Stroke Lecture 5 PDF - University of Kirkuk

**University of Kirkuk 2023-2024** **College of Nursing 4^th^ year students** **Critical care nursing (theory)** **First semester** **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** **Stroke (lecture 5)**...

**University of Kirkuk 2023-2024** **College of Nursing 4^th^ year students** **Critical care nursing (theory)** **First semester** **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** **Stroke (lecture 5)** **Cerebrovascular accident (CVA):** Cerebrovascular disorders is an umbrella term that refers to a functional abnormality of the central nervous system (CNS) that occurs when the blood supply to the brain is disrupted. Stroke is the primary cerebrovascular disorder. Strokes can be divided into two major categories: ischemic (approximately 87%), in which vascular occlusion and significant hypoperfusion occur, and hemorrhagic (approximately 13%), in which there is extravasation of blood into the brain or subarachnoid space **[STROKE]**: Sudden interruption of blood supply to an area of the brain. [Blood flow is disrupted because of an: (]Obstruction of a vessel, A thrombus, Embolus, Rupture of a vessel). Stroke is the third leading cause of death in the United States, after heart disease and cancer. **[Types of Stroke:]**  - **Thrombotic Stroke. Thrombotic** strokes occur when an occlusion builds up in an artery until it significantly decreases or stops blood flow to the brain. Thrombotic strokes most often occur in the internal or common carotid arteries. - **Embolic Stroke.** An **embolic** stroke is typically caused by a blood clot that is created somewhere in the body, often within the heart, and travels through the arteries until it becomes trapped in a smaller vessel, preventing the passage of blood. **[Risk factors for transient ischemic attack/stroke ]** 1. **Non-Modifiable** - Older age - Male gender - Family history - Race (African American) 2. **Modifiable** - Cigarette smoking - High blood pressure - Diabetes mellitus - Cardiovascular disease - High total cholesterol - Low high-density lipoprotein cholesterol - Dyslipidemia - Atrial fibrillation - Asymptomatic carotid stenosis - Obesity - Excessive alcohol intake - Poor diet (high sodium, high fat, low potassium) - Physical inactivity **[Clinical Manifestations]** An ischemic stroke can cause a wide variety of neurologic deficits, depending on the: ^1)^location of the lesion (which blood vessels are obstructed), ^2)^size of the area of inadequate perfusion, and ^3)^amount of collateral (secondary or accessory) blood flow 1. Numbness or weakness of the face, arm, or leg, especially on one side of the body 2. Confusion or change in mental status 3. Trouble speaking or understanding speech 4. Visual disturbances 5. Difficulty walking, dizziness, or loss of balance or coordination 6. Sudden severe headache 7. Motor Loss: a. Hemiplegia (paralysis of one side of the body b. Hemiparesis, or weakness of one side of the body 8. Communication Loss: a. expressive aphasia (inability to express oneself b. receptive aphasia (inability to understand language c. dysphasia (impaired speech) d. Dysarthria (difficulty in speaking) e. Apraxia (inability to perform a previously learned action) 9. Perceptual Disturbances: Perception is the ability to interpret sensation 10. Sensory Loss: impairment of touch 11. Cognitive Impairment and Psychological Effects **[Assessment and Diagnostic Findings]** 1. Initial assessment focuses on airway patency, gag or cough reflexes and altered respiratory pattern; cardiovascular status. 2. A TIA is manifested by a sudden loss of motor, sensory, or visual function. The symptoms result from temporary ischemia to a specific region of the brain. 3. computed tomography (CT) scan. performed within 25 minutes or less 4. A 12-lead electrocardiogram (ECG) and a carotid ultrasound are standard tests. CT angiography 5. magnetic resonance imaging (MRI) and magnetic resonance angiography transcranial Doppler flow studies 6. transthoracic or transesophageal echocardiography 7. single-photon emission CT scan. **[Early Management]** 1. Those with atrial fibrillation are treated with dose-adjusted **warfarin**. 2. Platelet-inhibiting medications, including **aspirin**, and **clopidogrel** decrease the incidence of cerebral infarction in patients who have experienced TIAs and stroke. 3. Statins as **simvastatin** (Zocor), reduce coronary events and ischemic strokes. 4. After acute stroke period, **antihypertensive** medications also used, Preferred drugs include angiotensin-converting enzyme (ACE) inhibitors and diuretics, or a both. 5. Medical management of acute ischemic stroke needs to include consideration for endovascular treatment (**balloon angioplasty or stenting**). The FDA has approved several devices that open the blocked artery and restore blood flow to the brain. 6. **Thrombolytic agents** are used to treat ischemic stroke by dissolving the blood clot that is blocking blood flow to the brain. **[Causes and Risk factors]** 1. Uncontrolled hypertension. 2. ruptured intracranial aneurysm 3. Overtreatment with blood thinners (anticoagulants) 4. Trauma (such as a car accident) 5. of beta-amyloid protein in the small- and medium sized blood vessels of the brain 6. arteriovenous malformations 7. intracranial aneurysms 8. certain medications (e.g., anticoagulants). **[Clinical Manifestations]** The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. **[Assessment and Diagnostic Findings]** 1. **CT scan or MRI** scan to determine the type of stroke, the size and location of the hematoma, and the presence or absence of ventricular blood and hydrocephalus. 2. **Cerebral angiography**: confirms the diagnosis of an intracranial aneurysm or AVM. 3. **Lumbar puncture** may be performed if there is no evidence of increased ICP, Lumbar puncture in the presence of increased ICP could result in brainstem herniation or re-bleeding. **[Medical Management]** 1. Bed rest with sedation to prevent agitation and stress. 2. If the bleeding is caused by anticoagulation with warfarin, the INR may be corrected with fresh-frozen plasma and vitamin K. 3. If seizures occur, they are treated with anticonvulsant drugs such as phenytoin. 4. Intermittent pneumatic compression devices should be used starting on the first day of the hospital admission to prevent DVT. 5. DVT prevention medications (heparin) may be prescribed. 6. Analgesic agents may be prescribed for head and neck pain. 7. Fever should be treated with acetaminophen. 8. Most patients will require antihypertensive medications. **[Nursing Management:]** 1. A complete neurologic assessment is performed initially and includes: a. Altered level of consciousness b. Sluggish pupillary reaction c. Motor and sensory dysfunction d. Cranial nerve deficits (facial droop, presence of ptosis) e. Speech difficulties and visual disturbance f. Headache and nuchal rigidity or other neurologic deficits 2. Optimizing cerebral tissue perfusion: the head of the bed is elevated 30 degrees to promote venous drainage and decrease ICP 3. Relieving anxiety: keeping the patient well informed of the plan of care provides reassurance and helps minimize anxiety. 4. physical therapist to regain muscle strength, balance, or the ability to walk. 5. A speech therapist may evaluate how well you can eat, drink, and speak. 6. If an arm or leg is paralyzed, an occupational therapist will help you learn how to dress yourself and bathe. 7. Provide full range of motion four or five times a day to maintain joint mobility. 8. Analyze voiding pattern and offer urinal or bedpan on patient's voiding schedule. 9. Frequently assess skin for signs of breakdown, Change position every 2 hours 10. Begin walking as soon as standing balance is achieved