Neurosensory Disorders: Stroke (CVA, Brain Attack)

Marnie Quick RN, MSN, CNRN

A. Pathophysiology/etiology Normal brain physiology and stroke    Ranks 3 rd as cause death Blood supply to one hemisphere is typically blocked, hence terms right & left stroke Functioning brain depends on continuous blood supply for oxygen and glucose & remove end products metabolism

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Risk factors for stroke:

Nonmodifible- age, gender, race, family history/heredity Modifible: hypertension*; atherosclerosis* heart disease; DM; medication (birth control, substance abuse-cocaine/heroin and alcohol; sedetary life style obesity; high cholesterol diet; smoking; stress; sickle cell disease

Brain dysfunction & length of time without blood supply      Brain function depends on collateral circulation and amount of cerebral edema TIA- neuro deficits last < 24 hrs RIND- neuro deficits last > 24 hrs but reverse not greater than 21 days CVA- irreversible brain damage with residual neuro deficits Stroke-in-evolution- progressive neuro deficits developing over hours or days. Usual cause thrombosis

Two basic disease process causing stroke

 Ischemic stroke- 80%  Occlusion of artery     Generally do not lose consciousness Better prognosis than hemorrhagic May have TIA’s before Thrombosis or embolism  Hemorrhagic stroke- 15%  Bleed occurs with activity    Usually rapid onset Generally loss of consciousness Poorer prognosis  Intracranial or subarachnoid

     Ischemic stroke: Thrombosis   Most common cause of a stroke (60%) Cause- narrowing of artery from atherosclerotic plaques Blood is blocked to part of brain that the artery supplies Often occurs in older individuals who are at rest/sleeping Tend to form in large arteries that bifurcate, internal carotid artery common site Can begin as TIA’s, present as stroke-in-evolution, or have completed stroke outright Lacunar strokes are strokes affecting smaller cerebral vessels in brain- they leave a cavity or ‘lake’

Ischemic stroke Embolism      Caused by: clotted blood from other arteries in the body (heart during atrial fibrillation) fat, bacteria (endocarditis) or air Emboli circulate until reach an artery in brain that is too narrow to pass through Usually awake with rapid onset Extent damage is less severe and recovery faster than other strokes Will recur if don’t treat cause

Hemorrhagic stroke Intracranial hemorrhage (ICH)        Caused by ruptured artery in the brain Bleeding varies in size from petechial to massive, edema occurs around the bleed Blood may form hematoma or be diffuse within the brain Usually occurs rapidly with the deep arteries Hypertension is main cause Most common cause of death due to a stroke Have more extensive residual deficits and slower recovery than other causes of stroke

Hemorrhagic: Subarchnoid hemorrhage (SAH)   Caused by bleeding into subarchnoid space from  Extension of a intracranial hemorrhage   Aneurysm AV malformation Usually occur in younger adults 30-60 than other strokes

Hemorrhagic: SAH Aneurysm     Occur at bifurcations, branches of carotids & vertebrobascular arteries 85% base brain in anterior circulation Most common type is berry-bleed from dome Caused by trauma, congential, arteriosclerosis

Hemorrhagic: SAH- Aneurysm      Aneurysms are graded 0-V on the Hunt/Hess scale; higher the number, poorer chance survival. Based on LOC & quality of cerebral function Aneurysm are usually asymptomatic until rupture Ruptured- sudden explosive headache; loss of consciousness; N & V; nuchal rigidity (stiff neck) and photophobia from meningeal irritation; cranial nerve deficits Major complications: rebleed, vasospasms, and hydrocephalus

Hemorrhagic: SAH A-V malformation    Congential abnormal joining of arteries to veins in the brain. As pressures changes occur becomes tangled collection of dilated vessels.

Ischemia symptoms seizures and interference with normal function of those brain cells

Common manifestations/complications by body systems

By artery affected by occlusion or hemorrhage Internal carotid

Middle cerebral artery

Middle cerebral artery

     Contralateral motor loss in the arm and the lower part of the face (central facial palsy) Contralateral sensory loss in face and arm Homonymous hemianopsia Left middle cerebral communication deficits Right- spatial/perceptual

Other main arteries off Circle of Willis

   Anterior cerebral Posterior cerebral Verebrobasilar   Pain or numbness of involved side Vertigo    Contralateral ataxia Dysphagia, dysarthria Cranial nerve dysfunctions

Common Manifestations: Motor deficits

    Motor nerve pathways cross in the medulla (brainstem) Prefix hemi- used to describe. Extremities not affected equally- middle cerebral Amount of motor involvement varies from weakness (-paresis) to paralysis (-plegia).

End paralysis can be flaccid or spastic depending on amount of damage to the motor strip Initially flaccid and if progress are spastic in 6-8 weeks.

Motor deficits- Characteristic body posture

Motor deficits

   Facial palsy (central/UMN) where

lower

part face affected Bells palsy (LMN- 7 th CN) where the

whole

side of face affected Dyphagia- difficulty swallowing

Sensory-perceptual deficits Lack of sensation/propriocetion   Lack of sensation (hemi)- inability to perceive/interpret pain, touch, pressure (post central gyrus) Lack of/decrease in proprioception or the inability to know where body part is without having to look at it; body’s ‘position sense’

Sensory-perceptual deficits Visual field deficits   Disruption anywhere along the pathway Homonymous hemianopsia- most common. Loss of half of visual field in each eye. Can’t see toward the same side as the paralysis

Homonymous hemianopsia What the patient sees

Communication Deficits

      Motor, speech, language, memory, reasoning, emotions can be affected Dominant hemisphere for the communication centers is left in most individuals Global (mixed) aphasia- both expressive (Broca’s area ) and receptive (Wernicke’s area) aphasia Aphasia- total loss of comprehension or use of language Dysphasia partial loss or difficulty with communication Dysarthria- difficulty with articulation or muscular control for speech. Sound like have mashed potatoes in their mouth

Communication Deficits Broca’s and Wernicke’s aphasia   Broca’s, expressive or nonfluent aphasia where unable to express- but understands Wernicke’s, receptive, fluent aphasia- can talk but unable to understand

Broca speech area Wernicke speech area

Communication Deficits Normal process recovery     Begin with one word speech- swearing, ‘ouch’ Progress to sayings – days of week, social speech, singing Volitional- normal speech Recovery may stop at any point, depending on the amount of damage to speech centers

Affect and intellectual deficits

     Change level consciousness- confusion to coma Emotional lability- exaggerated, unpredictable emotional responses. Physiological in nature Loss of self control, decrease tolerance for stress Depression, frustration (esp left CVA) Intellectual changes resulting in memory loss, decreased attention span, poor judgment, inability to think abstractly and make generalizations

Sensory-perceptual deficits Neglect syndrome (unilateral neglect)     Attention disorder in which individual ignores affected part of the body, Cannot integrate or use perceptions from affected side or from the environment from that side May observe head turned away from neglected side, does not dress that side, neglects people objects on that side. Diff judging distances More common in right CVA’s; patient may not be aware of deficit

Sensory-perceptual deficits: Agnosia Apraxia   Inability of the senses to perceive stimuli that were previously familiar.

May be any of the senses and varying degrees   Inability to carry out purposeful task in the absence of paralysis Or the individual carries out task inappropriately

Elimination Deficits

   Partial loss of sensation (hemi) can affect perception of need to eliminate bowel/bladder Cognitive problems may affect the social aspect of elimination Level of consciousness, immobility, dehydration, diet changes

Immobility complications of Stroke

         Any of the immobility complications can occur!

Orthostatic hypotension Thrombus formation Impaired respiratory function Formation of renal calculi Decreased CO Osteoporosis Decubitus ulcer Contractures

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Collaborative Care for Stroke Diagnostic tests

CT- Most important initial- within 25 min Read 45min indicate size location of lesion; differentiate ischemic from hemorrhagic. PET- cerebral blood flow and metabolic activity MRI or MRA (combined MRI with arteriogram) Cerebral blood flow   Arteriogram- abnormal structures; vasospasm, stemosis Transcranial ultrasound doppler velocity of blood flow, degree of occlusion Cardiac assessment: EKG; cardiac enzymes Other: LP- obtain CSF, ck bleeding; Blood studies-CBC, glucose, lipid, platelets

Collaborative Preventive care- Manag of modifiable risk factors- medications/surgical   Lewis p1466 Table 58-5 prevention of stroke guidelines and specific treatment for modifiable risk factors with:   medication- treat hypertension, DM, cardiac problems, etc life style changes: smoking, dietary changes treat hypertension, DM, cardiac problems, etc Preventative treatment with surgery, such as carotid endarterectomy, stenting

Carotid Endarterectomy

Brain stent to treat blockages in cerebral blood flow

Collaborative Acute Care: Emergency Management of a Stroke

  Lewis p. 1468 Table 58-6 Etiology   Assessment findings Interventions   Initial Ongoing

Collaborative Acute Care: Thrombolitic stroke   Medication     Thrombolitic agents to dissolve clot- 3 hrs!!! tPA Activace. Protocol prior to giving as R/O bleed Anticoagulants to prevent further extension Antithrombolitic inhibit platelet phase of clot formation (Ticlid, Plavix, aspirin) Anticonvulsants prevent seizures from focus Surgical    Endarterectomy Angioplasty, carotid artery stenting Bypass superficial temporal to middle cerebral

Collaborative Acute Care: Embolic/intracranial stroke   Embolic stroke  Medications: If blood clot- anticoagulants, thrombolitic agents, antiarrhythmics; If bacterial antibiotics  Surgical- Embolic retrieval (Merci retriever) Intracranial hemorrhage (ICH) stroke    Bedrest Medication- antihypertensives to normal BP Surgery- remove hematoma if possible

Merci retriever to remove cerebral clot

Collaborative Care: Intracranial Hemorrhage (ICH)

  Bedrest Medication- antihypertensives  Surgical- If hematoma remove

Collaborative Care: SAH   Aneurysm precautions- decrease external/internal stimuli Medications    Aide with aneurysm precautions- stool softners, antinausea,etc To prevent rebleed/lysis of clot- Ammicar To prevent vasospasms- Nimodipine  Before OR- Ca channel blocker- Nimodipine  After OR-triple H- vasodilators (Isuprel); induced arterial hypertension (Dopamine); hypervolemic hemodilution (Albumin)  Prophylactic antiepileptic- Cerebyx/Dilantin

SAH- Common manifestation/complications Major complications    Rebleed due to reabsorption of the clot that is stopping the bleed Vasospasms due to irritation of the blood vessels Hydrocephalus from blockage of normal absorption of CSF

Surgical intervention: Clipping and Wrapping of Aneurysms

Surgical: GDC Coil

SAH A-V malformation    Embolization, ligation of feeders, laser surgery to remove Gamma Knife- radiation to reduce size of A-V malformation> Cyberknife below

Collaborative Rehabilitation Care         Physiatrist (rehab physician): Outpatient or in house rehab Physical therapy; Occupational therapy; Speech therapy; Cognitive therapy, etc Exercise program Outpatient, in-house rehab, nursing home Home evaluation Encourage self-care Community resources Family support

Nursing assessment specific to stroke Health history & physical exam   Subjective data: Lewis 1472 Table 58-7  Health history- Risk factors; when symptoms began; describe symptoms; current medications (legal/illegal); other health problems; family history Objective data   General; respiratory; cardiovascular; GI; urinary; neuro; Vital signs; neuro vital signs (LOC, pupils, motor, sensory) Level of consciousness- Refer to Module 10

Nsg assess- neuro deficits common in stroke Motor     Movement, strength (with & without resistance), symmetry of all extremities Pronator drift- detects weakness of upper extremity. Hold arms, palms up in front with eyes closed- should be able to hold for 30 seconds. Weakness pronates and drifts downward Use similar techniques used to assess motor SCI motor pathways affected begin motor strip brain Test facial movement- smile/frown test for Bell’s (7 th CN) and central facial (motor strip)

Nursing assess- neuro deficits common stroke Motor  EOM’s- head still, follow your finger in all quadrants. Eyes should move together (conjugate gauze) Abnormal: dysconjugate gauze; nystagmus; 3 rd nerve palsy (occulomotor); 6 th nerve palsy (abducens)

Nursing assess neuro deficits: Motor 3 rd nerve palsy 6 th nerve palsy

Nursing assess- neuro deficits common stroke      Assess tongue deviation stick out tongue Ability to swallow, gag, Dysphagia- difficulty swallowing Assess ability to void and move bowels Assess communication ability Assess cognitive and behavioral aspects

Nursing assess-neuro deficits common stroke Sensory deficits    Superficial sensation With paperclip and eyes closed alternate sharp and dull ends Reference is the sensory strip on the parietal side

Nursing assess- neuro deficits common stroke Sensory   Proprioception position sense With eyes closed and hoding the toe on the sides, move toe up & down (not touching the other toes), stop then ask is toe up or down

Nursing assess- Sensory: visual field loss common- homonymous hemianopia    Patient look straight ahead & in a still position, cover one eye- test one at time Move your wiggling finger into the patients field of vision in all 6 quadrants State when 1 st sees

Nursing assess- neuro deficits common stroke Sensory-perceptual    Visual agnosia: individual becomes lost on unit; cannot read sign/symbols; difficulty estimating distance (spills food); cannot find objects; does not recognize faces on photo or own image Auditory agnosia: ind appears bewildered by sounds; and does not respond approp- phone ringing; can’t identify sound as running water Tactile agnosia- with eyes closed can’t recognize familiar objects- comb, pencil; unaware location; diff positioning self- slouches to one side

Nsg assess- neuro deficits common stroke Sensory-perceptual    Apraxia- stares at food tray unaware of how to get food to mouth; combs hair with toothbrush; puts shirt on legs Unilateral neglect; ignores paralyzed arm or leg; may claim it is not theirs; bumps into wall as going down hall; unaware of objects place on paralyzed side Loss of postural stability>>

Loss of postural stability. Unable to sit upright and tends to fall sideways

Nursing assessment specific to stroke National Institute Health (NIH) stroke scale     An assessment scale to reflect the degree of neurologic dysfunction specifically for stroke Based on level of consciousness, gaze, visual, facial palsy, motor, ataxia, sensory, language, dysarthria, and extinction and inattention (neglect) Know how to test for each aspect using the tool found on the website: http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

   NIH Stroke Score guidelines measuring stroke severity:  0= no stroke      1-4= minor stroke 5-15= moderate stroke 15-20= moderate/severe stroke 21-42= severe stroke A maximal score of 42 represents the most severe and devastating stroke. As of 2008 stroke patients scoring greater than 4 points can be treated with tPA . If meet other protocalcriteria http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

Pertinent Nursing problems/interventions Lewis p.1473 NCP 58-1 1. Ineffective tissue perfusion (cerebral)     Monitor resp status; provide O2; suction needed Monitor neuro, specifically increasing neuro deficits, seizures, and ICP(Module 10); HOB 30 degrees Monitor cardiac status, esp dysrhythmias If individual unconscious- coma care  2. Ineffective airway clearance

Nursing problems/interventions 3. Impaired physical mobility        Encourage active (when possible)& passive ROM Change position every 2 hrs, esp if comatose Monitor/prevent thrombophlebitis Work with Rehab team Arm sling- used to prevent subluxation of the shoulder from a paralyzed arm when OOB Splints- hand/foot to prevent contractures; set up schedule- on 2 hrs off 2 hrs- use ROM Assistive devices

Nursing problems/interventions 4. Impaired verbal communication     Assess speaking, writing, gestures, understanding Support speech therapist plan Support guidelines Swearing may be first sign of return of speech, not directed at you or family   5. Unilateral neglect 6. Impaired urinary elimination

Pertinent Nursing problems/interventions 7. Impaired swallowing     Dysphagia- impaired swallowing Provide safety when eating! Assess ability, head of bed up; begin with food of consistency; food on unaffected side; have pt think swallow Occupation therapy and /or speech therapy can evaluate the individuals ability to get food to mouth and to swallow Swallow studies

Nursing problems/interventions 8. Low self-esteem 9. Self-care deficit       Enourage use of paralyzed extremity Teach dsg tech- affected arm in clothing first Work with rehab team regarding ADL’s, use of assistive devices, plans for progress, home care Allow time and encouragement ADL’s Assess both physical & cognitive ability ADL With agnosia encourage pt use other senses

   With apraxia- break complex tasks down into simple steps; have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence Perseveration- may have to tell person to stop action that they are perseverating about or may have to physically stop them Homonymous hemianopsia in acute phase approach from the sighted side; as client progresses- teach/encourage to scan room and place objects on unsighted side

Pertinent Nursing Problems: Nursing Management of the following:        Health promotion Respiratory system Neurologic Cardiovascular Musculoskeletal Integumentry Gastrointestional       Urinary system Nutrition Communication Sensory-perceptual alterations Affect Coping

Pertinent Nursing Problems: Ambulatory and Home Care       Rehabilitation Musculoskeletal function Nutritional Therapy Bowel function Bladder function Sensory-Perceptual      Affect Coping Sexual function Communication Community integration