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129 terms

CVA & TIA

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Define Cerebral Vascular Accident (CVA)
Sudden loss of brain function resulting from a disruption of the normal blood supply to a part of the brain.
Define TIA
where there is mild ischemia & actual improvement between episodes & later progress to full-blown CVA. Vessels are narrowed or sometimes spasm & pt. has transient symptoms
Leading cause for adult long term disability
*Cause of death rank: 4th
*Stroke is the leading cause for adult long term disability.
FAST stands for?
Our job as nurses -- educate people about S&S: Call "911;" Get help fast! (Face, Arm, Speech, Time)
Brain Attack
term from American Stroke Association (ASA) to get lay public to recognize that, like a heart attack, best outcome will be achieved if person gets help quickly!
Treatment for hemorrhagic CVA
Management of hypertension with oral and IV agents to maintain systolic BP less than 160 mm Hg and seizure prophylaxis in acuter preiod
What causes an ischemic CVA
Caused by occlusion of a cerebral artery from either a thrombus (stationary clot) or embolus (moving clot)
Diagnosis of a TIA.
CT or MRI
Give signs & symptoms of a TIA
depends upon which blood vessels are involved.
carotid system - affects vision, sensation, speaking
vertebrobasilar - ears, eyes, ptosis,diploia, vertigo, tinnitus
Transient Ischemic attack
Sometimes referred to as a mini-stroke, temporary interruption in the blood supply to the brain.
dysphasia
difficulty in speaking - general term
Aphasia receptive
inability to use or comprehend language either partially or completely (Wernicke's Aphasia) inability to understand spoken or written word, thus , can't follow commands, May use "jargon" or meaningless words not in context and they don't realize they're not making sense
Aphasia expressive
(Broca's Aphasia) incorrect words are spoken pt. becomes very frustrated, becuae they hear the wrong words come out
dysarthria
difficulty in articulation & pronunciation (cause is loss of motor function of tongue & muscles of speech), A speech disorder characterized by difficulty speaking properly, due to paralysis of the muscles of speech.
perseveration
repetition of word, phrase, action inappropriately
anomia
inability to name objects even through usage is understood
agraphia
difficulty writing
apraxia
Oral motor muscles loose function, unable to speak with meaningfull utterances. DISORDER OF MOTOR PLANNING. LOSS OF LEARNED PURPOSEFUL MOVEMENTS.
agnosia
-The inability to understand and interpret the significance of sensory input
homonymous hemianopsia
loss of half of the visual field from damage to optic tract or occipital lobe most often occurs as a homonymous---blindness in same side of both eyes (eg Nasal field of Rt. eye & temporal field of left = LEFT HH). Client has to turn head toscan visual field
these fibers cross at the optic chiasm---
*LEFT HH means that the injury is to the right optic tract
*RIGHT HH means that injury is to left optic tract
bi-temporal hemianopsia
loss of vision in the temporal half of both fields:"Tunnerl Vision"--due to an injury at the optic chiasm---involves only fibers that are crossing over to the opposite side
diplopia
double vision
Resources utilized in transitioning a CVA client from hospital or rehab unit to home.
critical factor in discharge planning is pt's level of independance in performing ADLs
Concepts of stroke prevention
Modifiable concepts:
htn, a-fib, DM, poor diet, cholesterol
PVD, smoking, obesity
Discuss the importance of monitoring the Prothrombin Time (PT), Partial Thromboplastin Time (PTT), and International Normalized Ratio (INR) as a part of the treatment plan for a CVA client.
CVA patients are on anticoagulants to prevent future strokes by preventing the formation of a thrombus in the first place. These valuses need to be checked to have a balance between clot prevention and bleeding due to lack of clotting factors
Partial Thromboplastin Time (PTT)
Measures intrinsic clotting time, used to monitor heparin terapy; APTT range for heparin therapy is 1.5 - 2.5 times the normal value
Prothrombin Time (PT)
A test used to evaluate the extrinisic pathway; also used to monitor coumadin (warfin) therapy.
International Normalized Ratio (INR)
INR; a more consistant measure of coagulation for coagulation studies regardless of thromboplastin reagent used. Accepted from World Health Organization; makes results not dependent upon reagent used.
Determine when to notify the physician of a CVA patient's elevated blood pressure.
When BP is 220/120 or greater
Nursing interventions for CVA client with visual/perceptual deficits
approach patient from non-affected side, break tasks into small steps, develop structure, amy use eye patch for diplopia (alternate eye patch q4hr)
Nursing interventions for CVA client with self-care deficits
good skin care, promote elimination by offereing bedpan or urinal every 2 hours
Describe signs of increasing intracranial pressure.
causes brain compression and reduced cerebral blood flow.
*LOC - partial consciousness or unconsciousness
*Change in VS - pressure on thalamus, hypothalamus, pons, medulla causing cushing's triad
*ocular signs - compression of cranail nerve III, dialation of pupil on same side of injury, sluggish, ptosis of eyelid
*decrease motor function - contralateral hemiparesis or hemiplegia
*headache - continuous but gets orse
*vomiting -
Define & discuss neglect/extinction and identify appropriate nursing interventions.
put brightly colored object on affected limb to help re-integrate affected side into body image
*encourage pt. to touch affected side
*teach pt. to visually check position of limb
right-sided problems
caused by stroke on left side of brain, right hemiplegia, aphasis, impaired right/left discrimination, slow performance, cautious, aware of deficits, depression, anxiety, impaired comprehension related to language,math
left-sided problems
caused by stroke on right side of brain, left hemiplegia, left side neglect, spatial-perceptual deficits, deny or minimize problems, rapid performance, short attention span, impulsive, impaired judgement, impaired time concepts, safety problem
Expected outcome for CVA
1. maintenance of life
2. prevention of further neurological damage
3. promotion of recovery
4. restoration of prior performance
5.adaptation to visual, spatial, language, momory problems
6. prevention of injury & complications from CVA
Contributing factors for CVA
nonmodifiable:
*advance age above 65
*male
*latino or african american
*history of stroke
Modifiable
*HTN
*A-fib
*Diabetes
*hypercholesterolemia
*poor diet
*obesity
*diet
*smoking
*peripheral vasuclar disease (PVD)
Treatment for ischemic CVA
The use of tPA within the first 4.5 hours of onset of symptoms
What does frontal lobe control?
*motivation, emotions, social behavior
*attention, judgement, problem solving, desicion-making
*expressive language (Broca's area), motor function of speech
*motor integration; voluntary movement
Broca's aphasia
An aphasia associated with damage to the Broca's area of the brain, demonstrated by the impairment in producing understandable speech.
What does parietal lobe control?
*touch
*awareness of spatial relations (body consciousness, 3-dimensional perception
*singing, playing musical instruments, processin non-verbal cues (singing is primarily a right brain function & speech a left)
*taste sensation
*academic skills
What does temporal lobe control?
*memory
*language comprehension
*receptive language (Wernicke's Center)
*interpretation of complex sounds, allows for processing of words into coherent thought &
*recognition of printed words into ideas
*learning, memory, understanding speech
*musical awareness
*sequencing skills
Wernicke's Center
Speech Comprehension Center
What does the occipital lobe control?
Primary visual center receiving stimuli from retina, where fibers from other lobes all synapse allows for processing complex thoughts.
An area at the back of each cerebral hemisphere that is the primary receiving area for visual information.
dysarthria
Difficult and defective speech due to a dysfunction of the muscles used for speech
ipsilateral control
situated on same side of stroke, example right cerebellum controls right side balance & motor coordination
circle of willis
A structure at the base of the brain that is formed by the joining of the carotid and basilar arteries.
Where do strokes typically originate?
middle cerebral arteries MCA
Name two types of aphasia.
Broca's aphasia - expressive
Wernicke's aphasia - receptive
hemianopsia
loss of half of the visual field from damage to optic tract or occipital lobe
Name two types of hemianopsia.
homonymous - blindness in same side of both eyes
bitemporal-loss of vision in the temporal half of both fields
Name three surgical procedures to treat occlusive strokes or TIAs
carotid endarterectomy
superior temporal artery-middle cerebral artery (STA-MCA) anastomosis
carotid endarterectomy
the surgical removal of the inner lining of the carotid artery & re-establish blood flow leading to the brain.
What type of patient usually has a carotid endarterectomy?
Patients who have had warning signs of an impending CVA.
carotid angioplasty
a surgical option for treating cerebral stenosis by passing a balloon catheter and/or stent through blocked artery in the pt arm/leg to dialate and improve circulation.
ataxia
Double vision., Inability to coordinate the muscles in the execution of voluntary movement
ticlid
Ticlopidine Antiplatelet Used mainly for stroke related risk reductio
anastomosis
A surgical connection between two hollow or tubular structures
transient weakness
weakness is TEMPORARY or SHORT-LIVED; FLEETING
Superior temporal artery-middle cerebral artery anastomosis
bypass blocked artery by making a graft and anastomosing the two arteries, sets up a collateral circulation
Name 5 causes of hemorrhagic stroke.
1. HTN
2. ruptured aneurysm
3. Arteriovenous malformation (AVM)
4. Hypocoagulation of blood
5. ETOH consumption
ETOH
Alcohol
Arteriovenous malformation
congenital tangle of vessels
Name 4 blood thinners that can cause hemorrhagic stroke.
Asprin (ASA)
NSAIDs
Heparin
Coumadin
Most common cause of hemorrhagic stroke.
Hypertension
Name the three parts that make up the limbic lobe.
thalamus, hypothalamus, hippocampus
thalamus
A structure in the forebrain through which all sensory information (except smell) must pass to get to the cerebral cortex.
hypothalamus
A neural structure lying below the thalamus; directs eating, drinking, body temperature; helps govern the endocrine system via the pituitary gland, and is linked to emotion
hippocampus
A curved forebrain structure that is part of the limbic system and is involved in learning and forming new memories
TIA is caused by?
a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia
Name three main caused for a thrombotic stroke.
atherosclerosis
elevated BP
narrowing of blood vessels
Most common vessels affected in thrombotic stroke
interanl carotids, middle cerebral, anterior cerebral
Name three types of ischemic strokes
thrombic, embolic, lacunar
lacunar stroke
Stroke caused by the occlusion of a small branch of a larger blood vessel w/development of a cavity in the place of the infarcted brain tissue, softened tissue sloughs away leaving a "small cavity"
thrmobic stroke
results of thrombosis or narrowing of the blood vessel
embolic stroke
occurs when an embolus lodges in and occuldes a cerebral artery resulting in infraction and edema of the area supplied by involved vessel
when are embolic strokes more common?
When awake or after activity
What type of stroke has onset during sleep and sfter arising? wy?
is
penarba
area affected
tPA
"clot-busting drug" used occasionally stroke, myocardial infarction, and pulmonary embolism
Why are embolic strokes increasing in young adults?
amphetamine use
What type of stroke has sudden onset?
embolic stroke
Embolic strokes are cardic in orgin due to damage caused by
heart vlalves damage by rheumatic heart disease
MI
A fib
endocardidtis
atherosclerotic plaque
rheumatic heart disease
DAMAGE TO THE HEART MUSCLE OR HEART VALVES CAUSED BY ONE OR MORE EPISODES OF RHEUMATIC FEVER
atrial fibrulation
irregular and rapid atrial contraction, resulting in TOP of heart quivering, results in an irregularly irregular heart rhythm (atrium fire at irregular intervals)
Early treatment- intervention for TIA
anticogulant
antiplatelet aggregation drugs
vasodialators
lifestyle changes
Nursing managment pre-op tests for TIA
CT scan, chest x-ray, PTT, lab work
What diagnostic studies are done to determine cause of stroke?
CT w/o contrast
MRI --r/o hemorrhage or aneurysm
PTT
PT
INR
transcranial doppler
CTA
trancranial doppler
used to evaluate cerebral blood flow
PTT
(Partial Thromboplastin Time) evaluation of the intrinsic coagulation system. Patients on heparin therapy are monitored by a PTT
Name 6 clinical manifestations of strokes
1. motor function
2. communication
3. affect
4. intellectual function
5. spatial-perceptual alteration
6. eliminations
Angiography
A contrast x-ray showing circulation. (CTA)
Motor impairments caused by stroke
1. mobility
2. respiratory function
3. swallowing and speech
4. gag reflex
5. self-care abilities
prevention of stroke in healthy people.
reduce salt intake
maintain normal body weight and blood pressure
increase exercise
limit alcohol
avoid smoking
diet lowin saturated fat, high in fruit and vegies
What is the most frequently drug used to prevent stroke in patients with TIA?
aspirin (antiplatelet) - dose of 81 to 325 mg/day
Name 4 other medications used to prevent stroke in TIA patients.
1. ticlopidine (Ticlid)
2. clogpidogrel (Plavix)
3. dipyridamole (Persantine)
4. dipryridamole/aspirin (Aggrenox)
Best drug for patients with A-fib and TIA?
oral anticoagulate - warfarin
Drug alert for Ticlopidine and clopidogrel
all healthcare providers and dentist must be informed that drug is being taken prior to surgery. Pt. must be off of medication 10 to 14 days prior to surgery
nonfluent aphasia
(Language disorders) slow and labored speech with short phrases
fluent aphasia
(Language disorders) pace of speech is normal but contains made-up words and sentences that do not make sense, ie stroke
Name characteristics of Broca's
nonfluent aphasia
damage to frontal lobe of brain
understands speech
speaks in short phrases
global aphasia
Loss of all language skills.
What causes intracrantial pressure to increase during stroke?
Blood supply to part of the brain is interrupted, ischemia occurs deprived of O2 (hypoxia and anoxia)& glucose; tissue dies (infarct), cerebral edema occurs due to tissue injury of brain-INFLAMMATION
Nursing interventions for stroke patients Monitor what?
monitor for decreased LOC and increased ICP
What time frame is the greatest risk for increased ICP after a CVA?
first 72 hours
early sign = confusion
Nursing intervention for stroke pt. to prevent/reduce cerebral edema.
position HOB at 30-45 degree fowlers, position to prevent hip & neck flexion & contractures, aspiration
Tissue Plasminogen activator
TPA- Alteplase (Activase) a (thrombolytic) must be used within first 4.5 of symptom onset, preferably within 1 hour but CT first to rule out hemorrhage
After a stroke what VS is elevated and why?
elevated BP is common, may be protective response to maintain cerebral perfusion.
When should drugs be used for BP after a stroke?
Only if BP arterial pressure >130 mm Hg or systolic pressure > 220 mm Hg, use antihypertensives: metoprolol, micardipine preferred
List normal lab ranges for PT, PTT, APTT
PT = 11- 12.5 seconds
PTT = 60 - 70 seconds
APTT = 30 -40 seconds
What type of stroke is more likely to increase ICP?
hemorrhagic
Management of increased ICP includes.
pratices that improve venous drainage:
*elevating HOB
*head & neck alignmeny
*avoiding hip flexion
hip flexion
DECREASING THE ANGLE BETWEEN TWO BONES OR BENDING A LIMB AT A JOINT
Monitor Hyperthermia with stroke.
commonly following stroke during first 24 hours. increase temp = increase cerebral metabolism. 1 deg cel can increase metabolism by 10% = further damage
What medication is used to reduce cerebral edema in hemorrhagic CVA?
Steriods like Decadron
What medication is given t hemorrhagic CVA patients to prevent seizures?
Dilantin (anticonvulsant), must monitor peak & trough to prevent toxicity & maintain therapeutic level (10 - 20 for anticonvulsant levels; 10 -18 anti -arrhythmic level)
What is goal for anti-coag?
1 1/2 - 2x longer than normal for blood to clot
CVA norms 1.5x normal coagulation.
PT = 16.5 - 18.75
PTT = 90 - 105 sec
APTT = 45 - 60 sec
Patient teaching when on anticoagulants.
watch for blood in urine, bleeding gums, bruising, use soft toothbrush
Patient teaching what to avoid when on anticogulants.
foods high in Vitamin K (antidote for coumadin)
cranberry juice, grapefruit, kale, cabbage, broccoli, asparagus, lettuce, spinach, large doses of Vit C
When given coumadin what labs should be tested?
PT
INR
hold if
When given Heparin IV what labs should be tested?
PTT or APTT
hold if
What medication is given to SAH patients to prevent vasospasm?
Calcium channel blockers (nimodipine/Nimotop)
prevent spasm minimize cerebral damage.
hold for HR less than 60
When can a vasospasm occur?
after clipping/coiling treatment for aneurysm
What is a MERCI retriver?
mechanical embolus removal in cerebral ischemia retriever: under xray guidance catheter travels up carotid artery to clot in brain, tiny corkscrew dislodges it and captured and pulled out with balloon out of the body
What is the surgical treatment for an aneurysm to prevent rebleeding?
clipping or coiling
How does coiling work?
coil placed in aneurysm to occlude blood from circulating through the aneurysm reducing risk of rupture.
subarachnoid hemorrhage
Bleeding into the subarachnoid space into the cerebrospinal fluid- filled space between the arachoid and pia mater membrane on the surface of the brain, "Worst headache of my life"
Where do the majority of SAH occur?
in the circle of Willis, other causes trauma and cocaine abuse