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Risk factors for stroke
- Age
- Gender
- Race
- Heredity
- Modifiable:
- Hypertension
- asymptomatic carotic stenosis
- heart disease (afib)
- DM
- alcohol
- smoking
- hypercoagulability
- hyperlipidemia
- obesity
- oral congraceptives
- sickle cell
- physical inactivity
- migrane
- patent foramen ovale (PFO)
- Coacain
- Methamphetamine
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Pathophys of stroke
- Blood is suppied to the brain by two majro pair of arteries:
- internal carotic
- vertebral
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TIA
- tempr cessation of blood flow
- experience transient symptoms
- symptoms typically last <1hr, up to 24 hr
- pt should seek med care
- Event should be seen as an "early warning system," which will probably-->Rx asprin or other prophylactic treatment for stroke, diet education, etc.
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TIA SnSs
- Carotid symptoms
- tempt vison loss
- transient hemiparesis (one-sided weakness)
- numbness/loss of sensation
- aphasia (diff/inability to speak)
- Vertebrobasilar symptoms:
- tinnitus
- dysphagia
- vertigo
- ptosis
- ataxia
- dysarthria (slurred speech)
- blurred vission
- unilateral or bilateral numbness/weakness
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Management for TIA
- Diagnostics:
- CT (gold standard, but only good after 24 hours. Ischemic stroke only, will be good immediately for hemorrhagenous stroke)
- MRI
- Cardiac monitor (check for afib)
- ECHO
- Carotid NIVA
- Lipid panel
- coag panel
- Hgb A1C
- Rx:
- Antihypertensives
- Antiplatelet
- Surgery:
- Carotid endarterectomy
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TIA vs Stroke
- Transient
- resolve
- ischemia to brain
- no infarction
- no damage to brain on mri
- warning sign for future stroke
- short hospital stay
-
hemorrhagic stroke
- subarachnoid hemorrhage
- intracerebral hemorrhage
- ateriovenous malformation (congenital abnormality
- coag disorder
- anticoage/thrombotic (reverse)
- trauma
- brain tumor
- reptured aneurysm
- Intervensions:
- stat CT head
- Risk=HTN
- SnSs: Headache, n/v, v LOC, neuro deficits
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Hemorrhagic Stroke
- 40% mortality rate
- caused by: ruptured aneurysm, trauma, drug use.
- complications:
- vasospasm
- rebleeding
- hydrocephalus
- seizure
- EKG
- SnSs:
- Neuro deficits
- meningeal s/sx (stiff neck, bad headache, light sensitive)
- n/v
- vision issues
-
Ischemic stroke
- Infarction vs ischemia
- thrombotic: progressive SnSs
- Embolic: rapid onset (afib)
- small artery occlusive disease
- Cryptogenic (unknown source)
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SnSs of Ischemic stroke
- weakness/paralysis to face/arm/leg, often one side but can be bilat
- numbness
- sudden confusion, trouble speaking or understanding
- slurred speech
- vission problems
- dizziness/loss of balance/coord/ataxic
- diff swalling (npo)
- sudden severe headache, n/v
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Time is Brain
- FAST
- Face: smile will droop on one side
- Arm: both arms raised, should be symetrical bilat
- Speech: speak simple sentence, slurred? unable?
- Time: When was last time pt was normal? 3 hr clock starts then.
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Stroke: rt vs lt side
- rt side: Rt brain, lt body
- spatial perceptial deficits
- tend to deny or minimize problems
- rapid performance, short attention span
- impulsive, saftey problems
- impaired judment
- impaired time conception
- lt side: lt brain, right body
- impaired speech/language
- impaired rt/left discrimination
- slow performance, cautious
- aware of deficits, depression, anxiety
- impaired comprehension related to language math.
Both will have physical deficits on opposite side of body.
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Classic stroke symptoms
motor defictis (pronator drift)
- Mobility:
- --Hemiparalysis/paresis
- --Flaccid/spastic tonicity
- --Hypo/hyperreactive reflexes
- --Gait, balance, posture
- Respiratory
- --aspiration? Intubate
- Swallowing:
- --Dysphagia
- Speech:
- --Dysphasia/arthria
- Selfcare:
- --Diminished ADLs
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Stroke symptoms
Dysphasia
- print slide 31
- Aphasia
- --broca's: expressive. Diff talking
- --Wernicke's: receptive (cannot hear/understand language)
- --Global: all of the above. Do not rehab well and usually causes premanent deficits.
- Dysarthria: slurred speech
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Classic Stroke SnSs
affective
- Emotions exaggerated or upredictable
- --depression?
- --Mood lability (mood swings)?
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Classic stroke SnSs
Cognition
- Left-sided:
- --impaired memory
- --cautious
- Right-sided
- --Impaired judgment
- --impulsive
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Spatial perceptual issues
- more common with Rt side stroke
- four categories
- --lack of insight
- --neglect (extinction
- ----homonymous hemianopsia
- --agnosia (object recognition
- --apraxia (unable to do learned taskes)
-
Classic stroke symptoms
elimination issues
- temporary
- related to inablity to communicate or express need
- urinary (usually incontinence)
- bowels (constipation)
-
Ct diagnostics
- noncontrast ct head
- --CTA: angiogram
- --CTV: venogram
- --CTP: perfusion
- Cerebral angiogram (with contrast
- MRI/MRA (takes longer than CT; 45min vs 10.)
- Transcranial doppler: used to find vasospasm
- Lumbar puncture (test material) fetal side line position. Look for clear liquid at base of spine after procedure.
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How do we treat ischemic stroke?
Test
- TPA: tissue plasminogen activator
- --intravenous: 3 hour limit
- --intraarterial: 6 hour limit
- Intervential radiology-clot retrieval/stents
- antiplatelet: aspirin plavix, aggrenox, ticlid
- lipid lowering agent, ie statins
- coumadin: afib or clotting disorder
- surgical: carotid endarterectomy (CEA)
- maintain airway/monitor blood pressure
- rehab: pt/ot/st
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Carotid Endarterectomy
Post procedure monitor for any snss of neuro change that could signify a stroke!
-
thrombolytics-tPA
- for ischemic stroke
- Must be administered within 3 to 4.5 hours from onset
- increased risk of bleeding
- must meet set criteria
- NIH stroke scale:
- --LOC
- --motor: face/arm/leg
- --speech
- --sensory
- --vision
- --ataxia
- --extinction
-
acture care of ischemic cva
- neuro, resp, cardiac
- --risk of herniation peaks 72 hrs post cva
- antithrombolitics
- fluid balance, e-lytes
- normothermia (fever exacerbates ischemia), give tylenol
- maintain normal blood sugar
- assess for seizure
- dvt prophylaxis
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Collaborative care
prevention
test
- Risk factors
- --modifiable:
- ----HTN
- ----smoking
- ----ETOH
- ----diet
- ----exercise
- ----weight
- --Nonmodifiable?
- Antiplatelet drugs, ie ASA plavix-->assess for bleeding
- lipid lowering agents, ie statins
- Surgical interventions
- --interventional procedures
- --carotid endarterectomy
-
Collaborative care
Acute Care
- Initial Interventions
- --perform baseline lab tests
- --position head midline
- --elevate bed 30d if no SnSs of shock/symptoms
- --seizure precautions
- anticipate thrombolytic therapy for ischemic stroke
- --ensure patent airway and O2
- --Obtain CT scan immediately
- --
remove denture - --IV access with normal saline
- --maintian BP according to guidelines
- ----permissive HTN (ischemic)
- ----avoid hypotension-->hypoperfusion
-
post stroke assessment and care
- Vs and neuro checks
- NIHSS frequently
- LOC
- CN I-XII
- motor and sensory fucntion
- cerebellar fnxn
- pupil size and reactivity
- O2 sat
- Cardiac rhythm
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Nursing amangement
- Coping
- --stroke is often a family disease, ie emotionally, financially,
- ambulatory and home care
- --home
- --LTAC?
- et al
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