Neurology

Cerebrovascular Accident
Brunner¶s Ch. 62 pg 1887

Breaking down in tears 

I¶m a nursing student who¶s never seen a person die. When the time comes, I¶m afraid I¶ll lose it and upset the patient or family. How do you do this work all the time and not break down in tears?

Cerebrovascular accident
AKA  CVA  Stroke  Brain attack

CVA: Pathophysiology         Disruption of blood flow to part of the brain Ischemia Tissue Anoxia L PaO2 & K PaCO2 Acidosis Infarction Edema K ICP .

CVA: Etiology  Ischemic ‡ Thrombosis ‡ ‡ ‡ ‡ ‡ __?__ thrombosis Arteriosclerosis Common site ‡ ‡ ‡ Carotid artery Embolism Atrial fib or HTN Plaque breaking off and becoming an emboli d/t Long standing cardiovascular disease .

CVA: Etiology  Hemorrhage ‡ ‡ Rupture of the cerebral blood vessel Commonly caused by poor control of HTN .

CVA: Etiology  Hemorrhage ‡ This type of CVA results in: ‡ Slow recovery ‡ K probability of ‡ neurological deficits No meds to reverse the effects .

CVA: Etiology  Other causes ‡ ‡ ‡ ‡ ‡ Syphilis Trauma Hypertension Hypoxia ***Anything the L blood flow .

CVA: Risk Factors Changeable  Smoking  Obesity  HTN  Sedentary life  Stress  K fat diet  K Na diet  Substance abuse  Oral contraceptives  Diabetes mellitus Non-changeable  Age  Gender  Family history  Race .

Stress F.Weight C.Smoking B.Diet D.HTN E. Substance Abuse .CVA: Risk Factors Which is the most important risk factor for a stroke? A.

Stress F.CVA: Risk Factors What is the number one cause of CVA in a younger patient? A.HTN E.Diet D.Weight C.Smoking B. Substance Abuse .

crack) K Blood pressure K ICP Subarachnoid & intracerebral hemorrhage Interrupt blood flow L O2 & L glucose Depressed neurons .CVA: Pathophysiology substance abuse        Substance (PCP.

CVA: Pathophysiology   ** Vessels involved determine the area of the brain involved ***Area affected determines the S&S .

Location 2.CVA: Clinical manifestations S&S depend on: 1. Amount . Size 3.

CVA: Clinical Manifestations Common clinical manifestations           Syncope Alt. LOC Paresthesia H/A Aphasia Seizures Vision disturb Difficulty walking Labile emotion Hemiparesis/hemiplegia .

Left vs. Right Hemispheric CVA Left CVA Right CVA Language Speech Sensation Perception Movement Aphasia .

Left vs. Right Hemispheric CVA Left CVA Right CVA Language Speech Sensation Perception Movement Aphasia Dysarthria .

Right Hemispheric CVA Left CVA Right CVA Language Speech Sensation Aphasia Dysarthria Right Homonyous hemianopsia Perception Movement .Left vs.

Left vs. Right Hemispheric CVA Left CVA Right CVA Language Speech Sensation Aphasia Dysarthria Right Homonyous hemianopsia Normal awareness Perception Movement .

Left vs. Right Hemispheric CVA Left CVA Right CVA Language Speech Sensation Aphasia Dysarthria Right Homonyous hemianopsia Normal awareness Right side paresis Perception Movement .

Right Hemispheric CVA Judgment intact Depression Slow & cautious Behavior Cognition Memory .Left vs.

Right Hemispheric CVA Judgment intact Depression Slow & cautious Impaired analytical Behavior Cognition Memory .Left vs.

Left vs. Right Hemispheric CVA Judgment intact Depression Slow & cautious Impaired analytical Deficit new language info Behavior Cognition Memory .

Right Hemispheric CVA Left CVA Right CVA Language Speech Sensation Aphasia Dysarthria Right Homonyous hemianopsia Intact Normal awareness Right side paresis Perception Movement .Left vs.

Right Hemispheric CVA Left CVA Right CVA Language Speech Sensation Aphasia Dysarthria Right Homonyous hemianopsia Intact Dysarthria Normal awareness Right side paresis Perception Movement .Left vs.

Right Hemispheric CVA Left CVA Right CVA Language Speech Sensation Aphasia Dysarthria Right Homonyous hemianopsia Intact Dysarthria Left Homonyous hemianopsia Normal awareness Right side paresis Perception Movement .Left vs.

Right Hemispheric CVA Left CVA Right CVA Language Speech Sensation Aphasia Dysarthria Right Homonyous hemianopsia Intact Dysarthria Left Homonyous hemianopsia Normal awareness Right side paresis Perception Movement Unilateral neglect .Left vs.

Right Hemispheric CVA Left CVA Right CVA Language Speech Sensation Aphasia Dysarthria Right Homonyous hemianopsia Intact Dysarthria Left Homonyous hemianopsia Normal awareness Right side paresis Perception Movement Unilateral neglect Left side paresis .Left vs.

Left vs. Right Hemispheric CVA Judgment intact Depression Slow & cautious Impaired analytical Deficit new language info Behavior Judgment impaired Denial Impulsive behavior Cognition Memory .

Left vs. Right Hemispheric CVA Judgment intact Depression Slow & cautious Impaired analytical Deficit new language info Behavior Judgment impaired Denial Impulsive behavior Cognition Memory Deficit new spatial info .

My Mother:  What side stroke did she have? ‡ Right sided  How do you know? ‡ Denial ‡ Poor judgment ‡ No aphasia .

My step Father  What side stroke did she have? ‡ Left sided  How do you know? ‡ Depression ‡ Emotional labile ‡ Normal awareness ‡ Aphasia .

CVA: diagnostic findings  LP ‡ ‡ ‡ ‡ ‡ ‡ K pressure Blood Bleeding Infarction Shift Occlusion  CT / MRI  Angiography .

CVA: Medical Management Focus on Cause & Control  #1 cause = ‡ ‡ Hypertension Medications .

CVA: Rx .HTN  Beta-blockers ‡ ‡ Action ‡ Block sympathetic response Example ‡ Propranolol hydrochloride .

CVA: Rx .HTN  Central acting Anti-hypertensive ‡ ‡ Action ‡ ‡ L Cardiac output L Heart rate Example ‡ Catapres .

HTN  Vasodilators ‡ ‡ ‡ Action ‡ Relax smooth muscles Example ‡ Apresoline Emergency ‡ Hyperstat ‡ Nipride .CVA: Rx .

CVA: Medical Management  Diet ‡ ‡ ‡ ‡ ‡ Sodium ‡ Fat L L K L L ‡ ‡ ‡ ‡ Potassium Stimulants Fluids .

CVA: Medical Management  Prevent clot formation ‡ Meds / anticoagulants ‡ Coumadin ‡ Antidote? ‡ Vit K ‡ Heparin ‡ ASA .

CVA: Medical Management  Prevent clot formation ‡ Non-Rx ‡ Ted hose ‡ ROM ‡ Isometric exercise .

CVA: Medical Management  Surgery ‡ ‡ Endarterectomy ‡ Carotid stenosis Craniotomy ‡ Evacuate clot .

CVA: Medical Management  Thrombolytic agents ‡ ‡ ‡ ‡ ‡ Action ‡ Break down thrombi S/E ‡ Hemorrhage Streptokinase Urokinase Tissue-type prasminogen activator (tPA) .

CVA: Medical Management  Thrombolytic agents ‡ Tissue-type prasminogen activator (tPA) ‡ Take in 3 hrs of CVA .

CVA: Medical Management  Airway ‡ w ‡ ‡ ‡ Patent 3 reflex O2 Suction Mech vent .

CVA: Medical Management  Prevent Seizures ‡ ‡ ‡ Precaution Meds L stimuli .

CVA: Medical Management  L ICP ‡ ‡ ‡ ‡ ‡ O2 ‡ ‡ ‡ ‡ Mech vent HOB K Rest Diuretics Glucocorticoids BP Systolic < 180 Diastolic < 100 Position ‡ Activity Meds Monitor ‡ ‡ ‡ .

CVA: Medical Management  Nutrition ‡ NGT .

CVA: Medical Management  Monitor for trouble ‡ ‡ ‡ VS ‡ Rectal temp ‡ NO I&O Labs ‡ ‡ ‡ ‡ ‡ ‡ Na K Glucose ABG¶s PT/PTT Pulse oximetry .

CVA: Medical Management Prevent complications  ROM  PT/SLP  Isometric exercise  Antacids ‡ ‡ ‡ ‡ Maalox Tums Tagamet Zantac  Histamine antagonist  Pain ‡ Codeine .

CVA: NRS management Alt. tissue perfusion  r/t K ICP ‡ ‡ Monitor ICP Avoid act that K ICP .

CVA: NRS management Risk for injury     r/t seizures r/t repeat CVA r/t unilateral neglect r/t falls ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Padded side rails Call light Assist w. amb. Suction BR assist Items w/in reach Clear path H2O temps Turn & position .

CVA: NRS management Alt. nutrition    r/t impaired swallowing Motor deficits Impaired judgment ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Talk & eat ± NO SLP Swallow eval HOB high fowlers Straws ± no Thick liquids Swallow twice 3 pocketing food w w ‡ ‡ Easy chew Head position Unaffected side of tongue 3 gag 3 choking Small meals High texture food .

to do exercises . Mobility  r/t neuro deficits ‡ Splints ‡ ‡ ‡ ‡ ‡ Begin on admit Turn q2hr Pillows P skin ROM ‡ Hand & fingers ‡ Arm ‡ Legs ‡ ‡ ‡ ‡ ‡ Footboards Built-up utensils Raised toilet W/in reach Pt.CVA: NRS management Alt.

CVA: NRS management
Impaired Communication 

r/t aphasia

‡ ‡ ‡ ‡ ‡ ‡ ‡

SLP Time Anticipate Call bell Slow & clear Face patient Eye contact

‡ ‡ ‡ ‡

Yes/No ? ID methods Gestures Visual aids

CVA: NRS management
Knowledge Deficit  r/t new diagnosis

‡ ‡ ‡ ‡ ‡ ‡ ‡

Orient Explain K.I.S.S. Written, verbal & picture Little at a time Meds Safety

CVA: NRS management
Self-Care Deficit  Eating

‡ ‡ ‡ ‡

Non-skid mats Stabilizer plates Plate guards Wide grip utensils

CVA: NRS management Self-Care Deficit  Bathing & Grooming ‡ ‡ ‡ ‡ ‡ ‡ Long handle sponge Grab bars Non-skid mats Hand held showers Electric razor Shower seat .

CVA: NRS management Self-Care Deficit  Toileting ‡ ‡ Raised seat Grab bars .

CVA: NRS management Self-Care Deficit  Dressing ‡ ‡ ‡ Velcro Elastic shoelaces Long-handle shoehorn .

CVA: NRS management Self-Care Deficit  Mobility ‡ ‡ ‡ ‡ Canes Walkers Wheelchair Transfer devices .

CVA: NRS management  Risk of care-giver role strain ‡ Support systems .

CVA: NRS management Unilateral neglect  Unaffected side ‡ ‡ ‡    Personal items Approach Door face Cue Scan environment Sling .

CVA: NRS management Impaired thought processes  Family  KISS  SS&TTP  L distractions  Repeat  Visual reminders     Time Simple complex Positive feedback Non-judgmental .

Hemorrhagic Stroke   Usually more severe with a longer recovery period than ischemic stroke Caused by bleeding into: ‡ Brain ‡ Ventricles ‡ Subarachnoid space .

Hemorrhagic Stroke  Cerebral aneurysm ‡ ‡ Dilitation. bulging or ballooning out of part of the wall of a vein or artery in the brain When they enlarge and press upon cranial nerves or tissue ‡ Symptoms .

Hemorrhagic Stroke  Etiology ‡ ‡ ‡ HTN Arteriosclerosis Meds .

Hemorrhagic Stroke Clinical Manifestations  Similar to ischemic  Unique S&S ‡ ‡ ‡ H/A LOC Nuchal rigidity .

TIA: Transient Ischemic Attack   Short reversible ischemic event Duration ‡  < 24 hrs  No permanent neuro deficit Warning! .

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