Stroke (CVA): Causes, Types, and Statistics

Stroke (Cerebrovascular Accident - CVA)

• Stroke is the second most common cause of death, accounting for 9%, and a major cause of disability globally
• Stroke is more common in males and uncommon in individuals under 40
• The death rate following a stroke is 20-25%
• CVA is a sudden interruption of blood circulation to the brain, leading to serious damage or necrosis
• Ischemic stroke accounts for 85% of strokes, while hemorrhagic stroke accounts for 15%
• Ischemic strokes result from embolism, systemic hypoperfusion, or thrombosis
• Hemorrhagic strokes result from subarachnoid or intracerebral hemorrhage
• Embolism is caused by traveling debris, such as blood clots or plaque, originating elsewhere in the body
• Most embolic strokes are cardiogenic, resulting from valve disease or atrial fibrillation
• Systemic hypoperfusion results from decreased blood flow to the brain due to circulatory failure
• Thrombotic strokes are caused by blockage of large vessels, often due to atherosclerosis
• Subarachnoid hemorrhage may be caused by the rupture of an intracranial aneurysm or arteriovenous malformation
• Intracerebral hemorrhage results from rupture within the brain parenchyma, leading to hematoma, and may be caused by uncontrolled hypertension

Modifiable Risk Factors for Stroke

• Hypertension is a key modifiable risk factor
• Atrial fibrillation increases stroke risk
• Valvular heart disease contributes to stroke risk
• Hyperlipidemia is a modifiable risk factor
• Diabetes mellitus increases stroke risk
• Cigarette smoking is a significant risk factor
• Asymptomatic carotid stenosis increases risk
• Obesity is a modifiable risk factor
• Carotid stenosis is a risk factor
• Oral contraceptive use is a risk factor
• Postmenopausal hormonal therapy increases stroke risk

Clinical Manifestations of Stroke

• Neurologic deficits vary based on lesion location, affected area size, and collateral circulation amount
• Initial symptoms occur suddenly, including numbness or weakness in the face, arm, or leg, especially on one side of the body
• Other sudden symptoms include confusion, mental status changes, trouble speaking or understanding speech, visual disturbances, dizziness, loss of balance or coordination, and severe headache

Neurologic Deficits

• Hemiparesis is weakness on one side of the body
• Ataxia is a lack of muscle coordination
• Dysphagia is difficulty swallowing
• Hemiplegia is paralysis on one side of the body
• Dysarthria is difficulty speaking due to muscle weakness
• Visual field deficits include loss of half of the visual field (hemianopia), loss of peripheral vision, and diplopia (double vision)
• Sensory deficits: Paresthesia occurs on the side opposite the lesion site
• Verbal deficits: Expressive, receptive, and global aphasia
• Cognitive deficits: Short and long memory loss; decreased attention span; impaired ability to concentrate; poor abstract reasoning
• Emotional deficits: Loss of self-control, emotional lability, decreased tolerance to stress, depression, withdrawal, fear, anger, and feelings of isolation

Assessment and Diagnostic Findings for Stroke

• Complete history, physical, and neurologic examination
• Initial assessment includes airway patency, respiratory pattern, cardiovascular status, and neurologic deficits
• Airway patency can be compromised due to loss of gag or cough reflexes
• Diagnostic tests include non-contrast CT scans to identify ischemic or hemorrhagic stroke
• Standard tests include 12-lead ECG and Carotid Ultrasonography
• Arteriography involves injecting dye into brain arteries to locate blocked vessels
• Computed Tomography (CT) looks for aneurysms, arteriovenous malformations and narrowing evaluation of arteries
• Magnetic Resonance Imaging (MRI) detects brain tissue damage from ischemic stroke
• Echocardiography composes images of the heart

Stroke Prevention

• Control hypertension through exercise, stress management, healthy weight, and limiting sodium and alcohol
• Administer medications like diuretics, ACE inhibitors, and angiotensin receptor blockers if prescribed
• Lower cholesterol and saturated fat intake
• Cessation of Smoking
• Control diabetes
• Maintain a healthy weight
• Regular exercise
• Follow balanced diet.

Stroke Treatment

• Treatment depends on stroke type (ischemic vs. hemorrhagic)
• Ischemic stroke goals involve removing obstructions and restoring blood flow
• Quick treatment (within three hours) improves survival chances and reduces disability
• Tissue plasminogen activator (t-PA) use is contraindicated in hemorrhagic stroke
• Medical treatment for ischemic stroke involves anti-platelet drugs like aspirin or clopidogrel and thrombolytic therapy (recombinant t-PA)
• t-PA dosage is 0.9 mg/kg, with a maximum of 90 mg, administered via IV bolus and infusion
• During t-PA administration, patient is admitted to ICU with continuous monitoring and frequent neurological assessment
• Vital signs are checked every 15 minutes for the first 2 hours, then less frequently over the next 24 hours post-treatment
• Hemorrhagic stroke management focuses on symptom management with medications
• Anticonvulsants prevent seizure recurrence
• Antihypertensive agents reduce blood pressure
• Osmotic diuretics decrease intracranial pressure in subarachnoid space
• Surgical treatments include carotid endarterectomy to remove plaques and carotid stenting to compress plaques

Nursing Management During Acute Phase of Stroke

• Monitor all body systems
• Neurologic flow sheet data during acute phase
  • Change in consciousness or responsiveness
  • Presence/absence of voluntary movements
  • Muscle tone and body posture
  • Neck stiffness
  • Pupil size and reactivity
  • Ability to speak
  • Skin color, temperature, moisture
  • Pulse and respiration rates
  • Fluid balance
  • Presence of bleeding
• Nursing assessments after the acute phase
  • Mental status: Memory, attention, speech/language
  • Sensation: Awareness of pain and temperature
  • Motor control: Upper and lower extremity movement
  • Swallowing ability
  • Nutritional and hydration status
  • Skin integrity
  • Activity tolerance
  • Bowel and bladder function
• Nursing diagnoses include: -Impaired physical mobility and self-care deficits because of the stroke
  • Acute pain
  • Impaired swallowing
  • Disturbed sensory perception and thought processes
  • Urinary incontinence
  • Impaired communication
  • Risk for impaired skin integrity
  • Interrupted family processes
  • Sexual dysfunction

Nursing Interventions

• Proper body positioning is crucial to prevent contractures and relieve pressure.
• Use a posterior splint at night to maintain correct extremity position
• Position arm in slight flexion to prevent distal joint edema and encourage slight supination with hand
• Change patient position every 2 hours to prevent pressure ulcers; prone position prevents knee/shoulder flexion
• Active and passive exercises of affected extremities four/five times a day maintain mobility and enhance circulation
• Assist patient as soon as possible out of bed and start an active rehabilitation program when they regain consciousness
• Prevent the paralyzed arm from dangling without support using a sling during ambulation.
• Encourage personal hygiene and ensure patient does not neglect affected side
• Approach patient in area of intact visual perception and use visual stimuli on that side
• Provide thick liquid or pureed diet to assist nutrition. Initiate NGT if patient unable to orally feed
• Begin intermittent catheterization for temporary urinary incontinence
• High-fiber diet and fluids aid bowel control

Altered Level of Consciousness (LOC)

• A condition where patient is not oriented, doesn't follow commands, or needs persistent stimuli to achieve alertness.
• Lethargic: Drowsy but needs gentle stimulation to initiate response and follows simple commands.
• Confused: Disoriented to time, person, and place; impaired judgment; difficulty following commands.
• Stuporous: Responds only to vigorous stimulation; moans verbally.
• Coma: Prolonged state of unconsciousness where the patient is unaware of self or environment.
• Patient may exhibit reflexive posturing or no response to stimuli.

Types of Abnormal Posturing Due to Stimuli

• Decorticate posturing involves upper extremity flexion and internal rotation of lower extremities with plantar flexion.
• Decerebrate posturing involves extension and outward rotation of upper and lower extremities with plantar flexion.

Pathophysiology of Altered LOC

• Altered LOC results from multiple phenomena: neurologic (head injury, stroke), toxicologic (drug overdose, alcohol intoxication), or metabolic (hepatic/renal failure, diabetic ketoacidosis).

Clinical Manifestations of Altered LOC

• Initial alterations include behavioral changes like restlessness or anxiety
• Over time manifestations include -Decreased wakefulness -Poor memory -Decreased attention to the environment -Decreased ability to perform daily activities -Decreased mobility -Incontinence -Agitation -Hallucination -Delusions -Confusion/disorientation -Coma
• Pupils fixed with no light response.
• Patient doesn't open eyes, verbally respond, or move extremities to request.

Diagnostics for Altered Level of Consciousness

• Neurologic examination assesses mental status, cranial nerve function, balance/coordination, reflexes, and motor/sensory function
• Glasgow Coma Scale is a sensitive indicator -Score ranges from 3-15 -15 indicates fully responsive -3-8 is severe impairment -9-12 is moderate -13-14 is mild impairment
• Assume neurologic disease if patient is comatose with localized signs
• Suspect toxic/metabolic disorder if comatose but pupillary reflexes are preserved
• Diagnostic procedures for altered LOC: -Computed Tomography (CT) scanning -Magnetic Resonance Imaging (MRI) -Electroencephalography (EEG)
• Laboratory tests can show electrolyte imbalances, liver injury, etc: -Blood glucose -Electrolytes -Liver function tests -Blood urea nitrogen (BUN) levels -Serum osmolality -Calcium level -Partial thromboplastin (PTT) and prothrombin times(PT) -Serum ketones -Alcohol -Drug concentrations -Arterial blood gases (ABG)

Medical Management of Altered Level of Consciousness

• Maintain an airway via positioning or insertion of ETT/TT
• Maintain ventilation with O2 and possibly mechanical ventilation.
• Maintain circulation with IV fluids.
• Maintain neurologic status to prevent increases in intracranial pressure (ICP).
• Maintain nutrition with enteral or parenteral approach.
• Pharmacological management.
• Determine and address the underlying issues

Intracranial Pressure

• The Intracranial is the volume within the skull
• Contents of the skull: brain/interstitial, intravascular blood and cerebrospinal fluid (CSF)
• Normal Intracranial Pressure (ICP): 5-15 mm Hg
• Monro-Kellie Hypothesis: A change in volume in skull components has to be compensated via another component in order to remain the same

Potential Complications and Nursing Actions

• Infection with aspiration pneumonia.
• Monitor closely to prevent
• Difficulty breathing with respiratory distress
• Assist with ventilation
• Skin breakdown and pressure ulcers
• Maintain skin integrity.
• Deep vein Thrombosis
• Contractions
• ROM exercises and mobility.

Nursing Diagnosis and Assessments

Nursing Assessment points:

• Previous medical history including current medications
• Neurological examination findings
• Glasgow Coma Scale result

Nursing Diagnosis should include:

• Airway issues
• Risk for injury
• Possible fluid imbalances
• Nutrition concerns
• Skin integrity
• Intact cornea
• Thermoregulation issues

Nursing Interventions and Achieving Goals

Maintain clear airway:

• Use suction
• Promote pulmonary function

Monitoring Intracranial Pressure:

• Promote venal drainage
• Monitor agitation
• Frequent neuro assessments

Thermoregulation and Temp Control:

• Frequent temperature checks
• Cooling methods without shivering

Promote Bowel function and prevent straining:

• Assess Foley function, and catheterize with output.

Maintaining the Airway During Patient Transportation

• Elevating the head of the bed to 30 degrees helps prevent aspiration.
• Suction of oral cavity

Nursing actions cont'd

• Protect to prevent skin breakdown and contracture
• Assess skin
• Promote proper turning
• Maintain good nutrition and hygiene
• Offer support and empathy

Management Includes

• Amputation is the removal of a body part

• Indication

• Dead ~Arterial occlusion or stenosis tissue

• infarction and gangrene

• Deadly ~Moist gangrene (infection)

• Dead loss ~Severe laceration fracture with partial amputation due to trauma. -Severe contracture or paralysis that hinder walking or any movement Severe rest pain ischemic foot Amputation is indicated to decrease pain ~In addition to congenital chronic osteomyelitis or malignant tumor

Site Detection

• Circulation in the part.
• Functional isefulness

Levels of Amputation

• Lower extremity amputation

• Amputation of toes and part of foot causes minor changes in gait balance

• Upper extremity amputation

• They are performed to preserve the maximum functional length

• The prosthesis is fitted early for maximum function

Pre/post Op Mgt Includes

• Assess skin for breakdown.
• Assess VS for systemic infection/issue.

Pt Mgt Includes

_Pt Teaching _Manage Pain _Monitor wound

• Rehabilitation _Body image acceptance

Post-op Amputation Managment

• Nonpharm pain managment
• Evaluate pt pain response
• Control residual tissue
• PT/OT
• Psychological care

Fracture - Definition and Classifications

• A fracture is a break in the continuity of a bone
• Causes include Direct Blow, Crushing Force, Sudden Twisting Motion, Extreme Muscle Contraction and Pathological reasons such as tumors
• Predisposing factors: Age (children and old people) and Sex (men due to occupation)

Fracture Classifications Include

• Incomplete: Break thorough part of the bone. Also known as "Greenstick Fractures"
• Complete: Break across the entire bone
• Closed: Does not break the skin
• Open: Extends to the fractured bone.

Signs and Symptoms Include

- Pain

• Shortening of the extremity
• Deformity
• Dislocation
• Local Swelling
• Loss of Function
• Crepitus (grinding of bone)

Diagnostic Procedures Include

• X-ray. Looks at the location and extent of the fracture.
• CT/MRI. To determine soft tissue damage and tumors
• Arteriogram. Done when vascular damage occurs Hct and CBC taken to see if there's been blood loss Coagulation profile to check blood clotting ability

Fractures: Management and Goals

• In an emergency, they will immobilize the part with a padded splint.
• Splint must include joint connected to the injured limb
• In open fractures, cover with sterile bandage

Nursing Intervention - Neuro Checks

• Pain
• Pulse
• Pallor The Nursing Diagnosis should include Risk for Impaired physical mobility.

Actions for Nurses to Intervene

• Assess injuries
• Maintain proper alignment
• Elevate area
• Encourage Active/Passive exercises for function

Fat Embolism Syndrome (FES) vs. Compartment Syndrome

Key points of Fats Embolisms

• Pyrexia and or Respiratory failure
• Neurological change due lodging
• High risk are 20-30 age range.

1. The best prevention for FES is immobilization

Points for Compartment Syndrome

• Tissue pressures and neurovascular function becomes limited.
  • The #1 sign is paresthesia (numbness and tingling) -Elevate extremity -A fasciotomy may be required