Neurosensory Disorders: Stroke (CVA, Brain Attack)

Marnie Quick RN, MSN, CNRN

A. Pathophysiology/etiology Normal brain physiology and stroke

Ranks 3rd 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

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- 7th 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

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 p1510 Table 58-4 & Table above it for 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. 1511 Table 58-5 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- Cerebex/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 1514 Table 58-6 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 (7th 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; 3rd nerve palsy (occulomotor); 6th nerve palsy (abducens)

Nursing assess neuro deficits: Motor 3rd nerve palsy 6th 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 1st 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.1516 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/interventions4. Impaired verbal communication

Assess speaking, writing, gestures, understanding Support speech therapist plan Support guidelines as LeMone p. 1317 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/interventions7. Impaired swallowing

Dysphagia- difficulty swallowing LeMone 1317 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/interventions8. 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