CENTRAL PHILIPPINE ADVENTIST COLLEGE

SCHOOL OF NURSING

NCM 106 A ACUTE BIOLOGIC CRISIS

TITLE OF REPORT

Reporters: Professor:
Federezo, Chilcie Kay F. Doris May M. Frasco, RN, MSN
Garcesa, Frytz M.
1. Heart Failure
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2. What causes it?
A stroke may be caused by a blocked artery (ischemic stroke) or the leaking or bursting of a blood
vessel (hemorrhagic stroke). Some people may experience only a temporary disruption of blood flow to the
brain (transient ischemic attack, or TIA) that doesn't cause permanent damage.

Ischemic stroke

About 80 percent of strokes are ischemic strokes. Ischemic strokes occur when the arteries to your brain
become narrowed or blocked, causing severely reduced blood flow (ischemia). The most common ischemic
strokes include:

 Thrombotic stroke. A thrombotic stroke occurs when a blood clot (thrombus) forms in one of the
arteries that supply blood to your brain. A clot may be caused by fatty deposits (plaque) that build up
in arteries and cause reduced blood flow (atherosclerosis) or other artery conditions.

 Embolic stroke. An embolic stroke occurs when a blood clot or other debris forms away from your
brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower
brain arteries. This type of blood clot is called an embolus.
Hemorrhagic stroke

Hemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures. Brain hemorrhages can
result from many conditions that affect your blood vessels. These include:

 Uncontrolled high blood pressure (hypertension)

 Overtreatment with anticoagulants (blood thinners)
 Weak spots in your blood vessel walls (aneurysms)
A less common cause of hemorrhage is the rupture of an abnormal tangle of thin-walled blood vessels
(arteriovenous malformation). Types of hemorrhagic stroke include:
  Intracerebral hemorrhage. In an intracerebral hemorrhage, a blood vessel in the brain bursts and
spills into the surrounding brain tissue, damaging brain cells. Brain cells beyond the leak are deprived
of blood and are also damaged.
High blood pressure, trauma, vascular malformations, use of blood-thinning medications and other
conditions may cause an intracerebral hemorrhage.
 Subarachnoid hemorrhage. In a subarachnoid hemorrhage, an artery on or near the surface of your
brain bursts and spills into the space between the surface of your brain and your skull. This bleeding
is often signaled by a sudden, severe headache.
A subarachnoid hemorrhage is commonly caused by the bursting of a small sack-shaped or berry-
shaped aneurysm. After the hemorrhage, the blood vessels in your brain may widen and narrow
erratically (vasospasm), causing brain cell damage by further limiting blood flow.
Transient ischemic attack (TIA)

A transient ischemic attack (TIA) — sometimes known as a ministroke — is a temporary period of

symptoms similar to those you'd have in a stroke. A temporary decrease in blood supply to part of your
brain causes TIAs, which may last as little as five minutes.

Like an ischemic stroke, a TIA occurs when a clot or debris blocks blood flow to part of your nervous
system — but there is no permanent tissue damage and no lasting symptoms.

Seek emergency care even if your symptoms seem to clear up. Having a TIA puts you at greater risk of
having a full-blown stroke, causing permanent damage later. If you've had a TIA, it means there's likely a
partially blocked or narrowed artery leading to your brain or a clot source in the heart.

It's not possible to tell if you're having a stroke or a TIA based only on your symptoms. Even when
symptoms last for under an hour, there is still a risk of permanent tissue damage.

3. How it happens?

Many factors can increase your stroke risk. Some factors can also increase your chances of having a
heart attack. Potentially treatable stroke risk factors include:

Lifestyle risk factors

 Being overweight or obese

 Physical inactivity
 Heavy or binge drinking
 Use of illicit drugs such as cocaine and methamphetamines
Medical risk factors

 Blood pressure readings higher than 120/80 millimeters of mercury (mm Hg)
  Cigarette smoking or exposure to secondhand smoke
 High cholesterol
 Diabetes
 Obstructive sleep apnea
 Cardiovascular disease, including heart failure, heart defects, heart infection or abnormal heart
rhythm
 Personal or family history of stroke, heart attack or transient ischemic attack.
Other factors associated with a higher risk of stroke include:

 Age —People age 55 or older have a higher risk of stroke than do younger people.
 Race — African-Americans have a higher risk of stroke than do people of other races.
 Sex — Men have a higher risk of stroke than women. Women are usually older when they have
strokes, and they're more likely to die of strokes than are men.
 Hormones — use of birth control pills or hormone therapies that include estrogen, as well as
increased estrogen levels from pregnancy and childbirth.

4. What to look for?

A stroke can sometimes cause temporary or permanent disabilities, depending on how long the brain lacks
blood flow and which part was affected. Complications may include:

 Paralysis or loss of muscle movement. You may become paralyzed on one side of your body, or
lose control of certain muscles, such as those on one side of your face or one arm. Physical therapy
may help you return to activities affected by paralysis, such as walking, eating and dressing.
 Difficulty talking or swallowing. A stroke might affect control of the muscles in your mouth and
throat, making it difficult for you to talk clearly (dysarthria), swallow (dysphagia) or eat. You also
may have difficulty with language (aphasia), including speaking or understanding speech, reading,
or writing. Therapy with a speech-language pathologist might help.
 Memory loss or thinking difficulties. Many people who have had strokes experience some memory
loss. Others may have difficulty thinking, making judgments, reasoning and understanding concepts.
 Emotional problems. People who have had strokes may have more difficulty controlling their
emotions, or they may develop depression.
 Pain. Pain, numbness or other strange sensations may occur in the parts of the body affected by
stroke. For example, if a stroke causes you to lose feeling in your left arm, you may develop an
uncomfortable tingling sensation in that arm.
People also may be sensitive to temperature changes, especially extreme cold, after a stroke. This
complication is known as central stroke pain or central pain syndrome. This condition generally
develops several weeks after a stroke, and it may improve over time. But because the pain is caused
by a problem in your brain, rather than a physical injury, there are few treatments.
  Changes in behavior and self-care ability. People who have had strokes may become more
withdrawn and less social or more impulsive. They may need help with grooming and daily chores.

5. Test done to diagnose the disease

The first step in assessing a stroke patient is to determine whether the patient is experiencing an
ischemic or hemorrhagic stroke so that the correct treatment can begin. A CT scan or MRI of the head is
typically the first test performed.

 Computed tomography (CT) of the head: CT scanning combines special x-ray equipment with
sophisticated computers to produce multiple images or pictures of the inside of the body. Physicians
use CT of the head to detect a stroke from a blood clot or bleeding within the brain. To improve
the detection and characterization of stroke, CT angiography (CTA) may be performed. In CTA,
a contrast material may be injected intravenously and images are obtained of the cerebral blood
vessels. Images that detect blood flow, called CT perfusion (CTP), may be obtained at the same
time. The combination of CT, CTA and CTP can help physicians decide on the best therapy for a
patient experiencing a stroke.
 MRI of the head: MRI uses a powerful magnetic field, radio frequency pulses and a computer to
produce detailed pictures of organs, soft tissues, bone and virtually all other internal body
structures. MR is also used to image the cerebral vessels, a procedure called MR angiography
(MRA). Images of blood flow are produced with a procedure called MR perfusion (MRP).
Physicians use MRI of the head to assess brain damage from a stroke.
To help determine the type, location, and cause of a stroke and to rule out other disorders, physicians may
use:

 Blood tests.
 Electrocardiogram (ECG, EKG): An electrocardiogram, which checks the hearts' electrical
activity, can help determine whether heart problems caused the stroke.
 Carotid ultrasound/Doppler ultrasound: Ultrasound imaging involves exposing part of the body
to high-frequency sound waves to produce pictures of the inside of the body. Physicians use a
special ultrasound technique called Doppler ultrasound to check for narrowing and blockages in
the body's two carotid arteries, which are located on each side of the neck and carry blood from the
heart to the brain. Doppler ultrasound produces detailed pictures of these blood vessels and
information on blood flow.
 Cerebral angiography. Angiography is a medical test that is performed with one of three imaging
technologies—x-rays, CT or MRI, and in some cases a contrast material, to produce pictures of
major blood vessels in the brain. Cerebral angiography helps physicians detect or confirm
abnormalities such as a blood clot or narrowing of the arteries.

6. Treatment
To treat an ischemic stroke, doctors must quickly restore blood flow to your brain.

Emergency treatment with medications. Therapy with clot-busting drugs must start within 4.5 hours if
they are given into the vein — and the sooner, the better. Quick treatment not only improves your chances
of survival but also may reduce complications. You may be given:
  Intravenous injection of tissue plasminogen activator (tPA). This injection of recombinant tissue
plasminogen activator (tPA), also called alteplase, is considered the gold standard treatment for
ischemic stroke. An injection of tPA is usually given through a vein in the arm. This potent clot-
busting drug ideally is given within three hours. In some instances, tPA can be given up to 4.5 hours
after stroke symptoms begin.
This drug restores blood flow by dissolving the blood clot causing your stroke, and it may help people
who have had strokes recover more fully. Your doctor will consider certain risks, such as potential
bleeding in the brain, to determine if tPA is appropriate for you.
Emergency endovascular procedures. Doctors sometimes treat ischemic strokes with procedures
performed directly inside the blocked blood vessel. These procedures must be performed as soon as
possible, depending on features of the blood clot:

 Medications delivered directly to the brain. Doctors may insert a long, thin tube (catheter) through
an artery in your groin and thread it to your brain to deliver tPA directly into the area where the stroke
is occurring. This is called intra-arterial thrombolysis. The time window for this treatment is
somewhat longer than for intravenous tPA, but is still limited.
 Removing the clot with a stent retriever. Doctors may use a catheter to maneuver a device into the
blocked blood vessel in your brain and trap and remove the clot. This procedure is particularly
beneficial for people with large clots that can't be completely dissolved with tPA, though this
procedure is often performed in combination with intravenous tPA.
Several large and recent studies suggest that, depending on the location of the clot and other factors,
endovascular therapy might be the most effective treatment. Endovascular therapy has been shown to
significantly improve outcomes and reduce long-term disability after ischemic stroke.

Other procedures. To decrease your risk of having another stroke or transient ischemic attack, your doctor
may recommend a procedure to open up an artery that's narrowed by plaque. Doctors sometimes
recommend the following procedures to prevent a stroke. Options will vary depending on your situation:

 Carotid endarterectomy. In a carotid endarterectomy, a surgeon removes plaques from arteries that
run along each side of your neck to your brain (carotid arteries). In this procedure, your surgeon
makes an incision along the front of your neck, opens your carotid artery and removes plaque that
blocks the carotid artery.
Your surgeon then repairs the artery with stitches or a patch made from a vein or artificial material
(graft). The procedure may reduce your risk of ischemic stroke. However, a carotid endarterectomy
also involves risks, especially for people with heart disease or other medical conditions.

 Angioplasty and stents. In an angioplasty, a surgeon usually accesses your carotid arteries through
an artery in your groin. Here, your surgeon can gently and safely navigate to the carotid arteries in
your neck. A balloon is then inflated to expand the narrowed artery. Then a stent can be inserted to
support the opened artery.

7. What to do?

Medical Management
If you've had an ischemic stroke or TIA, your doctor may recommend medications to help reduce your risk
of having another stroke. These include:

 Anti-platelet drugs. Platelets are cells in your blood that form clots. Anti-platelet drugs make these
cells less sticky and less likely to clot. The most commonly used anti-platelet medication is aspirin.
Your doctor can help you determine the right dose of aspirin for you.
Your doctor might also consider prescribing Aggrenox, a combination of low-dose aspirin and the
anti-platelet drug dipyridamole to reduce the risk of blood clotting. If aspirin doesn't prevent your
TIA or stroke, or if you can't take aspirin, your doctor may instead prescribe an anti-platelet drug
such as clopidogrel (Plavix).
 Anticoagulants. These drugs, which include heparin and warfarin (Coumadin, Jantoven), reduce
blood clotting. Heparin is fast acting and may be used over a short period of time in the hospital.
Slower acting warfarin may be used over a longer term.
Warfarin is a powerful blood-thinning drug, so you'll need to take it exactly as directed and watch for
side effects. Your doctor may prescribe these drugs if you have certain blood-clotting disorders,
certain arterial abnormalities, an abnormal heart rhythm or other heart problems. Other newer blood
thinners may be used if your TIA or stroke was caused by an abnormal heart rhythm.

Nursing Management

Assessing patients for stroke

Stroke or suspected stroke is an emergency that calls for an immediate response. If you
suspect your patient is having a stroke, activate a stroke alert, notify the physician, or call 911
(depending on your location).
To detect stroke quickly, first responders and other frontline providers use several well-
known stroke scales, including the Cincinnati Stroke Scale and the Los Angeles Prehospital Stroke Scale.
These scales share many similar elements, some of which are part of the FAST exam. (See FAST and
BEFAST.)
The National Institute of Neurological Disorders and Stroke describes these major signs and symptoms of
stroke:
• sudden numbness or weakness of the face, arms, or legs
• sudden confusion or trouble speaking or understanding others
• sudden trouble seeing in one or both eyes
• sudden trouble walking, dizziness, or loss of balance or coordination
• sudden severe headache with no known cause.

NIHSS and mNIHSS tools

Nurses who manage patients with acute stroke should develop expertise in administering the
National Institutes of Health Stroke Scale (NIHSS), a tool that objectively quantifies a patient’s stroke
impairment. The NIHSS consists of 11 items that rate the patient’s neurologic functioning, including level
of consciousness, best gaze, visual fields, facial palsy, motor function, limb ataxia, sensory function,
language, articulation, and inattention. The lower the score, the better the patient’s prognosis. The
modified NIHSS (mNIHSS), a short version of the NIHSS, is less widely used but has better inter-rater
reliability than the older NIHSS.

Your role in thrombolytic therapy and stroke alert activation

Your initial evaluation of a patient with a suspected stroke should include airway, breathing, and
circulation, followed by neurologic assessment using either the NIHSS or the mNIHSS, per facility policy.
If you suspect a stroke, immediately notify the attending physician, who will call for a stroke alert or
code stroke.

Stroke alert team protocol

The following steps constitute a typical stroke alert team protocol with the goal of obtaining a CT scan
within 25 minutes of the patient’s hospital arrival.

Blood pressure monitoring

If the patient is a tPA candidate, maintain systolic BP below 185 mm Hg and diastolic BP below 110
mm Hg. Expect the physician to order labetalol or nicardipine to lower BP to goal pressures. If BP can’t
be maintained below these goals, the patient is not a tPA candidate. Caution: Rapidly lowering BP is
contraindicated because it may reduce perfusion to ischemic brain tissue.

CT: The gold standard

A noncontrast CT scan of the brain is the diagnostic test of choice to rule out hemorrhagic stroke in
an emergency. Time is critical, as studies show that delays in administering tPA correlate with poorer
patient outcomes. The patient should undergo a CT scan within 25 minutes of arrival at a stroke center. The
radiologist should read the CT scan within 45 minutes of patient arrival. A hemorrhagic stroke “lights up”
the scan image with hyperdense areas of bleeding, making the patient ineligible for tPA. The scan also can
detect a brain tumor, which also rules out tPA. A nurse, physician, or both must accompany the patient
(who should be on a monitor) to the CT scan.

Inclusion and exclusion criteria for tPA

For patients with ischemic stroke, the goal is to rapidly restore brain perfusion to save ischemic but viable
brain cells. Patients who receive tPA have a 30% higher chance of a good outcome at 3 months after the
stroke.