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STROKE (CVA)
- 3RD LEADING CAUSE OF DEATH IN THE U.S.
- #1 CAUSE OF LONG-TERM DISABILITY
- OVER 700,000 STROKES PER YEAR…1/3 DIE AS A RESULT
- $40 BILLION IN MEDICAL COSTS AND LOST PRODUCTIVITY
- 4.7 MILLION STROKE SURVIVORS ALIVE TODAY – MANY OF THEM REQUIRE SOME ASSISTANCE WITH THEIR ADL’S
WHAT IS A STROKE?
- BLOOD FLOW TO THE BRAIN IS SUDDENLY INTERRUPTED
- BRAIN CELLS IN THE IMMEDIATE AREA DIE
- LOSS OF BRAIN FUNCTION IN THAT AREA
- CAN LEAD TO DISABILITY (WILL DEPEND ON THE AREA OF AND HOW MUCH OF THE BRAIN IS INVOLVED)
TYPES OF STROKE
- ISCHEMIC – LOW BLOOD FLOW STROKES (MOST COMMON - ACCOUNTS FOR 85% OF STROKES)
O THROMBOTIC – CLOT FORMED WITHIN THE BRAIN CAUSES OCCLUSION OF BLOOD TO THE BRAIN –
ATHROSCLEROTIC PLAQUE FORMS WITHIN THE WALL AND IT BREAKS OFF.
O EMBOLIC – CLOT FORMED SOMEWHERE ELSE IN THE BODY (SUCH AS DVT, ATRIAL FIB) CAUSES
OCCLUSION OF BLOOD TO THE BRAIN
- HEMORRHAGIC – USUALLY OCCURS DUE TO HTN (MAIN CAUSE), ANDCEREBRAL ATHROSCLEROSIS (PATIENTS
THAT SUFFER THIS TYPE OF STROKE TYPICALLY HAVE POORER OUTCOMES – BECAUSE THE TISSUE DEATH IN AN
ISCHEMIC STROKE HAPPENS AT A MUCH SLOWER RATE THAN WITH A HEMORRHAGIC STROKE). WITH A
HEMORRHAGIC STROKE, THERE IS A RAPID INCREASE IN ICP.
O INTRACEREBRAL – HEMORRHAGE WITHIN BRAIN TISSUE – A VESSEL WITHIN THE ACTUAL BRAIN TISSUE
THAT RUPTURES AND BEGINS TO BLEED.
O SUBARACHNOID – HEMORRHAGE IN SUBARACHNOID LAYER OF THE BRAIN (ALSO CAN CAUSE
HYDROCEPHALUS DUE TO BLOCKAGE OF VILLI THAT DRAIN CSF) – MOST OFTEN CAUSED BY A
RUPTURED ANEURISM.
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LIFESPAN CONSIDERATIONS
- ELDERLY AT GREATEST RISK
- CHILDREN WITH SICKLE CELL AT RISK – THEIR RBC’S ARE MISHAPED AND THEY HAVE CLOTTING ISSUES
- ANYONE WITH NUMEROUS RISK FACTORS
PATHO OF STROKE (VARIES DEPENDING UPON WHAT TYPE OF STROKE THAT IT IS)
- ISCHEMIC (LOW BLOOD FLOW TO THE BRAIN)
O THE ARTERIES – BLOCK DUE TO ATHEROSCLEROSIS, CAN NARROW WITH AGE
O THE HEART – DIAGNOSIS OF A FIB, VALVE DISEASE, SEPTAL DEFFECTS OR ANYTHING THAT CAN CAUSE
A CLOT TO FORM AND TRAVEL TO THE BRAIN CAUSING OCCLUSION OF BLOOD FLOW. HEART FAILURE
CAN LEAD TO A LOW BLOOD FLOW ISCHEMIC STROKE – IF YOU ARE NOT HAVING ENOUGH CARDIAC
OUTPUT TO PERFUSE THE BRAIN.
O THE BLOOD – SICKLE CELL, DIC, LOW BLOOD VOLUME, ANYTHING THAT CAUSES OXYGEN DEPRIVATION
TO THE BRAIN BY BLOCKING BLOOD FLOW. ANYTHING THAT IS GOING TO CAUSE THE BLOOD TO BE MORE
PRONE TO CLOTTING. LOW BLOOD VOLUME FROM TRAUMA WHERE YOU ARE NOT GETTING ENOUGH
BLOOD FLOW AND PERFUSION TO THE BRAIN CAN LEAD TO AN ISCHEMIC STROKE.
O COMBINATION
- HEMORRHAGIC
O HIGH BLOOD PRESSURE (UNCONTROLLED HYPERTENSION), ATHEROSCLEROSIS, VESSEL DEFECTS
BY FAR UNCONTROLLED HYPERTENSION IS THE MAJOR CAUSE OF A HEMORRHAGIC STROKE.
ABOUT 80% OF THE TIME THE HEMORRHAGIC STROKE IS DUE TO A SMALL VESSEL RUPTURE
FROM UNCONTROLLED HYPERTENSION. THE OTHERS ARE CAUSED BY RUPTURE OF THOSE
ARTERIOVENOUS MALFORMATIONS (DEVELOP IN THE FETAL STAGE BUT MAY NOT MANIFEST FOR
YEARS).
AVM RUPTURE AND INTRACRANIAL INTRACEREBRAL ANEURISM RUPTURE ARE OTHER THINGS
THAT CAN LEAD TO HEMORRHAGIC STROKE.
VESSEL RUPTURE BLEEDING INCREASED ICP VASOSPASM
YOU HAVE VESSEL RUPTURE, YOU HAVE HEMORRHAGING INTO THE BRAIN, IT LEADS TO
INCREASED INTRACRANIAL PRESSURE AND AS A DEFENSE MECHANISM WITH THE VESSEL
RUPTURE, THE BODY’S ATTEMPT TO CONTROL THE HEMORRHAGE IS VASOSPASMS. THE
VESSELS ACTUALLY CLAMP DOWN WITHIN THE BRAIN TO TRY TO CONTROL THE BLEED, BUT THIS
CAN LEAD TO ISCHEMIC STROKE (CUTTING OFF BLOOD SUPPLY TO THE BRAIN)
IN AN ATTEMPT TO SAVE ITSELF THE VESSELS SPASM TO STOP BLEEDING WHICH ENDS UP
CAUSING AN ISCHEMIC STROKE DUE TO BLOCKAGE
VERY POOR PROGNOSIS WITH A HEMORRHAGIC STROKE
SYMPTOMS OF STOKE
- SUDDEN NUMBNESS OR WEAKNESS OF THE FACE, ARM OR LEG – ESPECIALLY ALL ON ONE SIDE
- SUDDEN CONFUSION, TROUBLE SPEAKING, OR TROUBLE UNDERSTANDING SPEECH (EXPRESSIVE OR RECEPTIVE
APHASIA)
- SUDDEN TROUBLE SEEING IN ONE OR BOTH EYES
- SUDDEN TROUBLE WALKING, DIZZINESS, LOSS OF BALANCE OR COORDINATION
- SUDDEN SEVERE HEADACHE WITH NO KNOWN CAUSE (ESPECIALLY WITH HEMORRHAGIC STROKE). PEOPLE WITH
INTRACRANIAL ANEURISM RUPTURES OR SOME OTHER TYPE OF INTRACEREBRAL HEMORRHAGE OR HEMORRHAGIC
STROKE WILL STATE THAT THIS IS THE WORST HEADACHE THAT I HAVE EVER HAD. THEY VERY QUICKLY BECOME
UNCONSCIOUS AND UNRESPONSIVE. THIS CAN BE VERY LIFE THREATENING AND GET FATAL VERY QUICKLY.
- AS NURSES WE KNOW THAT PRIMARY PREVENTION IS WHAT WE WOULD LIKE TO SEE. WE WOULD LIKE TO
PREVENT STROKES BEFORE THEY HAPPEN. THIS IS GOING TO FOCUS ON COMMUNITY EDUCATION:
- KNOW RISK FACTORS
- PRACTICE HEALTHY EATING HABITS
- EXERCISE REGULARLY
- LIMIT ALCOHOL
- AVOID CIGARETTES AND ILLICIT DRUGS
- DON’T DO ANYTHING THAT CAN SEVERELY OR CONSISTENTLY VASOCONSTRICT YOUR VESSELS
- SEE PHYSICIAN REGULARLY FOR MANAGEMENT OF CHRONIC DISEASE’S (HTN, DIABETES, CVD).
MANAGEMENT OF ALL OF THESE DISEASES THAT CAN LEAD TO STROKE IS CONSIDERED PRIMARY PREVENTION.
STARTING TO CHARACTERIZE STROKES AS BRAIN ATTACKS SO THE PUBLIC WILL POSSIBLY BETTER UNDERSTAND THE
URGENCY OF THE SITUATION.
SECONDARY PREVENTION
- KNOW SIGNS AND SYMPTOMS OF STOKE
- CALL 911 IF SYMPTOMS OCCUR
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O SOME OF THESE EMOTIONAL THINGS CAN OCCUR DUE TO THE AREA OF THE BRAIN THAT IS INVOLVED,
PARTICULARLY RIGHT HEMISPHERIC STROKES.
O BUT ALSO JUST BECAUSE IT IS A SUDDEN ADJUSTMENT THAT THEY ARE HAVING TO MAKE. IF YOU HAVE
SOMEONE THAT WAS COMPLETELY INDEPENDENT AND NOW THEY HAVE SEVERE DEFICITS. THERE CAN
BE A LOT OF HOSTILITY AND ANGER. MIGHT EVEN SEE GRIEVING PROCESS BECAUSE OF SUCH A
SEVERE LOSS OF FUNCTION.
DIAGNOSTIC TESTS
- CT SCAN – DONE IMMEDIATELY UPON ARRIVAL IF STROKE IS SUSPECTED – THIS IS GOING TO CONFIRM THE
PRESENCE OF THE STROKE AND WILL DETERMINE WHETHER THEY ARE HAVING HEMORRHAGE. YOU CANNOT
MAKE ANY TREATMENT DECISIONS UNTIL THIS TEST IS DONE.
- MRI WILL SHOW SPECIFICS ABOUT THE STROKE SUCH AS DAMAGE, INTENSITY, ETC…GET A MORE EXACT
PICTURE OF THE EXACT LOCATION AND SIZE OF THE PROBLEM THAT IS GOING ON.
- CEREBRAL ANGIOGRAPHY/ARTERIOGRAM – SHOW SPECIFICS ABOUT THE STROKE – IT WILL ALLOW YOU TO LOOK
AT THE ACTUAL VESSELS INVOLVED
- DOPPLER FLOW STUDIES – MACHINE THAT ACTUALLY WATCHES BLOOD FLOW THROUGH THE VESSELS - HELPS
LOOK FOR BLOCKAGE
- EKG – CHECKING FOR DYSRHYTHMIAS – A CLIENT CAN COME IN WITH A DIAGNOSIS OF A STROKE AND OBTAIN A
NEW DIAGNOSIS OF ATRIAL FIBRILLATION. THEY HAVE NEVER BEEN ON COUMADIN BECAUSE THEY DID NOT
KNOW THAT THEYHAD ATRIAL FIB AND THEY COME IN AND THEY HAVE HAD AN ISCHEMIC STROKE AND WE FIND A
EKG – SO WE HAVE NOW FOUND THE CAUSE OF THE STROKE. MUST ALSO TREAT THE ATRIAL FIB.
FIB ON THE
(TREATMENT OF A FIB CONSISTS OF COUMADIN, POSSIBLY DIGOXIN TO HELP WITH THEIR RHYTHM).
- ECHOCARDIOGRAM – CHECKS FOR SEPTAL DEFECTS, VALVE PROBLEMS, ETC….
“TIME IS BRAIN”
REMEMBER THAT THE FASTER THAT THE STROKE VICTIM RECEIVES TREATMENT, THE BETTER THE OUTCOME IS GOING TO
BE, THE FEWER DEFICITS THEY ARE GOING TO HAVE. USUALLY WITH A STROKE WHEN THEY COME IN WITH SYMPTOMS
LIKE COMPLETE PARALYSIS ON ONE SIDE. ALL OF THAT MAY NOT BE PERMANENT. THERE IS AN AREA AROUND THE
ISCHEMIA THAT CAN BE SALVAGED IF THE PATIENT IS GIVEN PROMPT TREATMENT. SO IF YOU CAN GET IN THERE AND
GET THEM ON EARLY TREATMENT (ANTICOAGULANTS, SOMETHING TO GET THE BLOOD FLOW RESTORED), THEN THE
SYMPTOMS ARE GOING TO IMPROVE.
DEPENDING UPON THE CAUSE OF THE STROKE AND THE SEVERITY, YOU WILL SEE THESE
PATIENTS ON DIFFERENT ANTICOAGULANTS)
WILL HAVE IV HEPARIN INFUSION (MUST KNOW HEPARIN PROTOCOL), WILL HAVE ORDERS
SOMEWHERE IN THE CHART AS TO HOW OFTEN THE PTT HAS TO BE DRAWN – DEPENDING
UPON THE RESULTS OF THE PTT WHAT TO DO WITH THE RATE OF THE HEPARIN. BE SURE
THAT AS THE PRIMARY NURSE FOR THIS CLIENT MAKE SURE THAT WHEN YOU ARE GETTING
REPORT THAT YOU FIND OUT WHEN THE LAST PTT WAS DRAWN? WHAT IS THE RATE OF THE
HEPARIN NOW? AND WHEN IS THE NEXT ONE DUE TO BE DRAWN? GET THIS INFORMATION
QUICKLY.
ALSO MAY BE ON COUMADIN WITH LOVENOX UNTIL INR IS THERAPUETIC. WITH COUMADIN
YOU CHECK THE PT AND INR. THE THERAPEUTIC RANGE OF THE INR WITH COUMADIN IS
AROUND 2 TO 3.
PLAVIX (ANTIPLATELET AGENT), ASA
PREVENT CLOTS FROM FORMING, PREVENT ADDITIONAL CLOTTING AROUND THAT AREA, BUT
THEY DO NOT DISSOLVE THE BLOOD CLOT.
VERY COMMONLY WILL BE ON COUMADIN IF IT IS AN EMBOLIC STROKE FROM ATRIAL FIB OR IF
THEY HAVE A DVT OR SOMETHING LIKE THAT
SHOULD NOT SEE HEPARIN AND LOVENOX GIVEN TOGETHER. THERE SHOULD BE SEVERAL
HOURS BETWEEN BEFORE YOU DISCONTINUE ONE AND START THE OTHER.
O OTHER TREATMENT MEASURES
ELEVATE HOB (TO PROMOTE VENOUS DRAINAGE)
SECURE AIRWAY
MONITOR HEMODYNAMICS – B/P (KEEP NORMOTENSIVE) → IF BP IS TOO LOW, YOU ARE
NOT GOING TO GET ENOUGH BLOOD FLOW TO THE BRAIN. IF THE BP IS TOO HIGH THERE WILL
BE TOO MUCH PRESSURE ON THE CEREBRAL VESSELS.
MONITOR FOR NEURO CHANGES – 1ST SIGN IS ↓ LOC
- HEMORRHAGIC – CT TO DIAGNOSE, MAY MONITOR IF SMALL BLEED
O OF COURSE WITH BLEEDING, WE ARE NOT GOING TO BE GIVING THIS PATIENT ANTICOAGULANTS
O EMERGENCY SUGERY (IF POSSIBLE) – IF IT IS AN INTRACEREBRAL HEMORRHAGE AND IF IT IS WITHIN
THE DEEP WITHIN THE TISSUE OF THE BRAIN, OFTEN TIMES THOSE HEMORRHAGES ARE INOPERABLE.
THEY HAVE TO HOPE THAT THE HEMORRHAGE STOPS ON ITS OWN, THEY MONITOR IT CLOSELY. THEY
MAY DO A CT SCAN EVERY DAY FOR A FEW DAYS TO MONITOR PROGRESSION. SOMETIMES THERE IS
ABSOLUTELY NOTHING THAT THEY CAN DO.
O MANAGE/PREVENT VASOSPASM
NIMOTOPINE – CALCIUM CHANNEL BLOCKERS (STOPS VASOSPAMS) – NIMOTOP. USUALLY
GIVE CALCIUM CHANNEL BLOCKERS FOR HYPERTENSION. THEREFORE WHEN WE GIVE
NIMOTOP, THE BLOOD PRESSURE IS GOING TO DECREASE. IF YOU HAVE A PATIENT THAT HAS A
LOW BLOOD PRESSURE, YOU WOULD NOT GIVE THE NIMOTOP TO PREVENT VASOSPASMS
BECAUSE IT WILL FURTHER BOTTOM OUT THE BLOOD PRESSURE. OUR GOAL IS TO KEEP THE
PATIENT NORMOTENSIVE.
STROKE REHABILITATION
- MOBILIZE AS EARLY AS POSSIBLE (ISCHEMIC STROKE CAN BE MOBILE QUICKER THAN HEMORRHAGIC). WITH A
HEMORRHAGIC STROKE, THESE CLIENTS ARE USUALLY MAINTAINED ON BEDREST AND WE DECREASE THE STIMULI
UNTIL THE RISK OF HEMORRHAGE IS GONE.CONFIRM THE CLIENTS ACTIVITY LEVEL IN THE PHYSICIANS ORDERS.
- PT, OT, SPEECH THERAPY – TO RELEARN CERTAIN MOVEMENTS, AND LANGUAGE SKILLS
- TREAT DEPRESSION – IF THE CLIENT IS DEPRESSED THEY WILL NOT BE AS LIKELY TO PARTICIPATE IN THEIR
TREATMENT AND REHABILITATION.
- EDUCATE CLIENT AND CAREGIVERS
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- DETERMINE PLACEMENT OPTIONS – NEED A PLACE IN CASE NOT ABLE TO RETURN HOME
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O PUT THINGS RELATED TO ORIENTATION (FOR INSTANCE THE CLOCK, TV) WITHIN THEIR FIELD OF VISION.
THIS IS FOR SAFETY – EVENTUALLY WE ARE GOING TO ENCOURAGE THEM TO PAY ATTENTION TO
THE SIDE THAT THEY CANNOT SEE FROM.
O MUST ACKNOWLEDGE AFFECTED SIDE (EVEN IF IT IS NOT A VISUAL PROBLEM, MAY BE NUMBNESS OR
DECREASED SENSATION). THEY COULD HAVE THEIR AFFECTED ARM STUCK IN THE BED RAIL AND THEY
WOULD NOT BE ABLE TO FEEL THIS.
O ADEQUATE LIGHTING
- MANAGING DYSPHASIA
O MUST ASSESS ABILITY TO SWALLOW
O IF UNABLE TO SWALLOW SMALL ABOUT OF H2O MUCH CONSULT SPEECH THERAPY
O HAVE THEM ON A PUREED DIET WITH A THICKENER FOR THIN LIQUIDS. THIN LIQUIDS ARE VERY
DIFFICULT TO MANIPULATE IN THE MOUTH. THEY ARE ALMOST IN THE BACK OF THE MOUTH BEFORE THE
PERSON CAN GET CONTROL OF THEM. IF THEY HAVE DYSPHAGIA THE MUSCLE MOVEMENTS ARE SLOW.
THEY NEED SOMETHING THICK SO THEY CAN GAIN CONTROL OF IT BEFORE IT GETS TO THE BACK OF
THEIR THROAT AND THEY ARE SWALLOWING IT. THIS IS ANOTHER REASON THAT WE DO NOT USE
STRAWS WITH A CLIENT THAT HAS DYSPHAGIA.
- ATTAINING BOWEL AND BLADDER CONTROL
O MAY HAVE INCONTINENCE
O MAY BE CONFUSED
O MAY BE IMPAIRED COMMUNICATION, NOT ABLE TO TELL YOU WHAT THEY NEED
O MAY NEED ASSISTIVE DEVICES
O NEED A BARRIER FREE ACCESS TO THE TOILET
O ALTERATE MODIFICATION TO THEIR CLOTHING IF THEY HAVE PARALYSIS ON ONE SIDE
- IMPROVING THOUGHT PROCESS
O SUPPORTIVE ROLE FOR CLIENT AND FAMILY – CAN BE VERY DIFFICULT IF THERE ARE PERSONALITY
CHANGES AFTER A STROKE, THIS MAY BE VERY DIFFICULT FOR FAMILY MEMBERS TO HANDLE.
- IMPROVING COMMUNICATION
O COMMUNICATION BOARD (EXPRESSIVE APHASIA)
O SLATE BOARD (DYSARTHRIA)
O USE SHORT PHRASES (RECEPTIVE APHASIA)
O USING GESTURES, FACE THEM WHEN SPEAKING TO THEM (RECEPTIVE APHASIA)
O DON’T RUSH THEM
O DON’T PUT WORDS IN THEIR MOUTH
- MAINTAINING SKIN INTEGRITY
O FREQUENT TURNING
O SKIN ASSESSMENT ESPECIALLY ON THE AFFECTED SIDE
O NUTRITIONAL STATUS
O GOOD HYGIENE
O MIGHT NEED SPECIALTY MATTRESS OR BED
O SKIN CARE
- IMPROVING FAMILY COPING
O SOME CLIENTS MAY BE ANGRY, CONFUSED, AND COMBATIVE
O SUPPORT FAMILY MEMBERS, BUT DO NOT GIVE THEM FALSE HOPE, YET BE AS OPTIMISTIC AS WE CAN
- ADDRESSING SEXUAL DYSFUNCTION
O MAY BE NEUROLOGICAL DAMAGE, PARALYSIS, DEPRESSION, MOTOR DEFICITS OR MEDICATION INDUCED
O KEEP OPEN MIND
O MAY HAVE TO TRY ALTERNATE POSITONS
- PROMOTING HOME AND COMMUNITY-BASED CARE
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PATHOPHYSIOLOGY
- ARTERY ENLARGES AND PRESSES ON CRANIAL NERVES OR BRAIN TISSUE – HOPEFULLY WILL START TO HAVE
SYMPTOMS THAT WILL START BEFORE RUPTURE
- ANEURYSM MAY RUPTURE, SPILLING BLOOD INTO THE BRAIN (SUBARACHNOID HEMORRHAGE – TYPE OF
HEMORRHAGIC STROKE)
- IF YOU HAVE AN ANEURYSM RUPTURE, YOU WILL HAVE:
O NORMAL BRAIN METABOLISM IS DISRUPTED
O INCREASED ICP – DUE TO BLEEDING INTO THE BRAIN TISSUE (EXTRA BLOOD) AND BLOCKAGE OF VILLI
THAT ABSORB CSF (WHEN THESE VILLI ARE CLOGGED WITH BLOOD CELLS IT CAN LEAD TO
HYDROCEPHALUS)
O ISCHEMIA DUE TO REDUCED PERFUSION AND VASOSPASM (DEVELOP VASOSPASM WITH HEMORRHAGIC
STROKE, IT IS THE BODY’S ATTEMPT TO STOP HEMORRHAGING, BU THEN YOU CAN HAVE A SECONDARY
ISCHEMIC STROKE)
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- CT SCAN – TO CONFIRM BLEED – THIS IS THE FIRST THING THAT WILL BE DONE
- CEREBRAL ANGIOGRAPHY/ARTERIOGRAM – SHOWS SIZE AND LOCATION (IF THE ANEURYSM IS RUPTURED THEY
WILL PROBABLY NOT TAKE THE TIME TO DO AN ARTERIOGRAM. IF IT IS JUST LEAKING THEY MIGHT GO DO ONE).
- LUMBAR PUNCTURE – BLOOD FOUND IN CSF IF THERE IS A SUBARACHNOID HEMORRHAGE (LP NOT TYPICALLY
DONE DUE TO INCREASED ICP) LUMBAR PUNCTURE IS ONLY DONE IF THE CT SCAN IS NEGATIVE FOR
HEMORRHAGE AND THERE ARE NO SIGNS OF INCREASED ICP.
MEDICAL MANAGEMENT
- RECOVER FROM THE INITIAL BLEED, PREVENT RE-BLEED
O PUT ON ABSOLUTE BEDREST, DECREASE STIMULI, ICP NURSING CARE
O READ ABOUT ANEURYSM PRECAUTIONS IN BRUNNER
- CONTROL VASOSPASM – GIVE CA CHANNEL BLOCKERS (PROCARDIA, NIMOTOPINE) – CHECK THE BLOOD
PRESSURE BEFORE ADMINISTERING CALCIUM CHANNEL BLOCKERS. WE DO NOT WANT THIS PATIENT’S BLOOD
PRESSURE TO GET REAL LOW. WE WANT TO KEEP THEM NORMOTENSIVE OR A LITTLE TINY BIT HIGHER THAN
NORMAL. IF THE BLOOD PRESSURE GETS TOO LOW THEN THERE WILL BE INADEQUATE PERFUSION TO THE BRAIN
AND THIS PATIENT ALREADY HAS COMPROMISED CEREBRAL PERFUSION.
- CONTROL HYPERTENSION – GOAL SYSTOLIC IS 150 TO ENSURE ADEQUATE PERFUSION TO BRAIN (MAY GIVE
DOPAMINE, OR VASOPRESSOR IF B/P IS TOO LOW). IF WE GET IT MUCH HIGHER THAN 150 THIS WILL PUT THE
PATIENT AT RISK FOR REBLEEDING.
- MONITOR FOR AND TREAT INCREASED ICP – WE TREAT ICP WITH MANNITOL (OSMOTIC DIURETIC),
DECADRON, WE GIVE LASIX WITH MANNITOL TO TRY TO DECREASE THE INTRAVASCULAR FLUID VOLUME – TRY
TO GET THE KIDNEYS TO EXCRETE URINE. WE GIVE DECADRON TO DECREASE CEREBRAL EDEMA. WE WILL
MONITOR THEIR FLUID INTAKE VERY CAREFULLY.
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NURSING INTERVENTIONS
- OPTIMIZING CEREBRAL TISSUE PERFUSION
O ANEURYSM PRECAUTIONS (HOB ↑, DECREASE STIMULI, ABSOLUTE BEDREST, ETC.)
O SEE CARE PLAN FOR INCREASED ICP
- RELIEVING SENSORY DEPRIVATION AND ANXIETY
O EXPLAIN TO PATIENT AND FAMILY THE IMPORTANCE OF DECREASED STIMULI
- MONITORING AND MANAGING POTENTIAL COMLICATIONS
O VASOSPASM – HAPPENS 4-14 DAYS AFTER HEMORRHAGE (ANEURYSM RUPTURE)
RE-BLEEDING CAN OCCUR DUE TO VASOSPASM
• SYMPTOMS OF RE-BLEEDING – THESE S/S DEPEND ON WHERE THIS OCCURS IN THE
BRAIN, MAY BE DIFFERENT AT DIFFERENT PARTS
O WORSENING HEADACHE
O INCREASED ICP
O ALTERED LOC, NEURO DEFICITS
O DIFFERENT DEFICITS DEPENDING UPON WHERE THE VASOSPASM IS OCCURING.
IT IS GOING TO MIMIC A STROKE, BECAUSE THAT IS REALLY WHAT IT CAN
CAUSE IS AN ISCHEMIC STROKE.
O SEIZURES
SEIZURES ARE NOT REAL COMMON, BUT THEY ARE VERY DANGEROUS FOR SOMEONE THAT HAS
AN ANEURYSM.
MIGHT PUT THE PATIENT ON PROPHYLACTIC ANTISEIZURE MEDICATION. (DILANTIN)
O HYDROCEPHALUS
CAN OCCUR VERY QUICKLY AFTER ANEURYSM RUPTURE OR IT CAN BE WEEKS AFTER THE
ANEURYSM RUPTURES
O REBLEEDING
NOT VERY COMMON, BUT IT IS OFTEN FATAL. THEY ARE GOING TO HAVE THE RECURRENT
SYMPTOMS OF THAT ANEURYSM RUPTURE OR OF A STROKE. THEY MIGHT DEVELOP THAT
NUCHAL RIGIDITY AGAIN. THEY MAY HAVE A SUDDEN SEVERE HEADACHE AND THEN SYMPTOMS
OF A STROKE (DEPENDING UPON THE AREA OF THE BRAIN INVOLVED).
THE BEST WAY TO PREVENT REBLEEDING IS TO KEEP THESE PATIENT’S BLOOD PRESSURE
UNDER CONTROL. WE WANT TO KEEP THEM NORMOTENSIVE, NO MORE THAN A SYSTOLIC
PRESSURE OF 150. THIS WILL HELP PREVENT THE CHANCES OF REBLEEDING.
- PROMOTING HOME AND COMMUNITY-BASED CARE
O TEACHING SELF CARE – S/S OF ICP, S/S OF STROKE
CHANGE IN LOC – THIS IS THE BIGGY. IF THE CLIENT SEEMS LIKE THEY ARE SLEEPING MORE
THAN USUAL, THEY ARE HARD TO WAKE UP OR THEY BECOME MORE AGITATED OR CONFUSED.
HEADACHES
STIFF NECK
SIGNS AND SYMPTOMS OF STROKE (DIFFICULTY WALKING, DIFFICULTY SEEING, DIFFICULTY
SPEAKING, NUMBNESS, WEAKNESS)
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HYDROCEPHALUS
OVERVIEW: CEREBROSPINAL FLUID (CSF)
- PRODUCED AND REABSORBED IN THE ARACHNOID LAYER OF THE BRAIN
- CONTAINED IN 4 VENTRICLES AND CIRCULATES AROUND THE BRAIN AND SPINAL CORD
- FUNCTIONS
O ACTS AS A “SHOCK ABSORBER” FOR THE BRAIN AND SPINAL CORD
O DELIVERS NUTRIENTS TO THE BRAIN AND REMOVES WASTE
O FLOWS BETWEEN THE CRANIUM AND SPINE TO COMPENSATE FOR CHANGES IN THE INTRACRANIAL
BLOOD VOLUME
- AVERAGE ADULT PRODUCES 500ML OF CSF PER DAY….. ALL BUT 125-150ML IS REABSORBED
WHAT IS HYDROCEPHALUS?
- A CONDITION CAUSED BY AN IMBALANCE IN THE RATES OF PRODUCTION AND ABSORPTION OF CSF IN THE
VENTRICULAR SYSTEM OF THE BRAIN. WHEN PRODUCTION IS TOO GREAT OR ABSORPTION IS INADEQUATE, CSF
ACCUMULATES IN THE VENTRICULAR SYSTEM, USUALLY UNDER INCREASED PRESSUE, PRODUCING DILATION OF
THE VENTRICLES OF THE BRAIN,
- A SYMPTOM OF AN UNDERLYING ILLNESS (FOR
NEUROLOGICAL EXAMPLE YOU CAN DEVELOP
HYDROCEPHALUS AS A RESULT OF SUBARACHNOID HEMORRHAGE)
TYPES OF HYDROCEPHALUS
- CONGENITAL
O ABNORMAL FETAL DEVELOPMENT – STRUCTURAL DEFECT
O GENETIC PREDISPOSITION
- ACQUIRED
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PATHOPHYSIOLOGY
- 2 TYPES
O COMMUNICATING
CSF FLOW IS RESTRICTED AFTER IT EXITS THE VENTRICLES
O NON-COMMUNICATING (OBSTRUCTIVE)
CSF FLOW IS RESTRICTED IN THE VENTRICLES (THERE IS SOMETHING WRONG WITHIN THE 4
VENTRICLES WHERE THE CSF IS NOT CIRCULATING PROPERLY)
O MULTI-STEP TEST
O FLOW AND UPTAKE OF CSF IS MONITORED (WITHIN THE VENTRICULAR SYSTEM AND ALSO AROUND THE
BRAIN AND SPINAL CORD WHERE THE CSF IS CIRCULATING AND THE WAY THAT IT IS REABSORBED
THROUGH THE VILLI)
O DYE (RADIOACTIVE ISOTOPE) INTO THE SUBARACHNOID
IS INSERTED SPACE. THEY WILL DO THIS
THROUGH A LUMBAR PUNCTURE.
O LOOK AT SEVERAL TIMES OVER A PERIOD OF DAYS
O THIS HELPS TO DETERMINE WHETHER IT WOULD BE EFFECTIVE TO HAVE A VP SHUNT OR THE
PLACEMENT OF IT.
MEDICAL MANAGEMENT
- MEDICATIONS TO TREAT INCREASED ICP – OSMOTIC DIURETICS, POSSIBLY STEROIDS
- LUMBAR PUNCTURE OR VENTRICULOSTOMY - TO DRAIN EXCESS CSF. THIS IS A TEMPORARY FIX, BUT IF THEY
DETERMINE THAT THEY HAVE HYDROCEPHALUS AND THEY DETERMINE THAT THERE IS INCREASED ICP, THEY
MIGHT DO CAREFUL CSF DRAINAGE. THEY WOULD NOT BE ABLE TO REMOVE A RAPID OR LARGE AMOUNT AT
ONE TIME. THIS WILL RELIEVE SOME OF THE PRESSURE.
SURGICAL MANAGEMENT
- DIRECT REMOVAL OF THE OBSTRUCTION (SUCH AS TUMOR)
- VENTRICULOPERITNEAL (VP) SHUNT – MOST OFTEN DONE – FLEXIBLE TUBE IS INSERTED INTO THE VENTRICLE,
USUALLY ON THE NON-DOMINANT SIDE OF THE BRAIN. THERE IS A ONE WAY VALVE THAT CONTROLS THE RATE
OF EMPTYING. THE TUBE IS INSERTED INTO THE VENTRICLE AND IT IS FED UP UNDER THE SKIN INTO THE
PERITONEAL CAVITY. IT EMPTIES THE CSF INTO THE PERITONEAL CAVITY WHERE IT IS REABSORBED INTO THE
BODY.
- ENDOSCOPIC THIRD VENTRICULOSTOMY – SMALL HOLE S/T VENTRICLES TO ALLOW FOR FLOW OF CSF – CAN
BE USED IF THERE IS OBSTRUCTIVE HYDROCEPHALUS.
FROM FILM (NPH)
- VENTRICULOPERITNEAL SHUNT – NEUROSURGEONS INSERT A TUBE CALLED A SHUNT INTO THE BRAIN. THE
TUBE DRAINS THE EXCESS FLUID FROM THE BRAIN AND MOVES IT TO THE BELLY WHERE IT CAN BE ABSORBED.
THE SHUNT MAY NEED TO BE ADJUSTED BECAUSE REMOVING TOO MUCH OR TOO LITTLE FLUID CAN BE
DANGEROUS. THE ADJUSTMENT IS DONE PAINLESSLY WITH A MAGNENT IN THE DOCTOR’S OFFICE.
- PATIENT’S AND THEIR FAMILIES SHOULD KNOW THAT IF SOMEONE IS AGING AND THEIR GAIT IS WORSENING,
THEIR MENTAL THOUGHT PROCESSES ARE BECOMING LESS CLEAR AND/OR THEY HAVE URINARY INCONTINENCE,
THEY NEED A CT SCAN/MRI.
NURSING MANAGEMENT
- CARE PLAN: INCREASED ICP
- ROUTINE CRANIOTOMY CARE POST-OP
O POSITION DICTATED BY SURGEON – USUALLY HOB ELEVATED (30°) TO ALLOW FOR DRAINAGE – THE
ONLY EXCEPTION TO THIS IS AN INFANT/SMALL CHILD; THEY ARE OFTEN KEPT FLAT TO AVOID RAPID
CHANGES IN THEIR INTRACRANIAL PRESSURE.
O OBSERVE FOR INFECTION – SYMPTOMS OF MENNIGITIS (STIFF NECK, HEADACEH), SYMTOMS OF
PERITONITIS (RIGGID STIFF BOARDLIKE ABDOMEN, DISTENSION), WE ARE GOING TO WATCH FOR FEVER –
THIS IS USUALLY ONE OF THE FIRST INDICATORS OF A SHUNT INFECTION. SOMETIMES YOU CAN SEE
REDNESS FOLLOWING THE SHUNT TRACT.
O OBSERVE FOR SHUNT MALFUNCTION– INCREASED ICP IF NOT WORKING (SHUNT IS BLOCKED); IF TOO
MUCH IS BEING DRAINED WILL HAVE VERY BAD HEADACHE WHILE SITTING UP BECAUSE THE BLOOD
VESSELS THAT ATTACH THE BRAIN TO THE OUTER COVERING GET PULLED ON. IF YOU DUMP OUT TOO
MUCH CSF AT ONE TIME – THE ULTIMATE COMPLICATION WOULD BE THAT THE BRAIN CAN HERNIATE.
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O OBSERVE FOR CSF LEAKAGE – MIGHT LEAK OUT OF THE INCISION SITE, MAY DEVELOP A MUSH
POCKET UNDER SKIN OF THE SCALP, HA WORSE WHILE SITTING UP
LONG-TERM MANAGEMENT
- CONSIDERATIONS FOR CHILDREN
O ABOUT 1/3 OF THESE CHILDREN HAVE NO INTELLECTUAL OR NEUROLOGICAL DEFICITS.
O CONDITION IS LIFE-LONG
O WE NEED TO ENCOURAGE PARENTS TO MAKE LIFE AS NORMAL AS POSSIBLE – NEED TO AVOID CONTACT
SPORTS
O IF THE CHILD HAS TO HAVE A VP SHUNT, THIS IS GOING TO BE A LIFELONG THING. PREPARE THAT
THERE MAY BE SHUNT MALFUNCTIONS. THERE WILL PROBABLY NEED TO HAVE REVISIONS OF THE
SHUNT AS THE CHILD GROWS.
- PROGNOSIS DEPENDS ON
1. CAUSE – IF THEY CAN FIX THE CAUSE, THEN THE PROGNOSIS IS BETTER
2. RATE THAT IT DEVELOPED – RAPID DEVELOPMENT = NEURO DAMAGE
3. NUMBER OF COMPLICATIONS – INFECTIONS, REVISIONS OF SHUNT, BLOCKAGE OF SHUNT
FYI: THERE ARE ONLY TWO TIMES THAT WE KEEP THE HEAD OF THE BED FLAT AFTER CRANIAL PROCEDURES. ONE IS
THE INFANT/SMALL CHILD AFTER RECEIVING A VP SHUNT. THE OTHER IS WITH INFRATENTORIAL SURGERY (HOB FLAT
OR NO MORE THAN 10°).
CASE STUDY #1
A CLIENT THAT IS 73 YEARS OLD, ADMITTED TO NEURO UNIT WITH DIAGNOSIS OF TIA, 23 HOUR ADMIT, SHOWING
ATRIAL FIB ON TELEMETRY, WITH A RATE OF 160. HAD AN EPISODE TODAY FOR 15 MINUTES, SO HE COULD NOT
SPEAK, WAS HARD TO GET TO RESPOND TO VERBAL COMMANDS, HAD RIGHT SIDED WEAKNESS IN THE UPPER AND LOWER
EXTREMETIES FOR 2 HOURS. WAS BROUGHT TO THE ER, IMMEDIATELY, BUT NOW IS ORIENTED X 3, MOVES ALL
EXTREMITIES AND HAS NOT DEFICITS.
A CLOT FROM A FIB WAS PROBABLY THIS CLIENTS REASON FOR HAVING A TIA. THE CLOT PROBABLY DISLODGED ITSELF
AND WENT SOMEWHERE ELSE AND DID NOT CAUSE A STROKE.
CASE STUDY #2
ADMITTED TO THE ER WITH A DIAGNOSIS OF A LEFT HEMISPHERIC CVA, SHE WENT TO BE THE NIGHT BEFORE AND THE
NEXT MORNING HER HUSBAND SAID SHE HAD WEAKNESS ON HER RIGHT SIDE AND WAS UNABLE TO TALK. HE RUSHED
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TCA 3
HER TO THE HOSPITAL, SHE STILL HAS RIGHT SIDED WEAKNESS, DIFFICULTY FORMING WORDS AND HOMONYMOUS
HEMIANOPSIA, SHE HAD DIABETES AND HIGH BLOOD PRESSURE, AND SHE IS ON A SOFT DIET.
CASE STUDY #3
THE SAME LADY HAS A LEFT HEMISPHERIC STROKE WITH RIGHT SIDED WEAKNESS, SOME DIFFICULTIES FORMING WORDS
(EXPRESSIVE APHASIA); SHE IS NOW GOING TO REHAB.
WHO IS GOING TO BE ON THE HEALTH CARE TEAM AND WHAT ARE THEIR RESPONSIBILITIES?
DIABETIC COUNSELOR
PT – GAIT TRAINING AND AMBULATION
OT – REGAIN SOME FUNCTIONING IN THE EXTREMITIES, PERFORMANCE OF ADL’S
SPEECH THERAPY – VERY IMPORTANT, CAN BE VERY IMPORTANT FOR CLIENT WITH EXPRESSIVE APHASIA
CARDIOLOGIST
NEUROLOGIST
WHAT ARE GOING TO BE SOME BARRIERS TO HER BEING ABLE TO HAVE A SUCCESSFUL REHABILITATION?
THE CASE STUDY SAID THAT SHE LIVED IN A SMALL TOWN, REHAB FACILITY WILL BE FAR FROM HOME,
FAMILY MIGHT NOT BE ABLE TO SEE HER AS OFTEN, THIS MAY GIVE HER FEELINGS OF ISOLATION AND
DEPRESSION, HER PHYSICAL LIMITATIONS WITH HER CHRONIC ILLNESSES (DIABETES, HYPERTENSION)
CASE STUDY #4
MISS ANDREWS HAD A CEREBRAL ANEURYSM THAT RUPTURED AND SHE HAD A SUBARACHNOID HEMORRHAGE. SHE HAS
AN INCISION WITH NO REDNESS OR DRAINAGE, NIMOTOP IS ORDERED.
WHAT ARE THE DIFFERENCES IN THE SIGNS AND SYMTOMS OF A HEMORRHAGIC AND AN ISCHEMIC STROKE?
HEMORRHAGIC STROKE – RAPID ONSET, SUDDEN SEVERE HEADACHE, LOSS OF CONSCIOUSNESS, NUCHAL
RIGIDITY
ISCHEMIC STOKE – SLOWER ONSET
HOW WOULD YOU DIAGNOSE A SUBARACHNOID HEMORRHAGE?
WITH A CT SCAN OR AN MRI
WHAT ARE THE COMPLICATIONS FOR A SUBARACHNOID HEMORRHAGE AND HOW DO WE TREAT THOSE?
VASOSPASMS – CALCIUM CHANNEL BLOCKERS
SEIZURES – ANTISEIZURE MEDS (DILANTIN)
HYDROCEPHALUS – POSSIBLE SHUNT
RE-BLEEDING - MONITOR THEIR BLOOD PRESSURE AND KEEP IT UNDER CONTROL
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TCA 3
CASE STUDY #5
THE LADY IN CASE STUDY #4 HAS DEVELOPED HYDROCEPHALUS
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TCA 3
HEMIPLEGIA PARALYSIS OF THE FACE, PLACE OBJECTS WITHIN PATIENT’S REACH ON THE NONAFFECTED SIDE.
ARM, AND LEG ON THE SAME PROVIDE IMMOVILIZATION AS NEEDED TO THE AFFECTED SIDE
SIDE. MAINTAIN BODY ALIGNMENT IN FUNCTIONAL POSITION.
EXERCISE UNAFFECTED LIMB TO INCREASE MOBILITY, STRENGTH, AND
USE.
ATAXIA STAGGERING, UNSTEADY SUPPORT PATIENT DURING THE INITIAL AMBULATION PHASE.
GAIT. PROVIDE SUPPORTIVE DEVICE FOR AMBULATION (WALKER, CANE).
UNABLE TO KEEP FEET INSTRUCT THE PATIENT NOT TO WALK WITHOUT ASSISTANCE OR
TOGETHER; NEEDS A BROAD SUPPORTIVE DEVICE.
VASE TO STAND.
DYSARTHRIA DIFFICULTY IN FORMING PROVIDE THE PATIENT WITH ALTERNATIVE METHODS OF COMMUNICATING.
WORDS ALLOW THE PATIENT SUFFICIENT TIME TO RESPOND TO VERBAL
COMMUNICATION.
SUPPORT PATIENT AND FAMILY TO ALLEVIATE FRUSTRATION RELATED TO
DIFFICULTY IN COMMUNICATING.
DYSPHAGIA DIFFICULTY IN SWALLOWING TEST THE PATIENT’S PHARYNGEAL REFLEXES BEFORE OFFERING FOOD
OR FLUIDS.
ASSIST THE PATIENT WITH MEALS.
PLACE FOOD ON THE UNAFFECTED SIDE OF THE MOUTH.
ALLOW AMPLE TIME TO EAT.
NEUROLOGICAL MANIFESTATION NURSING IMPLICATIONS/PATIENT TEACHING APPLICATIONS
DEFICIT
SENSORY DEFICITS
PARESTHESIA NUMBNESS AND TINGLING OF INSTRUCT THE PATIENT TO AVOID USING THIS EXTREMITY AS THE
EXTREMITY. DOMINANT LIMB DUE TO ALTERED SENSATION.
DIFFICULTY WITH PROVIDE RANGE OF MOTION TO AFFECTED AREAS AND APPLY
PROPRIOCEPTION. CORRECTIVE DEVICES AS NEEDED.
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TCA 3
VERBAL DEFICITS
EXPRESSIVE APHASIA USABLE TO FORM WORDS ENCOURAGE PATIENT TO REPEAT SOUNDS OF THE ALPHABET
THAT ARE UNDERSTANDABLE;
MAY BE ABLE TO SPEAK IN
SINGLE-WORD RESPONSES
RECEPTIVE APHASIA UNABLE TO COMPREHEND SPEAK SLOWLY AND CLEARLY TO ASSIST THE PATIENT IN FORMING THE
THE SPOKEN WORD; CAN SOUNDS.
SPEAK BUT MAY NOT MAKE
SENSE
GLOBAL APHASIA COMBINATION OF BOTH SPEAK CLEARLY AND IN SIMPLE SENTENCES; USE GESTURES OR
RECEPTIVE AND EXPRESSIVE PICTURES WHEN ABLE.
APHASIA ESTABLISH ALTERNATIVE MEANS OF COMMUNICATION.
COGNITIVE DEFICITS SHORT AND LONG TERM REORIENT PATIENT TO TIME, PLACE, AND SITUATION FREQUENTLY
MEMORY LOSS USE VERBAL AND AUDITORY CUES TO ORIENT PATIENT.
DECREASED ATTENTION PROVIDE FAMILIAR OBJECTS
SPAN USE NONCOMMPLICATED LANGUAGE
IMPAIRED ABILITY TO MATCH VISUAL TASKS WITH VERBAL CUES
CONCENTRATE MINIMIZE DESTRACTING NOISES WHEN TEACHING THE PATIENT
POOR ABSTRACT REASONING REPEAT AND REINFORCE INSTRUCTIONS FREQUENTLY
ALTERED JUDGMENT
EMOTIONAL DEFICITS LOSS OF SELF-CONTROL. SUPPORT PATIENT DURING UNCONTROLLABLE OUTBURSTS IS DUE TO
EMOTIONAL LABILITY. THE DISEASE PROCESS.
DECREASED TOLERANCE TO ENCOURAGE PATIENT TO PARTICIPATE IN GROUP ACTIVITY.
STRESSFUL SITUATIONS. PROVIDE STIMULATION FOR THE PATIENT.
DEPRESSION CONTROL STRESSFUL SITUATIONS, IF POSSIBLE.
WITHDRAWAL PROVIDE A SAFE ENVIROMENT.
FEAR, HOSTILITY, AND ENCOURAGE PATIENT TO EXPRESS FEELINGS AND FRUSTRATIONS
ANGER RELATED TO DISEASE PROCESS.
FEELINGS OF ISOLATION
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