1. Neuro Concept: Cerebral Vascular Accident (CVA) Or Stroke

2. Transient Ischemic Attack “TIA”  Transient ischemic attack  Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain  Symptoms last <1 hour 2

3. Collaborative Care Prevention  Antiplatelet drugs are usually the chosen treatment to prevent further stroke in patients who have had a TIA.  Aspirin is the most frequently used antiplatelet agent. 3

4. Collaborative Care Prevention  Surgical interventions for the patient with TIAs from carotid disease include  Carotid endarterectomy  Transluminal angioplasty  Stenting  Extracranial-intracranial bypass 4

5. Carotid Endarterectomy 5

6. Nursing Management Education  Health promotion  To reduce the incidence of stroke, the nurse should focus teaching toward stroke prevention.  Particularly in persons with known risk factors  Education about hypertension control and adherence to medication  Teaching patients and families about  Early symptoms  Stroke  TIA  When to seek health care for symptoms 6

7. Stroke  Stroke occurs when ischemia or hemorrhage into the brain results in death of brain cells  Also known as a brain attack 7

8. Stroke  Functions are lost or impaired.  Such as movement, sensation, or emotions that were controlled by the affected area of the brain  Severity of the loss of function varies according to the location and extent of the brain involved. 8

9. Stroke  Third most common cause of death in the United States and Canada  Leading cause of serious, long-term disability  Approximately 35% of individuals who have an initial stroke die within 1 year. 9

10. Collaborative Care Prevention  Priority for decreasing morbidity and mortality from stroke  Goals of stroke prevention include  Health promotion for the well individual  Education and management of modifiable risk factors to prevent a stroke 10

11. Collaborative Care Prevention  Patients with known risk factors require close management.  Diabetes mellitus  Hypertension  Obesity  High serum lipids  Cardiac dysfunction 11

12. Modify Risk Factors  Most effective way to decrease the burden of stroke is prevention.  Risk factors can be divided into non- modifiable and modifiable risks. 12

13. Risk Factors Modifiable  Hypertension  Metabolic syndrome  Heart disease  Heavy alcohol consumption  Poor diet  Drug abuse 13

14. Risk Factors Nonmodifiable  Age  Gender  Race  Heredity/family history 14

15. Risk Factors Modifiable  Sleep apnea  Obesity  Physical inactivity  Smoking 15

16. Atherosclerosis of Extracranial & Intracranial Arteries 16

17. Clinical Manifestations of CVA  Symptoms  Personality  Affect  Sensation  Communication 17

18. Diagnostic Studies  When symptoms of a stroke occur, diagnostic studies are used to:  Confirm that it is a stroke  Identify the likely cause of the stroke  CT is the primary diagnostic test used after a stroke 18

19. Diagnostic Studies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19  CT  MRI  Angiography  Transcranial Doppler  LICOX

20. Diagnostic Studies  For cardiac assessment  Electrocardiogram  Chest x-ray  Cardiac enzymes  Echocardiography  Holter monitor Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

21. Types of Stroke  Strokes are classified on the basis of underlying pathophysiologic findings.  Ischemic (thrombotic & embolic)  Hemorrhagic 21

22. Major Types of Stroke 22

23. Ischemic Stroke  Ischemic strokes result from  Inadequate blood flow to the brain from partial or complete occlusion of an artery  Ischemic strokes can be  Thrombotic  Embolic  80% of all strokes are ischemic strokes. 23

24. Thrombotic Stroke  Thrombotic stroke  Thrombosis occurs in relation to injury to a blood vessel wall and formation of a blood clot.  Result of thrombosis or narrowing of the blood vessel  Most common cause of stroke  Lacunar strokes are typically asymptomatic. 24

25. Embolic Stroke  Embolic stroke  Occurs 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 25

26. Embolic Stroke Manifestations  Embolic stroke  Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms.  Onset of embolic stroke is usually sudden and may or may not be related to activity.  Patient usually remains conscious, although he may have a headache. 26

27. Hemorrhagic Stroke  Account for approximately 15% of all strokes  Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles 27

28. Hemorrhagic Stroke  Intracerebral hemorrhage  Often a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding  Bleeding within the brain caused by rupture of a vessel  Hypertension is the most important cause.  Hemorrhage commonly occurs during periods of activity 28

29. Hemorrhagic Stroke  Intracerebral hemorrhage  Manifestations  Neurologic deficits  Headache  Nausea and/or vomiting  Decreased levels of consciousness  Hypertension 29

30. Hemorrhagic Stroke  Subarachnoid hemorrhage  Intracranial bleeding into cerebrospinal fluid–filled space between the arachnoid and pia mater  Commonly caused by rupture of a cerebral aneurysm 30

31. Hemorrhagic Stroke 31

32. Hemorrhagic Stroke  Subarachnoid hemorrhage  An aneurysm may be saccular or berry.  Majority of aneurysms are in the circle of Willis.  “Worst headache of one’s life” 32

33. Hemorrhagic Stroke  Subarachnoid hemorrhage  Most frequent surgical procedure to prevent rebleeding is clipping of the aneurysm.  Coiling is another procedure. 33

34. Clinical Manifestations Hemorrhagic CVA  Affects many body functions  Motor activity  Elimination  Intellectual function  Spatial-perceptual alterations 34

35. Manifestations of CVA Left & Right

36. Clinical Manifestations Motor Function  Most obvious effect of stroke  Include impairment of  Mobility  Communication  Respiratory function  Swallowing and speech  Gag reflex  Self-care abilities 36

37. Clinical Manifestations Motor Function  Characteristic motor deficits  Loss of skilled voluntary movement  Impairment of integration of movements  Alterations in muscle tone  Alterations in reflexes 37

38. Clinical Manifestations Motor Function  An initial period of flaccidity  May last from days to several weeks  Related to nerve damage  Spasticity of the muscles follows the flaccid stage.  Related to interruptions in upper motor neuron influence 38

39. Clinical Manifestations Communication Aphasia is the loss of comprehension and use of language  Expressive aphasia (non-fluent): With expressive aphasia, the person knows what he or she wants to say, yet has difficulty communicating it to others. It doesn't matter whether the person is trying to say or write what he or she is trying to communicate.  Receptive aphasia (fluent): With receptive aphasia, the person can hear a voice or read the print, but may not understand the meaning of the message. Oftentimes, someone with receptive aphasia takes language literally. Their own speech may be disturbed because they do not understand their own language 39

40. Aphasia Types Continued  Anomic aphasia. With anomic aphasia, the person has word- finding difficulties. This is called anomia. Because of the difficulties, the person struggles to find the right words for speaking and writing.  Global aphasia. This is the most severe type of aphasia. It is often seen right after someone has a stroke. With global aphasia, the person has difficulty speaking and understanding words. In addition, the person is unable to read or write.

41. Clinical Manifestations Communication  Many patients experience dysarthria.  Disturbance in the muscular control of speech  Impairments may involve  Pronunciation  Articulation  Phonation 41

42. Clinical Manifestations Affect  Patients who suffer a stroke may have difficulty controlling their emotions.  Emotional responses may be exaggerated or unpredictable. 42

43. Clinical Manifestations Intellectual Function  Both memory and judgment may be impaired as a result of stroke.  A left-brain stroke is more likely to result in memory problems related to language (refer to aphasia slides) 43

44. Clinical Manifestations Spatial–Perceptual Alterations  Stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation  Left hemiplegia may result in problems with spatial-perceptual tasks: ability to judge distance, size, position, rate of movement, form and how parts relate to wholes  People with severe spatial-perceptual deficits may have more trouble with self-care than those with equally severe language deficits. They may not be able to read a paper - because they lose their place on the page.  Quick and impulsive behavior results in overestimating their abilities  They are often unaware of their deficits, and may think themselves capable of tasks they really are not capable of  These alterations may also occur with left-brain stroke 44

45. Clinical Manifestations Spatial-Perceptual Alterations  Spatial-perceptual problems may be divided into four categories. 1 Incorrect perception of self and illness 2 Erroneous perception of self in space 3 Inability to recognize an object by sight, touch, or hearing 4 Inability to carry out learned sequential movements on command 45

46. Clinical Manifestations Elimination  Most problems with urinary and bowel elimination occur initially and are temporary.  When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is excellent. 46

47. Brain Stent 47

48. Nursing Management Nursing Assessment  If the patient is stable, obtain  Description of the current illness with attention to initial symptoms  History of similar symptoms previously experienced  Current medications  History of risk factors and other illnesses  Family history of stroke or cardiovascular disease 48

49. Collaborative Care Acute Care  Goals for collaborative care during the acute phase are  Preserving life  Preventing further brain damage  Reducing disability  Treatment differs according to type of stroke and as patient changes. 49

50. Collaborative Care Acute Care  Begins with managing the ABCs  Airway  Breathing  Circulation 50

51. Collaborative Care Acute Care  Recognize Causes  Sudden vascular compromise causing disruption of blood flow to the brain  Thrombosis  Trauma  Aneurysm  Embolism  Hemorrhage 51

52. Collaborative Care Acute Care  Assessment findings  Altered level of consciousness  Weakness, numbness, or paralysis  Speech or visual disturbances  Severe headache  ↑ or ↓ heart rate  Respiratory distress  Unequal pupils 52

53. Collaborative Care Acute Care  Assessment findings  Hypertension  Facial drooping on affected side  Difficulty swallowing  Seizures  Bladder or bowel incontinence  Nausea and vomiting  Vertigo 53

54. Collaborative Care Acute Care  Interventions: initial  Ensure patent airway.  Call stroke code or stroke team.  Perform pulse oximetry.  Maintain adequate oxygenation.  Obtain IV access with normal saline.  Maintain BP according to guidelines. 54

55. Collaborative Care Acute Care  Interventions: initial  Remove clothing.  Obtain CT scan immediately.  Perform baseline laboratory tests.  Position head midline.  Elevate head of bed 30 degrees if no symptoms of shock or injury occur  Institute seizure precautions.  Anticipate thrombolytic therapy for ischemic stroke.  55

56. Collaborative Care Acute Care  Hypertension is common immediately after stroke.  Drugs to lower BP are used only if BP is markedly increased.  Fluid and electrolyte balance must be controlled carefully.  Adequate hydration promotes perfusion and decreases further brain injury. 56

57. Collaborative Care Acute Care  Interventions: ongoing  Monitor vital signs and neurologic status.  Level of consciousness  Monitor and sensory function  Pupil size and reactivity  O 2 saturation  Cardiac rhythm 57

58. Nursing Management Nursing Implementation  Respiratory system  Management of the respiratory system is a nursing priority.  Risk for atelectasis  Risk for aspiration pneumonia  Risks for airway obstruction  May require endotracheal intubation and mechanical ventilation 58

59. Collaborative Care Acute Care  Recombinant tissue plasminogen activator (tPA)  Used to reestablish blood flow through a blocked artery to prevent cell death in patients with acute onset of ischemic stroke symptoms  Must be administered within 3 to 4.5 hours per qualifying criteria- of onset of clinical signs of ischemic stroke 59

60. Collaborative Care Acute Care  Aspirin is used within 24 to 48 hours of stroke.  Platelet inhibitors and anticoagulants may be used in thrombus and embolus stroke patients after stabilization.  Contraindicated for patients with hemorrhagic stroke 60

61. Merci Embolus Retriever in Cerebral Ischemic Stroke 61

62. Nursing Management Nursing Assessment  Comprehensive neuro examination  Level of consciousness  Cognition  Motor abilities  Cranial nerve function  Sensation  Proprioception  Cerebellar function  Deep tendon reflexes 62

63. Nursing Management Nursing Diagnoses  Risk for ineffective cerebral tissue perfusion  Ineffective airway clearance  Impaired physical mobility  Impaired verbal communication  Unilateral neglect 63

64. Nursing Management Nursing Diagnoses  Impaired urinary elimination  Impaired swallowing  Situational low self-esteem 64

65. Nursing Management Nursing Implementation  Neurologic system  Monitor closely to detect changes suggesting  Extension of the stroke  ↑ ICP  Vasospasm  Recovery from stroke symptoms 65

66. Nursing Management Nursing Implementation  Cardiovascular system  Goals aimed at maintaining homeostasis  Many patients with stroke have decreased cardiac reserves from the secondary diagnoses of cardiac disease.  Cardiac efficiency may be compromised. 66

67. Nursing Management Nursing Implementation  Cardiovascular system  Nursing interventions  Monitoring vital signs frequently  Monitoring cardiac rhythms  Calculating intake and output, noting imbalances  Regulating IV infusions 67

68. Nursing Management Nursing Implementation  Cardiovascular system  After stroke, patient is at risk for deep vein thrombosis.  Related to immobility, loss of venous tone, and ↓ muscle pumping in leg  Most effective prevention is keeping the patient moving. 68

69. Nursing Management Nursing Implementation  Musculoskeletal system  Goal is to maintain optimal function.  Accomplished by the prevention of joint contractures and muscular atrophy  In the acute phase, range-of-motion exercises and positioning are important.  Paralyzed or weak side needs special attention when positioned. 69

70. Nursing Management Nursing Implementation  Musculoskeletal system  Trochanter roll at hip to prevent external rotation  Hand cones to prevent hand contractures  Arm supports with slings and lap boards to prevent shoulder displacement 70

71. Nursing Management Nursing Implementation  Musculoskeletal system  Avoidance of pulling the patient by the arm to prevent shoulder displacement  Posterior leg splints, footboards, or high-topped tennis shoes to prevent foot drop  Hand splints to reduce spasticity 71

72. Nursing Management Nursing Implementation  Integumentary system  Susceptible to breakdown related to  Loss of sensation  Decreased circulation  Immobility  Compounded by patient age, poor nutrition, dehydration, edema, and incontinence 72

73. Nursing Management Nursing Implementation  Integumentary system  Pressure relief by position changes, special mattresses, or wheelchair cushions  Good skin hygiene  Emollients applied to dry skin  Early mobility  Position patient on the weak or paralyzed side for only 30 minutes. 73

74. Nursing Management Nursing Implementation  Gastrointestinal system  Stress of illness contributes to a catabolic state that can interfere with recovery.  Constipation is the most common bowel problem.  Patients may be placed on stool softeners or fiber prophylactically.  Physical activity promotes bowel function. 74

75. Nursing Management Nursing Implementation  Urinary system  In the acute stage, poor bladder control results in incontinence.  Efforts should be made to promote normal bladder function.  Avoid the use of indwelling catheters. 75

76. Nursing Management Nursing Implementation  Nutrition  Nutritional needs require quick assessment and treatment.  May initially receive IV infusions to maintain fluid and electrolyte balance  May require nutritional support 76

77. Nursing Management Nursing Implementation  Nutrition  First feeding should be approached carefully.  Test swallowing, chewing, gag reflex, and pocketing before beginning oral feeding.  Feedings must be followed by oral hygiene. 77

78. Nursing Management Nursing Implementation  Communication  Nurse’s role in meeting psychologic needs of the patient is primarily supportive.  Patient is assessed for both the ability to speak and the ability to understand.  Speak slowly and calmly, using simple words or sentences.  Gestures may be used to support verbal cues. 78

79. Nursing Management Nursing Implementation  Sensory-perceptual alterations  Blindness in same half of each visual field is a common problem after stroke.  Known as homonymous hemianopsia  Other visual problems may include  Diplopia (double vision)  Loss of the corneal reflex  Ptosis (drooping eyelid) 79

80. Homonymous Hemianopsia (Food on left side is not seen) 80

81. Nursing Management Nursing Implementation  Coping  CVA is often a “family disease”  Affects family  Emotionally  Socially  Financially  Changing roles and responsibilities 81

82. Nursing Management Nursing Implementation  Coping  Explain  What has happened  Diagnosis  Therapeutic procedures  Should be clear and understood by patient  Patient’s family should be given a careful, detailed explanation of what has happened to the patient.  Family members usually have not had time to prepare for the illness—social services referral is often helpful 82

83. Collaborative Care Rehabilitation  After stroke has stabilized for 12 to 24 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning 83

84. Nursing Management Nursing Implementation  Ambulatory and home care  Ideally, discharge planning with the patient and family starts early in the hospitalization and promotes a smooth transition from one care setting to another. 84

85. Nursing Management Nursing Implementation  Ambulatory and home care  Patient is usually discharged from the acute care setting to home, an intermediate or long-term care facility, or a rehabilitation facility. 85

86. Nursing Management Nursing Implementation  Ambulatory and home care  Nurse initially emphasizes musculoskeletal functions of  Eating  Toileting  Walking 86

87. Nursing Management Nursing Implementation  Ambulatory and home care  Nurses have an excellent opportunity to prepare the patient and family for discharge through  Education  Demonstration  Practice  Evaluation of self-care skills 87

88. Nursing Management Nursing Implementation/Collaborative Care  Ambulatory and Home Care  Rehabilitation is the process of maximizing the patient’s capabilities and resources to promote optimal functioning.  Physical, mental, and social well-being 88

89. Nursing Management Nursing Implementation  Ambulatory and home care  The rehabilitation nurse assesses the patient and family for  Rehabilitation potential of the patient  Physical status of all body systems  Presence of complications caused by the stroke or other chronic conditions  Cognitive status of the patient 89

90. Nursing Management Nursing Implementation  Ambulatory and home care  The rehabilitation nurse assesses the patient and family for:  Family resources and support  Expectations of the patient and family related to the rehabilitation program 90

91. Nursing Management Nursing Implementation  Ambulatory and home care  Rehabilitation goals are mutually set by  Patient  Family  Nurse  Other members of rehabilitation team 91

92. Nursing Management Nursing Implementation  Ambulatory and home care  Rehabilitation goals  Learn techniques to self-monitor and maintain physical wellness.  Demonstrate self-care skills.  Exhibit problem-solving skills with self-care. 92

93. Nursing Management Nursing Implementation  Ambulatory and home care  Rehabilitation goals  Avoid complications associated with stroke.  Establish and maintain a useful communication system.  Maintain nutritional and hydration status. 93

94. Nursing Management Nursing Implementation  Ambulatory and home care  Rehabilitation goals  List community resources for equipment, supplies, and support.  Establish flexible role behaviors to promote family cohesiveness. 94

95. Nursing Management Nursing Implementation  Ambulatory and home care  If muscles are still flaccid several weeks after the stroke, prognosis for regaining function is poor.  Focus of care is on preventing additional loss.  Most patients begin to show signs of spasticity with exaggerated reflexes within 48 hours following the stroke. 95

96. Loss of Postural Stability 96

97. Nursing Management Nursing Implementation  Ambulatory and home care  Musculoskeletal interventions  Balance training  Transferring from bed to chair  Bobath method or constraint-induced movement therapy may be used in musculoskeletal rehabilitation.  CIMT is a more recent approach. 97

98. Nursing Management Nursing Implementation  Ambulatory and home care  After acute phase, a dietitian can assist in determining appropriate daily caloric intake based on the patient’s  Size  Weight  Activity level 98

99. Nursing Management Nursing Implementation  Ambulatory and home care  Nurse and speech therapist must assess ability of patient to swallow solids and fluids and must adjust the diet appropriately.  Inability to feed oneself can be frustrating and may result in malnutrition and dehydration. 99

100. Assistive Devices for Eating 100

101. Nursing Management Nursing Implementation  Ambulatory and home care  Interventions to promote self-feeding  Removing unnecessary items from tray or table, reducing spills  Providing a nondistracting environment to reduce sensory overload with distraction 101

102. Nursing Management Nursing Implementation  Ambulatory and home care  Patients with stroke on right side of brain  Difficulty in judging position, distance, and movement  Impulsive, impatient, and denying problems related to stroke  Respond best to directions given verbally 102

103. Nursing Management Nursing Implementation  Ambulatory and home care  Patients with stroke on left side of brain  Slower in organization and performance of tasks  Impaired spatial discrimination  Have fearful, anxious response to stroke  Respond well to nonverbal cues 103

104. Nursing Management Nursing Implementation  Ambulatory and home care  Interventions for atypical emotional response  Distract the patient.  Explain that emotional outbursts may occur.  Maintain a calm environment.  Avoid shaming or scolding patient. 104

105. Nursing Management Nursing Implementation  Ambulatory and home care  Patients with a stroke may be coping with many losses (i.e., sensory, intellectual).  Often go through the process of grief  Some patients experience long-term depression. 105

106. Nursing Management Nursing Implementation  Ambulatory and home care  Nurse may assist the coping process.  Support communication between the patient and family.  Discuss lifestyle changes.  Discuss changing roles within the family  Be an active listener.  Include family in goal planning and patient care.  Support family conferences 106

107. Nursing Management Nursing Implementation  Ambulatory and home care  Implement a bowel management program for problems with  Bowel control  Constipation  Incontinence  High-fiber diet and adequate fluid intake 107

108. Collaborative Care  Ambulatory and home care  Speech, comprehension, and language deficits are the most difficult problem for the patient and family.  Speech therapists can assess and formulate a plan to support communication. 108

109. Nursing Management Planning  Goals are that the patient will:  Maintain stable or improved level of consciousness  Attain maximum physical functioning  Maximize self-care abilities and skills  Maintain stable body functions  Maximize communication abilities.  Avoid complications of stroke.  Maintain effective personal and family coping. 109

110. Nursing Management Nursing Implementation/Education  Ambulatory and home care  Family members must cope with these aspects of patient’s behavior: 1. Recognition of behavioral changes resulting from neurologic deficits that are not changeable 2. Responses to multiple losses by both the patient and the family 110

111. Nursing Management Nursing Implementation  Ambulatory and home care  Stroke support groups within rehab facilities and community are helpful.  Mutual sharing  Education  Coping  Understanding 111