Cerebral Vascular Accident

Cerebral Vascular Accident

1. Types of Stroke

   • TIA
     • Transient ischemia that lasts less than 1 hour
     • Usually focal ischemia in brain, spinal cord, or retina
     • 1/3 of people never experience another episode
       • 1/3 of people will have more episodes
         • 1/3 of people will have a stroke
   • Ischemic
     • Lacunar
       • Occlusion of small penetrating artery with lesion development
       • Usually asymptomatic
       • 2/3 of incidences due to HTN/diabetes
     • Embolic
       • Fatty plaque or blood clot blocks artery
     • Thrombotic
       • Thrombus blocks flow of blood in brain
   • Hemorrhagic
     • Intracerebral Hemorrhage
       • Caused by ruptured vessel
       • HTN is the biggest culprit
       • Usually occurs during periods of activity
       • 40-80% mortality within first 30 days
         • 50% mortality within first 48 hours
     • Subarachnoid Hemorrhage
       • Intracranial bleeding in CSF filled space between arachnoid and pia matter
       • Caused by rupture of cerebral aneurysm
       • Majority occur in the Circle of Willis
       • 40% die during first episode
       • 15% die of subsequent bleeding

2. Risk Factors

   • Modifiable
     • Hypertension
       • Highest culprit of strokes in men and those under 50
     • Metabolic Syndrome
       • Increased BP, high blood glucose, excess fat, abnormal cholesterol levels
     • Increased Alcohol Consumption
       • Increases stroke risk as much as HTN and diabetes
     • Oral Contraceptive Use
       • Increased risk of blood clots and risk of embolism
     • Inactivity
       • Contributes to metabolic syndrome, blood pooling, weaker heart health
     • Smoking
       • Contributes to atherosclerosis, lung disorders, atherosclerosis
     • Heart Disease
       • Complications including atrial fibrillation, MI, Cardiomyopathy, cardiac valve abnormalities contribute to stroke risk
   • Non-Modifiable
     • Age
       • Stroke prevalence increases after ages 55-65 years
         • Atherosclerosis and natural aging contribute to stroke risk
     • Gender
       • Under 50: Stroke more prevalent in women Over 50: Stroke more prevalent in men
     • Ethnicity
       • Black, Indigenous, Asian/Pacific Islander, and Hispanic populations have higher mortality for stroke than white populations
     • Genetics
       • Inherited genetic risks may increase risk of stroke
     • Low Birth Weight
       • Affected childhood growth may be a risk factor

3. Incidence

4. Collaborative Care

   • Prevention
   • Health Promotion
     • Educational management of modifiable risk factors
     • Stroke prevention teaching
       • Minimize risk factors
       • Hypertension control
       • Medication adherence and education
     • Health teaching
       • Early symptoms
   • Interventions
     • Drugs
       • Antihypertensives
         • Nicardipine (Cardene)
         • Metoprolol (Lopressor)
       • Antiplatelets
         • Aspirin
         • Clopidogrel (Plavix)
         • Dipyridamole (Persantine)
         • Aggrenox
       • Anticoagulants
         • Warfarin (Coumadin)
     • Surgical Intervention
       • Ischemic Stroke
         • Carotid endarcterectomy
           • Removal of material buildup in arteries
         • Transluminal angioplasty
           • Balloon angioplasty to widen narrowed arteries
         • Stenting
           • Tube inserted into lumen of duct to keep passageway open
         • Extracranial-Intracranial Bypass
           • Promotes perfusion using surgically connected arteries
       • Hemorrhagic Stroke
         • Evacuation of hematomas caused by aneurysm

5. Nursing Management

   • Initial
     • Therapy: Endotracheal Intubation, Mechanical Ventilation
     • Assessment of airway patency and function
     • Oxygenation, suctioning, positioning
     • Monitor VS, LOC changes suggesting worsening condition
     • Obtain diagnostic tests
   • Acute
     • Preserve life
     • Prevent further brain damage
     • Reduce disability
     • Manage ABCs
   • Ongoing
     • Maintain homeostasis, monitor for decreased cardiac reserves
     • Integuementary: Pressure relief, good hygiene, mobility, moisturizers
     • Position to prevent aspiration, skin injury, muscle/joint pain
     • Passive ROM exercises to maintain muscle and joint movement
     • Monitor and control fluid and electrolyte balance
     • Reduce DVT risk with positioning and compression stockings
   • Rehabilitation
     • Goals
       • Maximize communication abilities
       • Lessen disability
       • Attain optimal function
       • Forward patient motility
         • Rehabilitation Unit
           • Outpatient Facility
             • Home/Family based care
       • Communication
         • Use of picture board
         • Speak slowly and clearly
         • Use of gestures
       • Mobility
       • Bladder Retraining
     • Coping
       • Social Supports
       • Family Supports
         • Emotional Social Financial
         • Understand behavioral changes
       • Occupational Therapy

6. Clinical Manifestations

   • Frontal Lobe
     • Sense of smell, control of muscle activity
     • Broca's Area - Production of language
     • Prefrontal Area - Attention, memory, information processing, executive function
   • Parietal Lobe
     • Sensory information processing, sensory integration and perception, spatial awareness
   • Occipital Lobe
     • Vision, interpretation of visual stimuli
   • Temporal Lobe
     • Hearing, memory, emotion, behaviour
     • Wernicke's Area - Language comprehension
   • Cerebellum and Brainstem
     • Cerebellum - Coordination of movement and balance
     • Brainstem - Breathing, circulation, heart rate, wake/sleep cycles
   • Contralateral Damage

7. Assessment and Evaluation

   • Objective Systems Evaluation
     • Neurological
       • Increased ICP
       • Mental status
         • Communication - Aphasia and dysphasia
           • Dysarthria
       • Pupillary Responses
       • Vital Signs
       • Clinical Assessment Tools
       • Cranial Nerve Function
       • Sensation
       • Affect
     • Respiratory
       • Impaired consciousness, dysphagia
         • Risks: Atelectasis, Aspiration Pneumonia, Airway Obstruction
       • Ineffective airway clearance
     • Cardiovascular
       • Monitor for complications
         • Fluid retention Overhydration Dehydration BP Variation
         • Adventitious Lung Sounds Adventitious Heart Sounds DVT risk
       • Ineffective cerebral tissue perfusion
     • Musculoskeletal
       • Hemiparalysis
         • Internal rotation of shoulder
         • Contractures of wrist, hand, elbow
         • Plantar flexion of foot
         • Unilateral neglect
       • Impaired physical mobility
       • Motor Function
     • Integumentary
       • Susceptible breakdown
         • Loss of sensation Decreased circulation Immobility
     • Gastrointestinal
       • Catabolic state
         • Extreme fatigue Joint/Muscle pain Sleeplessness
       • Constipation
       • Impaction
     • Urinary
       • Incontinence
   • Diagnostic Studies
     • CT Scan
       • Rapidly distinguish ischemic vs hemorrhagic stroke
       • Serial scans to monitor treatment and recovery
     • MRI, MRA
     • Cerebral angiography
     • Lumbar puncture (rare)
   • Cardiac Assessment
     • Electrocardigram
     • Chest X-ray
     • Heart disease often contributes to symptoms
     • Cardiac enzymes
     • Echocardiography
   • Assessment Findings
   • Subjective Assessment
     • History of symptoms
     • Active medications
     • Risk factors and behaviours
     • Family history of disease

8. Carolyn Liow

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