Cerebrovascular Accident

Cerebrovascular Accident

1. Ischemic Stroke

   • Blockage/clot of blood vessel in the brain
   • Types
     • Embolic Strokes
       • Blockage from outside of the brain, travelling through the blood stream to block a cerebral vessel
       • Causes
     • Transient Ischemic Attacks
       • "mini stroke" - temporary disturbance in cerebral blood flow, reverses before infarction (stroke symptoms resolve within an hour)
       • 10-20% risk of stroke within year following a TIA
     • Thrombotic Stroke
       • Obstruction of cerebral vessel
       • Causes
   • 87% of all strokes

2. Hemmorhagic Stroke

   • Rupture of blood vessel in the brain (disruption of blood flow)
   • Risk Factors
     • Modifiable
       • Hypertension
         • 35-50% higher stroke risk -- damage vessel walls --> increase atherosclerosis
       • Hyperlipidemia
       • Smoking
         • Increases risk of stroke 20-30%
       • Diabetes
         • 2-3x more likely to develop a stroke = damage vessel walls
       • Atrial Fibrillation
         • increases risk of clot formation
       • History of CVD
         • predisposes to cardioembolic stroke
       • Coagulation Disease
       • Obesity
         • increased weight --> HTN, diabetes, high cholesterol
       • Heavy Alcohol Use
         • increases HTN, hypercoagability of blood, reduction of cerebral blood flow
       • Cocaine Use
         • increases vasospasms, enhances platelet activity, increases BP, HR, narrows blood vessels
       • HRT/Oral Contraceptives
         • Increases risk of stroke, especially when smoking (increase blood clot)
     • Non-modifiable
       • Age
         • Pediatrics
           • One of the top 10 causes of death in infants. Risk of stroke in Children = greatest in 1st year of life + between right before --> right after birth. Symptoms: seizures, extreme sleepiness, tendency to use only one side of the body
         • Older adults
           • After age 55, risk of stroke 2x for every 10 years
           • Elderly = more at risk for stroke due to decrease of elasticity and increase atherosclerosis
       • Gender
         • Male
           • Higher rate in younger age groups
         • Female
           • Post-menopause
             • Reduction in estrogen + progesterone = increase in total blood cholesterol, LDL, TG, decrease in HDL = higher risk of stroke
               • Older Adults
           • Pregnancy
             • Pre-eclampsia (60% greater risk to have a stroke)
           • Higher rate of mortality in women (45% higher in women) - due to longer lifespan
       • Race
         • African Americans, Aboriginal People and South Asians: higher incidence to Diabetes, HTN --> greater risk for stroke
       • Family History
         • Higher risk if immediate family members had a stroke before 65
     • Stroke Prevention
       • Aspirin
       • Control Blood Pressure
       • Quit smoking
       • Eat Healthy
         • Adhere to Canada's Food guide, decrease salt intake
       • Stay Active
         • 150 minutes of mod-vigorous aerobic exercise/week -- helps maintain blood pressure, diabetes
       • Control Cholesterol
   • Types
     • Intracerebral hemmorhage
       • 15% of strokes, causes 40% of stroke deaths
       • Bleeding directly in the brain causing brain cell death, increased pressure
         • Causes
     • Subarachnoid hemmorhage
       • Bleeding in the subarachnoid space causing increased pressure
         • Causes

3. Emergency Department

   • Acute Care
     • Rehabilitation
       • Discharge
         • Ensures that the same quality and frequency of medical care is provided in order to prevent re-hospitalization.
           • Community-based stroke support groups may allow the patient and the family to learn from others with similar problems and to share their experiences.
       • The goal of a stroke rehabilitation program is to help the patient relearn skills he/she lost. It can help the patient regain independence and improve his/her quality of life
     • Nursing Care
       • Evaluation
         • Restore Family Function
         • achievement of self-care
         • Absence of complications
         • Patient Satisfaction
       • Implementation
         • Acute Interventions (a)
           • BODY SYSTEMS
             • cv
               • • MSK
                   • GU
                     • GI
                       • skin
                         • resp
                           • (a) Treat any airway obstruction and prevent aspiration. Prepare for possible intubation and mechanical ventilation.
                           • (o) Maintain patent airway to promote oxygenation
                         • (a) Patient may have fallen at the time of the attack. Treat any cuts or bruises
                         • (o) Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts. Reposition patient if he/she cannot move certain parts of the body. Maintain skin hygiene
                       • (o) Provide highfiber diet and adequate fluid intake (2 to 3 L/day), unless contraindicated.
                       • (a) treat any gastrointestinal bleeding
                     • (a) Perform intermittent sterile catheterization during the period of loss of sphincter control.
                     • (o) Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
                   • (a) minimize metabolic requirements
                   • (o) provide ROM to maintain joint mobility. This can also prevent edema and muscle atrophy
                 • (o) preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.
                   • Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (e.g., shortness of breath, chest pain, cyanosis, and increasing pulse rate).
                 • (a) restore heart rate, blood pressure and blood flow
               • (a) treat vasospasm and reduce intracranial pressure
               • (o) treat neurological stroke symptoms
           • Drug therapy
             • aspirin
               • tissue plasminogen activator
                 • Clopidogrel
         • Ongoing Interventions (o)
           • Drug Therapy
             • to lower blood pressure
               • ACE inhibitors
                 • beta blockers
                   • calcium channel blockers
                     • diuretics
             • antiplatelets
               • dipyridamole
                 • warfarin
                   • Alteplase
         • Health Promotion
           • Patient education: Teach patient about modifiable risk factors, symptoms of stroke and when to seek medical attention
       • Planning
         • Nursing Goals
           • (1) Improve verbal communication (2) improve physical mobility (3) urinary and bowel continence (4) prevent complications (5) maintenance of skin integrity (6) relief of sensory and perceptual deprivation
         • Client Centred Care
           • Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with health care providers. If the patient agrees, families and carers should also have the opportunity to be involved in decisions about treatment and care Families and carers should be given the information and support they need
             • Be consistent in the schedule, routines, and repetitions; a written schedule, checklists, and audiotapes may help with memory and concentration, and a communication board may be used.
         • Interprofessional Collbaboration
       • Assessment
         • Subjective Data
           • Patient History
             • Diabetes?
               • Heart Diseases?
                 • Previous TIAs?
                   • Medication Use?
           • Body System Changes
             • Changes in bowel/bladder (incontinence/frequency)
             • Muscle weakness, loss of movement or sensation
             • Changes in memory, difficulty speaking, difficulty swallowing
           • Family History
             • Stroke?
               • Hypertension?
                 • Heart Disease?
                   • MI?
                     • Diabetes?
                       • Coagulation Disease?
         • Objective Data
           • Area of the brain
             • Left side
               • Hemiplegia (right side) / Hemiparesis (right side)
                 • Speech/language problems (Aphasia or Dysarthria)
                   • Slow, careful movements
                     • Right side neglect
                       • Memory loss (trouble remembering/learning new things)
             • Right side
               • Hemiplegia (left side) / Hemiparesis (left side)
                 • Left side neglect (unable to see things to the left of the body)
                   • Poor decision making (lack of insight into changes in abchanges in ability since stroke)
                     • Impulsivness / Short attention span
                       • Vision problems (difficulty knowing how far/near an object is to the body)
                         • Facial weakness, unclear speech, problems swallowing
           • Carotid Bruit
           • Hypertension
           • Irregular Respiration
         • Diagnostic Imaging
           • MRI
             • Imaging ischemic lesions, immediately after occurrence in all areas
           • CT
             • Insensitive to ischemia within 24 hours + small infarcts
           • Catheter Based Arteriography/Angiography
             • MR angiography
             • CT angiography
             • Gold Standard
             • Can visualize vascular abnormality + dynamic patterns of collateral flow
           • Essential in diagnosing stroke, differentiating hemorrhage + ischemia
         • Laboratory Assessments
           • No laboratory assessment for stroke, These are used to rule out, other causes of symptoms
             • Complete Blood Count
             • Lipid Profile
             • Blood clotting time
     • Depending on the severity of the incident, patient may or may not need surgery
       • transluminal angioplasty
       • cerebral bypass
       • vessel stenting
       • carotid enarterectomy
   • Obtain patient medical history and perform all assessments. Rule out stroke mimics such as Todd's paralysis, brain neoplasm, or migrainous aura. Maintain a patent airway and minimize metabolic requirements. No foods, fluids, or medications should be given orally until dysphagia screening has been completed

4. Signs and Symptoms

   • Sudden confusion/trouble speaking/understanding others
   • Sudden severe headache with no known cause
   • Sudden trouble walking, dizziness, loss of balance, coordination
   • Sudden trouble seeing in one/both eyes
   • Sudden numbness/weakness of face, arms legs

5. Current Research

   • post-stroke depression and suicide
   • injection of modified adult stem cells
   • medications that limit brain damage and promote repair
   • "re-wiring" the brain

6. By: Karen Chow (209797002) and Rachelle Yang (212508867)

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