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
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).
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:
- No
eye opening
- 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.)
- Eye
opening to speech. (Not to be confused with an awaking of a sleeping
person; such patients receive a score of 4, not 3.)
- Eyes
opening spontaneously
Best verbal response (V)
There are 5 grades starting with the most severe:
- No
verbal response
- Incomprehensible
sounds. (Moaning but no words.)
- Inappropriate
words. (Random or exclamatory articulated speech, but no conversational
exchange)
- Confused.
(The patient responds to questions coherently but there is some
disorientation and confusion.)
- 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:
- No
motor response
- Extension
to pain (abduction
of arm, internal rotation of shoulder, pronation of forearm, extension
of wrist, decerebrate
response)
- Abnormal
flexion to pain (adduction of
arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate
response)
- 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)
- Localizes
to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses
mid-line and gets above clavicle when
supra-orbital pressure applied.)
- 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.
