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Neurological Disorders: Stroke Basic Medical-Surgical Nursing NUR 1210C neurological emergency leading cause of disability or death 1  Objectives Understand the pathophysiology related to...

Neurological Disorders: Stroke Basic Medical-Surgical Nursing NUR 1210C neurological emergency leading cause of disability or death 1  Objectives Understand the pathophysiology related to acute neurologic disorders. Recognize the clinical manifestations related to selected acute neurologic disorders. Identify and recognize the importance of laboratory and diagnostic test findings as related to selected neurologic disorders. Develop and evaluate the plan of care for a patient experiencing neurologic disorders. The plan of care will include: Patient education/Discharge planning Interventions/Nursing care Understand commonly utilized pharmacological interventions for clients with specific neurologic disorders. 2  considered neurological emergency leading cause of disability, can kill patient risks – A-fib, CAD, HTN, atherosclerosis no need to memorize all the functions frontal lobe stroke – motor function issues, behavior, cognition temporal lobe – issues with sound, language parietal lobe – issues with space and spatial awareness, ability to have posture occipital lobe – issues w vision left hemisphere stroke – RIGHT SIDED motor weakness (and vice versa) right hemisphere – affects left sided motor functioning need to anticipate what s/s they’ll have 3  Cerebrovascular Accident (CVA) or Stroke Brain Attack Medical emergency Time Lost = Brain Lost brain attack – like heart attack but for brain ○ some literature uses this to show how severe this condition is not everyone thinks stroke is severe it IS MEDICAL EMERGENCY ○ more time to treat – more exacerbated s/s will be → more of the brain will die time lost = more brain is lost 4  Pathophysiology Brain cannot store glucose or oxygen Disruption in blood flow in or out leads to cerebral tissue death (infarction). Effect depends on: Where How long Amount of tissue involved https://enableme.org.au/resources/br infarction – obstruction of blood supply to an organ or region of tissue ain-and-arteries ○ example – thrombus embolus causing local death of tissue brain CANNOT store glucose or oxygen oxygen loss to brain → confusion, seizures, hypoxic, ischemia when stroke occurs – disruption of blood flow to specific cerebral tissue infarction – just means tissue dies (like myocardial infarction of the heart) How we're going to see that stroke appear depends on where it is. where? – what lobe? how long – how long has it had decreased blood flow amount of tissue involved ○ all these factors determine how much brain damage was caused by blood flow blockage to and from the brain; causing tissue to die Having decreased blood flow, as in in 30 minutes, Has it been three days? is it small port of tissue with decreased blood flow or entire hemissphere 5  Stroke Recognition Importance is to recognize and be fast!! Patient education Multiple types of strokes; gotta catch them all! ***memorize BE FAST acronym for stroke signs and symptoms ○ loss of balance ○ blurred vision ○ one side of face drooping ○ arm or leg weakness ○ speech difficulty ○ time to call for help ASAP patient education – teaching patients about B.E. F.A.S.T. 6  Types of Strokes Ischemic vs Hemorrhagic hemorrhagic – rupture or bleeding related to high BP ischemic stroke – clot blocking blood flow to an area of brain 7  Ischemic Strokes: Thrombotic Stroke Presentation: slow, gradual onset of signs & symptoms Development of plaque → clot formation occludes the vessel → decreased or absent blood flow to an area → ischemia Improvement occurs gradually clot forms in the vessel slowly forms, gradual signs and symptoms ○ numbness ○ tingling ○ can’t move arm 8  Ischemic Stroke: Embolic Strokes Usually develop suddenly and rapid onset of neurologic deficits Atrial fibrillation is a common etiology STOP & Think: Where is the clot coming from? Middle Cerebral Artery (MCA) is most common involved sudden onset of symptoms a-fib – common cause of this clot forms outside of elsewhere 9  Atrial Fibrillation most common dysrhythmia 10  Atrial Fibrillation https://www.aclsmedicaltraining.com/atrial-fibrillation/ Electricity of A Fib No “p-waves”, fibrillatory waves, irregular Pooling of blood STOP & Think: What do you think happens to the cardiac output? Increased risk of stroke Most common arrythmia what happens to cardiac output – decreased cardiac output a-fib patients have an increased risk of stroke → monitor a-fib patients for s/s of strkoe 11  Hemorrhagic Stroke Cerebral tissue damage due to bleeding Ruptured aneurysm or AV malformation Sudden onset (gradual=hypertension) Intracerebral (rare) vs. Subarachnoid (more common) Severe HTN: common Illicit drug use: cocaine http://iahealth.net/wp-content/uploads/2009/03/hemorrhagic-stroke.jpg subarachnoid – below arachnoid space 12  Hemorrhagic Stroke Subarachnoid hemorrhage (SAH) From ruptured AVM or aneurysm Intracerebral Hemorrhage (ICH) From hypertensive emergency or sustained https://www.semanticscholar.org/paper/Intracerebral-Hemorrhage.-Influence-of-Clinical-on-Hansen/83e037a483991a93098d815aecbd43045caa77cb/f hypertension igure/0 13  Hemorrhagic Stroke: Aneurysm A weakened area on a cerebral vessel aneurysm → can lead to stroke 14  Hemorrhagic Arteriovenous Malformation (AVM): Malformed , dilated blood vessels with abnormal blood flow between arteries & veins. http://neurosurgery.med.u-tokai.ac.jp/en/patients/avm/index.html weak, malformed vessel → easy ruptures and can cause stroke 15 LOOK IT UP! – Differential Features of the types of Strokes 10th edition: Table 41.1 Pg. 900 11th edition: Table 38.1 Pg. 944 16 17  Diagnostic tests CT scan or CT angiography Rapid, can show hemorrhage quickly Goal: CT completed by 25 minutes, read within 45 minutes (fast) MRI or MRA Show ischemia earlier than CT scan CT scan ASAP CT scan is faster than MRI must determine what kind of stroke before treatment is given – thus why CT scan is done MRI – show ischemia 18  Risk Factors Hypertension Smoking Obesity Elevated cholesterol Diabetes mellitus Sedentary Lifestyle Oral Contraceptive use hyperlipidemia – elevated cholesterol 19  Risk Factors Atrial Fibrillation Heart Disease Diagnosis of aneurysm Hypercoagulability Family History Substance abuse: Heavy alcohol use and cocaine use the venn diagram = virchow’s triad heavy alcohol use and cocaine use = especially important risk factor 20  Transient Ischemic Attack (TIA) Often precede ischemic strokes Causes a transient episode of neurological dysfunction TIA lasts from a few minutes to less than 24 hours & usually resolve within 30-60 minutes Symptoms come & go which includes motor, sensory, and/or visual function Common causes: carotid stenosis Tx: Treating the underlying cause left sided drooping weakness carotid stenosis – left and right carotid is occluded TIA – occurs before a true stroke (considered a mini stroke) atherosclerosis can add risk considered a warning sign to patients to change their lifestyle! 21  Medical Emergency Must make a diagnosis quickly to preserve brain tissue Stroke Alerts/Brain attacks Must be assessed within 10 minutes of arrival to ED Endovascular Procedure: within 2 hours of arriving to hospital Thrombolytics: within 3 hours (up to 4.5) from last known normal oNewest recommendations: door to needle (ED to administration)= 45 minutes ****MUST KNOW – need to be evaluated within 10 minutes of arrival to ED endovascular procedure – within 2 hours of arriving to hospital ○ look it up ○ def – minimally invasive vascular surgery procedure that treats acute ischemic strokes by removing blood clots and restoring blood flow to brain requires a multidisciplinary assessment newest recommendation – door to needle (ED to administration) = 45 minutes 22  History: Very Important Critical Questions When did it happen? Last time normal ? Other important questions: Onset, progression, worsening, improving Medical History Current medications OTC, prescription , herbal, illicit drugs Social history we administer thrombolytics based on the 3-4 hours from last known normal onset, progression, worsening, improving – important what meds were they taking prior to hospital stay **need to know slide 23  Clinical Manifestations Impacted By Cerebral artery affected Area of brain supplied by vessel Adequacy of collateral circulation better outcome, less symptoms 24  Assessment/Recognize Cues National Institue of Health Stroke Scale (NIHSS) (in Iggy) Level of consciousness (LOC)/Glasgow Coma Score (GCS) Orientation: Person, Place, Time, Situation Speech Motor Response Extremity Movement Mood/Behavior Assess for posturing GCS shouldn’t drop weakness with extremity movement and motor response frontal lobe damage – changes mood and behavior abdominal flexion and extension – may have issues the higher the NIHSS scale, the worse the stroke 25  Glasgow Coma Scale (GCS) Allows for a rapid neurological assessment Standardized assessment Scored on three areas eye opening motor response verbal response. The higher the score the better. 15 is the best; 3 is the worst ****15 = the best 3 = the worst 26  Assessment/Recognize Cues 5 Most common symptoms: Additional Sudden confusion or trouble assessments/symptoms: speaking or understanding Severe headache others Nausea/vomiting Sudden numbness or Pupillary assessment weakness of face, arm and/or Difficulty speaking leg Balance instability Muscle strength different Sudden trouble seeing in one on one side or both eyes Past medical history Sudden dizziness, trouble Illegal drug use walking, or loss of balance or coordination Sudden severe headache with no cause ****must know 5 most common symptoms: sudden confusion sudden numbness sudden trouble seeing in one or both eyes sudden dizziness sudden severe headache severe headache that feels like intense pressure ○ thunderclap headache can indicate hemorrhagic stroke need to know past medical history and illegal drug use 27  Recognize Cues: Right hemisphere stroke More involved with visual and spatial awareness May be unaware of deficits Disoriented: time and place Personality changes Impulsivity Poor judgement check slide ahead  Recognize Cues: Left Hemisphere stroke Difficulty with speech Problems with analytical thinking Math, problem solving Slower processing Difficulty understanding language difficulty with speech – speech requires complex thinking math, problem solving – also huge indicator of hemispheric stroke  Level of Consciousness (LOC) Must be very exact with documentation. Alert, Lethargic, Stuporous, Comatose Subtle changes can be a big deal. Changes can be: Headache Restlessness Irritability or very quiet Slurred speech Changes in level of orientation Increase in weakness subtle changes = BIG deal be as exact and detailed as possible when documenting 30  Manifestations: Increased Intracranial Pressure (ICP) Decreased LOC Late signs: Lethargy Severe Hypertension Restlessness Widened pulse pressure Headache Bradycardia Nausea/Vomiting Posturing Change in speech Aphasia Vision Changes Double Vision Seizures HTN both strokes can increase pressure in brain nausea vomiting is very common severe hypertension – 200/20 ○ systolic and diastolic are very far from each other 31  Recognizing Cushing's Triad Shows elevated ICP Can be from edema or hemorrhage I. Widening pulse pressure I. Example: 180/40 II. Bradycardia III. Irregular/decreased respirations 33  Posturing decorticate posturing – going towards core ○ suggests damage to cerebral cortex (responsible for movement/sensation) decerebrate posturing – going away from core ○ suggests damage to brainstem below cerebral cortex both are very bad signs of a lot of damage 34  Motor Problems Motor nerve fibers cross the midline before going to the spinal cord. Right hemisphere problems mean left sided paralysis. Neglect syndrome: damage to right cerebral hemisphere; ignore left side can’t remember they have a left sided part of their body 35  Neglect Syndrome Unable to recognize impairment on affected side due to impaired proprioception (body position sensing) May only use the unaffected side Educate patient to use both sides May have hemianopsia Teach them to turn head to get better view Example of neglect syndrome: Is this slide made only on one side? Patient that made this slide might not realize it is only on right side if they had left-sided neglect can happen to either side of the body with stroke 36  Sensory problems Ptosis Hemianopsia 37  Communication Problems: Aphasia Expressive Aphasia Receptive Aphasia Damage in Broca area Damage in Wernicke area in frontal lobe in temporo-parietal area Can understand Spoken word or speech is speech but cannot often meaningless speak properly May be thought to be “just May have difficulty confused” writing but can read fine “Problem with Global Aphasia expressing” “Word Finding” Combination of both receptive trouble and expressive aphasia expressive ○ have trouble expressing themselves ○ stutter a lot receptive ○ have a problem understanding and receiving info global aphasia – combo of receptive and expressive aphasia 38  Swallowing Deficits Assess ability to swallow early on and throughout recovery NPO until swallowing assessed Swallow Study: Often modified barium under fluoroscopy 🡪 tells provider diet to order Might need thickened liquids Position upright (90o) to eat & drink Work with dietitian & speech therapist use water to detect any cough or desaturation of SPo2 pt is NPO until swallow test is done high fowler's to eat 39  Cerebral Angiogram/Angioplasty To visualize cerebral circulation Helps identify abnormalities Gold standard for diagnosis of intracerebral vascular disease Can help restore blood flow to affected area gold standard for diagnosing intracerebral vascular disease angioplasty – can help restore blood to affected area not considered a treatment 40  Cerebral Angiogram/Angioplasty Can be done to place a stent Post Procedure Care: Check site Keep extremity straight and immobile Maintain pressure dressing x2 hours balloon gets inflated to place stent check site to make sure there’s no bleeding keep extremity straight and immobile maintain pressure dressing for 2 hours to prevent bleeding 41  Embolectomy/Thrombectomy Removal of clot (embolism/thrombus) Similar procedure to angioplasty Post-procedure care same as angioplasty Stent used as net to “catch and remove” clot from site Large vessel occlusion: used in conjunction with fibrinolytic therapy embolectomy – net that catches and catches clot and pulls it out for fibrinolytic therapy – both meds and these procedures can treat 42 Patient Preparation for Cerebral Angiogram/Angioplasty Check allergies Obtain consent NPO Baseline neurological assessment Explain procedure Will need to be still/lay on hard table May or may not receive sedation Will feel pressure in the groin area when catheter is inserted 43  Post Angiogram/Angioplasty Nursing care Assess VS frequently Neurologic assessment frequently Neurovascular checks frequently Check pulses/color/sensation Bed rest with leg straight/immobilized Assess insertion site frequently Encourage fluids 44  Stroke Interventions Depends on the type of stroke 4.5 hour window for thrombolytic agents ABCs (CABs) Priority: Obtain and maintain patent airway Monitor for signs of IICP (increased intracranial pressure) Change in LOC, changes in behavior, changes in vital signs Evidence of IICP usually occurs within the first 72 hours Edema from IICP can impair cerebral perfusion control blood pressure for patients with hemorrhagic stroke depending on how bad symptoms get → part of skull could be removed to get pressure off of skull typically control BP and monitor closely neuro checks every 1-2 hours most pts – thrombolytics up to 4.5 hours most pts with strokes – unless they have breathing problems, we’re just focusing on stroke if not taken care of immediately – chance of becoming lethal photophobia, nausea/vomiting 45  Planning and Goals Maintain airway Protect from injury Maintain/attain fluid volume balance Maintain skin integrity Effective thermoregulation Effective urinary elimination Encourage family or support system participation NPO until swallow study completed Therapy: PT , OT or SLP May need additional help at home if patient becomes respiratory compromised – intubate patient protect from injury and fall precautions and turning patients put on boots that elevate heels strict I/O – watch for adequate hydration check temperature due to ineffective temperature regulation bladder issues – monitor strict I/Os, if not a lot of output then do bladder scan, straight catheter, or foley encourage family support due to a lot of gained disabilities swallowing issues – high risk of dysphagia with stroke patients PT/OT/Speech are part of team – nurse and therapists all work together once d/c -education on falls, put dog in separate room, remove throw rugs, night light use, 46  Nursing Care of Stroke Patients Neurological assessment (ongoing) PT/OT/ST/ROM/ADLs Safety Reorient Remind patients with neglect syndrome of their other side Incontinence Bladder/bowel programs Diet Stool softeners Support groups because stroke doesn’t always present with all s/s – assess patient regularly and note any small changes if confused – reorient patient if they forget that they have – turn their head incontinnet? – bowel program, scheduling voiding q 2 hours encourage patients to participate in support programs since this condition is life changing 47 48  Stroke Prevention Patient Education Hypertension Obesity Substance Use Diet Comorbidities General ABCS rule Aspirin use if appropriate Blood pressure control Cholesterol management Smoking cessation make sure you control HTN obese? – healthy diet, movement and mobility increased, substances – educate about harmful effects of cocaine and increased chance low fat, mediterranean diet comorbidities – CAD, cardiac disease, DM – looking at aspirin use – arterial diseases (like strokes) use these control BP manage cholesterol with statins or diet smoking cessation is import 49  Anticoagulants/Antiplatelet Medications Anticoagulants contraindicated with hemorrhagic strokes STOP & Think: Why? Used more to prevent recurrent strokes Need to monitor neurological status closely Could see conversion Duel antiplatelet therapy (DAPT) Some antiplatelet examples Aspirin Clopidogrel (Plavix) Ticagrelor (Brilinta) use anticoags and antiplatelets anticoags – only if patient has AFIb ○ number ONE cause of strokes ○ embolic stroke – given anticoag ischemic stroke → antiplatelets aspirin + antiplatelet = dual antiplatelet therapy ○ typically plavix + aspirin ○ risk of HEMORRHAGE ○ research shows diet, BP control, smoking cessation, controlling comorbidities = very effective at preventing strokes 50  Aspirin Mechanism of action Irreversibly prevents platelet aggregation; prevents blood clotting by reducing platelet adhesiveness Side effects Bruising, GI upset Potential adverse effects Bleeding, liver disease, bleeding, thrombocytopenia, tinnitus (ototoxicity) Nursing considerations Recommended within 24-48h after onset of CVA; should not be given within 24h of tPA. Assess platelet count, H/H frequently. Instruct pt to report s/s of bleeding &/or tinnitus. Can be given as suppository. important thing to look at ischemic stroke – core measure is to give patient aspirin in first 24-48 hours if NPO ○ rectal aspirin can be given as suppository ○ proven to help prevent worsening signs of stroke definitely watch bleeding 51  Clopidogrel (Plavix) Mechanism of action Irreversibly prevents platelet aggregation; slows down clot formation Side effects Diarrhea, dyspepsia, abdominal pain Potential adverse effects Bleeding, thrombotic thrombocytopenic purpura (TTP) Nursing considerations Assess platelet counts, H/H frequently. Teach patient to take with food and to report s/s of bleeding. May be given with aspirin to maintain patency of vessels (DAPT). biggest problem – BLEEDING antiplatelet 52  Apixaban (Eliquis) Mechanism of action Inhibits factor Xa preventing thrombin formation and coagulation Side effects Nausea and/or vomiting, dizziness Potential adverse effects Bleeding Nursing considerations Educate on s/s of bleeding and when to call HCP. Should be placed on fall precautions. Caution with use in patients with renal impairment. Limit alcoholic beverage use. anticoagulant BIGGEST problem – BLEEDING 53  Thrombolytic Therapy Need to be administered within 4.5 hours of symptom onset Used for ischemic strokes Dissolves clots Recommended door to needle time is 45 minutes Nursing care pre/post tPA: p. 906 IGGY 10th thrombo (clot) + lytic (breaking of) only medication class that breaks up clot only for ischemic, NOT HEMORRHAGIC ○ could injure patient important to know – when it happened, s/s of stroke episode start this med within 45 minutes given AFTER CT scan, assess pt, ○ if confirmed ischemic → then give tPA 54  Tissue plasminogen activator (tPA) [Alteplase] Mechanism of action Stimulates the enzyme plasmin to breakdown blood clots Side effects Bleeding, headache Potential adverse effects Hemorrhagic conversion; extension of CVA Nursing considerations tPA is used to treat embolic or thrombotic stroke; contraindicated in hemorrhagic stroke & head trauma. Monitor VS and labs to assess for bleeding. Make sure patient not taking aspirin or other antiplatelet or anticoagulants. Patient's blood pressure can't be too high. Don't place invasive lines (foley, NG) Special considerations Only FDA approved drug treatment of ischemic stroke and only recommends given within 3 hrs Strict guidelines for IV infusion and follow-up. American Stroke Association – up to 4.5 hours based off strict criteria present in our body, helps break up clots alteplase, bad side effects – YES it breaks clots, but for patient with ischemic stroke if tissue is too far gone…. ○ can turn into a hemorrhagic stroke → what we call hemorrhagic conversion (won’t be tested on this) ○ in Iggy book about monitoring BP strictly ○ typically requires ICU care, requires every 15 minute vital checks ○ first 16 hours – every 15 minutes ○ after first 16 hours – every hour, sent to neuro unit 55  Supplemental Medications Goal: Provides symptom management, not curative for stroke Seizure meds – levetiracetam (Keppra) Calcium channel blockers – nimodipine (Nimotop) Stool softeners Analgesics Antianxiety drugs Antihyperlipidemic drugs given keppra via IV, well tolerated given prophylactic for seizures nimodipine – subarachnoid hemorrhage ○ only calcium channel blocker that crosses brain blood barrier, increased risk of ○ use calcium channel blocker to help vessel stop spasming ○ only one that reaches brain stool softeners – no straining wanted to avoid pressure sent to the head ○ slip and slide bowel movements pain – can give pain meds anxiety – anti anxiety meds most patients will have a HLD med – statins :) 56  Surgical Interventions: Preventing Aneurysm Rupture Endovascular Coiling AVM/Aneurysm seal or clip endovascular coiling ○ most of the time with aneurysm – headaches are caused by little pocketed coils ○ body will recognize coil as something foreign and clot it off AVM ○ if not coiling, surgical intervention will be used to prevent outpouching and seal off vessel ○ craniotomy – very invasive 57  Stroke Complications Hydrocephalus Vasospasms Re-bleed Conversion hydrocephalus – extra fluid in ventricular systems ○ causes increased intracranial pressure vasospasm ○ when patient has ischemia subarachnoid hemorrhages – daily transcranial doppler check ○ every day for 21 days while in hospital hemorrhage – could occur again ○ constant neuro checks, baseline comparison, look at previous assessments, any decline needs reporting ischemic stroke – can become hemorrhagic 58  Carotid Endarterectomy Severe narrowing of carotid artery due to atherosclerosis Done to prevent stroke or stroke recurrence Restores perfusion through carotid Process: 🡪Identify plaque: CTA or MRA Neck 🡪Surgical incision 🡪Removal of Plaque for stenosis or plaque in carotid arteries go in → cut out plaque → restore perfusion to brain → prevent stroke!! blood flow is diverted from plaque area to reach brain another way while procedure is happening if neck is swelling → wrap it around the neck to make sure that it’s not swelling ○ get a baseline neck measurement to compare post procedure measurement to this can ALSO CAUSE A STROKE ○ if plaque escapes and dislodges → goes upstream → stroke occurs 59