What is the etiology and causes of CVA?
Basic process=Ischemia of the brain occurs due to an interrupted blood supply
What are some risk factors for CVA?
Atherosclerosis: Primary prob in thrombotic strokes
Hypertension: Major prob for ischemic and hemorrhagic strokes. Oral contraceptives, alcohol can cause
Embolic Risks: Anything that activates the clotting process. Plaque, artificial heart valve, septic emboli, air emboli, fat emboli (fracture of long bone)
Diabetes Mellitus: Due to vascular changes
Surgery or Major Trauma: Inflammatory process
Pathophysiology for CVA:
Disruption in bloodflow occurs. (May be gradual, may be abrupt)
Brain requires a constant supply of O2, glucose, etc; has no reserve
Brain normally regulates bloodflow through systemic mechanisms and locally by constricting and dilating arteries
Brain cell death occurs within 3-10 min
Surrounding tissue is compromised and inflamed and does not funtion properly. Without intervention, it may die also
Neuro changes result from dead or impaired tissue
What is a Transient Ischemic Attack (TIA-Related to CVA)?
Temporary neurologic dysfunction: Last <24hr; often 5-20 min
Between episodes, neuro assess WNLs
Major complication=1/3 of people will have CVA in <5years
What is an evolving stroke?
Neuro deficit develop over 1-2 days
Gradual worsening because affected area is enlarging
What is a completed strok?
Neuro deficits established and consistent; no further deterioration
Usually reached in 2-3 days
Damage is complete and permanent; although neuro deficits from inflamed tissue may reverse or improve
What are the signs and symptoms of a Thrombosis CVA?
Affects middle aged and elderly most often
Gradual onset and symptom development (hours/days)
Develops during sleep or just after arising
Pattern of Hypertension
Typical presentation=hemiparesis(weakness), loss of speech, and hemisensory loss
Hx of atherosclerosis, DM or hypertension
What are the Signs and symptoms of an emolism CVA?
Can affect any age group
Sudden onset and symptom development (sec to min)
Unrelated to time of day or activity
Typical Presentation=Same as thrombotic stroke
Hx of rheumatic fever, dysrhythmias or surgery
What are the signs and symptoms of a hemorrhage CVA?
Can affect any age group
Rapid onset and symptom development - blood accumulates and compresses brain tissue (min - 1 hour)
Occurs during active, waking hours
Typical presentation=Severe occipital or nuchal HA, vertigo or syncope, paresthesias, paralysis, eepistaxis, retinal hemorrhages, and rapid LOC
HX of uncontrolled hypertension, cocain use or aneurysm
What are some general Left sided Signs and symptoms of CVA?
Right side of body affected
Speech & language deficit
Slow, cautious behavior style
Language memory deficit
What are some general Right sided Signs and symptoms of CVA?
Left side of body affected
Spatial and perceptual deficits
Quick, impulsive behavior style
Performance Memory deficits (Can no longer do simple tasks that they use to be able to do)
What is paralysis of half of the body (L/R)?
Hemiplegia (Motor Deficit)
What is weakness of half?
What is the lack of muscle tone?
What is the increased resistance as an extremity stretches?
What is uniform resistance to stretching throughout movement?
What are some sensory perceptual deficits when pertaining to CVA?
Dec ability to integrate, interperret and attend to sensory data
Alterations in vision, hearing, taste, smell or equiliibrium
Change in perceptions: vibration, pain, heat, cold, pressure
Change in proprioception
What are some cognitive and behavioral changes when pertaining to CVA?
Mild confusion to coma
Loss of self-control (language and acts)
Poor attention span
Loss of abstract thought
Agnosia (Failure to recognize objects)
What are some other changes after a CVA?
Increased intracranial pressure
Dysphasia (difficulty swallowing)
Apraxia (inability to carry out a skilled taks due to lack of motor integration)
Dysarthria (difficulty articulating words; may slur words; no problem in sentence structure or grammar)
What are some Communication changes (Aphasia) as pertaining to CVA?
Expressive or motor (Broca's) Aphasia:
Affects speech production, writing, and ability to make signs
CVA involves frontal lobe
Receptive or sensory (Wernicke's) aphasia:
Affects speech comprehension, including written or printed
CVA involves temporal lobe
Affects speech comprehension and production
May simply repeat sounds they hear and have poor comprehension
Computed Tomography (CT) Scan is a diagnostic test for CVA, what is it?
Used initially to differentiate between ischemic and hemorrhagic strokes (no contrast)
Usues X-Ray's to visualize damaged brain tissue or the abnormal presence of blood
May use IV contrast dye for better visualization once a hemorrhage has been ruled out
If dye is used, client must not be allergic to iodine and should be NPO prior to test
Infarcted areas may not be visualized until several hours have passed
Magnetic Resonance Imagin (MRI) is a diagnostic test used for CVA, what is it?
Superior to CT for most CNS problems, especially 8-12 hours after a stroke
Uses strong magnets to visualize differences in soft tissues
No prep and client is not NPO
Client's size may prevent test
Anti-Anxiety meds may be given prior to test to minimize claustrophobic effects
Client or nurse can not have any metal in or on their body; including orthopedic devices
Cerebral Angiography is a diagnostic test used for CVA, what is it?
Uses X-Ray and intra-arterial contrast dye to visualize cerebral arterial system
Client is NPO
Client must not be allergic to iodine (shellfish)
What are some peripheral tests that might be ordered?
Carotid Doppler Study
Electrocardiogram (ECG) - Rythym
Electroencephalogram (EEG) - Electrical Activity
Used to identify contributing factors that might be treated
What are some Labs that might be ordered when pertaining to CVA?
CBC (RBC< WBC< Hgb, Hct, & platelets)- Thrombolytics and infection
PT, PTT - Anticoagulation therapy
Kidney Function (BUN, Creatine) - IV dye use
What are thrombolytics, examples and nursing interventions??
Deissolve/degrade a thrombus or emboli; restores bloodflow through cerebral arteries
Does not reverse cell ddeath but may prevent further cell death
Must be started within 3 hours of symptom onset
Observe for bleeding from all sources
Avoid invasice procedures-arterial and venous sticks, NG placement, IM injections.
What are Antiplatelet aggregation agents & anticoagulant examples and nursing interventions??
Antipllatelet Agents - Interfere with clot formation by affecting platelets
Example: ASA, Persantine, Plavix
Anticoagulants - Interfere with clot formation by affectinjg clotting factors and enzymes
Examples: Heparin, Coumadin, Lovenox
Used to prevent stroke from extending or re-occuring
Usually held for 24 hours if thrombolytic is used
What are vasodilators, examples and nursing interventions?
Relaxes vascular smooth muscle which dec arterial resistance which dec BP, In cardiac output, and inc cerebral bloodflow
Examples: Nipride, Apresoline
Observe for HA, Hypotension or cerebral Hypoperfusion
Frequent BP checks (every 5-15 min)
What are osmotic diuretics, examples and nursing interventions?
Inc osmotic pressure of plasma, diffusion of fluid in tissues back into vascular space, diuresis; net effect=reduces cerebral edema
Must be given IV through a filter; watch for precipitates
Observe for F/E imbalances, especially hyponatremia & dehydration
A ventriculostomy is a surgical intervention for CVA, what is it?
Used to relieve pressure from cerebrospinal fluid (CSF) accumulation
Burr holeinto skull; catheter is placed into lateral ventricle to allow for controlled drainage of CSF.
A Evacuation of Hematoma is a surgical intervention for CVA, what is it?
Surgical removal of large hematoma that is causing compromise due to compression
A Carotid endartectomy is a surgical intervention for CVA, what is it?
Opening of the carotid artery to remove obstructing and embolizing plaque
A Carotentid angioplasty and stenting is a surgical intervention for CVA, what is it?
Uses a bolloon0tipped catheter inserted retrograde through femoral artery into carotid
Balloon is inflated several times to compress plaque
Stent may be inserted to prevent re-stenosis
What are some interventions for CVA? LOTS OF THEM!!
Ongoing assessment (Focused Neuro)
Set Client specific goals:
Return client to optimal level of functioning
Address lower and higher needs
Maintain airway & prevent aspiration
Keep HOB up 30 deg to reduce cerebral edema
Frequent reposition with skin care; insure proper body alignment
Address vital sign changes promptly, esp. temp and BP
Provide for F/E and dietary needs (IV, NG, or feeding tube may be necessary)
Provide rest/sleep and activity/ROM as indicated
Address bowel and bladder concers, esp. incontinence (Foley and bowel/bladder training may be necessary)
Approach client from unaffected side
Encourage independence but assist is needed
Support family and friends; involve them in client's care when they are ready
Teach, teach, teach
What is the RN responsible for with CVA's?
During acute phase, close monitoring and frequent changes in client status deman RN direct involvement
If stroke is evolving, direct one-on-one care by RN is ideal
What is the LPN responsible for with CVA's?
As client stabalizes, portions of care may be delegated
Steroidal Anti-Inflammatory agents are used for CVA's, what do they do?
Disrupts inflammatory process by arious means including reducing capillary dilation and permeability= Dec cerebral edema
Nursing Interventions: May cause hyperglycemia or delayed wound healing
Causes immunosuppression, protect client from infection
Anti-Convulsants are used for CVA's, what do they do?
Reduce voltage, frequency and spread of electrical discharges within the motor cortex.
Examples: ilantin, Penobarbital
Observe for cardiovascular collapse (bradycardia, hypotension)
May mask changing neuro S/S (Dec LOC, confusion, headache)
What are some community resources for CVA pt?
Meals on Wheels
American Stroke Association
National Stroke Association
Stroke Support Groups
Local Service Groups
What are some cultural and spirituality considerations for CVA?
Be aware that losses may be perceived as punishment
Client's sense of value and signifigance may be severely threatened despite their religious beliefs
Client's role within a family or social group may be threatened depending on that client's culture
Peripheral Vascular Disease is primarily caused by atherosclerosis, what happens?
Lower limbs most susceptible
May progress to complete occlusion of medium and large arteries:
-Embolism-MOST COMMON, usually cardiac in orgin (AFIB)
Complete occlusion causes tissue hypoxia/damage
PVD may cause intermittent claudication, what happens if this occurs?
Pain occuring when a muscle had inadequate supply of oxygen and nutrients; often in calf or arch of foot
Usually occurs with walking or exercise; may be relieved with rest
Pain is consistent, reproducible, and not positional; different than lower extremity pain from other diseases
What are some S/S of PVD?
Possible cyanosis or edema
Pallor on elevation & Rubor in dependent position
Decreased or Absent pulses
What are some nursing interventions for PVD?
Assess 6 P's of ischemia
Assess pain and precipitating factors
Monitor skin integrity
Provide client-specific exercise
Elevate legs to level of heart to promote perfusion and reduce swelling
Position of comfort & bloodflow
What are some health teachings for PVD?
Proper foot care
Exercise to claudication, stop, rest and then proceed
Don't cross legs
Avoid cold and wear socks or insulated shoes
Avoid direct heat to limb
What is Buerger's Disease (Thromboangitis Obliterans)?
Inflammatory disease of small and medium arteries and veins of the extremities.
May be a hypersensitivity reaction to nicotine
Lesions and thrombi's are formed
What are some S&S of Beurger's Disease?
Pain is the outstanding one
Other S/S as PVD
What are some nursing interventions for Buerger's Disease?
Same as PVD
Promote body image (if amputation occurs)
Avoid precipitating factors such as stress and temperature extremes
What is Raynaud's Syndrome?
Condition in which small arteries and arterioles constrict in response to various stimuli
-Cold, nicotine, caffeine, stress
Usually involves uppper extremities but may affect toes, ears and nose; It is bilaterally symmetrical
Color changes in response to stimuli
Normal color and sensation can be restored with heat
Numbness, Tingling, Burning, Pain
There are two types of Raynaud's Syndrome, The disease(Vasospastic) and Phenomenon (obstructive), what are they?
Benign Primary Disorder
Secondary to another disease or cause (Lupus, Scleroderma, or Rheumatoid Arthritus)
What are some nursing interventions for Raynaud's Syndrome?
Same as PVD and Buerger's
Hand and foot care
-avoid precipitating factors
-Keep hands and feet warm
-Stress management and relaxation
What are some labs for Raynauds Syndrome?
Any lab that pertains to Atherosclerosis
(Lipid profile, Homocysteine, C Reactive Prot)
(PT, PTT) Especially prior to therapy
What are 3 diagnostic tests for Raynauds?
Exercise or Stress Test
Red Blood Cell Modifier's are used for PVD, what do they do?
Decrease viscosity of blood and improve bloodflow=dec tissue hypoxia
observe for inc in walking performance (time/duration)
Observe for bleeding
Monitor coagulation studies (PT/INR)
Vasodilators/Antiplatelet Agents are used for PVD, what are they?
Improves blood flow to extremities y vasodilation and inhibiting platelet aggregation
Observe for HA & GI complaints
Observe for improved exercise tolerance
Teach to avoid grapefruit/juice (Inc blood Levels)
Calcium Channel Blockers are used for PVD, what do they do?
Interferes with Ca++ movement across cell membranes = Vasodilation in coronary nd peripheral arteries
Observe for HA, Dizziness, light-headedness, and dec BP
Monitor Liver function test
Non-steroidal anti-inflammatory agents are used for PVD, what do they do?
Disrupt inflammatory process by various means including blocking prostaglandin synthesis. Often have analgesic, antipyretic and antiplatelet effects
Example: Ibuprofen, Naprosyn
Observe for occult blood loss and ototoxicity
Monitor liver function test
Be aware of possible cross-sensitivity between NSAIDS
What are some cultural considerations when dealing with PVD?
Chronic Pain and disability can have spiritual implications for some clients
Some Native Americans may want any amputated limbs in orer to have them buried with client
Which type of CVA has the following items:
Affects any age group
Unrelated to time of day or activity
Presentation=Hemiparesis, loss of speech, and hemisensory loss
Hx of rheumatic fever, dysrhythmia,or surgery
What type of CVA has the following characteristics?
Affects middle-aged and elderly most often
Gradual onset and symptom development
During sleep or just after sleep
Presentation=Hemiparesis, loss of speech and hemisensory loss
Hx of atherosclerosis, Diabetes, or hypertension
Which type of CVA has the following characteristics?
Affects any age grouP
Rapid onset and symptom development
During active, waking hours
Presentation=Severe occipital or nuchal HA, vertigo or syncope, paresthesias, paralysis, epistaxis, retinal hemorrhage, and rapid LOC
Hx of uncontrolled hypertension, cocaine use or aneurysm
In PVD the pulse will be _____ or ______ if arterial and _____ on the venous side
In PVD the pulse will be ABSENT or WEAK if arterial and PRESENT on the venous side
Temp with PVD on the arterial side would be _____ and on the venous side ______
Temp with PVD on the arterial side would be COOL and on the venous side WARM
Edema with PVD would be ________ on the arterial side but PRESENT on the venous side but would improve with _______
Edema with PVD would be ABSENT on the arterial side but PRESENT on the venous side but would improve with ELEVATION
What would you see in the legs/feet on the arterial side of PVD?
Dependent rubor (redness) that changes to pallor with elevation
Thin shiny skin
What would you see in the legs/feet on the venous side of PVD?
What would you see in ulcers on the arterial side of PVD?
What would you see in ulcers on the venous side of PVD?
Irregular border edges
Pain on the arterial side would be what in PVD?
(Calf pain during ambulation)
Pain on the venous side of PVD would be?