Nurses Notes on Cerebrovascular Stroke

CVA

A stroke (cerebrovascular accident, CVA), also referred as a brain attack, is a condition in which neurologic deficits result from decreased blood flow to a localized area of the brain.

Classifications:

1)      Ischemic Stroke- blood supply to a part of the brain is suddenly interrupted by a thrombus or embolus

·         Thrombotic Stroke- caused by occlusion of a large cerebral vessel by a thrombus (a blood clot). Thrombotic CVAs most often occur in older people who are resting or sleeping. The blood pressure is lower during sleep, so there is less pressure to push the blood through an already narrowed arterial lumen, and ischemia may result.

·         Embolic Stroke- occurs when a blood clot or clump of matter travelling through the cerebral blood vessels becomes lodged in a vessel too narrow to permit further movement.

2)      Hemorrhagic Stroke- occurs when a blood vessel breaks open, spilling blood into spaces surrounding neurons

The most common signs of a stroke:

·         weakness down one side of the body, ranging from numbness to paralysis that can affect the arm and leg

·         weakness down one side of the face, causing the mouth to droop

·         speech may be difficult or become difficult to understand

·         swallowing may be affected

·         loss of muscle coordination or balance

·         brief loss of vision

·         severe headache

·         confusion

Motor Deficits:

Depending on the area of the brain involved, strokes may cause weakness, paralysis, and/ or spasticity. The deficits include:

·         Hemiplegia: paralysis of the left or right half of the body

·         Hemiparesis: weakness of the left or right half of the body

·         Flaccidity: Absence of muscle tone (hypotonia)

·         Spasticity: increased muscle tone (hypertonia), usually with some degree of weakness. The flexor muscles are usually more strongly affected in the upper extremities and the extensor muscles are more strongly affected in the lower extremities.

Sensory- Perceptual Deficits:

·         Hemianopnia: the loss of half of the visual field of one or both eyes; when the same half is missing in each eye, the condition is called homonymous hemianopnia

·         Agnosia: the inability to recognize one or more subjects that were previously familiar; agnosia may be visual, tactile, or auditory.

·         Apraxia: the inability to carry out some motor pattern (e.g., drawing a figure, getting dressed)even when strength and coordination are adequate

·         Neglect syndrome (unilateral neglect): the client has a disorder of attention. In this syndrome, the client cannot integrate and use perceptions from the affected side of the body or from the environment on the affected side, and ignores that part. In severe cases, the client may even deny the paralysis.

Communication Disorders

Aphasia: the inability to use or understand language;

            Types:

a) Expressive Aphasia: a motor speech problem in which one can understand what is being said but can respond verbally only in short phrases: also called Broca’s aphasia.

b) Receptive Aphasia: a sensory speech problem in which one cannot understand the spoken (and often written) word. Speech maybe fluent but with inappropriate content; also called Wernicke’s aphasia

c) Mixed or global aphasia: language dysfunction in both understanding and expression

d) Dysarthria: any disturbance in muscular control of speech

Cognitive Changes

a)   Memory loss

b)   Short attention span

c)   Distractibility

d)  Poor Judgment

e)   Poor problem- solving ability

f)    Disorientation

Behavioral Changes

a) Emotional Lability

b) Loss of social inhibitions

c) Fear

d) Hostility

e) Anger

f) Depression

·         Increased intracranial pressure (projective vomiting and headaches)

·         Alterations in consciousness

·         Sensory loss (touch, pain, heat, cold, pressure)

Respiratory

·         Respiratory center damage

·         Airway obstruction

·         Decreased ability to cough

Gastrointestinal

·         Dysphagia

·         Constipation

·         Stool Impaction

Genitourinary

·         Incontinence

·         Frequency

·         Urgency

·         Urinary Retention

·         Renal Calculi

Musculoskeletal

·         Hemiplegia

·         Contractures

·         Disuse atrophy

·         Dysarthria

Integument

·         Decubitus (pressure) ulcers

Risk Factors

·         High blood pressure does not cause any symptoms, so everyone over the age of 40 should have an annual blood pressure check.

Increased systolic and diastolic pressure is associated with damage to all blood vessels, including the cerebral vessels.

·         Smokers have double the risk of stroke as non-smokers.

·         Irregular heart beat (atrial fibrillation) is fairly common in old age. It increases the risk of stroke by causing blood clots to form in the heart. Blood clots can be prevented from forming by taking warfarin (eg Marevan), a medicine that makes the blood less likely to clot. Warfarin treatment requires careful monitoring with regular blood checks and is a very effective way to reduce the risk of stroke.

·         Diabetes Mellitus leads to cerebral changes in both the systemic and cerebral circulation and increases the risk of hypertension. Diabetes affects 1 in 20 older people and can increase the risk of having a stroke. Good control of diabetes is important and requires attention to diet, regular urine tests or blood tests and probably some medication.

·         Sickle cell disease- changes in the shape of the red blood cells increase blood viscosity and produce erythrocyte clumps that may occlude small blood vessels.

·         Too much alcohol increases the risk of a stroke. The recommended safe limits for alcohol consumption are 21 units each week for women and 28 units each week for men. One unit of alcohol is equivalent to a measure of spirits, a 125ml glass of wine or half a pint of beer. People who drink more than this run a higher risk of stroke, liver disease and dementia.

·         Atherosclerosis- Occlusion of cerebral vessels by atherosclerotic plaque impairs or obstructs blood flow to specific areas of the brain.

Diagnostic Tests

ü  Computed Tomography (CT) scan with contrast is used to detect

·         bleeding caused by a ruptured or leaking aneurysm, ischemia, edema, and tissue necrosis

·         a blood clot or bleeding within the brain shortly after a patient exhibits symptoms of a stroke.

·          

Nursing Considerations:

Preprocedure Interventions:

a. obtain an informed consent because a dye is used

b. assess for allergies to iodine, contrast dyes, or shellfish if a dye is used

c. instruct the client in the need to lie still and flat during the test

d. instruct the client in the need to hold his or her breath when requested

e. initiate an intravenous line if prescribed

f. remove objects from the head, such as wigs, barrettes, earrings, and hairpins

g. assess for claustrophobia

h. inform the client of possible mechanical noises as the scanning occurs

i. Note that some clients may be given the dye even if they report an allergy and are treated with an antihistamine and corticosteroids before the injection to reduce the severity of a reaction

Postprocedure interventions

a. Provide replacement fluids because dieresis from the dye is expected

b. Monitor for an allergic reaction to the dye

c. Assess dye injection site for bleeding or hematoma, and monitor extremity for color, warmth, and the presence of distal pulses

ü  Arteriography of cerebral vessels is performed to demonstrate abnormal vessel structures, vasospasm, loss of vessel wall integrity, and stenosis of the carotid arteries.

ü  Transcranial Ultrasound Doppler (TCD) studies are used to evaluate the velocity of the blood flow through the intracranial arteries and provide information about partial or complete occlusion

ü  Magnetic Resonance Imaging (MRI) test may be conducted to examine cerebral blood flow distribution and metabolic activity of the brain. Both tests  use very short- lived radionuclides that emit radioactive energy as they move through the circulation. PET allows the identification of the location and sixe of the stroke; SPECT provides information about the metabolism of and blood flow through the brain tissue affected by the stroke.

ü  Lumbar Puncture may be performed to obtain cerebrospinal fluid for examination if there is no danger of increased intracranial pressure. (Removal of cerebrospinal fluid when intracranial pressure is increased can result in herniation of the brainstem.) A thrombotic stroke may elevate cerebrospinal fluid pressure; after a hemorrhagic stroke frank blood may be seen in the cerebrospinal fluid.

ü  Electroencephalography is a graphic recording of the electrical activity of the superficial layers of the cerebral cortex.

Preprocedure Interventions:

a. Wash/ Shampoo the client’s hair

b. Inform the client that electrodes are attached to the head and that electricity does not enter the head

c. Withhold stimulants, antidepressants, tranquilizers, and anticonvulsants for 24 to 48 hours before the test as prescribed.

d. Allow the client to have breakfast if prescribed

e. Premedicate for sedation as prescribed

Postprocedure Interventions

a. Wash the client’s hair

b. Maintain side rails and safety precautions if the client was sedated

Nursing Diagnoses and Interventions

Ø  Ineffective Tissue Perfusion (Cerebral)

- Monitor respiratory status and airway patency. Auscultate pulmonary sounds and monitor respiratory rate and results of studies of arterial blood gases.

-Suction as necessary, using care to suction no longer than 10 to 15 seconds at any one time, and using sterile technique

- Place in a side- lying position (Positioning the client on the side allows secretions to drain out of the mouth, helping to prevent aspiration)

- Administer oxygen as prescribed

Ø  Impaired Physical Mobility

The brand goals of care for clients with Impaired Physical Mobility are to maintain and improve functional abilities (by maintaining normal function and alignment, preventing edema of extremities, and reducing spasticity) and to prevent complications.

- Encourage active ROM exercises for unaffected extremities and perform passive ROM exercises for affected extremities every 4 hours during day and evening shifts and once during the night shift. Support the joint during passive ROM exercises. Active ROM exercises maintain or improve muscle strength and endurance, and help to maintain cardiopulmonary function. Passive ROM exercises do not strengthen muscles but do help maintain joint flexibility. (Both active and passive exercise increase venous return, decreasing the risk of thrombophlebitis)

- Turn every 2 hours around the clock, following a posted schedule for side- to- side and supine- to- prone position changes (verify prone positioning with the physician). Maintain body alignment and support extremities in proper position with pillows. Turning on a regular basis, accompanied by proper positioning, maintain joint function, alleviated pressure on bony prominences that can lead to skin breakdown, decreases dependent edema in hands and feet, and lessens the risk of complications resulting from immobility

Ø  Self- Care Deficit

- Encourage use of unaffected arm to bathe, brush teeth, comb hair, and other activities of daily living (ADLs). Used of the unaffected arm promotes functional ability and independence.

- Teach patient to put on clothing by first dressing the affected extremities and then dressing the unaffected extremities. This technique facilitates self- dressing with minimal assistance.

- Collaborate with the occupational therapist in scheduling times for training for upper extremity functioning necessary for activities of daily living. Encourage the use assistive devices (if required) for eating, physical hygiene, and dressing. Following a regular schedule in daily routines promotes learning. The use of assistive devices promotes independence and decrease feelings of powerlessness. Optimal grooming facilitates positive self- concept.

Ø  Impaired Verbal Communication

- Approach and teach the client as an adult

- Do not assume that the client who does not respond verbally cannot hear. Do not use a raised voice when addressing the client. Speak softly.

- Allow adequate time for the client to respond

- Face the client and speak slowly

- when you do not understand the client’s speech, be honest and say no

- use short, simple statements and questions

- try alternative method of communication, including writing tablets, flash cards, and computerized talking boards.

Impaired Urinary Elimination and Risk for Constipation

- Assess for urinary frequency, urgency, incontinence, nocturia, and voiding in small amounts. In addition, assess the client’s ability to respond to the need to void and the ability to use the toileting equipment.

- Encourage bladder training by having client void on schedule, such as every 2 hours, rather than in response to the urge to void.

- Teach Kegel exercises. To perform Kegel exercises, the client contracts the perineal muscles as though stopping urination, holds the contraction for 5 seconds, and then releases.

- Use positive reinforcement (verbal praise) for successful management of urinary elimination

Voiding every 2 hours or on schedule promotes bladder tone and urine storage. Kegel exercises increase pubococcygeal muscle tone and bladder control, decreasing incontinence. Positive reinforcement can be a useful part of the teaching program

- Discuss prestrike habits, as well as the pattern of bowel elimination since the stroke

- If the client is able to swallow without difficulty, encourage fluids (up to 2000 mL per day) and a high- fiber diet

- Increase physical activity as tolerated

- assist in using the toilet facilities at the same time each day (based on usual patterns of bowel elimination), ensuring privacy and having client sit in upright position if at all possible.

- Administer prescribes stool softeners if the client is following a bowel elimination routine or is not drinking sufficient fluids.

Impaired swallowing

- Ensure safety when eating

- Positioning upright sitting position with neck slightly flexed

- Order pureed or soft foods

- Feed or teach the client to eat by putting food behind the front teeth on the unaffected side of mouth and tilting the head slightly backward. Teach to swallow one bite at a time.

- Have suction equipment available at bedside in case of choking or aspiration

NOTE:

A. Before administering a medication through a nasogastric tube, the nurse should Introduce 10 ml of air into the NG tube and aspirate.

B. When administering intermittent tube feedings via an NG tube, flushing the tube with water is the most important thing to perform after feeding is complete.

C. The best indicator of proper placement of a nasogastric tube in the stomach is having a Ph of the aspirate that is less than 6.

D. Proper technique with gravity tube feeding

-Feeding bag is hung 1 foot higher than the tube’s insertion point into the client

Medications

ü  Anticoagulant Therapy- is often ordered for thrombotic stroke during the stroke-in- evolution phase but is contraindicated in completed stroke because it may increase the risk of cerebral hemorrhage. Anticoagulants are never administered to a client with a hemorrhagic stroke. Anticoagulants do not dissolve an existing clot but prevent further extension of the clot and formation of new clots. Sodium heparin maybe given subcutaneously or by continuous IV drip, or warfarin sodium (Coumadin) may be given orally.

Note: Suggest a treatment regimen to keep the patient on schedule of taking the drug.

ü  Thrombolytic Therapy, using a tissue plasminogen activator such as recombinant altephase, sometimes given concurrently with an antiacoagulant, is used to treat thrombotic stroke. The drug converts plasminogen to plasmin, resulting in fibrinolysis of the clot. To be effective, it must be given within 2 hours of the onset of manifestations.

ü  Antithrombotic drugs, which inhibit the platelet phase of clot formation, have been used as a preventive measure for clients at risk for embolic and thrombotic CVA. Both aspirin and dypiridamole have been used for this purpose. Antiplatelet agents are contraindicate in patients with hemorrhagic stroke.

ü  Calcium Channel blockers, such as Nicardipine are under investigation and have been used in clinical trials to reduce ischemic deficits and death from stroke. They block glutamate, an excitatory neurotransmitter, to reduce the sensitivity of neurons to ischemia.

Note: Proper preparation for Nicardipine Drip includes, combining D5W 90 cc + 10 cc of nicardipine to make up 100 cc and infuse via soluset and regulate according to doctor’s order.

ü  Corticosteroids, such as prednisone and dexamethasone have been used to treat cerebral edema. If the client has increased intracranial pressure, hyperosmolar solutions (such as mannitol) or diuretics (such as furosemide) may be administered.

- Mannitol is an osmotic diuretic that is frequently used for patients with increased intracranial pressure (cerebral edema). Diuresis occurs within 1 to 3 hours after administration.

Note: Nursing Considerations

1)                  Check first the blood pressure of the patient before administering the drug

2)                  Monitor for I & O

3)                  Monitor for serum electrolytes

4)                  Crystallization of mannitol in vial may occur when the drug is exposed to low temperature. The vial should be warmed to dissolve the crystals.

ü  Anticonvulsant, such as phenytoin (Dilantin), and barbiturates may be prescribes if increased intracranial pressure causes seizures.

Glasgow Coma Scale

Glasgow Coma Scale or GCS, is a neurological scale which aims to give a reliable, objective way of recording the conscious state of a person, for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale).

GCS was initially used to assess level of consciousness after head injury, and the scale is now used by first aid, EMS and doctors as being applicable to all acute medical and trauma patients. In hospitals it is also used in monitoring chronic patients in intensive care.

  

Elements of the scale

Glasgow Coma Scale
	1	2	3	4	5	6
Eyes	Does not open eyes	Opens eyes in response to painful stimuli	Opens eyes in response to voice	Opens eyes spontaneously	N/A	N/A
Verbal	Makes no sounds	Incomprehensible sounds	Utters inappropriate words	Confused, disorientated	Oriented, converses normally	N/A
Motor	Makes no movements	Extension to painful stimuli	Abnormal flexion to painful stimuli	Flexion / Withdrawal to painful stimuli	Localizes painful stimuli	Obeys commands

The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person).

Best eye response (E)

There are 4 grades starting with the most severe:

1. No eye opening
2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)
4. Eyes opening spontaneously

Best verbal response (V)

There are 5 grades starting with the most severe:

1. No verbal response
2. Incomprehensible sounds. (Moaning but no words.)
3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

Best motor response (M)

There are 6 grades starting with the most severe:

1. No motor response
2. Extension to pain (abduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response)
3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
6. Obeys commands. (The patient does simple things as asked.)

NOTE: When checking the pupillary response, the doctor should first darken the room.

Pupil checks are ordered because blurred vision is a sign of increasing ICP.