1. CVA

Medical-Surgical Nursing 2 Overview ® Neurologic problems can affect locomotion, perception and coordination. o Locomotion: ability to move. o Perception interpretation of sensory information (e.g. touch, sight, or sound). o Coordination: ability to control and synthesize movements. Cerebrovascular Accident (CVA) ® CVA or stroke, is an umbrella term that refers to a functional abnormality of the CNS that occurs when the blood supply to the brain is disrupted. ® Symptoms may include: o facial asymmetry o arm weakness o slurring of speech (dysarthria) o visual disturbance o loss of balance o dizziness ® 2 main types: Hemorrhagic and Ischemic stroke 1. Ischemic Stroke ® Blockage in a blood vessel due to a blood clot resulting in a restricted blood supply to the brain. 2. Hemorrhagic Stroke ® Blood vessel ruptures, causing blood to leak into the intracranial cavity. Cardiovascular Accident (Stroke) thickening of cerebral arteries, increasing the risk of atherosclerosis. Genetics ® Familial hypercholesterolemia contributes to early plaque formation and atherosclerosis in cerebral arteries Sedentary Lifestyle ® Lack of physical activity contributes to obesity and high cholesterol levels. Diabetes ® Promote inflammation and the formation of advanced glycation end products (AGEs), which damages the endothelial lining and accelerate atherosclerosis in the brain. Age ® As people age, the arteries naturally lose elasticity, and endothelial function declines. Pathophysiology Transient Ischemic Attack (TIA) ® TIA is a neurologic deficit typically lasting less than 1 hour, manifested by a sudden loss of motor, sensory, or visual function. ® There is an area of temporarily blocked blood flow due to blood clot in the middle of cerebral artery, thereby resulting to blockage. ® May serve as a warning of impending stroke Prevalence ® The country faces an increasing burden of noncommunicable diseases (NCDs), and stroke is among the leading causes of morbidity, disability, and death. ® In 2020, stroke was the third leading cause of death, following heart diseases and cancer, according to the DOH. Causes Hypertension ® Causes damage to blood vessel walls, promoting atherosclerosis, and increasing the risk of vessel rupture or blockage, leading to impaired blood flow to the brain. High Cholesterol (Hyperlipidemia) ® Causes lipid infiltration into the arterial walls, initiating the formation of atherosclerotic plaques Smoking ® Introduces toxins that damage endothelial cells, leading to inflammation, plaque formation, and By: Joel C. Boniao | BSN3-N4 Circle of Willis Internal Carotid Artery ® Internal carotid artery occlusion (L/R): if internal carotid artery is blocked, blood flow to the anterior cerebral artery (ACA) and middle cerebral artery (MCA) is reduces. o Contralateral weakness or sensory loss from MCA distribution o Behavioral or cognitive changes from ACA distribution 1 Medical-Surgical Nursing 2 Vertebral/Basilar Artery ® Supply blood to the posterior cerebral arteries (PCA) via the basilar artery. ® Occlusion of the vertebral artery reduces blood flow to the brainstem and the occipital lobe (via PCA) o When blocked, cerebellar symptoms: ataxia, dizziness. o Visual disturbances: occipital lobe, ischemia can lead to vision impairment. o Brainstem signs: dysphagia, dysarthria or even coma Anterior Communicating Artery ® When ACA is occluded, the blood flow between the left and right anterior cerebral arteries are compromised. o Sudden severe headache (often describes as the worst headache of life) o Nausea and vomiting o Neurological deficits depending on the rupture location. Posterior Communicating Artery ® When the PCA is occluded, the blood flow between the posterior cerebral artery (PCA) and the internal carotid artery (ICA) is compromised. o Visual disturbances o Oculomotor nerve palsy leading to ptosis (lazy eye), diplopia (double vision), impaired eye movement. ® Commonly affected artery due to its role in connecting the internal carotid and vertebrobasilar circulation. MOTOR and SENSORY deficits in CVA 1. Ataxia ® neurological symptom characterized by lack of coordination and control over voluntary movements, resulting in unsteady gait and difficulty with tasks requiring fine motor skills. 2. Dysarthria or Dysphasia ® Caused by paralysis of the muscles responsible for producing speech, leading to difficulty in moving the facial muscles or the tongue. ® Speech abnormalities include slowed or slurred speech, rapid speech that is difficult to understand, monotonous speech, and abnormal speech rhythm. ® Voice changes may involve a strained, raspy, or nasal-sounding voice, uneven speech volume, and an inability to speak louder than a whisper or to project the voice. 3. Aphasia, which can be: ® Aphasia: A language disorder that affects a person’s ability to understand or express themselves verbally or in writing. ® Expressive aphasia: Inability to express oneself. ® Receptive aphasia: Inability to understand language. By: Joel C. Boniao | BSN3-N4 Cardiovascular Accident (Stroke) ® Global (mixed) aphasia: Severe impairment affecting both expression and comprehension. 4. Apraxia ® Inability to perform a previously learned action, as many be seen when a patient makes a verbal substitution for desired syllables or words. Pathophysiology of Ischemic Stroke Pathophysiology of Hemorrhagic Stroke Penumbra Region ® The penumbra is the area of brain tissue surrounding the ischemic core in a stroke. It's a region of reversible brain injury that can be salvaged if blood flow is restored quickly. 2 Medical-Surgical Nursing 2 Nursing Process and CVA A. Assessment ® Assess when the symptoms first appeared to determine eligibility for thrombolytic therapy. o Most effective if given within 3-4.5 hours of symptom onset. ® Assess the type of stroke o Hemorrhagic: Sudden, severe headache, nausea and vomiting, especially with altered mental status. o Ischemic: Sudden weakness, numbness, or difficulty of speaking ® Assess smoking, alcohol use, substance abuse, and physical activity o Smoking narrows the arteries to your brain causing them to become blocked. This causes a stroke that can result in permanent paralysis, inability to speak, disability or death. It doubles the risk for stroke. ® Assess living situation, support systems, and ability to perform activities of daily living (ADLs) o A CVA patient are at risks of falls, mobility issues, or difficulty performing tasks due to motor or sensory deficits. o Stroke can affect a person’s physical, behavioral and cognitive abilities ® Assess the patient’s social support network can help the healthcare team determine whether the patient has someone who can assist with daily tasks. ® Assess BEFAST ® Assess mental status: evaluate orientation to time, place, person, and situation; check for aphasia, agnosia, or confusion. ® Assess motor function: assess strength, coordination, and signs of hemiparesis or hemiplegia (weakness or paralysis on one side of the body) ® Assess 12 cranial nerves: evaluate the function of cranial nerves (e.g. facial droop, vision changes, loss of gag reflex, etc.) By: Joel C. Boniao | BSN3-N4 Cardiovascular Accident (Stroke) ® Motor coordination: tests like finger-to-nose and heel-to-shin may be performed to assess coordination, ® Monitor vital signs and assess abnormal heart sounds. B. Diagnostics ® CT non-contrast scan: to rule out hemorrhage and confirm ischemic stroke or other brain pathology ® CT angiography or CT perfusion: To assess the blood vessels in the brain for blockages or abnormalities. ® MRI: to detect ischemic stroke, in early hours and in the posterior circulation. Can identify areas of infarction or damage. ® Transcranial doppler: evaluate blood flow in the brain’s major arteries, especially with stenosis. ® Echocardiogram: To assess for heart condition (atrial fibrillation, valvular disease or cardiac thrombus) C. Nursing Diagnosis ® Ineffective cerebral tissue perfusion related to partial cranial occlusion as evidenced by difficulty moving the affected limb, inability to bear weight on the affected side, and limited range of motion in the affected extremities. D. Nursing Diagnosis Improving mobility and preventing joint deformities ® after a stroke, a patient develops contractures due to muscle weakness, spasticity, and immobility. Preventing shoulder adduction ® Shoulder spasticity contracture ® Cause: spasticity in the shoulder muscles and joints Hip Flexion ® Amorphosynthesis is the brain’s ability to adapt and find new ways to do things after stroke. It helps the brain “re-wire” to recover lost abilities, such as movement or speech, by using other parts of the brain ® Positioning the hands and fingers: ® If the upper extremity is flaccid, a splint can be used to support the wrist and hand in a functional position. ® Used for wrist drop and hand claw symptoms ® Flexion contracture ® If the upper extremity is spastic, a hand roll is not used, because it stimulates the grasp reflex. ® A dorsal wrist splint is useful in allowing the palm to be free of pressure. Every effort is made to prevent hand edema. ® Other treatments for spasticity may include stretching, splinting (in selected patients) 1. Changing positions ® The patient’s position should be changed every 2 hours. ® If patient is placed in a prone position, a support/pillow can be placed under the pelvis. 3 Medical-Surgical Nursing 2 This promotes hyperextension of the hip joints, which is essential for normal gait. ® Prone position with pillow support helps prevent hip flexion. 2. Establishing an exercise program ® The affected extremities are exercised passively and put through a full range of motion four or five times a day 3. Preparing for ambulation ® If the patient has difficulty standing, a tilt table can be used. 4. Exercises for post-stroke recovery ® Useful: reach and grasp, trunk rotation, walking, yoga, strength training ® Tips: Have someone to watch for your safety, get assistance to read exercise instructions or remember exercise sequence if needed. Enhancing self-care ® Carry out all self-care activities on the unaffected side. However, affected side must not be neglected. Walking, Assistive Devices to enhance self-care after stroke ® Bathing and grooming devices ® Eating devices ® Mobility aids Assisting with nutrition and problems in swallowing ® Advised to take smaller, boluses of food and educate on foods that are easier to swallow ® Small, frequent diet ® Having the patient sit upright, preferably out of bed in a chair, and instructing them to tuck the chin toward the chest as they swallow to help prevent aspiration. Attaining bladder and bowel control ® Sometimes, control of the external urinary sphincter is lost or diminished. During this period, clean intermittent catheterization is carried out. ® A high-fiber diet and adequate fluid intake (23L/day) should be provided, and a regular time (usually after breakfast) should be established for toileting. Improving thought processes ® After a stroke, the patient may have problems with cognitive, behavioral, and emotional deficits related to brain damage. ® Nurse role is supportive Improving communication ® Face the patient ad establish eye contact ® Speak in a clear, unhurried manner, and normal tone of voice ® Use short phrases, and pause between phrases ® Limit conversation to practical and concrete matters ® Use gestures, pictures, objects, and writing ® Say what the object is By: Joel C. Boniao | BSN3-N4 Cardiovascular Accident (Stroke) ® Be consistent in using the same words and gestures each time you give instructions ® Keep extraneous noises and sounds to a minimum. Managing skin integrity ® A regular turning schedule (e.g. every 2 hours) is adhered to, even if pressure-relieving devices are used to prevent tissue and skin breakdown. ® The patient’s skin must be kept clean and dry; gentle massage of healthy (non-reddened) skin and adequate nutrition. Improving family coping ® Family-centered care involves seeing patients and family caregivers as a one unit Coping with sexual dysfunction ® Sexual dysfunction can be managed through education, communication, physical interventions, psychological support, and adaptations in intimacy. Adjusting to physical changes ® Patients with a decreased field of vision should be approached on the side where visual perception is intact. ® All visual stimuli (e.g. clock, calendar, television) should be placed on their side. Environmental modifications ® Ensure that the patient’s environment is free of hazards ® Use bright lighting, high-contrast colors, and large print for reading materials or labels. ® Install safety rails and ensure pathways are clear. ® Promoting home, community-based and transitional care ® Modify your home for the safety and convenience of the stroke patient ® Ensure proper diet, medication and plenty of rest ® Enlist rehabilitation therapies or palliative care team ® Join stroke counselling and support groups ® Be prepared that the journey can take months or even years DASH Diet (Dietary approach to Stop Hypertension) 4 Medical-Surgical Nursing 2 E. Medical Management Ischemic Stroke Medicatons Thrombolytics (Fibrinolytics) ® Dissolves clots ® Alteplase IV bolus 0.9 mg/kg (max 90 mg) IV over 1 hour. ® Initial bolus: 10% of the total dose over 1 minute. ® Remaining dose: Infuse the remaining 90% over the next 60 minutes. Antiplatelet ® Aspirin o Reduces the risk of recurrent stroke postischemic event. o 160-325 mg orally OD By: Joel C. Boniao | BSN3-N4 Cardiovascular Accident (Stroke) ® Clopidogrel (Plavix) o Used as a second-line antiplatelet agent, often in combination with aspirin. o Adult 75 mg orally once daily Statins ® Lower cholesterol and reduce the risk of recurrent strokes. ® Atorvastatin o Adult Dose: 10-80 mg orally once daily ® Rosuvastatin (Crestor) o Adult Dose: 5-40 mg orally once daily. Anticoagulant Agents ® Warfarin (Coumadin) o Dose adjusted to 2.0-3.0. o For stroke patients with atrial fibrillation or other conditions that increase the risk of embolic strokes. ® Direct Oral Anticoagulants (DOACS): ® Apixaban (Eliquis): 5 mg orally twice daily. ® Rivaroxaban (Xarelto): 20 mg orally once daily. ® Dabigatran (Pradaxa): 150 mg orally twice daily. Hemorrhagic Stroke Medications Antihypertensive ® Lower blood pressure and vasospasm ® Labetalol o Adult Dose: Initial 10o 20 mg IV over 2 o minutes, may repeat every 10 minutes up to a max of 300 mg/day. ® Nimodipine o Adult Dose: 60 mg o orally every 4 hours for 21 days Reverse Anticoagulation (if applicable) ® Vitamin K (for warfarin reversal) o Indication: To reverse the effects of warfarin o 5-10 mg IV (administer slowly over 30 minutes). ® Protamine Sulfate (for heparin reversal) o To reverse the effects of heparin o 1 mg for every 100 units of heparin (given IV). ® Andexanet Alfa (for factor Xa inhibitors reversal, e.g., rivaroxaban, apixaban) o Indication: For reversal of direct Xa inhibitors in cases of life-threatening bleeding. o Adult Dose: IV bolus: 400 mg (initial), then 4 mg/min for 120 minutes Seizure Medications (if applicable) ® Phenytoin (Dilantin) o Indication: Prevent or treat seizures. o Adult Dose: IV: 15-20 mg/kg loading dose, then maintenance o 100 mg every 8 hours. ® Levetiracetam (Keppra) o Indication: An alternative anticonvulsant for stroke patients. o Adult Dose: 500 mg orally 5 Medical-Surgical Nursing 2 BID twice daily, for 2 weeks to a max of 3,000 mg/day. Cerebral Vasospasm Management ® Nimodipine (Calcium Channel Blocker) o Indication: Prevent cerebral vasospasm o Adult Dose: 60 mg orally Q4H for 21 days (subarachnoid hemorrhage) General Stroke Medication (Both Types) Pain and Muscle Spasm Management ® Acetaminophen (Tylenol) 325-650 mg orally every 4-6 hours as needed, max 4,000 mg per day. ® Baclofen 5 mg orally TID, titrate up to 20 mg 3 times daily. Management for Depression ® Sertraline (Zoloft) 50 mg orally once daily, may increase to 100 mg/day as needed. ® Amitriptyline 25-50 mg orally once daily (usually at bedtime Cardiovascular Accident (Stroke) o F. Surgical Management Ischemic Stroke Endovascular Thrombectomy Hemorrhagic Stroke Craniotomy for Hematoma Evacuation ® A section of the skull is removed to allow the surgeon to access the hemorrhagic area, where the blood clot (hematoma) is evacuated Decompressive Craniectomy ® A large section of the skull is removed to allow the brain to swell outward, relieving pressure and preventing further damage. Aneurysm Clipping ® A catheter is inserted through the groin into the artery, and a device is used to remove the clot or embolus that is blocking blood flow to the brain. ® This is done under imaging guidance. Carotid Endarterectomy (CEA) ® A surgical clip is placed around the base of the aneurysm to prevent further bleeding. This is typically performed through a craniotomy. Endovascular Coiling (for Aneurysms) ® The surgeon removes the plaque (atherosclerotic material) that is blocking the carotid artery to improve blood flow to the brain. Carotid Artery Stenting ® A stent is placed within the carotid artery via an angioplasty technique to open up the artery and prevent it from becoming narrowed again. By: Joel C. Boniao | BSN3-N4 ® A catheter is inserted through the groin and threaded to the aneurysm. ® Coils are then deployed into the aneurysm to promote clotting and seal off the aneurysm from the blood circulation. 6 Medical-Surgical Nursing 2 Arteriovenous Malformation (AVM) Resection Cardiovascular Accident (Stroke) G. Evaluation ® The patient has demonstrated improved tissue perfusion as evidenced by increased range of motion, the ability to bear weight on the affected side, and enhanced performance in basic activities of daily living (ADLs) within the 2-week timeframe. ® The AVM is surgically removed, or the abnormal vessels are cauterized or embolized. Endovascular Embolization ® A catheter is inserted into the blood vessels supplying the AVM or aneurysm, and embolic agents (e.g., coils, glue) are used to block the abnormal vessels and prevent further bleeding. Other Surgical Considerations Ventriculostomy (External Ventricular Drain) ® A catheter is inserted into the ventricles of the brain to drain excess CSF and reduce pressure inside the skull. Burr Hole for Drainage ® A small hole is drilled into the skull, and the hematoma is drained to relieve pressure By: Joel C. Boniao | BSN3-N4 7