cva- brain
TRANSCRIPT
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Brain Attack
NR-75D
Diana Diaz RN, MS
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Objectives Define stroke
Discuss incidence & risk factors
Review Cerebral flow and factors thataffect it
Discuss pathophysiology of CVA
Correlate clinical manifestations ofstroke with the pathophysiology.
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History of Stroke Hippocrates-2,400 yrs ago
Names for Stroke
Most commonly known today
Brain Attack
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Incidence 3rdCause of death in US and Canada
Statistics
2/3 in people >65
= in men and women
Higher incidence and death ratesamong African-Americans, Hispanics,Native-American, Asian Americans
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Risk FactorsNon Modifiable
Age
Gender
Race
Heredity
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Risk FactorsModifiable
Obesity
HTN
Smoking
Heavy alcohol
consumption Hypercoagulability
Hyperlipidemia
Asymptomaticcarotid stenosis
Diabetes mellitus Heart disease, atrial
fibrillation
Oral contraceptives Physical inactivity
Sickle cell disease
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Review of Cerebral Circulation
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Blood supply by arteries Blood is supplied to the brain by two
major pairs of arteries Internal carotid arteries
Vertebral arteries
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Blood supply by arteries Carotid arteries branch to supply most
of the
Frontal, parietal, and temporal lobes
Basal ganglia
Part of the diencephalon
Thalamus Hypothalamus
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Blood supply by arteriesVertebral arteries join to form the
basilar artery, which supply the
Middle and lower temporal lobes
Occipital lobes
Cerebellum
Brainstem Part of the diencephalon
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Brain Attack means:
Blood flow to the brain istotally interrupted
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EtiologyAtherosclerosisDisease of the
arteries; hardening and thickening of
the arterial wall because of softdeposits of intraarterial fat and fibrinthat harden over time.
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Common sites for thedevelopment of Atherosclerosis
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Transient Ischemic Attack
(TIA) Transient ischemic attack (TIA) is a
temporary focal loss of neurologic
function caused by ischemia Most TIAs resolve within 3 hours
TIAs are a warning sign of progressive
cerebrovascular disease
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Types of Stroke
Strokes are classified based on theunderlying pathophysiologic findings
Ischemic
Hemorrhagic
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Ischemic vs. Hemorrhagic
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Ischemic Stroke
Thrombotic or Embolic
Most patients with ischemicstroke do not have a decreasedlevel of consciousness in thefirst 24 hours
May progress in the first 72hours
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Thrombotic stroke
Thrombosis occurs in relation to injury to a
blood vessel wall and formation of a bloodclot
Result of thrombosis or narrowing of the
blood vessel Most common cause of stroke
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Embolic stroke
Occur when an embolus lodges in and
occludes a cerebral artery Results in infarction and edema of the area
supplied by the involved vessel
Second most common cause of stroke
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Embolic stroke
Majority of emboli originate in the insidelayer of the heart, with plaque breaking off
from the endocardium and entering thecirculation
Patient with an embolic stroke commonlyhas a rapid occurrence of severe clinical
symptoms
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Hemorrhagic Stroke
Account for approximately 15% of allstrokes
Result from bleeding into the braintissue itself or into the subarachnoidspace or ventricles
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Hemorrhagic Stroke
Intracerebral hemorrhage
Bleeding within the brain caused by a
rupture of a vessel Hypertension is the most important cause
Hemorrhage commonly occurs during
periods of activity
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Hemorrhagic Stroke
Intracerebral hemorrhage
Manifestations include neurologic deficits,
headache, nausea, vomiting, decreasedlevels of consciousness, and hypertension
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Hemorrhagic Stroke
Subarachnoid hemorrhage
Occurs when there is intracranial bleeding
into cerebrospinal fluid-filled spacebetween the arachnoid and pia mater
Commonly caused by rupture of acerebral aneurysm
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Clinical Manifestations
Affects many body functions Motor activity
Elimination Intellectual function
Spatial-perceptual alterations
Personality
Affect Sensation
Communication
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Clinical Manifestations
Brain attack Term increasingly being used to describe
stroke and communicate urgency ofrecognizing stroke symptoms and treatingtheir onset as a medical emergency
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Clinical ManifestationsMotor Function
Most obvious effect of stroke
Include impairment of
Mobility
Respiratory function
Swallowing and speech
Gag reflex
Self-care abilities
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Clinical ManifestationsMotor Function
An initial period of flaccidity may lastfrom days to several weeks and is
related to nerve damage Spasticity of the muscles follows the
flaccid stage and is related to
interruption of upper motor neuroninfluence
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Clinical ManifestationsCommunication
Patient may experience aphasia whena stroke damages the dominant
hemisphere of the brainAphasia is a total loss of
comprehension and use of language
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Clinical ManifestationsCommunication
Dysphasia refers to difficulty related tothe comprehension or use of language
and is due to partial disruption or loss Dysphasia can be classified as
nonfluent or fluent
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Clinical ManifestationsCommunication
Dysarthria does not affect themeaning of communication or the
comprehension of language It does affect the mechanics of speech
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Clinical ManifestationsAffect
Patients who suffer a stroke may havedifficulty controlling their emotions
Emotional responses may beexaggerated or unpredictable
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Clinical ManifestationsIntellectual Function
Both memory and judgment may beimpaired as a result of stroke
A left-brain stroke is more likely toresult in memory problems related tolanguage
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Clinical ManifestationsSpatial-Perceptual Alterations
Spatial-perceptual problems may bedivided into four categories
1. Incorrect perception of self andillness
2. Erroneous perception of self in space
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Clinical ManifestationsSpatial-Perceptual Alterations
3. Inability to recognize an objectby sight, touch, or hearing
4. Inability to carry out learnedsequential movements oncommand
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Diagnostic Studies
When symptoms of a stroke occur,diagnostic studies are done to
Confirm that it is a stroke Identify the likely cause of the stroke
CT is the primary diagnostic test used
after a stroke
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Diagnostic Studies
Additional studies
Complete blood count
Platelets, prothrombin time, activatedpartial thromboplastin time
Electrolytes, blood glucose
Renal and hepatic studies Lipid profile
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Collaborative CarePrevention
Goals of stroke prevention include
Health management for the well individual
Education and management of modifiablerisk factors to prevent a stroke
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Collaborative CarePrevention
Antiplatelet drugs are usually thechosen treatment to prevent further
stroke in patients who have had a TIAAspirin is the most frequently used
antiplatelet drug
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Collaborative CarePrevention
Surgical interventions for the patientwith TIAs from carotid disease include
Carotid endarterectomy Transluminal angioplasty
Stenting
Extracranial-intracranial bypass
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Collaborative CareAcute Care
Assessment findingsAltered level of consciousness
Weakness, numbness, or paralysis Speech or visual disturbances
Severe headache
or heart rate
Respiratory distress
Unequal pupils
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Collaborative CareAcute Care
InterventionsInitial
Ensure patient airway
Remove dentures Perform pulse oximetry
Maintain adequate oxygenation
IV access with normal saline Maintain BP according to guidelines
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Collaborative CareAcute Care
InterventionsInitial
Remove clothing
Obtain CT scan immediately Perform baseline laboratory tests
Position head midline
Elevate head of bed 30 degrees if nosymptoms of shock or injury
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Collaborative CareAcute Care
InterventionsOngoing
Monitor vital signs and neurologic status
Level of consciousness Motor and sensory function
Pupil size and reactivity
O2saturation
Cardiac rhythm
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Collaborative CareAcute Care
Recombinant tissue plasminogenactivator (tPA) is used to
Reestablish blood flow through a blockedartery to prevent cell death in patientswith acute onset of ischemic strokesymptoms
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Collaborative CareAcute Care
Thrombolytic therapy given within 3hours of the onset of symptoms
disability But at the expense of in deaths within
the first 7 to 10 days and in intracranial
hemorrhage
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Collaborative CareAcute Care
Surgical interventions for stroke
include immediate evacuation ofAneurysm-induced hematomas
Cerebellar hematomas (>3 cm)
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Collaborative CareRehabilitation Care
After the stroke has stabilized for 12-24 hours, collaborative care shifts from
preserving life to lessening disabilityand attaining optimal functioning
Patient may be transferred to a
rehabilitation unit
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Nursing ManagementNursing Implementation
Respiratory System
Management of the respiratory system is a
nursing priority Risk for aspiration pneumonia
Risks for airway obstruction
May require endotracheal intubation andmechanical ventilation
N i M
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Nursing ManagementNursing Implementation
Neurologic System
Monitor closely to detect changes
suggesting Extension of the stroke
ICP
Vasospasm
Recovery from stroke symptoms
N i M
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Nursing ManagementNursing Implementation
Cardiovascular System
Monitoring vital signs frequently
Monitoring cardiac rhythms Calculating intake and output, noting
imbalances
Regulating IV infusions
N i M t
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Nursing ManagementNursing Implementation
Cardiovascular System
Adjusting fluid intake to the individual
needs of the patient Monitoring lung sounds for crackles and
rhonchi (pulmonary congestion)
Monitoring heart sounds for murmurs orfor S3or S4heart sounds
N i M t
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Nursing ManagementNursing Implementation
Musculoskeletal System Trochanter roll at hip to prevent external
rotation
Hand cones to prevent hand contractures
Arm supports with slings and lap boardsto prevent shoulder displacement
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N i M t
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Nursing ManagementNursing Implementation
Integumentary System
Pressure relief by position changes,
special mattresses, or wheelchaircushions
Good skin hygiene
Emollients applied to dry skin
N i M t
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Nursing ManagementNursing Implementation
Integumentary System
Early mobility
Position patient on the weak or paralyzedside for only 30 minutes
N i M t
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Nursing ManagementNursing Implementation
Gastrointestinal System
After careful assessment of swallowing,
chewing, gag reflex, and pocketing, oralfeedings can be initiated
Feedings must be followed by scrupulousoral hygiene
N i M t
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Nursing ManagementNursing Implementation
Communication Nurses role in meeting psychologic needs
of the patient is primarily supportive Patient is assessed both for the ability to
speak and the ability to understand
Speak slowly and calmly, using simple
words or sentences
N i M t
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Nursing ManagementNursing Implementation
Sensory-Perceptual Alterations Blindness in the same half of each visual
field is a common problem after stroke Other visual problems may include diplopia
(double vision), loss of the corneal reflex,and ptosis (drooping eyelid)
N i M t
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Nursing ManagementNursing Implementation
Ambulatory and Home Care The rehabilitation nurse assesses the
patient and family with Rehabilitation potential of the patient
Physical status of all body systems
Presence of complications caused by the strokeor other chronic conditions
Cognitive status of the patient
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N i M t
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Nursing ManagementNursing Implementation
Ambulatory and Home Care Nurses have an excellent opportunity to
prepare the patient and family fordischarge through Education
Demonstration
Practice Evaluation of self-care skills