Management of Cerebro vascular accident (CVA)

Explains about stroke

1. Cerebrovascular accident Or Stroke

2. Definition Stroke occurs when there is ischemia (inadequate blood flow) to a part of the brain or hemorrhage into the brain that results in death of brain cells.

3. Transient Ischemic Attack Transient ischemic attack (TIA) is a temporary impairment of the cerebral circulation causing neurological impairment. It may last for minutes to hours in duration Symptoms resolve completely within 24 hours.

4. Etiology Atherosclerosis Emboli may lodge in cerebral vessels, resulting in occlusion, ischemia, and infarct. Atrial fibrillation.

5. Pathophysiology Interruption of blood flow to the brain deprives neurons of needed glucose and oxygen. A transient ischemic attack may be a warning of an impending cerebrovascular accident

6. Signs and Symptoms Visual disturbances, Difficulty with speech, Weakness or paralysis on one side of the body, and Transient confusion. Diagnostic Tests Carotid Doppler Echocardiogram CT scan or MRI Cerebral angiogram

7. Treatment Focuses on controlling the cause of the transient ischemic attack. Medications are used to control atrial fibrillation or hypertension Warfarin (Coumadin) may be prescribed for patients prone to clot development. Education regarding safety precautions is essential for these patients.

8. The possible development of a cerebral hematoma following a fall or blow to the head must be stressed to the patient and significant others. Antiplatelet drugs such as ticlopidine ( Ticlid ) or aspirin are often prescribed for patients experiencing transient ischemic attacks.

9. SURGICAL MANAGEMENT Carotid endarterectomy During this surgical procedure, the carotid artery is opened and the plaque removed. Nursing care focuses on careful neurological assessment for signs of deterioration related to ischemia. The incision is monitored for hematoma development and bleeding. Balloon angioplasty for carotid stenosis is being investigated as a potential treatment.

10. Ischemic stroke Thrombotic stroke A thrombotic stroke occurs from injury to a blood vessel wall and formation of a blood clot. The lumen of the blood vessel becomes narrowed and, if it becomes occluded, infarction occurs . A lacunar stroke refers to a stroke from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue.

11. Embolic Stroke Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema. Majority of emboli originate in the endocardial layer of the heart. Atrial fibrillation, myocardial infarction, infective endocarditis, rheumatic heart disease, valvular prostheses, and atrial septal defects . The patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms.

12. Disruption of the cerebral blood flow due to obstruction of a blood vessel Ischemic cascade ( cerebral blood flow falls to less than 25 mL/100 g/min) Mitochondria switch to anaerobic respiration Large amounts of lactic acid, causing a change in the pH level Neuron becomes incapable of producing sufficient quantities of adenosine triphosphate (ATP) Electrolyte balances begin to fail and the cells cease to function.

13. Penumbra Around the core area of ischemia is a border zone of reduced blood flow where ischemia is potentially reversible If adequate blood flow can be restored early (e.g., within 3 hours) and the ischemic cascade can be interrupted, there may be less brain damage and less neurologic function lost.

14. Hemorrhagic stroke Result from bleeding into the brain tissue itself ( intracerebral or intraparenchymal hemorrhage ) or Into the subarachnoid space or Ventricles ( subarachnoid hemorrhage or intraventricular hemorrhage )

15. Types of hemorrhage Intracerebral haemorrhage Hypertension cerebral amyloid angiopathy , vascular malformations, coagulation disorders, anticoagulant and thrombolytic drugs, trauma, brain tumors, and ruptured aneurysms Subarachnoid Hemorrhage Rupture of a cerebral aneurysm arteriovenous malformations (AVMs), trauma, and illicit drug (cocaine) abuse

16. Pathophysiology of H emorrhagic stroke Aneurysm or AVM ruptures, causing subarachnoid haemorrhage Normal brain metabolism is disrupted by the brain being exposed to blood sudden entry of blood into the subarachnoid space compresses and injures brain tissue Increase in ICP secondary ischemia of the brain resulting from the reduced perfusion pressure and vasospasm

17. Clinical Manifestations Motor Function Includes impairment of mobility , respiratory function, swallowing and speech, gag reflex, and self-care abilities. The characteristic motor deficits include Loss of skilled voluntary movement ( akinesia ) , Impairment of integration of movements, Alterations in muscle tone, and alterations in reflexes. Initial hyporeflexia (depressed reflexes) progresses to hyperreflexia (hyperactive reflexes ) The arms and legs of the affected side may be weakened or paralyzed to different degrees

18. Communication Involve expression and comprehension of written and spoken words. Aphasia (total loss of comprehension and use of language) when a stroke damages the dominant hemisphere of the brain. Dysphasia refers to difficulty related to the comprehension or use of language Nonfluent (minimal speech activity with slow speech that requires obvious effort) F luent (speech is present but contains little meaningful communication).

19. Global aphasia ( massive stroke ) , A ll communication and receptive function is lost. Receptive aphasia Affecting Wernicke's area. Neither the sounds of speech nor its meaning can be understood. Expressive aphasia Affecting Broca's area of the brain cause ( difficulty in speaking and writing). Dysarthria D isturbance in the muscular control of speech. Involves pronunciation, articulation, and phonation .

20. Affect Depression and feelings associated with changes in body image and loss of function Patients may also be frustrated by mobility and communication problems

21. Intellectual Function Memory and judgment may be impaired. A left-brain stroke is more likely to result in memory problems related to language. The patient with a right-brain stroke tends to be impulsive and to move quickly . Difficulty making generalizations

22. Spatial-Perceptual Alterations Four categories: Related to the patient's incorrect perception of self and illness . Second category concerns the patient's erroneous perception of self in space. Homonymous hemianopsia B lindness occurs in the same half of the visual fields of both eyes. The patient also has difficulty with spatial orientation , such as judging distances. 3. Agnosia T he inability to recognize an object by sight, touch, or hearing. 4. Apraxia T he inability to carry out learned sequential movements on command.

23. Elimination Initially, frequency , urgency, and incontinence . Constipation is associated with immobility, weak abdominal muscles, dehydration, and diminished response to the defecation reflex. Urinary and bowel elimination problems may also be related to inability to express needs and to manage clothing.

24. DIAGNOSTIC STUDIES CT scan The single most important diagnostic tool for patients who have experienced a stroke is the noncontrast CT scan Obtained within 25 minutes and read within 45 minutes of arrival at the emergency department. Indicates the size and location of the lesion and differentiates between ischemic and hemorrhagic stroke. If the stroke is less than 3 hours old and is ischemic in nature, the CT will appear normal.

25. Computed tomographic angiography (CTA ) Magnetic resonance imaging (MRI) Diffusion-weighted MRI Magnetic resonance angiography (MRA) Other tests Positron emission tomography (PET) Magnetic resonance spectroscopy (MRS ) Xenon CT , Single-photon emission computed tomography (SPECT ) , Cerebral angiography Intraarterial digital subtraction angiography ( DSA) Transcranial Doppler (TCD) ultrasonography Lumbar puncture EEG

26. Blood tests Complete blood count Platelets, prothrombin time, activated partial thromboplastin time Electrolytes, blood glucose Renal and hepatic studies Lipid profile Arterial blood gases (if hypoxia suspected)

27. Collaborative Preventive Care Goals: Health promotion for the well individual Education and management of modifiable risk factors Health promotion healthy diet, weight control, regular exercise, no smoking, limiting alcohol consumption, and routine health assessments.

28. Prevention of Stroke Reduce salt and sodium intake Maintain a normal body weight Increase level of physical exercise Avoid cigarette smoking or tobacco products Limit consumption of alcohol to moderate levels Use a diet that is low in saturated fat, total fat, and dietary cholesterol and high in fruits and vegetables Control of diabetes mellitus and hypertension Treatment of underlying cardiac problem Anticoagulation therapy for atrial fibrillation Platelet inhibitors Surgical interventions for aneurysms at risk of bleeding  

29. Drug Therapy Measures to prevent the development of a thrombus or embolus Aspirin is the most frequently used Other drugs include ticlopidine , clopidogrel , dipyridamole and combined dipyridamole and aspirin Oral anticoagulation in individuals with atrial fibrillation

30. Surgical Therapy Carotid endarterectomy T he atheromatous lesion is removed from the carotid artery to improve blood flow Transluminal angioplasty I nsertion of a balloon to open a stenosed artery and improve blood flow .

31. Stenting I ntravascular placement of a stent in an attempt to maintain patency of the artery Extracranial -intracranial (EC-IC) bypass I nvolves anastomosing a branch of an extracranial artery to an intracranial artery beyond an area of obstruction with the goal of increasing cerebral perfusion.

32. Collaborative Acute Care Goals : Preserving life, Preventing further brain damage, and Reducing disability.

33. EMERGENCY MANAGEMENT

34. EMERGENCY MANAGEMENT Initial • Ensure patent airway. • Call a stroke code or the stroke team. • Remove dentures. • Perform pulse oximetry . • Maintain adequate oxygenation (SaO 2 >92%) with supplemental O 2 , if necessary. • Establish IV access with normal saline. • Maintain BP according to guidelines • Remove clothing. • Obtain CT scan immediately.

35. Perform baseline laboratory tests (including blood glucose) immediately, and treat if hypoglycemic. • Position head midline. • Elevate head of bed 30 degrees if no symptoms of shock or injury. • Institute seizure precautions. • Anticipate thrombolytic therapy for ischemic stroke. Ongoing Monitoring • Monitor vital signs and neurologic status, including level of consciousness (Glasgow Coma Scale), motor and sensory function, pupil size and reactivity, SaO 2 , and cardiac rhythm. • Reassure patient and family.

36. use of drugs to lower BP is recommended only if systolic pressure >220 mm Hg Oral antihypertensive drugs are generally preferred. Hypervolemic hemodilution using crystalloids or colloids Fluid and electrolyte balance must be controlled carefully. oral, intravenous (IV), or tube feedings should be 1500 to 2000 ml/day.

37. Urine output is monitored. IV solutions with glucose and water are avoided because they are hypotonic and may further increase cerebral edema and ICP.

38. Increased ICP Elevating the head of the bed, maintaining head and neck in alignment, and avoiding hip flexion. Hyperthermia, needs to be avoided. Other measures pain management, avoidance of hypervolemia management of constipation. CSF drainage may be used in some patients to reduce ICP. Diuretic drugs, such as mannitol and f urosemide may be used to decrease cerebral edema. A bone flap may be removed to allow for cerebral edema without increases in ICP. The bone flap is frozen and replaced later

39. Drug Therapy Recombinant tissue plasminogen activator ( tPA ) administered IV tPA must be administered within 3 hours of the onset of clinical signs of ischemic stroke. Control of BP is critical during treatment and for 24 hours following tPA Acetylsalicylic acid (aspirin) is used within 48 hours of the stroke. To prevent further clot formation, may be treated with platelet inhibitors and anticoagulants are given. Anticoagulants and platelet inhibitors are contraindicated in patients with hemorrhagic strokes.

40. Drug therapies to treat hyperthermia include aspirin or acetaminophen (Tylenol). Cooling blankets may be used cautiously to lower temperature. An antiseizure drug, such as phenytoin is used

41. Surgical Therapy Aneurysms and Hemorrhage Evacuation of aneurysm-induced hematomas or cerebellar hematomas larger than 3 cm. Treatment of an aneurysm involves clipping, wrapping, or coiling the aneurysm to prevent rebleeding . Administration of the calcium channel blocker nimodipine to treat cerebral vasospasm. Arteriovenous malformation Surgical resection and/or radiosurgery (i.e., gamma knife ) preceeded by embolization of blood vessel that supply AVM.

42. Subarachnoid and intracerebral hemorrhage Bleeding into the ventricles produces hydrocephalus thus increasing the ICP. Insertion of a ventriculostomy for CSF drainage can result in dramatic improvement in these situations.

43. Ischemic Stroke Mechanical embolus retrieval in cerebral ischemia . The retriever goes to the artery that is blocked, directly to the site of the problem, and pulls the clot out.

44. Collaborative Rehabilitation Care After 12 to 24 hours of stabilization, collaborative care shifts from preserving life to lessening disability and attaining optimal function. Depends on patients status, resources available and rehabilitation potential patient.

45. NURSING MANAGEMENT Nursing Assessment Subjective data Past health history Medications Objective Data Nursing implementation Health Promotion Stroke prevention

46. Acute Intervention Respiratory System risk for atelectasis and pneumonia Risk for aspiration pneumonia Airway obstruction Nursing interventions Oropharyngeal airway to prevent the tongue fall & provide access for suctioning Tracheostomy assessment of airway , oxygenation, suctioning, patient mobility, positioning of the patient to prevent aspiration, and encouraging deep breathing.

47. Neurologic System Neurologic status must be monitored closely to detect changes suggesting extension of the stroke, increased ICP, vasospasm, or recovery from stroke symptoms. Glasgow Coma Scale,mental status, pupillary responses, and extremity movement and strength. Decreasing level of consciousness may indicate increasing ICP . Cerebral perfusion pressure may be monitored

48. Cardiovascular System Monitoring vital signs frequently; Monitoring cardiac rhythms; Calculating intake and output, noting imbalances; Regulating IV infusions; Adjusting fluid intake to the individual needs of the patient; Maintaining homeostasis Avoid fluid overload Central venous pressure, pulmonary artery pressure, or hemodynamic monitoring monitoring lung sounds for crackles and rhonchi monitor for orthostatic hypotension

49. Deep vein thrombosis Measuring the calf and thigh daily, Observing swelling of the lower extremities, Note unusual warmth of the leg, and asking the patient about pain in the calf. Keep the patient moving. Active range-of-motion exercises. For, passive range-of-motion exercises should be done several times a day.

50. Positioning to minimize dependent edema use of elastic compression gradient stockings or support hose. Intermittent pneumatic compression stockings prophylaxis may include low-molecular-weight heparin (e.g., enoxaparin.

51. Musculoskeletal System Prevention of joint contractures and muscular atrophy Range-of-motion exercises and positioning Stroke is due to subarachnoid hemorrhage, the movement is limited to the extremities. paralyzed or weak side needs special attention

52. Each joint should be positioned higher than the joint proximal to it to prevent dependent edema. trochanter roll at the hip to prevent external rotation; hand cones (not rolled washcloths) to prevent hand contractures; arm supports with slings and lap boards to prevent shoulder displacement; avoidance of pulling the patient by the arm to avoid shoulder displacement; posterior leg splints, footboards or high-top tennis shoes to prevent footdrop ; hand splints to reduce spasticity.

53. Integumentary System Prevention of skin breakdown includes Pressure relief by position changes, special mattresses, or wheelchair cushions; Good skin hygiene; Emollients applied to dry skin; and Early mobility. Position change schedule is side-back-side, with a maximum duration of 2 hours for any position. Position patient on the weak or paralyzed side for only 30 minutes. The damaged area should not be massaged because this may cause additional damage. Pillows can be used under lower extremities to reduce pressure on the heels.

54. Gastrointestinal System Constipation Stool softeners and/or fiber as prophylaxis. checked for impaction. Fluid intake should be at least 1800 to 2000 ml/day and fiber intake up to 25 g/day. Laxatives, suppositories, or additional stool softeners may be ordered Enemas as last provision ( increase ICP)

55. Urinary System Incontinence ( a/c stage of shock) Long-term use of an indwelling catheter is associated with urinary tract infections and delayed bladder retraining. Intermittent catheterization program for urine retention. External catheter for male patients. Bladder retraining program Fluid intake between 8:00 am and 7:00 pm Scheduled toileting every 2 hours Noting signs of restlessness, which may indicate the need for urination

56. Nutrition Initial support with IV infusions. Enteral or parenteral nutrition support. Perform a swallowing evaluation before patients are started on oral intake. Mouth care before feeding improves sensation and salivation. High Fowler's position. Food should be placed on the unaffected side of the mouth. Feedings must be followed by oral hygiene

57. Communication Assessed for the ability to speak and the ability to understand. Patient cannot understand words, gestures may be used to support verbal cues. Speak slowly and calmly, using simple words or sentences. Give the patient extra time to comprehend and respond to communication. A picture board may be helpful for communicating with the stroke patient.

58. Sensory-Perceptual Alterations Homonymous hemianopsia Initially compensate by arranging the environment within the patient's perceptual field Later teach to compensate for the visual defect by consciously attending the neglected side. Neglect syndrome results in decreased safety awareness and places the patient at high risk for injury. Protect from injury by close observation of the patient, elevating side rails, lowering the height of the bed, and video monitors

59. Diplopia Diplopia is treated with an eye patch. Corneal abrasion can be prevented with artificial tears or gel and an eye shield. Ptosis is generally not treated because it usually does not inhibit vision

60. Coping Explanations to the patient about what has happened and about diagnostic and therapeutic procedures. The patient's family should be given a careful, detailed explanation Provide assistance in arranging care for family members and finances. A social services referral is often helpful.

61. Ambulatory and Home Care Prepare the patient and family for discharge through education, demonstration and return demonstration, practice , and evaluation of self-care skills before discharge . medications , nutrition , mobility , exercises , hygiene and toileting.

62. Rehabilitation Rehabilitation is the process of maximizing the patient's capabilities and resources to promote optimal functioning related to physical, mental, and social well-being. Goals Prevent deformity and Maintain and improve function

63. Team Nurses Physicians Psychiatrist Physical therapist Occupational therapist Speech therapist Dietitian Respiratory therapist Vocational therapist Recreational therapist Social worker Psychologist Pharmacist Chaplain

64. Musculoskeletal Function Balance training is the initial step The next step is transferring from bed to chair or wheelchair. Supportive or assistive equipment, such as canes, walkers, and leg braces, may be needed on a short- or long-term basis for mobility.

65. Nutritional Therapy Assess the ability of the patient to swallow solids and fluids Dietitian plans the diet type, texture, calorie count, and fluids Providing a non distracting environment Employing assistive devices such as rocker knives, plate guards, and nonslip pads for dishes Evaluate maintenance of weight, adequate hydration, and patient satisfaction.

66. Bowel Function Fluid intake of 2500 to 3000 ml daily unless contraindicated. Cooked vegetables three times daily Whole-grain cereal or bread three to five times daily Placing the patient on the bedpan or bedside commode or taking the patient to the bathroom at a regular time daily to reestablish bowel regularity. 30 minutes after breakfast because eating stimulates the gastrocolic reflex and peristalsis. Stool softeners or suppositories if bowel programs are ineffective.

67. Bladder Function Assessment for bladder distention by palpation; Offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; Scheduling the majority of fluid intake between 7:00 am and 7:00 pm; and Encouraging the usual position for urinating (standing for men and sitting for women).

68. Sensory-Perceptual Function The task should be broken down to simple steps for ease of understanding. Environmental control, such as removing clutter and obstacles and using good lighting, aids in concentration and safer mobility. One-sided neglect in right-brain stroke, assist or remind the patient to dress the weak or paralyzed side or shave the forgotten side of the face.

69. Affect Distract the patient who suddenly becomes emotional, Explain to the patient and family that emotional outbursts may occur after a stroke, Maintain a calm environment, and Avoid shaming or scolding the patient during emotional outbursts.

70. Communication Frequent, meaningful communication; Allowing time for the patient to comprehend and answer; Using simple, short sentences; Using visual cues; Structuring conversation so that it permits simple answers by the patient; and Praising the patient honestly for improvements with speech.

71. Nursing diagnosis Decreased intracranial adaptive capacity Impaired physical mobility Ineffective airway clearance related to stasis of secretions Imbalanced nutrition, less than requirements related to impaired swallowing and motor deficits Disturbed sensory perception related to CNS damage Self-care deficit related to decreased motor function, spatial-perceptual alterations, and fear of injury Risk for impaired skin integrity