery at
the brainstem
• Second division forms posterior cerebral artery
• Internal carotid and vertebrobasilar arteries
unite to form the circle of Willis
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Figure 28-2
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Cerebrovascular Accidents
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Risk Factors for Stroke
• Nonmodifiable factors
• Risk factors that cannot be changed
• Age, race, gender, and heredity
• Modifiable factors
• Those that can be eliminated or controlled
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Transient Ischemic Attack
• Temporary neurologic deficit caused by
impairment of cerebral blood flow
• Blood vessels occluded by spasms, fragments
of plaque, or blood clots
• Important warning signs for the individual
experiencing a full stroke
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Transient Ischemic Attack
• Signs and symptoms
• Dizziness, momentary confusion, loss of speech,
loss of balance, tinnitus, visual disturbances, ptosis,
dysarthria, dysphagia, drooping mouth, weakness,
and tingling or numbness on one side of the body
• Medical diagnosis
• Health history, physical examination findings, and
results of brain imaging studies
• Laboratory studies, electrocardiography (ECG),
duplex ultrasonography, and cerebral angiography
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Transient Ischemic Attack
• Medical treatment
• Depends on the location of the narrowed vessel and
the degree of narrowing
• Acetylsalicylic acid (aspirin), ticlopidine
hydrochloride (Ticlid), extended-release
dipyridamole (Aggrenox), or clopidogrel bisulfate
(Plavix) decrease platelet clumping
• Warfarin (Coumadin) and heparin
• Carotid endarterectomy and transluminal
angioplasty
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Figure 28-3
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Stroke
• An abrupt impairment of brain function
resulting in a set of neurologic signs and
symptoms that are caused by impaired blood
flow to the brain and last more than 24 hours
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Stroke: Pathophysiology
• Hemorrhagic stroke
• Blood vessel in brain ruptures; bleeding into the
brain occurs
• Ischemic stroke
• Obstruction of blood vessel by atherosclerotic
plaque, blood clot, or a combination of the two, or by
other debris released into vessel that impedes blood
flow to an area of the brain
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Figure 28-4
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Stroke: Signs and Symptoms
• Different signs and symptoms, depending on
the type, location, and extent of brain injury
• Hemorrhagic stroke
• Occurs suddenly; may include severe headache
described as “the worst headache of my life”
• Other symptoms: stiff neck, loss of consciousness,
vomiting, and seizures
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Stroke: Signs and Symptoms
• Embolic stroke
• Appear without warning
• One or more of the following signs and symptoms:
one-sided weakness, numbness, visual problems,
confusion and memory lapses, headache,
dysphagia, and language problems
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Figure 28-5
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Stroke: Signs and Symptoms
• Aphasia
• A defect in the use of language; speech, reading, writing, or
word comprehension
• Dysarthria
• The inability to speak clearly
• Dysphagia
• Swallowing difficulty
• Dyspraxia
• The partial inability to initiate coordinated voluntary motor acts
• Hemiplegia
• Defined as paralysis of one side of the body
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Figure 28-8
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Stroke: Signs and Symptoms
• Sensory impairment
• Unable to feel touch, pain, or temperature in affected body
parts
• Unilateral neglect
• Do not recognize one side of the body as belonging to them
• Homonymous hemianopsia
• Perceptual problem: involves loss of one side of field of vision
• Elimination disturbances
• Neurogenic bladder
• Flaccid bladder
• Bowel incontinence
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Medical Diagnosis
• Blood studies, electrocardiogram (ECG),
computed tomography, magnetic resonance
imaging, carotid ultrasound studies, cerebral
and carotid angiography, electrocardiography,
positron-emission tomography, and singlephoton emission computed tomography
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Complications
• Constipation, dehydration, contractures,
urinary tract infections, thrombophlebitis,
decubitus ulcers, and pneumonia
• Sensory losses put patient at risk for traumatic
and thermal injuries
• Swallowing difficulties place patient at risk for
pulmonary complications, such as choking and
aspiration pneumonia
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Prognosis
• Prognosis for TIA or stroke increasingly hopeful
• Critical variables for recovery: patient’s condition
before the stroke, time between stroke and diagnosis,
treatment and support in acute phase (usually the first
48 hours), severity of patient’s symptoms, and access
to rehabilitative therapy
• Long-term recovery may depend on the care received
immediately after the stroke
• Most recovery takes place in the first 3-6 months, but
progress often continues long after that
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Medical Treatment in the Acute
Phase
• Begins with the onset of signs and symptoms
and continues until vital signs, particularly
blood pressure and neurologic condition,
stabilize
• This phase usually lasts 24 to 48 hours
• Many medical management interventions are
directed at minimizing complications and
deterioration of the patient’s condition after a
stroke
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Medical Treatment in the Acute
Phase
• Major focus areas
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Hypertension
Oxygenation
Hyperthermia
Hyperglycemia
• Drug therapy
• Tissue plasminogen activator (rt-PA, alteplase,
Activase)
• Given to dissolve clots in acute ischemic strokes
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Medical Treatment in the Acute
Phase
• Other medications
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•
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Mannitol
Nimodipine (Nimotop)
Phenytoin (Dilantin) and phenobarbital
Acetylsalicylic acid (aspirin), ticlopidine
hydrochloride (Ticlid), Aggrenox, and clopidogrel
(Plavix)
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Medical Treatment in the Acute
Phase
• Surgical intervention
• An option for some patients with hemorrhagic
strokes
• Decisions about surgery are based on patient’s age,
intracranial pressure, and location of the
hemorrhage
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Medical Treatment in the Acute
Phase
• Fluids and nutrition
• Intravenous fluids
• Dietary order based on patient’s nutritional
requirements and ability to eat
• Regular, soft, or pureed
• Total parenteral nutrition may be ordered for the
malnourished patient
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Medical Treatment in the Acute
Phase
• Urine elimination
• Indwelling catheter to manage urinary incontinence
• Intermittent catheterization: controlling incontinence
caused by a flaccid bladder
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Nursing Care in the Acute Phase
• Assessment
• Evaluate type and extent of the stroke: time of onset,
symptoms, other details
• Cincinnati Pre-hospital Stroke Scale
• Health history
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Chief complaint and history of present illness
Medical history
Family history
Review of systems
Functional assessment
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Nursing Care in the Acute Phase
• Physical examination
• Assess patient’s general appearance,
responsiveness, and behavior
• Record restlessness or agitation
• Measure vital signs; weight and height if possible
• Inspect the face for symmetry; mouth for moisture
and drooling
• Evaluate the alert patient’s ability to swallow
• Inspect pupils for size, equality, and reaction to light
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Nursing Care in the Acute Phase
• Physical examination
• Conduct a gross vision assessment
• Inspect skin color and palpate for moisture and turgor
• Assess extremities for muscle tone and strength, sensation,
and voluntary movement
• Record evidence of incontinence or bladder distention
• Frequently repeat neurologic checks: evaluating level of
consciousness, pupil appearance and response to light, the
patient’s ability to follow commands, and the movement and
sensation of extremities
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Nursing Care in the Acute Phase
• Interventions
• Ineffective Airway Clearance and Ineffective
Breathing Patterns
• Risk for Injury
• Deficient Fluid Volume or Excess Fluid Volume
• Imbalanced Nutrition
• Disturbed Sensory Perception
• Ineffective Thermoregulation
• Disturbed Thought Processes
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Nursing Care in the Acute Phase
• Interventions
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Impaired Verbal Communication
Impaired Physical Mobility
Total or Functional Urinary Incontinence
Constipation and/or Bowel Incontinence
Ineffective Coping
Interrupted Family Processes
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Nursing Care in the
Rehabilitation Phase
• Assessment
• Reassess patient’s abilities, expectations,
knowledge, motivation, and resources
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Nursing Care in the
Rehabilitation Phase
• Interventions
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Self-Care Deficit
Risk for Injury
Ineffective Coping
Impaired Verbal Communication
Imbalanced Nutrition
Impaired Physical Mobility
Constipation
Total and Functional Urinary Incontinence
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Figure 28-6
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Figure 28-7
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Figure 28-9
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Discharge
• Patients may be discharged to home or go to
specialized rehabilitation centers for continued
therapy
• Outpatient therapy is an option for some
patients
• When able, patients are transitioned back into
the home setting
• Essential to include family, friends, and
significant others in this process
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Discharge
• During and after the rehabilitation phase,
patients and families need to be made aware
of resources to help them deal with continuing
disabilities
• In rehabilitation, the patient is respectfully
challenged to return to the highest level of
function possible
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