Care of Patient with CVA

1. Care of Patient with CVA Rita Carey-Nita

2. Transient Ischemic Attack • Temporary impairment of the cerebral circulation • Sudden loss of neurological function is noted due to inadequate perfusion of a portion of the brain • Neurological impairment lasts minutes to hours but does not exceed 24 hours • Patient’s who suffer from TIA are at greater risk for developing a CVA • Imperative that further evaluation to prevent CVA from occurring

3. Cerebral Vascular Accident • Infarction of the brain tissue caused by the disruption of blood flow to the brain • Neurological deficits are reflective to the area in the brain affected • Referred to as brain attack • Need immediate intervention • Need treatment within 3 hours of symptom onset

4. Pathophysiology • Pathophysiology • Cerebral function is dependent upon oxygen and glucose delivery neurons • Impaired blood flow affects the delivery of oxygen and glucose to brain tissue • Brain tissue dies • Permanent damage is a result without immediate intervention • Pneumbra is an area of brain tissue surrounding the damage that may be revived if reperfused quickly

5. Etiology • Etiology • Can be ischemic or hemorrhagic • Need MRI or CT Scan to determine which • Ischemic Stroke • Caused by emboli or thrombosis that decrease perfusion • Artherosclerosis narrowing vessels causing occlusion causes thrombotic stroke • Emboli breaking off and traveling and lodging in narrowed vessel causes embolic stroke • Common vessel is bifurcation of common carotid into internal & external carotid

6. Etiology • Emboli • Cardiac origin • A-fib • SA node disorder • Acute MI • Bacterial endocarditis • Cardiac tumors • Valve disorder • Arterial • Severe stenosis of carotid & basilar arteries • Severe stenosis of small deep arteries of brain • Vasculitis • Inflammatory condition involving cerebral blood vessels • Causes include: • Lupus—meningitis—fungal infections—herpes zoster arteritis

7. Hemorrhagic Stroke • Caused by the rupture of a cerebral blood vessel • Brain tissue beyond vessel does not receive blood supply resulting in tissue death • Brain tissue surrounding the hemorrhage is also damage by the released blood • Intracerebral hemorrhage (ICH) • Most common cause is uncontrolled HTN • Ruptured aneurysm is another cause • Subarachnoid hemorrhage (SAH) • Rupture of blood vessels on surface of brain • Slowest recovery • Most patient suffer extensive neurological impairment

8. Risk Factors • Modifiable • Can be changed with treatment • Smoking cessation—lifestyle modification—treat hypertension • Nonmodifiable risk factors • Can not be altered • Gender—race—prior stroke—hereditary—age

9. Warning Signs • Teach warning signs • Sudden numbness or weakness of face, arm or leg on one side • Sudden confusion, trouble speaking, or comprehending • Sudden impaired vision in one or both eyes • Sudden dizziness, loss of balance, or coordination • Sudden severe headache

10. Acute Signs & Symptoms Symptoms result from either hemorrhagic or ischemic • Visual disturbances • All or part of one eye • Affect eye on same side of CVA • Horizontal—bitemporal—homonymous—hemianopsia—quandrantic • Language disturbances • Dysphasia • Aphasia • Expressive or receptive • Global aphasia • Both • Dysarhtria • Motor speech deficit

11. Acute Signs & Symptoms • Motor disturbance • Weakness or paralysis or numbness on one side of body • Commonly presents in face and arm • Can have complete hemiparesis • Unilateral & opposite to area of damage • Brainstem or vertebrobasilar stroke affects both side of body • Ataxia • Dysphagia • Specific to Hemorrhagic • Rapid deterioration • Drowsiness • Severe headache

13. Diagnostic Tests • CPSS—The Cincinnati Prehospital Stroke Scale • Implemented for quick intervention with stroke victims • Three components • Have patient smile • take note of facial droop or uneven symmetry • Ask patient to hold out arms in front of them with eyes closed • watch for downward drift • Ask patient to repeat a phrase • did they comprehend • repeat phrase exactly • is speech slurred • If any one of three positive the patient needs immediate treatment

14. Diagnostic Tests CT scan • Useful in diagnosing hemorrhagic stroke • Negative with TIA • Ischemic stroke will not be detected early on • EKG • Echocardiogram • CBC • Metabolic panel • Blood typing • PT & INR • Serum Pregnancy • Stools & emesis for blood • Cardiac monitoring • Pulse oximetry • Dysphagia screening • Carotid Doppler • Cerebral angiogram • NIH Stroke Scale

15. Therapeutic Interventions Acute emergent care • Think ABC’s • Airway—breathing—circulation • Oxygen therapy to keep O2 greater than 90% • Cardiac monitoring • Vital signs • Diagnostic test to determine if hemorrhagic or ischemic • After results immediate interventions

16. Therapeutic Interventions • Thrombolytic Therapy • Alteplase or Tissue plaminogen activator (t-PA) for ischemic • Goal is to break down thrombus that is occluding the vessel • Hope to prevent or reverse symptoms • Acts by converting plasminogen to plasmin which lysis the clot • If successful the patient will have no residual effects from stroke • Need treatment within 3 hours of onset of symptoms • Stabilize • Obtain diagnostic test results promptly • If CT scan shows ischemic than angiogram • Need to meet specific criteria—not all are canditate • Has risk of cerebral hemorrhage

17. Therapeutic Interventions Pharmacological Management • Control of blood pressure vital • Should not lower too quickly or too far • No more than 10% of baseline at one time • Can cause more ischemia • Monitor BP frequently • Some physician do not lower BP because believe higher BP needed for cerebral perfusion in hypertensive patient • Prevention of seizure activity • Anti-seizure medication • In hemorrhagic stroke • Prevention of vasospasm with nimodipine--calcium channel blockers relax the smooth muscle of vessel • Antifibrinolytic to inhibit plaminogenacitvation reducing rebleeding

18. Therapeutic Interventions Post emergent care • Control cause of TIA or CVA • If deficits with CVA • PT—OT—Speech • Antiplatelet therapy within 24 hours • Plavix—Aggrenox—aspirin • Antidysrhythmic medication with atrial fibrillation • Anticoagulants • Coumadin—heparin • Prevention of aspiration • Decreased LOC—dysphagia

19. Carotid Stenosis • More than 70% blockage requires surgical intervention of carotid endarterectomy • Carotid is opened and plaque removed • Nursing Interventions • Neurological assessment • Monitor for deterioration • Assess site • Bleeding—hematoma • Larger hospitals trying balloon angioplasty

20. Prevention Prevention • Control • HTN—cholesterol—weight—diabetes • Smoking cessation • Coumadin therapy with chronic atrial fibrillation • Aspirin and anti-platelet to prevent abnormal clotting • Treat carotid stenosis with endarterectomy • Educate • Signs & symptoms of stroke • Call for help immediately • Early intervention & treatment within 3 hours

21. Long Term Effects • Impaired motor function • Hemiplegia • Hemiparesis • Contracture • Dysphagia • Incontinence • Sensation impairment • Early mobilization imperative to prevent long term complications • PT—OT—Speech

22. Long Term Effects Aphasia • Is infarct is on dominant side of brain speech center affected • Expressive—receptive—global • Speech therapy may be effective Emotional Lability • Moods swing between happy and sad at any given time Impaired Judgment • Especially seen with right sided injury • At risk for injury • Frontal lobe • Inappropriate behavior

23. Long Term Effects Unilateral Neglect • Mainly seen in right hemisphere infarcts • Do not acknowledge left side • Therapy helpful to teach patient to focus on the left Nursing Interventions • Place belonging on right side • Call bell on right side of bed • Door to patient right • Teach patient to assess left side

24. Long Term Effects Homonymous Hemianopsia • Visual disturbance where patient has vision loss on one side • Contributes to unilateral neglect Other long-term effects • Depression—pressure ulcers—DVT—PE—pneumonia