Lisa Randall, RN, MSN, ACNS-BC RNSG 2432 Spring 2011 CEREBROVASCULAR ACCIDENT “BRAIN ATTACK” Objectives Define cerebrovascular accident and associated terminology Discuss related pathophysiology and presentation of various types of stroke Discuss etiology, risk factors, diagnostics, management, and outcomes of stroke Review case studies and nursing diagnoses, interventions, and goals Definition Stroke or “brain attack” is an acute CNS injury that results in neurologic S/S brought on by a reduction or absence of perfusion to a territory of the brain. The disruption in flow is from either an occlusion (ischemic) or rupture (hemorrhagic) of the blood vessel. Incidence & Prevalence Third leading cause of death in the USA 750,000+ people/year 175,000 die within one year (25%) Leading cause of long-term disabilities 5.5 million survivors (USA) 15 to 30 % live with permanent disability Definitions Cerebrovascular Accident Ischemic Stroke Thrombotic Embolic Lacunar infarct TIA Hemorrhagic Stroke ICH SAH Stroke: Emergency Care http://youtu.be/-d8__FkW-nU Thrombotic Stroke Occlusion of large cerebral vessel Older population Sleeping/resting Rapid event, but slow progression (usually reach max deficit in 3 days) Embolic Stroke Embolus becomes lodged in vessel and causes occlusion Bifurcations are most common site Sudden onset with immediate deficits Embolysis Hemorrhagic Transformation Lacunar Strokes - 20% of all stokes Minor deficits Paralysis and sensory loss Lacune Small, deep penetrating arteries High incidence: Chronic hypertension Elderly DIC Transient Ischemic Attack Warning sign for stroke Brief localized ischemia Common manifestations: Contralateral numbness/ weakness of hand, forearm, corner of mouth Aphasia Visual disturbancesblurring Deficits last less than 24 hours (usually less than 1 or 2 hrs) Can occur due to: Inflammatory artery disorders Sickle cell anemia Atherosclerotic changes Hemorrhagic Stroke Definitions Intracerebral hemorrhage Intracranial hemorrhage Parenchymal hemorrhage Intraparenchymal hematoma Contusion Subarachnoid hemorrhage Hemorrhagic Stroke Rupture of vessel Sudden Active Fatal HTN Trauma Varied manifestations Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage Pathophysiology Hemorrhagic Stroke Changes in vasculature Tear or rupture Hemorrhage Decreased perfusion Clotting Edema Increased intracranial pressure Cortical irritation Mom: Bowel/bladder Reasoning/judgment Long term memory Voluntary Motor Legs Arms Sensations Pain & Touch Taste Head Hearing/association & Smell & taste Short term Memory Vision & visual memory Balance, Coordination of each muscle group CN 5,6,7,8 P,R, B/P CN 9,10,11,12 Tracks cross over Coordinate movement, HR,B/P Vessels of the Brain Vessels of the Brain Right Side Circle of Willis Physiology Normal Cerebral Blood Flow Oxygen Glucose 20% of Cardiac Output / oxygen Arterial supply to the brain: Internal carotid (anteriorly) Vertebral arteries (posteriorly) Venous drainage 2 sets of veins - venous plexuses Dural sinuses to internal jugular veins Sagittal sinus to vertebral veins No valves, depend on gravity and venous pressure gradient for flow Risk Factors NON-MODIFIABLE MODIFIABLE Age 2/3 over 65 Gender M=F Female>fatality Race AA > hispanics, NA Asians > hem Heredity Family history Previous TIA/CVA Hypertension Diabetes mellitus Heart disease A-fib Asymptomatic carotid stenosis Hyperlipidemia Obesity Oral contraceptive use Heavy alcohol use Physical inactivity Sickle cell disease Smoking Procedure precautions Etiology Ischemic Stroke Embolism Prothrombotic states Hemostatic regulatory Atrial fib Sinoatrial D/O Recent MI Endocarditis Cardiac tumors Valvular D/O Patent foramen ovale Carotid/basilar artery stenosis Atherosclerotic lesions Vasculitis protein abnormalities Antiphospholipid antibodies Hep cofactor II Etiology Hemorrhagic Stroke Chronic HTN** Cerebral Amyloid Angiopathy* Anticoagulation* AVM Ruptured aneurysm (usually subarachnoid) Tumor Sympathomimetics Infection Trauma Transformation of ischemic stroke Physical exertion, Pregnancy Post-operative Aneurysm Localized dilation of arterial lumen Degenerative vascular disease Bifurcations of circle of Willis 85% anterior 15% posterior Aneurysm Subarachnoid Hemorrhage SAH Mortality 70% 97% HA Nuchal rigidity Fever Photophobia Lethargy Nausea Vomiting Aneurysm/SAH Complications HCP Vasospasm Triple H Therapy HTN Hemodilution Hypervolemia Surgical treatment Clip Coil INR Nursing Management Assessment Monitoring BP TCDs CBC Preventing complications Bowel program DVT prophylaxis Siezure prophylaxis Psychological support Discharge planning Arteriovenous Malformations AVM Tangled mass of arteries and veins Seizure or ICH Treatment AVM Endovascular Neurosurgery Radiosurgery Presentation Sudden onset Focal neurological deficit Progresses over minutes to hours HA, N/V, <<LOC, HTN Depends on location Stroke Symptoms include: SUDDEN numbness or weakness of face, arm or leg SUDDEN confusion, trouble speaking or understanding. SUDDEN trouble with vison. SUDDEN trouble walking, dizziness, loss of balance or coordination. SUDDEN severe HA. Manifestations by Vessel Vertebral Artery Pain in face, nose, or eye Numbness and weakness of face (involved side) Gait disturbances Dysphagia Dysarthria (motor speech) Manifestations by Vessel Internal carotid artery Contralateral paralysis (arm, leg, face) Contralateral sensory deficits Aphasia (dominant hemisphere involvement) Apraxia (motor task), Agnosia (obj. recognition), Unilateral neglect (non-dominant hemisphere involvement) Homonymous hemianopia Manifestations & Complications by Body System Neurological Hyperthermia Neglect syndrome Seizures Agnosias (familiar obj) Communication deficits Aphasia (expressive, receptive, global) Agraphia Visual deficits Homonymous hemianopia Diplopia Decreased acuity Decreased blink reflex Manifestations & Complications by Body System Neurological (cont.) Cognitive changes Memory loss Short attention span Poor judgment Disorientation Poor problemsolving ability Behavioral changes Emotional lability Loss of inhibitions Fear Hostility Manifestations & Complications by Body System Musculoskeletal Hemiplegia or hemiparesis Contractures Bony ankylosis Disuse atrophy Dysarthria - word formation Dysphagia – swallow Apraxia – complex movements Flaccidity/spasticity GU Incontinence Frequency Urgency Urinary retention Renal calculi Manifestations & Complications by Body System Integument Pressure ulcers Respiratory Respiratory center damage Airway obstruction Decreased cough ability GI Dysphagia Constipation Stool impaction Initial Stroke Assessment/Interventions Neurological assessment & NIH assessment Call “Stroke Alert” Code Ensure patient airway VS IV access Maintain BP within parameters Position head midline HOB 30 (if no shock/injury) CT, blood work, data collection/NIH Stroke Scale Anticipate thrombolytic therapy for ischemic stroke NIH Stroke Scale Score Standardized method measures degree of stroke r/t impairment and change in a patient over time. Helps determine if degree of disability merits treatment with tPA. As of 2008 stroke patients scoring greater than 4 points can be treated with tPA. Standardized research tool to compare efficacy stroke treatments and rehabilitation interventions. Measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language not measured by Glasgow coma scale. Current NIH Stroke Score guidelines for measuring stroke severity: Points are given for each impairment. 0= no stroke 1-4= minor stroke 5-15= moderate stroke 15-20= moderate/severe stroke 21-42= severe stroke A maximal score of 42 represents the most severe and devastating stroke. Comic Relief Question The neurologic functions that are affected by a stroke are primarily related to A. the amount of tissue area involved. B. the rapidity of the onset of symptoms. C. the brain area perfused by the affected artery. D. the presence or absence of collateral circulation. Question A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipated that the health care provider will request a A. CT scan. B. lumbar puncture. C. cerebral angiogram. D. PET scan. Diagnostics Tests for the Emergent Evaluation of the Patient with Acute Ischemic Stroke CT head (-) Electrocardiogram Chest x-ray Hematologic studies (complete blood count, platelet count, prothrombin time, partial thromboplastin time) Serum electrolytes Blood glucose Renal and hepatic chemical analyses National Institute of Health Scale (NIHSS) score Diagnostics Ischemic Stroke Hemorrhagic Stoke Medical Management BP MAP CPP Fluid management euvolemia Seizure prophylaxis Factor VII, Vit K, FFP ICP HOB Sedation Osmotherapy Hyperventilation Paralytics Keppra Dilantin Sedation Body temperature PT/OT/ST DVT prophylaxis Treatment Ischemic Hemorrhagic Medical management Medical management TpA Decompression Craniotomy Endovascular Carotid endarectomy Craniectomy Merci clot removal http://youtu.be/P2TNz-TniIA PT/OT/ST REHABILITATION Medications Anti-coagulants – A fib & TIA Antithrombotics Calcium channel blockers – Nimotop (nimodipine) Corticosteroids ??? Diuretics – Mannitol, Lasix (Furosemide) Anticonvulsants – Dilantin (phenytoin) or Cerebyx (Fosphenytoin Sodium Injection) Thrombolytics - tPA (recombinant tissue plasminogen activator) Medications Thrombolytics Recombinant Alteplase (rtPA) Activase, Tissue plasminogen activator Treatment must be initiated promptly after CT to R/O bleed Systemic within 3 hours of onset of symptoms Intra-arterial within 6 hours of symptoms Some exclusions: Seizure at onset Subarachnoid hemorrhage Trauma within 3 months History of prior intracranial hemorrhage AV malformation or aneurysm Surgery 14 days, pregnancy, Cardiac cath. 7 days Neurosurgical Management Craniotomy Craniectomy EVD placement ICP monitor placement Recommendations for Surgical Treatment of ICH Nonsurgical candidates Surgical candidates Small hemorrhage >3cm Minimal deficit Neuro deficit Brain stem compression MLS, HCP Aneurysm, AVM, cavernous hemangioma GCS </= 4 (unless brain stem compression) Loss of brainstem fxn Severe coagulopathy Basal ganglion or thalamic Young c mod/large lobar hemorrhage c clinical deterioration Question A carotid endarectomy is being considered as treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery A. is used to restore blood circulation to the brain following an obstruction of a cerebral artery. B. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery. C. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke. D. is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation. Standing Orders Per facility policy Nursing Concerns Medical management! Post-op care Infection Mobilization Patient/family teaching Nutrition Follow-up Constipation Medications Skin Resources available Question An essential intervention in the emergency management of the patient with a stroke is A. intravenous fluid replacement. B. administration of osmotic diuretics to reduce cerebral edema. C. initiation of hypothermia to decrease oxygen needs of the brain. D. maintenance of respiratory function with a patent airway and oxygen administration. Overview http://youtu.be/-d8__FkW-nU NCLEX A patient comes to the ED immediately after experiencing numbness of the face and inability to speak, but while the patient awaits examination, the symptoms disappear and the patient requests discharge. The RN stresses that it is important for the patient to be evaluated, primarily because A. the patient has probably experienced an asymptomatic lacunar stroke. B. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours. C. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off. D. the patient has probably experienced a TIA that is a sign of progressive vascular disease. Nursing Diagnosis Ineffective cerebral tissue perfusion Impaired mobility Self-care deficit Impaired verbal communication Impaired swallowing Nursing Diagnoses/Interventions Ineffective Tissue Perfusion Goal is to maintain cerebral perfusion Monitor respiratory status Auscultate, monitor lung sounds Suction as needed – increases ICP Place in side-lying position (secretions) O2 as needed/prescribed Assess LoC, other neuro vital signs NIH Stroke Scale Glasgow Coma Scale – Eyes, Verbal, & Motor Nursing Diagnoses/Interventions Ineffective Tissue Perfusion (cont) Monitor strength/reflexes Assess for HA, sluggish pupils, posturing Monitor cardiac status Monitor I&O’s Can get DI as result of pituitary gland damage Monitor seizure activity Nursing Diagnoses/Interventions Impaired Physical Mobility Goal is to maintain and improve functioning Active ROM for unaffected extremities Passive ROM for affected extremities Q2 hr turns Assess for thrombophlebitis Confer with PT for movement and positioning techniques for each stage of rehab Nursing Diagnoses/Interventions Impaired Physical Mobility Flaccidity & spasticity Meds used to treat spasticity: Kemstro or Lioresal (baclofen) Valium (diazepam) Dantrium (dantrolene sodium) Zanaflex (tizanidine hydrochloride) New drugs being tried – Neurontin (Gabapentin) & Botox (botulinum toxin) Nursing Diagnoses/Interventions Self-Care Deficit Goals are to promote functional ability, increase independence, improve self-esteem Encourage use of unaffected arm in ADLs Self-dressing (using unaffected side to dress affected side first) Sling or support for affected arm Confer with OT for techniques to promote return to independence Nursing Diagnoses/Interventions Impaired Verbal Communication Goal is to increase communication Speak in normal tones unless there is a documented hearing impairment Allow adequate time for responses Face center client when speaking, speak simply and enunciate words If you don’t understand what the client is saying, let them know, and have them try again Nursing Diagnoses/Interventions Impaired Verbal Communication (cont) Try alternate method of communication if needed Writing, computerized boards, etc Allow client anger and frustration at loss of previous functioning Allow client to touch (hands, arms), may be the only way of expressing (comfort, etc) If client has visual disturbances: During initial phase of recovery, position where client can easily see you; in later stages, client can be directed to adjust position for visual contact Nursing Diagnoses/Interventions Impaired Swallowing Goal is safety, adequate nutrition, and hydration Position client upright, using **pureed – less often ** or finely chopped soft foods Hot or cold food or thickened liquids Teach client to put food behind teeth on unaffected side and tilt head backwards Check for food pockets, especially on affected side Have suctioning equipment at bedside Minimize distractions while eating Never leave client with food etc. in mouth Question A patient with a right hemisphere stroke has a nursing diagnosis of unilateral neglect R/T sensory-perceptual deficits. During the patient’s rehabilatation, it is important for the nurse to A. avoid positioning the patient on the affected side. B. place all objects for care on the patient’s unaffected side. C. teach the patient to care consciously for the affected side. D. protect the affected side from injury with pillows and supports. Complications Increased intracranial pressure Rebleeding Vasospasm HCP Death Outcomes Age Size, volume Location HCP, IVH Deficit, LOC, MAP Duration Co-morbidities 44% mortality Evaluation Reduce mortality and morbidity Baseline neurological function Outcomes Evidenced based practice Patient/Family Education PREVENTION is key Smoking cessation Physical activity Weight reduction Diet Plavix LDL chol reduction Statins > HDL BP normilization ACE inhibitos ARB Thiazide diuretics Antiplatelet agents ASA DM ETOH Homocysteine reduction http://youtu.be/awtFZQkoBPc Legal/Ethical Concerns Advanced directives MPOA Category status Code status Withdrawal of care Palliative care Placement Resources www.stroke.org -- National Stroke Association (800-7876537) www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke (800-352-9424) www.naric.com -- National Rehabilitation Information Center (8003462742) www.aphasia.org -- National Aphasia Association (800922-4622) www.aan.com -- American Academy of Neurology www.dynamic-living.com -- Daily living products www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf -- NIH stroke scoring system www.strokecenter.org/trials -- Find a clinical trial on stroke Case Study #1 34 yo AAM R temporoparietal ICH c IVH, HCP h/o L MCA ischemic Sentis protocol Coumadin (INR 13) Factor VII, Vit K Craniotomy ICP EVD x 2 Jackson, William J J^3172551 1/12/1975 34 YEAR M A BRACKENRIDGE CT Head w/o Contrast Head W/O ST. 12/3/2009 6:43:15 AM 3725860 --LOC: -111.80 THK: 4.80 HFS R 512x512 RD: 250 Tilt: -10 KVp: 120 mA: 460 eff. mAs: 460 Acq No: 4 --Page: 14 of 36 L --P C: 35 W: 80 Compressed 11:1 IM: 14 SE: 2 cm Question The incidence of ischemic stroke in pateints with TIAs and other risk factors is reduced with the administration of A. furosemide (Lasix). B. lovastatin (Mevacor). C. daily low-dose aspirin (ASA). D. nimodipine (Nimotop). Question A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include a. hyperventilation therapy. b. surgical clipping of the aneurysm. c. administration of hypersomotic agents. d. administration of thrombolytic therapy. Question A nursing intervention that is indicated for the patient with hemiplegia is A. the use of a footboard to prevent plantar flexion. B. immobilization of the affected arm against the chest with a sling. C. positioning the patient in bed with each joint lower that the joint proximal to it. D. having the patient perform passive ROM of the affected limb with the unaffected limb. Question The nurse can assist the patient and the family in coping with the long-term effects of a stroke by A. informing the family members that the patient will need assistance with almost all ADLs. B. explaining that the patient’s prestroke behavior will return as improvement progresses. C. encouraging the patient and family members to seek assistance from family therapy or stroke support group. D. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning. References AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St. Broderick, J., et. al. (1999) Guidelines for the management of spontaneous intracerebral hemorrhage. AHA. El-Mitwali, A., Malkoff, M. (2001) Intracerebral hemorrhage. The Internet Journal of Neurosurgery. 1.1. Greenberg, Mark. (2006). Handbook of Neurosurgery. Greenberg Graphics, Tampa, Florida.