Neurovascular

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Stroke-CVA(Cardiovascular Accident)=Brain Attack
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Stroke-CVA(Cardiovascular Accident)=Brain Attack
Sudden loss of functioning resulting from a disruption of the blood supply to a part of the brain.
Risk Factors For Stroke
Age-middle age to old age
Race-African Americans
Modifiable Risk Factors
-Hypertension
-Cardiovascular Disease
-Elevated Choesterol/hematocrit
-Obesity
-Diabetes
Categories of Stroke
-Ischemic Stroke(80-85%)
-Hemorrhagic(15-20%)
Ischemic Stroke
disruption of the blood supply due to an obstruction, usually a thrombus or embolus, that causes deprivation of blood supply to brain tissue.
Signs of Stroke
Image: Signs of Stroke
Types of Ischemic Stroke
•Large artery thrombosis
•Small penetrating artery thrombosis (lacunar)
•Cardiogenic embolic
•Cryptogenic
•Other
Thrombotic Strokes(occlusive)
Occlusion of a large cerebral vessel by a thrombus, often seen in people who are resting or sleeping.
Embolic Strokes(occlusive)
-Most frequent site=bifurcation(branching) of vessels(carotid and middle cerebral arteries)
*embolus plug
-Most embolic strokes originate from the thrombi in the left ventricle of the heart durring atrial fibrillation.
-Valvular heart disease
-Occurs in younger patients
-Usually occurs while the client is awake and active
Occlusive Stroke
Image: Occlusive Stroke
Transient Ischemic Stroke(TIA)Temproaory neurologic deficit resulting from a temporary impairment of blood flow. -Most only last 15 mins -Warning sign for ischemic brain attacksManifestations of Ischemic Stroke-Numbness or weakness of face, arm, or leg especially on one side -Confusion or change in mental status -Trouble speaking or understanding speech -Difficulty in walking, dizziness, or loss of balance or coordination -Sudden severe headache Perceptual disturbances -Difficulty swallowingMotor changes w/TIAHemiplegia Hemiparesis Hypotonia (flaccid paralysis) Hypertonia (spastic paralysis)Sensory Changes w/TIAAgnosia Apraxia Neglect syndrome Ptosis Homonymous hemianopsiaAphasiainability to use or understand language (spoken or written) because of a brain lesionCognitive Changes w/TIAAphasia Dysarthria Impaired verbal communicationImpaired verbal communication w/TIA-Language disorders involve comprehension and expression of written and spoken words. -Expressive aphasia, result of damage in Broca's area of the brain. -Receptive (Wernicke's or sensory) aphasia, due to injury in the temporoparietal area.Unilateral Neglect-Commonly seen with right cerebral stroke Teach patient to: -observe safety measures -touch and use both sides of the body -use scanning technique of turning the head from side to side to expand the visual field.Diagnostic tests-TIA-CT scan (non-contrast)-differentiates between ischemic and hemorrhagic -Computed tomographic angiography (CTA)-visulaization of the blood vessels, detects intracranial and extracranial occlusions -Transcranial Doppler-non-invasive detects microemboli and vasospasms -Cerebral angiography-invasive(catheter), identifies occlusions atheroscleretic plaque and malformation of vessels -MRI (brain,neck)-determines the extent of the brain injuryPreventative Treatment/Secondary Prevention of Stroke-healthy diet -exercise -carotid endarterectomy -anticoagulant therapy -antiplatelet therapy(aspirin,plavix,ticlid) -statins -anit-hypertensive medications -transluminal angioplastySurgical intervention for TIA-carotid angioplasty -carotid endarterectomyCarotid Angioplastyballoon tipped catheter threaded to site of blockage and balloon opens and flattens plaque or stent is placedCarotid EndarterectomyMedical Management During Acute Phase of Stroke-Prompt diagnosis and treatment -Thrombolytic Therapy *Tissue plasminogen activator(3 hours) *IV dosage and administration *Patient monitoring *Side Effects:potential bleedingNurse Management During Acute Phase of Stroke-Ensure patent airway -Maintain adequate oxygenation with O2 -Elevate HOB 30 degrees if no symptoms of shock or injury -Monitor vital signs and neurologic status, (Glasgow coma scale), motor and sensory function, pupil size and reactivity, SaO2 -Monitor intracranial pressure(probe in brain) -Frequent/ongoing monitoring of all systems -Monitor lung sounds for crackles and rhonchiDrug Therapy:StrokeThrombolytic therapy(tPA-clot disslover) Anticoagulants Lorazepam and other antiepileptic drugs Calcium channel blockers9blood pressure) Stool softeners(no straining) Analgesic for pain Antianxiety drugsThrombolytic therapy(tPA-clot disslover)Patient Teaching-soft toothbrush,monitor signs of bleeding, use electric razors, no aspirin or NSAID'sTherapy for Patients with Ischemic Stroke with no tPA-Administration of osmotic diuretic-Mannitol -Maintain partial pressure of carbon dioxide within 30-35mm/Hg -Elevation of HOB -Intubation with endotracheal tube for patent airway -Frequent neurologic assessment -Continuous hemodynamic monitoringMajor Goals after Stroke-improved mobility -avoidance of shoulder pain -achievement of self-care -relief of sensory and perceptual deprivation -prevention of aspiration -contnence of bowel and bladder -improved thought processes -improved form of communicationWays to improve mobility and prevent joint deformities in stroke patients:-trochanter rollStroke InterventionEncourage the patient with visual field loss to turn his head and look to side.Hemorrhagic Stroke-about 15% of all strokes -Caused by bleeding into brain tissues, the ventricles, or subarachnoid spaceTypes of Hemorrhagic Stroke• Intracerebral hemorrhage •Subarachnoid -caused by rupture of a cerebral aneurysm •Arteriovenous malformations -trauma, cocaine abuseHemorrhagic CVA-most deadly -most lasting damageHemorrhagic Stroke"Intracranial Hemorrhage"Patho of Hemorrhagic Stroke-Ruptured aneurysm -Arterio-venous malformation -Severe hypertensionManifestations of Hemorrhagic StrokeOnset is rapid unless bleed is a slow leak. Similar to ischemic stroke Vomi;ng -projec;le Headache (sudden severe) Early and sudden changes in level of consciousness (LOC)Medical Management of Hemorrhagic StrokePreven;on: control hypertension (HTN) Diagnosis: CT scan, cerebral angiography, lumbar puncture if CT is nega;ve, ICP not elevated Suppor;ve care Bed rest with seda;on Oxygen Treatment of vasospasm, increased ICP, HTN, poten;al seizures, preven;on of further bleeding -Supine position for monitoringSurgical Management of Hemorrhagic Stroke-Extracranial/intracranial bypassCerebral Aneurysm Precaution-Monitor respiratory status and oxygenation -Ongoing neurologic assessment -Monitor ICP -Monitor in the ICU patients with (intracerebral or subarachnoid hemorrhage -Report all changes immediately -Monitor fluid balances and laboratory data -Monitor for potential complicationsComplications-Cerebral Aneurysm-Vasospasm -Seizures -Hydrocephalus -Rebleeding -HyponatremiaICP Monitoring-Not on a monitor- pt can lay flat -Monitor-15-30%Care Plan-Cerebral Aneurysm-Absolute bed rest -HOB elevated 30 degrees -Avoid all activity that may increase ICP or BP -Exhale through the mouth when voiding or defecatingHome Care and Teaching for patient recovering from stroke:-Prevention, health promotion,follow-up care -Identify signs/symptoms of complications -Medication teaching -Safety measures -Use of adaptive devices for ADLs -Nutrition -Elimination -Exercise and activates -Socialization,support groups, resourcesWhich intervention would be best to prevent shoulder subluxation?Put the affected arm in a slingParkinson's Disease-decrease in dopamine, neurological disease -Four Cardinal Signs= *Tremors *Ridgidity *Bradykinesia(overall slowing of active movement) *Postural instabilityParkinson's Assessment-Fatigue -Problems w/manual dexterity -Changes in voluntary movement -Excessive perspiration -Orthostatic hypotensionParkinson's Clinical Manifestation's-Mask like expression -Decreased blinking -Staring expression -Uncontrolled drooling -Speech changes=Soft,low monotone -Handwriting changes=Micrographia(small) -Depression -Mental changes=cognitive and perceptual memory deficits, may be a feature of PD or side effect of the med'sAnticholinergic Drugs-Benztropine mesylate(Cogentin) *Reduces tremors Contraindications:Colitis, GI obstructionAntiparkinsonian-Levadopa(Larodopa) *Relieves tremors -Levodopa+carbidopa(sinemet) Side effects: involuntary movements,blurred vision, bad taste Patient teaching: avoid rising fast to avoid orthostatic hypotension, admiister with protein, dont stop taking abruptly, urine may darken, do not crushAntiviral-amantadine(Symmertrel) -release dopamine -Side Effects: Mood changes and confusionMonoamine oxidase type B inhibitors-slows progression of the disease -inhibits dopamine breakdown -no tyramine foods=could cause orthostatic hypertensionCathechol O-methyltransferase Inhibitors-Tolcapone(Tasmar) -Entacapone(Comtan) -Decreases motor fluctuations in advanced PD -Increase in fiber and fluid to prevent constipation, take with food, wear dark glasses avoid bright sunlight, regular eye examsNursing Interventions for PD-Improve mobility -Self-care -Bowel elimination -Nutrition -Enhanced swallowing -Communication -Psychosocial support -Teach to face listener -Speak in short sentencesPromoting Home and Community Based Care-Assess respiratory and neurological status -Maintain adequate diet -Prevent contractures -Administer medications -Promote daily ambulation -Promote measures to prevent falls -Change patient's position slowly -Provide active and passive ROM -Assist with ADL's -Reinforce independenceComplications of PD-Urinary tract infection -Respiratory tract infection -Contractures -Depression -Muscle RidgityAmytropic Lateral Sclerosis Medication: Riluzole(Rilutek)Glutamate antagonist used for treating ALS. Action: inhibits the release of presynaptic glutamic acid in the CNS. Reduces the degeneration of neurons that occur in ALS. Contraindicated in pregnancy and/or sensitivity to the drug Adverse effects: Generalized effect: Headache, back pain, malaise, weight loss, flu-like symptoms, peripheral edema, lack or loss of strength Respiratory: increased cough, apnea, dyspnea CNS: Dizziness, circumoral paresthesia, insomnia CV: Hypertension, tachycardia GI: nausea, vomiting, anorexia, abd. pain, diarrhea Skin: pruritis, exfoliative dermatitis Lab tests: Liver function before and during course of treatment, ALT/ALT every month for first 3 months, every 3 months for remainder of first year Monitor Hct and Hcb, blood chemistry, alkaline phosphatase periodically, WBC if fever develops.Amyotrophic Lateral Sclerosis "Lou Gehrig's Disease"-Cause: Unknown -Possible Autoimmune Disease -Muscle weakness or stiffness of upper extremity-early stage -Progressive wasting and paralysis of muscles -Tongue atrophy and dysarthria -Dysphagia and Dyspnea occur -Mental Function Remains IntactTreatment of ALS-Rilutek (riluzole) slows deterioration of motor neurons (only drug) -Baclofen (lioresal) -Valium (diazepam) Dantrium (dantrolene sodium)-muscle relaxant -Exercise and mobility program -Management of swallowing difficulties -Respiratory supportMedium Survival Time of ALS25 monthsDiagnosis of ALS-Electromyography -Spinal tap -Blood and urine studies -MRI and X-rays -Myelogram of cervical spine -24-hour urine collection for heavy metals -Muscle biopsy studiesManagement of ALS-Respiratory therapy -Speech therapy -Physical therapy -Occupational therapy -Nutrition enteral feeding -End of life issues-hospice -Social worker/support groupRilutek(riluzole)Monitor AST ad ALT for the first three months Report Elevated temp. to the physcian Class:Benzothiazole Treatment of Amyotrophic Lateral Sclerosis -Slows progress of ALS -Dose 50 mg PO every 12 hours on an empty stomach, I hour before or 2 hours after meals -Common side effects: headache, hypertension, nausea, weight loss, increased cough -Teach patient to report fever to healthcare provider, stop smoking, alcohol use -Labs: liver function tests, CBCLow Back PainDermatomes, Sciatic Nerve damage Assessment:continuous acute pain, altered gait, paresthesia(along affected dermatomes)Non-surgical management of Back Pain-Firm mattress -Exercise -Drug therapy -Heat/ice therapy -Diet therappy(weight loss) -Heat 20-30 mins four times a daySurgical Management-Diskectomy-removal of part of the disk -Laminectomy-removal of part of the lamina -Spinal fusion-fusion of vertebrae -Minimally invasive lumbar proceduresPostoperative Care for Back Pain Surgery-Prevention and assessment of complications -Vital Signs -Neurologic Assessment -Pain Control(likely have a PCA) -Ability to voidMultiple Sclerosis(MS)disease of the central nervous system characterized by the demyelination (deterioration of the myelin sheath) of nerve fibers, with episodes of neurologic dysfunction (exacerbation) followed by recovery (remission)Major Types of MSRelapsing-remitting-most common, attacks followed by remission or reovery Progressive -relapsing-least common, relapses or attacks occur periodically, symptoms continue and are progressive between relapses Primary Progressive-symptoms continually worsen Secondary Progressive-progressive relapsing continuous,disabling progresses and has exacerbationsMSusually starts in the lower extremities, high protein diet neededScotomaspatchy blindnessAssessment Findings MS-Fatigue -Weakness -Parethesia -Total or partial loss of vision in one eye -Unsteady gait -Muscle spasticity -Diplopia -Blurred vision -Nystagmus -Scotomas -Signs of facial and trigeminal nerve involvement -Bowel/bladder dysfunction -Retention/incontinence -Lessening or absence of touchCharcot's Triad(seen in MS after several years)-Intention Tremors(occur when a patient is trying to perform a task) -Scanning Speech(pauses between words and symbols) -Nystagmus(uncontrollable movements of eye)Late Assessment findings of MSPartial or total paralysis of lower extremities Use of upper extremi;es may be severely limited Small percent have gross loss of memory Crippling joint contractures Muscle atrophy LhermiKe's SignDrugs for MSBiologic response modifiers Steroids Antispasmodic drugs ImmunosuppressiveSide effect of Interferon(Beta1)FLU SYMPTOMSGuillain-Barré Syndrome (GBS)-Peripheral Nerve Disorder -Autoimmune disorder where the body creates antibodies against its own tissue -Common cause of rapidly acquired paralysis"Rapid onset" -It is reversible -Rapidly progressive disorderS/S of Guillain-Barré Syndrome-Muscle weakness of lower extremities -Paresthesia and pain - hands and feet -Weakness/paralysis starting in legs (generally) "ascending disease" -Ascending progressive paralysis (more common) -Unsteady walking or inability to walk -Difficulty with speaking, chewing, swallowing -Severe lower back pain -Bradycardia/ hypotension -Loss of bladder/ bowel control -Difficulty breathing -Respiratory failure(major cause of death)Diagnostic Tests of GBS-EMG(electromyography-shows slow conduction in affected areas -Elevated CSF(cerebral spinal fluid) protein levels increase 7-10 days after onset -Increase in white blood cells in early stage -Elevated Serum levels due to inflammationNursing Interventions GBS-Maintain adequate respiratory function -Elevate head of bed/ prevent aspiration -Suction (PRN) -Prevent deep vein thrombosis -Prevent pressure ulcers -Cardiac monitor -High calorie diet -Develop communica;on system -Administer stool softner(colace)Treatment of GBS-Ongoing assessment of respiratory function, vitals signs, and cardiac status -Monitor changes in vital capacity -IV immunoglobulin -Plasmopheresis -Electrocardiogram -IV fluids, force fluids, manage hypertensionComplications of GBS-Respiratory failure -Autonomic dysfunction -DVT and Pulmonary embolism(lovenox, SCD's,, ROM exercises, adequate hydration) -Constipation/ urinary retention -Impaired Physical Mobility -Range of motion exercises -Turn and reposition frequently -Prevent deep vein thrombosis -Assist pa;ent to perform ADLsGBSmost patients recover in one year