Transient Ischemic Attack and Stroke Overview

Transient Ischemic Attack (TIA)

• A temporary episode of neurological dysfunction
• Caused by a blockage in blood flow to the brain, spinal cord, or retina
• Symptoms last less than 1 hour
• May be a warning sign of a stroke
• Caused by micro emboli
• A thrombotic stroke is a type of cerebrovascular accident (CVA)

Stroke

• A stroke, sometimes called a brain attack, happens in one of two ways:
  • Blocked Artery: An ischemic stroke occurs when a blood clot blocks blood flow in a brain artery.
  • Ruptured Artery: A hemorrhagic stroke occurs when a blood vessel bursts within the brain.
• Etiology:
  • Thrombosis
  • Trauma
  • Aneurysm
  • Embolism
  • Hemorrhage
  • Sudden vascular compromise causing disruption of blood flow to the brain

Stroke Manifestations

• Right-brain damage (stroke):

  • Paralyzed left side (hemiplegia)
  • Left-sided neglect
  • Spatial-perceptual deficits
  • Tends to deny or minimize problems
  • Rapid performance, short attention span
  • Impulsive, safety problems
  • Impaired judgment
  • Impaired time concepts

• Left-brain damage (stroke):

  • Paralyzed right side (hemiplegia)
  • Impaired speech/language (aphasias)
  • Impaired right/left discrimination
  • Slow performance, cautious
  • Aware of deficits: depression, anxiety
  • Impaired comprehension related to language, math

Acute Care Assessment

• Altered level of consciousness
• Weakness, numbness, or paralysis
• Speech or visual disturbances
• Severe headache
• Increased or decreased heart rate
• Respiratory distress
• Unequal pupils
• Hypertension
• Facial drooping on affected side
• Difficulty swallowing
• Seizures
• Bladder or bowel incontinence
• Nausea and vomiting
• Vertigo

Acute Care Goals

• Preserve life
• Prevent further brain damage
• Reduce disability
• Treatment differs according to stroke type and patient changes
• Begins with managing the ABCs (Airway, Breathing, Circulation)

Nursing Goals

• Maintain a stable or improved level of consciousness
• Attain maximum physical functioning
• Attain maximum self-care abilities and skills
• Maintain stable body functions (e.g., bladder control)
• Maximize communication abilities
• Maintain adequate nutrition
• Avoid complications of stroke
• Maintain effective personal and family coping

Acute Care Initial Interventions

• Managing circulation, airway, and breathing
• Ensuring the client's airway is open and clear
• Calling the stroke code or stroke team
• Removing dentures
• Assessing pulse oximetry
• Maintaining adequate oxygenation
• Maintaining blood pressure according to guidelines
• IV access with normal saline
• Performing baseline laboratory tests
• Positioning the head midline
• Elevating the head of the bed to 30 degrees if no symptoms of shock or injury
• Instituting seizure precautions
• Anticipating thrombolytic therapy for ischemic stroke
• Keeping the client NPO until swallow reflex is evaluated (Nothing by mouth)

Acute Care Ongoing Interventions

• Monitoring vital signs and neurologic status
• Assessing level of consciousness
• Evaluating motor and sensory function
• Assessing pupil size and reactivity
• Monitoring oxygen saturation
• Monitoring cardiac rhythm
• Managing hypertension (if needed) with medication
• Managing fluid and electrolyte balance
• Promoting adequate hydration

Treatment: Acute Care

• Aspirin is used within 24-48 hours of a stroke
• Contraindicated in hemorrhagic stroke
• Platelet inhibitors and anticoagulants may be used in thrombus and embolus strokes
• Recombinant tissue plasminogen activator (rtPA) is used to re-establish blood flow
• Thrombolytic therapy within 3-4.5 hours of ischemic stroke onset
• Risk of disability reduction vs. risks (death, intracerebral hemorrhage) are considered
• Seizures may occur within 24 hours in approximately 10-15% of patients

Collaborative Care: Rehabilitation

• Collaborative care shifts from preserving life to lessening disability and attaining optimal functioning after stroke stabilization (12-24 hours)
• Patient may be transferred to a rehabilitation unit, outpatient therapy, or home care-based rehabilitation
• Ideally, discharge planning begins early in the hospitalization and promotes a smooth transition between care settings

Collaborative Care Rehabilitation Goals

• Learning techniques to self-monitor and maintain physical wellness
• Demonstrating self-care skills
• Exhibiting problem-solving skills with self-care
• Avoiding complications associated with stroke
• Establishing and maintaining a useful communication system
• Maintaining nutritional and hydration status
• Listing community resources for equipment, supplies, and support
• Establishing flexible role behaviors to promote family cohesiveness

Nursing Diagnosis

• Risk for ineffective cerebral tissue perfusion
• Decreased Intracranial adaptive capacity
• Impaired transfer ability
• Impaired verbal communication
• Risk for aspiration
• Unilateral neglect
• Impaired urinary elimination
• Risk for chronic functional constipation
• Impaired swallowing
• Situational low self-esteem
• Impaired social interaction
• Impaired home maintenance

Nursing Management Planning

• Goals for the client include:
  • Maintaining a stable or improved level of consciousness
  • Attaining maximum physical functioning
  • Attaining maximum self-care abilities and skills
  • Maximizing communication abilities
  • Maintaining adequate nutrition
  • Avoiding complications of stroke
  • Maintaining effective personal and family coping

Health Promotion

• Recognizing that individuals are responsible for their own and future generations' health
• Teaching clients and families about early stroke symptoms and when to seek health care
• Hypertension management
• Diabetes management (glucose control)
• Lifestyle modifications

Nursing Management Implementation - Respiratory System

• Management of the respiratory system is a priority
• Risk for aspiration pneumonia due to impaired consciousness or dysphagia
• Risks for airway obstruction
• May require endotracheal intubation and mechanical ventilation

Nursing Management - Neurological System

• Monitor closely for stroke progression, extension of the stroke,
• Monitor for increased intracranial pressure (ICP)
• Document recovery from stroke symptoms

Nursing Management - Cardiovascular System

• Goals aimed at maintaining homeostasis
• Many stroke clients have cardiac reserves from secondary cardiac diseases
• Prevent deep vein thrombosis (DVT)
• Cardiac monitoring

Nursing Management - Musculoskeletal System

• Maintain optimal function
• Prevent joint contractures and muscular atrophy
• Range-of-motion exercises and positioning during the acute phase
• Using trochanter rolls to prevent external hip rotation
• Using hand cones to prevent hand contractures
• Using arm supports with slings and lap boards to prevent shoulder displacement

Nursing Management - Integumentary System

• Skin of the client is susceptible to breakdown related to loss of sensation, decreased circulation, and immobility
• Compound by client age, poor nutrition, dehydration, edema, and incontinence
• Pressure relief by position changes, special mattresses, or wheelchair cushions
• Applying emollients to dry skin
• Early mobility
• Positioning client on the weak or paralyzed side for only 30 minutes

Nursing Management - Gastrointestinal System

• Stress of illness contributes to a catabolic state that can interfere with recovery (increased risk of stress ulcers)
• May require nutrition support
• First feeding should be approached carefully
• Test the gag reflex
• Collaborate with Speech Language Pathologist (SLP)
• After careful assessment of swallowing, chewing, gag reflex, and pocketing, oral feedings can be initiated
• Feedings must be followed by scrupulous oral hygiene
• Constipation is a common problem in stroke patients, so physical activity, and stool softeners/laxatives may be needed

Nursing Management - Urinary System

• In the acute stage, poor bladder control is the primary urinary problem, resulting in incontinence
• Efforts should be made to promote normal bladder function and to avoid the use of in-dwelling catheters
• Bladder retraining program may be needed

Nursing Management - Communication

• Nurse's role in assessing and meeting psychological needs of the client is primarily supportive
• Client is assessed for the ability to speak and the ability to understand
• Speaking slowly and calmly, using simple words or sentences
• Allow time to process information (aphasia may worsen with fatigue)

Nursing Management - Sensory-Perceptual Alterations

• Blindness in one half of the visual field (hemianopsia) is common
• Other visual problems may include diplopia (double vision), loss of the corneal reflex, and ptosis (drooping eyelid)
• Arrange the environment within the patient's field of vision

Nursing Management - Coping

• Stroke can affect the family emotionally, socially, and financially
• Changing roles and responsibilities may occur
• Thorough explanation of diagnosis should be understandable to client
• Detail explanation of events to the family
• Social service referral may be beneficial

Nursing Management - Ambulatory and Home Care

• Client is usually discharged from acute care to: home, intermediate/long term facility, or rehabilitation facility
• Discharge planning with the client and family, early on, is essential
• Nurses have opportunity to prepare client/family through education, demonstration, and practice
• Evaluating self-care skills

Prevention

• Priority is for decreasing morbidity and mortality from stroke
• Goals include:
  • Health management of the well individual
  • Education and management of modifiable risk factors, such as:
    • Diabetes mellitus
    • Hypertension
    • Obesity
    • High serum lipids
    • Cardiac dysfunction (atrial fibrillation)
• Drug therapy including:
  • Antiplatelets (aspirin most commonly)
  • Anticoagulants
  • Antiepileptics (lorazepam)
  • Calcium channel blockers
  • Stool softeners
  • Analgesics
  • Anti-anxiety drugs

This quiz covers the key concepts of Transient Ischemic Attacks (TIA) and strokes, including their causes, symptoms, and manifestations. Understand the differences between ischemic and hemorrhagic strokes, along with their potential warning signs and complications.