1. No category

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
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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
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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
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 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
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 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
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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
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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


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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
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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





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
hemiparesis
Contractures
Bony ankylosis
Disuse atrophy
Dysarthria - word
formation
Dysphagia – swallow
Apraxia – complex
movements
Flaccidity/spasticity
 GU
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
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
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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
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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.
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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

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HOB
Sedation
Osmotherapy
Hyperventilation
Paralytics
 Keppra
 Dilantin
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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:
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
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

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


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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.