Rnur 141 Cerebrovascular
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CVA; brain attack; sudden loss of function resulting from disruption of blood supply to part of the brain.
- Energy failure (anaerobic = no ATP)
- Acidosis (ion imbalance)
- Intracellular Ca increases
- Cell membranes breakdown
- Proteins breakdown
- Free radicals form
- Cell injury/cell death
5 Types of Ischemic Stroke
- Large Artery Thrombotic Stroke
- Small Penetrating Artery Thrombotic Stroke
- Cardiogenic Embolic Stroke
- Crytopgenic Stroke
- Other (Cocaine use, Migraine, Spontaneous dissection of arteries)
Atherosclerotic plaques in the large blood vessels of the brain lead to ______ stroke.
Large Artery thrombosis
Thrombosis in one or more vessels is a ___ stroke. It is also called a lacunar stroke, due to the cavity created after death of infarcted tissue.
Small Penetrating Artery thrombotic stroke
_____ strokes are associated with cardiac dysrhythmias, usually a-fib. Emboli originate in the heart and circulate to the brain.
Cardiogenic Embolic strokes
___ strokes have no known cause.
Strokes may be from other causes, such as:
- cocaine use
- spontaneous dissection of the carotid or vertebral arteries
Area of low cerebral blood flow, exists around the infarction. Changes in cell membrane depolarization enlarges the area of infarction into the penumbra, extending the stroke. It can be salvaged with timely intervention.
Clinical manifestations of Ischemic Stroke:
- Numbness of weakness of face, arm, leg, or one side of body
- Confusion or change in mental status
- Trouble speaking or understanding speech
- Visual disturbances
- Difficulty walking, dizziness, loss of coordination or balance
- Sudden severe headache
difficulty in speaking
- loss of speech
- Can be expressive, receptive, or global (mixed)
inability to perform previously learned actions
loss of half of visual field
inability to recognize previously familiar objects
weakness/paralysis of one side of the body
zone of tissue deprived of blood supply
numbness or tingling of extremity, occurs opposite side of lesion
Transient Ischemic Attack (TIA) :
neurologic deficit lasting less than 1 hour.
Clinical manifestations of a TIA:
- sudden loss of motor, sensory, or visual function.
- Serves as a warning of impending stroke.
- Hemorrhagic or Ischemic?
- Maintain patent airway
- Carotid Ultrasound
Diagnostic Findings of Ischemic Stroke:
- Fall Risk
- Impaired physical mobility
- Disturbed sensory perception
- Impaired swallowing
- Impaired urinary elimination
- Disturbed thought process
- Ineffective communication
- Self care deficit
Medical Management of Ischemic Stroke
- Thrombolytic Therapy (TPA)
- Streptokinase (decrease/prevent brain damage)
- Heparin, Warfarin, Aspirin, Plavix
- Diuretic (Mannitol)
- Managing potential complications (oxygenation, UTI, dysrhythmias)
Prevention of Ischemic Stroke
- Stroke screenings
- Nonmodifiable risk factors: 55+, Men, Afr Amer, Native Amer, Hisp, Asians
- Modifiable risk factors: HTN, CAD, Smoking, Obesity, Alcoholics, Diabetes, A-fib
- bleeding into the brain tissue, ventricles, subarachnoid space.
- Have more severe deficits and longer recovery time than ischemic stroke.
bleeding into the brain tissue, most common in patients with HTN and atherosclerosis.
Intracranial (Cerebral) Aneurysm
dilation of arterial walls due to a weakening, often r/t congenital, athersclerosis, HTN, head trauma.
abnormality with no capillary bed, leads to dilation, tangle of arteries & veins, which will eventually rupture. Typical in kids/infants.
bleeding in subarachnoid space r/t trauma, HTN. Often seen at Circle of Willis, or congenital AVM.
Clinical manifestations of Hemorrhagic Stroke:
- presents similarly to TIA--
- Sudden onset of severe headache
- Decreased LOC
- Pain & rigidity of spine
- Visual disturbances
- If aneurysm clots, s/s will be minimal.
- If aneurysm bleeds, can lead to cerebral damage, coma, death.
Hemorrhagic Stroke Assessment:
- Ischemic or Hemorrhagic?
- Size/location of hematoma
- CT negative = lumbar puncture.
- Increased ICP = no puncture (risks to brainstem)
Medical Management of Hemorrhagic Stroke
- PREVENTION IS KEY!
- Allow for rest! --Sedation, Pain meds, Bedrest
- TEDS, SCDS
- Diuretic (mannitol) to decrease ICP
- Surgery if hematoma exceeds 3cm and Glasgow decreases.
- Prevent/lessen risk of bleeding
- Prevent/treat complications
Diagnostic Findings of Hemorrhagic Stroke:
- Ineffective tissue perfusion r/t bleeding or vasospasm
- Disturbed sensory perception r/t medically imposed restrictions
- Anxiety r/t illness and/or medically imposed restrictions
Preventions/Interventions for Hemorragic Stroke
- Elevate HOB 15-30 degrees to decrease ICP
- Avoid Valsalva maneuver, sneezing, straining, pushing,
- No enemas
- Dim lights
- No caffeine, external stimuli
- a symptom rather than disease
- Primary- no organic cause. Ex. Migraine, tension, cluster
- Secondary - organic cause. Ex. r/t Brain tumor, aneurysm, trauma.
Diagnosis of Headache
- Neuro exam
- Severe, unrelenting headache often accompanied by symptoms such as N/V and visual disturbances.
- Due to vasoconstriction and changes in serotonin
- Cause unknown
Triggers for Migraine Headaches
- Menstrual cycle
- Bright lights
- Sleep deprivation
- Certain foods
- Oral contraceptives
Migraine with an aura can be divided into 4 phases:
- Experienced by 60% of patients hours to days prior
- S/s: depression, irritability, feeling cold, food cravings, anorexia, change in activity level, increased urination, diarrhea, constipation
- Experienced by minority of patients less than hour prior
- S/s: visual disturbances, numbness, tingling, mild confusion, slight weakness in extremity, drowsiness, dizziness
Throbbing headache intensifies, often associated with photophobia, nausea, vomiting.
- Termination and postdrome, pain gradually subsides.
- Muscle contraction in neck and scalp, muscle ache, tenderness, exhaustion, mood changes, sleep.
- Inderal (B blocker)
- Lopressor (B blocker)
- Elavil (antidepressant)
- Depakote (antiseizure)
- Cafergot (combo caffeine & ergotamine)
- * Imitrex (triptan). Contraindicated w/St Johns Wort
- Dark room
- Head slightly elevated
- Drink black coffee
- Symptomatic treatment
- Identify precipitators and eliminate
- Condition of 5th cranial nerve
- Causes facial pain, muscle contractions, painful twitches
- Lasts seconds to minutes
- More common in women, multiple sclerosis
Trigeminal Neuralgia Triggers
- Brushing teeth
- Cold air drafts
- Direct pressure
- Hot/cold food
Trigeminal Neuralgia Management
- Anticonvulsants (carbamazepine Tegretol, phenytoin Delantin)
- Alcohol injection into nerve root
- Surgical intervention (decompression, microcompression, radiofrequency)
Nurse Mangement of Trigeminal Neuralgia
- Foods/fluids at room temp
- Soft foods
- Chew on unaffected side
- Artificial tears for dryness
- Post op check sensory deficits, chewing/swallowing deficits
aka Facial paralysis
- Inflammation of 7th Cranial Nerve
- Cause unknown
- Sudden onset with no triggers
- Spontaneous recovery in 3-5 weeks
Clinical manifestations of Bell's Palsy
- Distortion of face due to paralysis of facial muscles
- Increased lacrimation (tearing)
- Pain in face, behind ear, and in eye
- Speech and eating difficulties
Management of Bell's Palsy
- Maintain muscle tone
- Reassure no stroke has occurred
- Corticosteroid therapy (Prednisone) to reduce inflammation
- Analgesics for pain
- Apply heat to promote circulation
- Avoid drafts
- Protect the eye since blink reflex is diminished
- Eye drops
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