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Flashcards in CVA Deck (52):
1

CVA

Also known as a “stroke” or “brain attack”
Results from inadequate blood flow to the brain
4th leading cause of death in the U.S.

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CVA patho

-Permanent Brain Damage occurs within 3 to 10 minutes when deprived of oxygen
-Type of deficit that results depends on the location and size of the brain area most affected

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causes of CVA

thrombosis
cerebral embolism

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CVA- thrombosis

Associated with atherosclerosis and HTN
Occurs most often at bifurcations; branch of vessel
Most common cause (over half of all strokes)
Onset: gradual
May be preceded by TIA (transient ischemic attack)
plaque buildup

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cerebral embolism

Emboli often arise from the heart (rheumatic heart disease with mitral stenosis; atrial fibrillation)
2nd most common cause of CVA
Middle cerebral artery most commonly involved (MCA)
traveling clot

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(Ischemic strokes) both thrombotic and embolic strokes may be preceded by warning signs

majority of emboli originate in the heart due to ineffective pumping or dysrhythmias
TIA (Transient Ischemic Attack): transient neurologic dysfunction caused by temporary ischemia
Warning sign of an impending stroke
Lasts

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hemorrhagic strokes

caused by rupture of blood vessel due to:
Poorly controlled HTN**, trauma, bleeding disorders
Rupture of intracranial aneurysms (abnormal dilation in a cerebral vessel); aneurysm can be congenital, traumatic, arteriosclerotic in origin and usually rupture during activity

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CVA cerebral vessels most affected

Middle Cerebral Artery (most common)
Internal Carotid Artery (2nd most common)

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risk factors for CVA

1. African American
2. Increase blood viscosity or clotting
3. Certain meds/drugs
4. Smoking History/Heavy ETOH Use
5. Obesity
6. Sedentary Lifestyle
7. Sickle Cell Anemia
8. Hypertension
9. Hyperlipidemia
10. Diabetes Mellitus
11. Heart Disease
12. Cardiac Disorders (Dysrhythmias, CHF, A-fib)
13. Age
14. Family History
15. Male
16. Periodontal Disease

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stroke prevention

1. Decrease Risk Factors
2. Control blood pressure (Can reduce risk of stroke up to 30%)
3. Use of blood thinners (inhibit platelet aggregation)
– ASA (aspirin)
– Persantine (Dipyridamole)
– Plavix (Clopidogrel)
– A-fib (blood thinners): Pradaxa, Xarelto, Coumadin
– Lipid Lowering Agents: Statins

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CVA if there are symptoms of a TIA

Suggestive of possible impending ischemic stroke
Assess for significant occlusion of carotids
Ultrasound or Arteriogram of the carotids is done

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CVA diagnostics

Carotid or Cerebral Arteriogram:
Purpose: used to identify aneurysms. Stenosis, AVMs (arteriovenous malformation)
CT: Differentiates hemorrhagic vs. non-hemorrhagic stroke; can visualize infarcted areas
MRI
ECG: determine dysrhythmias
Lumbar Puncture:

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carotid endarterectomy (CEA)

Purpose: remove atherosclerotic plaque from the inner lining of artery to restore blood flow
Carries a risk of death or stroke (1-9%)

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Post-op care for carotid endarterectomy (CEA)

Monitor: for hemorrhage
Monitor: for swelling (which could compromise airway)
Closely monitor neurological status:
1. LOC (level of consciousness), Mental Status
2. Pupil Checks
3. Hand Grips (muscle strength, symmetry)
4. Speech
Frequent vital sign assessment (BP management)

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assessment findings of thrombotic stroke

Sx may appear over minutes to hours to days

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assessment findings of hemorrhagic stroke

SX occur suddenly without warning

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right side brain function

specialized in sensory-perceptual functions, awareness of body space, visual-spatial processing

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left sided brain function

dominant for language in most persons

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characteristics of a left CVA

Right sided hemiparesis (weakness)
Right sided hemiplegia (paralysis)
Behavior is cautious, plodding, careful
Increased language problems

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characteristics of a right CVA

Left sided Hemiparesis (weakness)
Left sided Hemiplegia (paralysis)
Behavior is impatient, impulsive, lack of insight
Greater deficits in function ADL
Often have left sided (unilateral) neglect

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CVA unilateral neglect

Inability to respond to stimulus on the contralateral side of the cerebral infarction
May not believe arm is part of body, or unaware of position of extremity, or deny that limb is paralyzed

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Assessment Findings Common to Both Left & Right CVAs

1. Memory loss
2. Early fatigue
3. Visual changes
4. Motor weakness and paralysis
5. Emotional lability (sudden uncontrolled change in emotion or mood)
6. Decreased sensation, esp. temperature and pain

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CVA aphasia

Defined: impairment of ability to formulate or interpret language symbols
Classified as expressive, receptive, or global (mixed)

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Expressive aphasia CVA

Also known as: Broca’s or nonfluent (stutter)
Results from: damage in Broca’s area of frontal lobe
Client understands what is said but is unable to communicate verbally; has difficulty in initiating motor speech
Uses: hesitant, slow, labored, single word speech

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Receptive aphasia CVA

Also known as: Wernicke’s or fluent
Results from: damage to the Wernicke’s area in the temporoparietal area
Client unable to understand what is spoke or written; comprehension is impaired
Client may be able to: talk at a normal rate, but speech makes no sense
Client is unaware of: mistakes in speech

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global aphasia CVA

Also known as: mixed aphasia
Occurs with dysfunction in: both areas of expression and reception
Reading and writing ability are: equally effected
Few language skills

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dysarthria CVA

Difficulty pronouncing words from cranial nerve dysfunction or from weakness or paralysis of the muscles of the lips, tongue, and larynx

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visual changes due to CVA

Damage to the optic tract or occipital lobe may result in homonymous hemianopia

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CVA homonymous hemianopia

1. Blindness in the same side of both sides
2. Results in loss of half of the visual field

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CVA depending on area affected homonymous hemianopia

1. Changes may occur in depth perception
2. Diplopia may occur

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cognitive changes due to CVA

Depend on area and extent of injury:
Changes in attention span, concentration, orientation
Changes in judgment, memory, problem solving
LOC: ranges from alert to barely arousable, comatos; Use GCS (Glasgow Coma Scale to assess, 3-15)
may have agnosia or apraxia

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agnosia CVA

inability to recognize common objects, people, or sounds

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apraxia CVA

inability to carry out a previously learned action/activity

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cranial nerve damage due to CVA

May result in: Dysphagia:
Inability to chew (CN V trigeminal)
Absent gag reflex (CN X vagus)
Impaired tongue movement or deviation (CN XII hypoglossal)
Inability to swallow (CN IX glossopharyngeal and X vagus)

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cranial nerve damage due to CVA may result in

Facial paralysis, weakness with droop, or ptosis (CN VII facial)
Position on their unaffected side

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If stroke is hemorrhagic in nature, signs of meningeal irritation might be present including:

Severe headache, Nuchal rigidity, Irritability, Seizures

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CVA- Signs of meningeal irritation:

(+) Brudzinski’s: flex neck and pt. flexes hip/knee to relieve tension in their neck

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CVA nursing diagnoses

Ineffective Tissue Perfusion (Cerebral) R/T interruption of arterial blood flow
Many others related to motor, sensory, cognitive deficits:

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goals post-CVA

Prevent Complications
Maintain Function
Promote Optimal Functioning

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to maintain cerebral perfusion (CVA)

Thrombolytic Therapy: (for ischemic strokes)
To dissolve the clot and prevent neurologic deficits
TPA (Tissue Plasminogen Activator) or other enzyme (Streptokinase or Urokinase)
Must be given within three hours of the onset of stroke symptoms to be effective

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CVA nursing interventions

Neuro Assessments (GCS, vital signs)
Stabilize BP (Systolic BP directly affects cerebral blood flow)
Control Seizures (increased BP and oxygen demands occur with seizures)

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dysphagia is common

1. May need suction equipment if patient unable to handle secretions
2. Position on side if unable to handle secretions (to prevent pooling at the back of the mouth/throat
3. Evaluation by speech therapy
“Cookie Swallow” or modified barium swallow to determine if aspiration is occurring
4. Check for “pocketing of food” in cheeks (occurs with decreased sensation)

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maintain nutritional status CVA

1. Offer frequent oral hygiene
2. Use adaptive devices to promote feeding independence (OT)
3. If dysphagia is severe:
TPN or NG enteral feedings short term
PEG tube (G-tube) for long term enteral feedings

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CVA- promote perceptual/sensory function

1. Approach from side of intact vision
2. Teaching patient “scanning”
3. Promote consistent environment
4. Encourage familiar objects from home

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to promote mobility post CVA

1. Active and Passive ROM- Active achieves muscle strength and tone (movement the individual does on his/her own)
2. Physical therapy- for gait training or gross motor
3. Occupational therapy – for mine motor movement
4. Hand splints, leg braces, slings, etc. may be used to prevent contractures, prevent subluxation of shoulder, etc.

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promote self-care post CVA

1. Occupational Therapy
2. Emphasize routine and repetition to relearn self care activities
3. Use assist devices to promote independence
4. If aproxia (inability to carry out motor activities on command): use pictures, cues versus just verbal directions
5. Use loose fitting clothing with Velcro closures to easily put on and take off
6. Dress affected side first

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promote bowel and bladder function post CVA

1. Neurogenic bladder often occurs (bladder empties when it reaches a certain volume without voluntary control; incontinence) due to: cortical damage which affects inhibitory center in the brain
2. Stress regular toileting routines and times rather than waiting for an urge to go
3. Progressively increase the time between voidings to decrease frequency
4. Use fluids and diet to promote bowel irregularity

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promote efective communication post CVA

1. Speak slowly early
2. Allow sufficient time for response
3. Repeat names of objects used routinely
4. Speech Therapy
5. Use a picture board versus words

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Avoid Activity Intolerance post CVA

1. Teach energy conservation techniques
2. Intersperse activity with rest periods

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Persons with stroke often easily distracted with short attention spans

1. Schedule teaching during peak periods of alertness often early in the day
2. Break tasks into shorter components
3. Use memory aids (pictures, cue cards, etc.)

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Apathy, depression, emotional lability often present

1. Provide information on support groups, “stroke clubs”

52

CVA morbidity/mortality

Stroke produces significant morbidity in survivors:
31% require assistance with self-care
20% require assistance with ambulation
16% are institutionalized