BRAIN ATTACKS AKA: CVAs

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BRAIN ATTACKSAKA CVAs
Adult Health Summer Session 2004
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INTRODUCTION / DEFINITION

• Other terms
• Stroke
• Cerebral Vascular Accident
• Condition in which neurologic deficits result
  from decreased blood flow to the brain
• Incidence
• 3rd Leading cause of death in North America
• 600,000 (approx.) CVA victims per year
• At least 80 of CVA victims survive
• Many survivors are left with functional
  impairments.

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CLASSIFICATIONS / CATEGORIES

• Ischemic
• Blood supply to part of the brain is suddently
  interrupted by
• Thrombus
• Embolus
• TIAs (transient ishemic attack)
• Hemorrhagic
• Blood vessel breaks and spills blood into the
  brain

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RISK FACTORS

• TIAs
• Hypertension
• Diabetes mellitus
• Substance abuse
• Atherosclerosis
• Obesity
• Sedentary life-style
• Hyperlipidemia
• Atrial fibrillation
• Oral contraceptives

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Cerebral Blood Flow
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Stroke

• Pathophysiology
• Ischemia
• Hypoxia
• Death

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Types of Stroke
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ISCHEMIC CVAsTIAs

• Localized cerebral ischemia which causes
  temporary neurologic deficits
• Considered to be a warning signal for ischemic
  CVAs

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TIAs (cont.)

• Causes
• Inflammatory artery disorders
• Sickle cell anemia
• Atherosclerotic changes in cerebral vessels
• Thrombosis
• Emboli
• Subclavian Steal Syndrome

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TIAs (cont.)

• Manifestations
• Depend upon location and size of cerebral vessel
  involve
• Sudden onset with disappearance within minutes,
  hours or a couple of days
• Contralateral numbness or weakness of hand,
  forearm, corner of mouth (middle cerebral artery)
• Aphasia
• Visual disturbances such as blurring (posterior
  cerebral artery)

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THROMBOTIC CVAs

• Definition
• Occlusion of a large cerebral vessel by a
  thrombus
• Target Population
• Often seen in older people who are resting or
  sleeping

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THROMBOTIC CVAs (cont.)

• Patho
• Clots tend to form in
• Large arteries that bifurcate and . . .
• Narrowed lumens as a result of atherosclerotic
  plaque
• Common locations
• Internal carotid artery
• Vertebral arteries
• Junction of vertebral and basilar arteries

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THROMBOTIC CVAs (cont.)

• Lacunar strokes
• Thrombotic strokes which affect smaller cerebral
  vessels and leave small cavities or lakes
• Manitestations
• Occur rapidly but usually progress slowly
• May start as TIA and worsen (stroke-in-evolution
  )
• Maximum neurological damage usually reached in 3
  days (completed stroke)
• Affected area is edematous may become necrotic

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EMBOLIC CVAs

• Definition
• Pathophysiology
• Most frequent site bifurcation of vessels
  (carotid and middle cerebral arteries)
• Most embolic CVAs originate from thrombi in the
  left chamber of the heart during atrial
  fibrillation.
• Other sources of emboli
• Target Population

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HEMORRHAGIC CVAs

• Defined as intracranial hemorrhage
• Occur when cerebral blood vessel ruptures

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HEMORRHAGIC CVAs (cont.)

• RISK FACTORS
• Sustained increase in BP
• Intracranial aneurysms
• Trauma
• Erosion of blood vessels by tumors
• Arteriovenous malformations
• Anticoagulant therapy
• Blood disorders

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HEMORRHAGIC CVAs (cont.)

• Pathophysiology
• Blood vessel ruptures and blood enters tissues,
  cerebral ventricles or subarachnoid space. This
  leads to . . .
• Compression of adjacent tissues causing . . .
• Blood vessel spasms and cerebral edema
• Blood in ventricles or subarachnoid space
  irritates meninges brain tissue causing . . .
• Inflammatory reaction and . .
• Impairing absorption and circulation of CSF

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HEMORRHAGIC CVAs (cont.)

• Prognosis
• Manifestations
• Onset of S/Sx is rapid unless bleed is a slow
  leak.
• Depend upon location of hemorrhage
• Vomiting
• Headache
• Seizures
• Hemiplegia
• S/Sx of increased intracranial pressure
• LOC (loss of consciousness)

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TYPICAL SIGNS/SYMPTOMS OF CVAs

• Focal
• Weakness
• Paralysis
• Sensory loss
• Language disorders
• Brocas
• Wernickes
• Reflex changes
• Visual changes

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TYPICAL SIGNS/SYMPTOMS OF CVAs

• Generalized
• Headache
• Vomiting
• Confusion / Disorientation
• Seizures
• Coma
• ? BP
• Memory impairment other mental changes
• Fever
• Cardiac abnormalities
• Nuchal rigidity
• Sclerosis of peripheral vessels retinal vessels

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Assessment

• History
• Activity when the stroke began
• Progression of the symptoms
• Onset of the stroke
• Severity of the symptoms
• Observe clients level of consciousness
• Assess intellectual or memory impariment

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Assessment (contd)

• Difficulty with speech or hearing
• Presence of any sensory or motor changes
• Visual problems
• Problems with balance or gait
• Changes in reading or writing ability
• Clients medical history
• List of current medications

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Physical Assessment

• Neurological Assessment
• Cognitive Changes
• Denial of illness
• Neglect syndrome or hemiparesis
• Spatial and proprioceptive dysfunction
• Impairment of memory, judgement, problem-solving
  and decision making
• Decreased ability to concentrate and attend to
  tasks.

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Neurological Assessment

• Motor Changes
• Hemiplegia or hemiparesis
• Muscle tone
• Range of motion (ROM)
• Assess proprioception
• Loss of inhibitory nervous control from the
  cerebral cortex

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Neurological Assessment (contd)

• Sensory Changes
• Response to touch and painful stimuli
• Ability to write and comprehend reading material
• Ability to use an object correctly (agnosia)
• Ability to carry out a purposeful motor activity
  (apraxia)
• Neglect syndrome
• Visual ability

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Neurological Assessment (contd)

• Cranial Nerve Intactness
• Ability to chew (CN-V)
• Ability to swallow (CN-IX X)
• Facial paralysis (CN-VII)
• Absent gag reflex (CN-IX)
• Impaired tongue movement (CN- XII)

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Cardiovascular Assessment

• Heart murmur
• Dysrhythmias
• Hypertension

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Psychosocial Assessment

• Clients reaction to illness
• Coping mechanisms or personality changes
• Financial status and occupation
• Emotional lability

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Laboratory Assessment

• Elevated hemoglobin and hematocrit
• Elevated white blood cell count (WBC)
• PT and PTT (coagulation profile)
• Cerebrospinal fluid (CSF) analysis

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Radiographic Assessment

• CT scan of the head
• MRI of the head
• MRA of the head
• Angiography

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Other Diagnostic Assessment

• Carotid artery ultrasound
• EKG
• Holter monitor test
• Cardiac enzymes
• Echocardiogram

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Nursing Diagnosis

• Ineffective Tissue Perfusion (Cerebral)
• Impaired Physical Mobility and Self-Care Deficit
• Disturbed Sensory Perception
• Unilateral Neglect
• Impaired Verbal Communication
• Impaired Swallowing
• Total Urinary Incontinence and Bowel Incontinence

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Management

• Nonsurgical Management
• Neurological checks every four hours using the
  Glasgow Coma Scale (GCS)

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Additional Management Measures

• Avoid clustering of nursing procedures
• Quiet environment with lights lowered
• Monitor vital signs at least every four hours
• Cardiac monitor
• Cardiac assessment
• Hemodynamic monitoring

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Drug Therapy

• Thrombolytic Therapy - (TPA)
• Anticoagulant Therapy (Aspirin, Heparin,
  Lovenox, Coumadin)
• Antiplatelet Therapy (Ticlid, Plavix,
  Persantine)
• Other drugs (antiepileptic and calcium channel
  blockers)

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Surgical Management

• Carotid endarterectomy
• Extracranial-intracranial bypass
• Craniotomy (cerebral aneurysms and intracranial
  bleeding)
• Interventional therapy (arteriovenous
  malformation) (AVM)

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AHA Stroke Chain of Survival

• Step 1 Detection
• Step 2 Dispatch
• Step 3 Delivery
• Step 4 Door
• Step 5 Data
• Step 6 Decision
• Step 7 - Drug

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Nursing Interventions

• Maintain patent airway (suction prn)
• Frequent assessments (neuro checks and vital
  signs)
• Close observation to signs of progression of CVA
• LOC changes
• Increase loss of motor or sensory function
• Progressive aphasia
• Increase respiratory difficulty

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Nursing Interventions (contd)

• Ensure fluid and electrolyte balance
• Maintain proper positioning and body alignment
• Maintain adequate elimination
• Include significant others in plan of care
• Promote restful, quiet environment
• Administer meds as ordered

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Nursing Interventions (contd)

• Observe for visual and perceptual defects
• Prevent eye irritation
• Mouth care every three to four hours
• Skin Care
• Prevent intellectual regression.
• Encourage participation in therapy and reward
  their improvements

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Discharge Teaching

• Medication Schedule
• Mobility transfer skills
• Communication skills
• Safety precautions
• Dietary management
• Activity levels
• Self-care skills

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Summary

• BECOME STROKE SMART
• Reduce Your Risk
• Recognition of the Symptoms
• Responding Quickly and Appropriately