Stroke (Brain Attack)

Stroke: is a sudden focal neurological deficit caused by cerebrovascular disease Cerebral circulation is interrupted causing neurological deficits Can be sudden or gradual

Risk Factors: HTN DM Sickle Cell Disease Substance Abuse Cardiac Dysrhythmias aTHErosclerosis Obesity Oral Contraceptives Stress Anticoagulation therapy Ischemia followed by cell death results from severe & prolonged cerebral blood flow obstruction: resulting deficits predict location of stroke. (4) Types of Brain Attacks (Stroke) 1) Transient Ischemic Attack (TIA) is a brief period of neurological deficits that resolve within 24 hours, they are frequent precursors to a permanent stroke. Causes: inflammatory arterial disorders, sickle cell anemia or aTHEsclotic changes in cerebral, jugular and or carotid blood vessels, thrombosis, & emboli 2) Thrombotic: caused by a thrombus (blood clot) occluding a cerebral vesseltend to form on aTHEsceloritic plaque in larger arteries while blood pressure is low ( during rest or sleep) Thrombus occur quickly but progess slowly 3) Embolic: caused by a traveling blood clot, source of clot is elsewhere in bodyhas a sudden onset with immediate symptoms, **If embolus is not absorbed, deficits will be persistent 4) Hemorrhagic: intracranial hemorrhage occurs when blood vessel ruptures Most often occurs in presence of long-term poorly controlled hypertension. Other factors: intracranial aneurysm, embolic CVA, tumor, anticoagulant therapy, liver disease & blood disorders. ** Assessment findings depends upon the area of the brain affected******

Aphasia= loss of ability to use language Agnosia = inability to recognize Hemianopsia= loss in one half of visual field in each eye Dysphagia= difficulty swallowing **Lesions in the cerebral hemisphere result in manifestations on the contralateral side, which is the side of the body OPPOSITE the stroke Right-Brain Damage * Stroke on Right Side Left side: Paralyzed Left sided neglect Spatial perception deficits Deny or minimize problems Short attention span Impulsive, safety issues Impaired Judgment Impaired time concepts Neurological Assessment in Stroke Changes in LOC Signs of increasing intracranial pressure Assessment of Cranial Nerves V, VII, IX, X XII Left-Brain Damage * Stroke of Left Side Right side: Paralyzed Impaired speech/language Impaired R/L discrimination Slow performance (cautious) Aware of deficits, depression Impaired comprehension related Language, math

V = difficulty swallowing VII = facial paralysis IV & X = dysphagia IX = absent Gag reflex XII = impaired tongue movement ** Airway patency is TOP Priority!!!!!! Risk for aspirations!!!!!!

S/S:

Pulse ( slow & bounding) Respirations ( Cheyne-Stokes) BP ( hypertension) Headache, nausea, vomiting Facial drooping Nuchal rigidity Visual changes Ataxia Dysphagia Speech changes Decreased sensation to heat & cold Bowel & bladder dysfunctions Paralysis

Aphasia Expressive: damage occurs in the Brocas area of the frontal brain Understands what is said but is unable to communicate verbally Receptive: injury of the Wernickes area in the temproparietal area Can not understand the spoken and often the written word Global or Mixed: dysfunction occurs in expression and reception

Diagnostic Studies
CT scan : can decipher between ischemic & hemorrhage CT Angiography ( CTA) : blood vessels MRI : determine extent of brain injury Magnetic Resonance Angiography(MRA): arterial-vascular lesions & blockage Carotid endarterectomy: performed to prevent impending cerebral infarction by reroute plaque ***** SWALLOW STUDY should be done prior to resuming diet**** Teachings should be focused on prevention of stroke

Prevention of Stroke
Reduce sodium & salt intake Maintain normal body weight Maintain normal BP

Increase exercise Avoid smoking Limit alcohol consumption Diet that is low in saturated fats, total fats, & dietary cholesterol, High in fruits & vegetables

SOME KEY POINTS TO REMEMBER: A stroke is considered a family disease-effects the family emotionally, financially, & socially. **Nursing Interventions : focus on coping (provide info & emotional support) During an Ischemic stroke tPA must be administed within 3 to 4.5 hours of the onset of clinical signs. TIMING is the single most important factor!! **** tPA can not be given if patient has a hx of GI bleeds, or major surgery within 14 days. ( Ischemic Stroke only) Elevated BP is common after a STROKE and is a protective response to maintain cerebral perfusion!!!!!!! * Bring down BP gradually over time is best! Thrombotic Stroke: #1 common : ( accounts for 60% of strokes) Blood clot * More common in HTN & Diabetes Subarachnoid Hemorrhage is described as the worst headache of ones life Intracerebral Hemorrhage #2 common : bleeding within the brain caused by a ruptured vessel (10% of all stroke) More common in HTN, Trauma, TIAs 1/3 will never have another episode, 1/3 will have another episode, 1/3 will have a stroke * Antiplatelet agents are used to treat TIAs******

Stroke manifestations related to artery involvement

Anterior cerebral: motor & sensory deficits, rigidity & gait, fine, touch Middle cerebral: dominant side, aphasia, motor & sensory Non-dominant side: neglect motor & sensory deficit (Hemianopsia) Posterior cerebral: hemianopsia- visual hallucinations, dizziness, pain,

Vertebral: cranial nerve deficits, diplopia, dizziness, nausea vomiting, coma, dysphagia

Nursing Interventions:
Health Promotion in people who have Risk Factors- Nursing measures to reduce risk factors. Education about HTN (uncontrolled HTN is Primary cause of STROKE) If diabetic- keep tight control If A-fib- an anticoagulant such as Warfarin or aspirin may be given to prevent the risk of stroke Respiratory: Priority is atelectasis & pneumonia (advancing age & immobility) Airway patency #1 Risk for aspiration pneumonia is high ( due to dysphagia) Neurological: monitor patients neuro status Primary clinical assessment tool is: NIH Stroke Scale (predicts both short & long term outcome of stroke patients) Additional assessment tools: mental status, pupillary responses & estremity movement & strength Cardiovascular: Nursing goals are aimed at maintain homeostatis Many patients with stroke have decreased cardiac reserves secondary to cardiac disease. Cardiac efficiency is further compromised by fluid retention, overhydration, dehydration, and or blood pressure issues. Priority is monitor vitals, I & Os , cardiac rhythms, lung sounds & heart sounds Musculoskeletal: Maintain optimal function Prevention of joint contractures & muscle atrophy Range of Motion exercises & positioning are important Integumentary: Skin breakdown is huge due to loss of sensation, decreased circulation, & immobility Pressure relief from repositioning Special mattress Good skin hygiene Early mobility GI : most common bowel problem for the patient is constipation Stool softeners prophylactically The patient who has liquid stool needs to be checked for stool impaction.

Physical activity promotes bowel function

Urinary: poor bladder control resulting in incontinence Promote normal bladder function & avoid indwelling catheters Nutrition: Patients may require IV infusion to maintain fluid & electrolyte ad well as enteral or parenteral nutrition support The first oral feeding should be approached carefully because the gag reflex may be impaired due to dysphagia. Priority Nursing Diagnoses: Impaired physical mobility Self-care deficit Impaired verbal communication