Neurological Stressors IV Cerebrovascular Accidents

1. Neurological Stressors IV Cerebrovascular Accidents Joy Borrero, RN, MSN 5/10

2. Transient Ischemic Attacks (TIAs) • Brief reversible episode of neurologic function (mini stroke) • TIAs last from a few minutes to several hours • Highest incidence >age 65 but can occur at any age • Most common site- internal carotid artery

3. TIAs Causes: 1.Athersclerosis of extra cranial arteries 2.Hypercoagulability, polycythemia, embolism 3.Arterial insufficiency-  CO or mechanical obstruction of vessels in neck Risk Factors: • Family hx • Medical Hx

4. TIAs • S&S: dizziness, vision changes, slurred speech, dysphagia, motor weakness • Presentation depends on affected vessel. • Diagnostic eval- bruit, carotid angiography • Medical management- anticoagulants. • Surgical- carotid endarterectomy and angioplasty • http://www.stroke.org

5. Stroke- CVA • Disruption in cerebral blood flow • ”BRAIN ATTACK” • Medical emergency that strikes suddenly and should be treated STAT • 700,000 occur yearly • 49% die before they reach hospital • 50-75% of stroke survivors regain functional independence • Third most common cause of death in US and leading cause of adult disability

6. Be Stroke Smart The “3 R’s” of Stroke: Reduce Stroke Risk Recognize Stroke Symptoms Respond: At the first sign of stroke, Call 911 or Get to the Hospital Fast! 80% of all Strokes are Preventable!

7. Think FAST! F = Face: ask the person to smile A = Arm: ask the person to raise both arms S= Speech, ask the person to speak a simple sentence T = Time: to call 911

8. Stroke Detection Ask 3 questions (FIRST 3 LETTERS OF STROKE) • SMILE- ask individual to smile • TALK- Ask the person to speak a simple sentence • RAISE- Ask the person to raise both arms • Call 911

9. CVA- Risk Factors • Hypertension • Heart Disease Atrial fibrillation Coronary heart disease Disease of the heart vessels • Diabetes • TIAs • Smoking • Cerebral aneurysm • Use of oral contraceptives

10. Cerebrovascular Accident- CVA • Causes: Thrombosis, embolism (85%), cerebral hemorrhage(15%) • Manifestations: numbness or weakness of face, arm, leg, on one side body • Confusion, change mental status • Trouble speaking or understanding speech • Visual disturbances • Difficulty walking, coordination • Sudden severe headache

11. Pathophysiology • Ischemia in brain tissue supplied by affected artery • Ischemiahypoxia/anoxia brain dysfunction • Infarction/death of neurons in involved area of brain • Contralateral (opposite side) hemisphere

12. Types of Stroke • Ischemic-80% Hypoperfusion Embolism Thrombus • Hemorrhagic- 20% Intracerebral Subarachnoid 50% mortality

13. Right cerebrum: Visual & spatial awareness Loss of depth perception Disorientation Poor judgement, impulsive L hemiplegia or hemiparesis Visual changes Left cerebrum: Language, math and analytical skills Aphasia Alexia Agraphia R hemiparesis or hemiplegia Slow, cautious behavior Depression and quick frustration Visual changes CVA Symptoms

14. CVA • Diagnostic- history, neuro exam, CT, MRI, carotid ultrasound or MRA/angiography. Nursing Diagnoses: • Impaired physical mobility • Self care deficits • Impaired verbal communication • Altered thought processes • Impaired swallowing • Altered (cerebral) tissue perfusion • Unilateral neglect

15. Assessment • Airway patency • LOC • Pupillary abnormalities • Motor loss • Mouth droop • Aphasia/Communication loss • Dysarthria • Dysphagia/ aspiration risk • Glasgow Coma Scale score • Visual disturbances:Hemianopsia, diplopia, loss of peripheral vision • Bladder dysfunction • Reflexes indicating meningeal irritation

16. NIH Stroke Scale • Level of Consciousness • Best gaze • Visual field testing • Facial paresis • Motor function- Arm • Motor function- Leg • Limb ataxia • Sensory- Use pinprick to test arms, legs • Best Language • Dysarthria • Extinction and Inattention Http://www.ninds.nih.gov/doctors/NIH Stroke Scale. pdf

17. JCAHO: Disease Specific Care • Initiate DVT prophylaxis • Give antithrombotics within 48hrs hospitalization • Prescribe antithrombotics at discharge • Provide anticoags to pts with afib • Consider tPA therapy-ischemic stroke • Evaluate lipid profile • Screen for dysphagia • Provide stroke education to pt and family • Provide smoking cessation materials • Consider rehab plans

18. Tx of Embolic Stroke • Restore cerebral blood flow • Monitor for  ICP • Reduce pooling of blood in lower extremities • Avoid sudden postural changes • Prevent further clot formation • Monitor VS and Temp • Prevent deformities-rehab • Dysphagia screening • Smoking cessation

19. Tx of Hemorrhagic Stroke • Control of seizures • Control of hyperthermia • Tx of HTN • Control restlessness • Relief of HA and stiff neck • Prevention of straining • Provide rest periods • Reduction of ICP • Surgical removal of blood clot

20. CVA- Nursing Interventions Goals: • Improving mobility, preventing deformities • Enhancing self care • Managing sensory- perceptual difficulties • Managing dysphagia and good nutrition • Attaining bowel and bladder control • Improving communication • Maintaining skin integrity • Helping pt. cope with sexual dysfunction