Download Chapter 34

Chapter 28
Cerebrovascular
Accident
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
1
Learning Objectives
• Discuss the risk factors for cerebrovascular accident
(CVA).
• Identify the two major types of CVA.
• Describe the pathophysiology, signs and symptoms,
and medical treatment for each type of CVA.
• Describe the neurologic deficits that may result from
CVA.
• Explain the tests and procedures used to diagnose
a CVA and nursing responsibilities for patients undergoing those
tests and procedures.
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
2
Learning Objectives
• List data to be included in the nursing assessment of
the CVA patient.
• Assist in developing a nursing care plan for a CVA
patient during the acute and rehabilitation phases.
• Specify criteria used to evaluate the outcomes of
nursing care for the CVA patient.
• Identify resources for the CVA patient and family.
• Discuss criteria used to identify patients eligible for
treatment with rt-PA.
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
3
Cerebrum
• Complex functions: initiation of movements,
recognition of sensory input, higher-order
thinking, regulating emotional behavior and
endocrine and autonomic functions
• Divided into two halves: hemispheres
• Each hemisphere controls the opposite side of the
body: the right hemisphere controls the left side of
the body, and the left hemisphere controls the right
side of the body
• The cortex of each is divided into the parietal, frontal,
temporal, and occipital lobes; each has a different
area of function
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
4
Figure 28-1
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
5
Cerebrum
• Brainstem
• Includes midbrain, pons, medulla, and part of the
reticular activating system
• Controls vital, basic functions, including respiration,
heart rate, and consciousness
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
6
Cerebellum
• Uses information received from the cerebrum, muscles,
joints, and inner ear to coordinate movement, balance,
and posture
• Unlike the cerebrum, the right side of the cerebellum
controls the right side of the body, and the left side of
the cerebellum controls the left side of the body
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
7
Circulation
• Carotid system
• Begins as one common artery; later divides into the
external and internal carotid arteries
• The external carotid arteries divide to supply blood to the
face
• The internal arteries further divide into the middle cerebral
artery and the anterior cerebral artery to supply blood to
the brain
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
8
Circulation
• Vertebral arteries
• Originate from the subclavian artery, travel up the
anterior neck to merge and form the basilar artery at
the brainstem
• Second division forms posterior cerebral artery
• Internal carotid and vertebrobasilar arteries
unite to form the circle of Willis
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
9
Figure 28-2
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
10
Cerebrovascular Accidents
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
11
Risk Factors for Stroke
• Nonmodifiable factors
• Risk factors that cannot be changed
• Age, race, gender, and heredity
• Modifiable factors
• Those that can be eliminated or controlled
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
12
Transient Ischemic Attack
• Temporary neurologic deficit caused by
impairment of cerebral blood flow
• Blood vessels occluded by spasms, fragments
of plaque, or blood clots
• Important warning signs for the individual
experiencing a full stroke
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
13
Transient Ischemic Attack
• Signs and symptoms
• Dizziness, momentary confusion, loss of speech,
loss of balance, tinnitus, visual disturbances, ptosis,
dysarthria, dysphagia, drooping mouth, weakness,
and tingling or numbness on one side of the body
• Medical diagnosis
• Health history, physical examination findings, and
results of brain imaging studies
• Laboratory studies, electrocardiography (ECG),
duplex ultrasonography, and cerebral angiography
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
14
Transient Ischemic Attack
• Medical treatment
• Depends on the location of the narrowed vessel and
the degree of narrowing
• Acetylsalicylic acid (aspirin), ticlopidine
hydrochloride (Ticlid), extended-release
dipyridamole (Aggrenox), or clopidogrel bisulfate
(Plavix) decrease platelet clumping
• Warfarin (Coumadin) and heparin
• Carotid endarterectomy and transluminal
angioplasty
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
15
Figure 28-3
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
16
Stroke
• An abrupt impairment of brain function
resulting in a set of neurologic signs and
symptoms that are caused by impaired blood
flow to the brain and last more than 24 hours
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
17
Stroke: Pathophysiology
• Hemorrhagic stroke
• Blood vessel in brain ruptures; bleeding into the
brain occurs
• Ischemic stroke
• Obstruction of blood vessel by atherosclerotic
plaque, blood clot, or a combination of the two, or by
other debris released into vessel that impedes blood
flow to an area of the brain
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
18
Figure 28-4
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
19
Stroke: Signs and Symptoms
• Different signs and symptoms, depending on
the type, location, and extent of brain injury
• Hemorrhagic stroke
• Occurs suddenly; may include severe headache
described as “the worst headache of my life”
• Other symptoms: stiff neck, loss of consciousness,
vomiting, and seizures
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
20
Stroke: Signs and Symptoms
• Embolic stroke
• Appear without warning
• One or more of the following signs and symptoms:
one-sided weakness, numbness, visual problems,
confusion and memory lapses, headache,
dysphagia, and language problems
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
21
Figure 28-5
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
22
Stroke: Signs and Symptoms
• Aphasia
• A defect in the use of language; speech, reading, writing, or
word comprehension
• Dysarthria
• The inability to speak clearly
• Dysphagia
• Swallowing difficulty
• Dyspraxia
• The partial inability to initiate coordinated voluntary motor acts
• Hemiplegia
• Defined as paralysis of one side of the body
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
23
Figure 28-8
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
24
Stroke: Signs and Symptoms
• Sensory impairment
• Unable to feel touch, pain, or temperature in affected body
parts
• Unilateral neglect
• Do not recognize one side of the body as belonging to them
• Homonymous hemianopsia
• Perceptual problem: involves loss of one side of field of vision
• Elimination disturbances
• Neurogenic bladder
• Flaccid bladder
• Bowel incontinence
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
25
Medical Diagnosis
• Blood studies, electrocardiogram (ECG),
computed tomography, magnetic resonance
imaging, carotid ultrasound studies, cerebral
and carotid angiography, electrocardiography,
positron-emission tomography, and singlephoton emission computed tomography
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
26
Complications
• Constipation, dehydration, contractures,
urinary tract infections, thrombophlebitis,
decubitus ulcers, and pneumonia
• Sensory losses put patient at risk for traumatic
and thermal injuries
• Swallowing difficulties place patient at risk for
pulmonary complications, such as choking and
aspiration pneumonia
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
27
Prognosis
• Prognosis for TIA or stroke increasingly hopeful
• Critical variables for recovery: patient’s condition
before the stroke, time between stroke and diagnosis,
treatment and support in acute phase (usually the first
48 hours), severity of patient’s symptoms, and access
to rehabilitative therapy
• Long-term recovery may depend on the care received
immediately after the stroke
• Most recovery takes place in the first 3-6 months, but
progress often continues long after that
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
28
Medical Treatment in the Acute
Phase
• Begins with the onset of signs and symptoms
and continues until vital signs, particularly
blood pressure and neurologic condition,
stabilize
• This phase usually lasts 24 to 48 hours
• Many medical management interventions are
directed at minimizing complications and
deterioration of the patient’s condition after a
stroke
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
29
Medical Treatment in the Acute
Phase
• Major focus areas
•
•
•
•
Hypertension
Oxygenation
Hyperthermia
Hyperglycemia
• Drug therapy
• Tissue plasminogen activator (rt-PA, alteplase,
Activase)
• Given to dissolve clots in acute ischemic strokes
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
30
Medical Treatment in the Acute
Phase
• Other medications
•
•
•
•
Mannitol
Nimodipine (Nimotop)
Phenytoin (Dilantin) and phenobarbital
Acetylsalicylic acid (aspirin), ticlopidine
hydrochloride (Ticlid), Aggrenox, and clopidogrel
(Plavix)
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
31
Medical Treatment in the Acute
Phase
• Surgical intervention
• An option for some patients with hemorrhagic
strokes
• Decisions about surgery are based on patient’s age,
intracranial pressure, and location of the
hemorrhage
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
32
Medical Treatment in the Acute
Phase
• Fluids and nutrition
• Intravenous fluids
• Dietary order based on patient’s nutritional
requirements and ability to eat
• Regular, soft, or pureed
• Total parenteral nutrition may be ordered for the
malnourished patient
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
33
Medical Treatment in the Acute
Phase
• Urine elimination
• Indwelling catheter to manage urinary incontinence
• Intermittent catheterization: controlling incontinence
caused by a flaccid bladder
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
34
Nursing Care in the Acute Phase
• Assessment
• Evaluate type and extent of the stroke: time of onset,
symptoms, other details
• Cincinnati Pre-hospital Stroke Scale
• Health history
•
•
•
•
•
Chief complaint and history of present illness
Medical history
Family history
Review of systems
Functional assessment
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
35
Nursing Care in the Acute Phase
• Physical examination
• Assess patient’s general appearance,
responsiveness, and behavior
• Record restlessness or agitation
• Measure vital signs; weight and height if possible
• Inspect the face for symmetry; mouth for moisture
and drooling
• Evaluate the alert patient’s ability to swallow
• Inspect pupils for size, equality, and reaction to light
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
36
Nursing Care in the Acute Phase
• Physical examination
• Conduct a gross vision assessment
• Inspect skin color and palpate for moisture and turgor
• Assess extremities for muscle tone and strength, sensation,
and voluntary movement
• Record evidence of incontinence or bladder distention
• Frequently repeat neurologic checks: evaluating level of
consciousness, pupil appearance and response to light, the
patient’s ability to follow commands, and the movement and
sensation of extremities
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
37
Nursing Care in the Acute Phase
• Interventions
• Ineffective Airway Clearance and Ineffective
Breathing Patterns
• Risk for Injury
• Deficient Fluid Volume or Excess Fluid Volume
• Imbalanced Nutrition
• Disturbed Sensory Perception
• Ineffective Thermoregulation
• Disturbed Thought Processes
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
38
Nursing Care in the Acute Phase
• Interventions
•
•
•
•
•
•
Impaired Verbal Communication
Impaired Physical Mobility
Total or Functional Urinary Incontinence
Constipation and/or Bowel Incontinence
Ineffective Coping
Interrupted Family Processes
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
39
Nursing Care in the
Rehabilitation Phase
• Assessment
• Reassess patient’s abilities, expectations,
knowledge, motivation, and resources
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
40
Nursing Care in the
Rehabilitation Phase
• Interventions
•
•
•
•
•
•
•
•
Self-Care Deficit
Risk for Injury
Ineffective Coping
Impaired Verbal Communication
Imbalanced Nutrition
Impaired Physical Mobility
Constipation
Total and Functional Urinary Incontinence
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
41
Figure 28-6
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
42
Figure 28-7
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
43
Figure 28-9
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
44
Discharge
• Patients may be discharged to home or go to
specialized rehabilitation centers for continued
therapy
• Outpatient therapy is an option for some
patients
• When able, patients are transitioned back into
the home setting
• Essential to include family, friends, and
significant others in this process
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
45
Discharge
• During and after the rehabilitation phase,
patients and families need to be made aware
of resources to help them deal with continuing
disabilities
• In rehabilitation, the patient is respectfully
challenged to return to the highest level of
function possible
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
46