Ischemic and vascular Stroke CVA Brain attack.ppt
- 1. Cerebrovascular Accident (CVA) Cerebrovascular Accident (CVA) & & Brain Attack ( Stroke) Brain Attack ( Stroke)
- 2. Definition: Definition: Sudden brain damage. Sudden brain damage. Lack of blood flow to the brain caused by a Lack of blood flow to the brain caused by a clote or rupture of a blood vessele. clote or rupture of a blood vessele.
- 3. Stroke Stroke Movement, sensation, or emotions Movement, sensation, or emotions controlled by affected area are lost or controlled by affected area are lost or impaired impaired Loss of function varies with location Loss of function varies with location and extent of damage and extent of damage
- 4. Stroke Stroke Brain attack Brain attack – Term increasingly being used to Term increasingly being used to describe stroke and communicate describe stroke and communicate urgency of recognizing stroke urgency of recognizing stroke symptoms and treating their onset as symptoms and treating their onset as a medical emergency a medical emergency
- 5. Risk Factors Risk Factors Nonmodifiable Nonmodifiable Age Age Gender (women more likely to die) Gender (women more likely to die) Race (African Americans) Race (African Americans) Heredity Heredity
- 6. Risk Factors Risk Factors Modifiable Modifiable Asymptomatic carotid stenosis Asymptomatic carotid stenosis Diabetes mellitus Diabetes mellitus Heart disease, atrial fibrillation Heart disease, atrial fibrillation Heavy alcohol consumption Heavy alcohol consumption Hypercoagulability Hypercoagulability Hyperlipidemia Hyperlipidemia T. I. A T. I. A
- 7. Risk Factors Risk Factors Modifiable Modifiable Hypertension Hypertension Obesity Obesity Oral contraceptive use Oral contraceptive use Physical inactivity Physical inactivity Sickle cell disease Sickle cell disease Smoking Smoking
- 8. Etiology and Pathophysiology Etiology and Pathophysiology Brain requires continuous supply of O2 Brain requires continuous supply of O2 and glucose for neurons to function and glucose for neurons to function If blood flow is interrupted If blood flow is interrupted – Neurologic metabolism is altered in Neurologic metabolism is altered in 30 seconds 30 seconds – Metabolism stops in 2 minutes Metabolism stops in 2 minutes – Cell death occurs in 5 minutes Cell death occurs in 5 minutes
- 9. Etiology and Pathophysiology Etiology and Pathophysiology Atherosclerosis is a major cause of Atherosclerosis is a major cause of stroke stroke – Can lead to thrombus formation and Can lead to thrombus formation and contribute to emboli contribute to emboli
- 10. Sites for Atherosclerosis Sites for Atherosclerosis Fig. 56-2
- 11. Etiology and Pathophysiology Etiology and Pathophysiology Around the core area of ischemia is a Around the core area of ischemia is a border zone of reduced blood flow border zone of reduced blood flow where ischemia is potentially reversible where ischemia is potentially reversible If adequate blood flow can be restored If adequate blood flow can be restored early (<3 hours) and the ischemic early (<3 hours) and the ischemic cascade can be interrupted cascade can be interrupted – less brain damage and less neurologic less brain damage and less neurologic function lost function lost
- 12. Transient Ischemic Attacks Transient Ischemic Attacks (TIA) (TIA) Temporary focal loss of neurologic Temporary focal loss of neurologic function caused by ischemia (analogous function caused by ischemia (analogous to angina in CAD) to angina in CAD) Most resolve within 3 hours Most resolve within 3 hours May be due to micro-emboli that May be due to micro-emboli that temporarily block blood flow temporarily block blood flow A warning sign of progressive A warning sign of progressive cerebrovascular disease cerebrovascular disease
- 13. Types of Stroke Types of Stroke Classification based on underlying Classification based on underlying pathophysiologic findings pathophysiologic findings – Ischemic Ischemic Thrombotic Thrombotic Embolic Embolic – Hemorrhagic Hemorrhagic
- 14. Major Types of Stroke Major Types of Stroke Fig. 56-3
- 15. Ischemic Stroke Ischemic Stroke Result of inadequate blood flow to brain Result of inadequate blood flow to brain due to partial or complete occlusion of due to partial or complete occlusion of an artery an artery Constitute 85% of all strokes Constitute 85% of all strokes Most patients with ischemic stroke do Most patients with ischemic stroke do not have a decreased level of not have a decreased level of consciousness in the first 24 hours consciousness in the first 24 hours Symptoms often worsen during first 72 Symptoms often worsen during first 72 hours d/t cerebral edema hours d/t cerebral edema
- 16. Ischemic Stroke Ischemic Stroke Thrombotic stroke Thrombotic stroke – Thrombosis occurs in relation to Thrombosis occurs in relation to injury to a blood vessel wall injury to a blood vessel wall → → blood blood clot clot – Result of thrombosis or narrowing of Result of thrombosis or narrowing of the blood vessel the blood vessel – Most common cause of stroke Most common cause of stroke
- 17. Ischemic Stroke Ischemic Stroke Thrombotic stroke Thrombotic stroke – Two-thirds are associated with HTN Two-thirds are associated with HTN and diabetes and diabetes – Often preceded by a TIA Often preceded by a TIA
- 18. Ischemic Stroke Ischemic Stroke Embolic stroke Embolic stroke – Embolus lodges in and occludes a Embolus lodges in and occludes a cerebral artery cerebral artery – Results in infarction and edema of the Results in infarction and edema of the area supplied by the vessel area supplied by the vessel – Second most common cause of stroke Second most common cause of stroke
- 19. Ischemic Stroke Ischemic Stroke Embolic stroke Embolic stroke – Majority of emboli originate in heart, Majority of emboli originate in heart, with plaque breaking off from the with plaque breaking off from the endocardium and entering circulation endocardium and entering circulation – Associated with sudden, rapid Associated with sudden, rapid occurrence of severe clinical occurrence of severe clinical symptoms symptoms
- 20. Ischemic Stroke Ischemic Stroke Embolic stroke Embolic stroke – Patient usually remains conscious Patient usually remains conscious although may have a headache although may have a headache – Recurrence is common unless the Recurrence is common unless the underlying cause is aggressively underlying cause is aggressively treated treated
- 21. Hemorrhagic Stroke Hemorrhagic Stroke Account for approximately 15% of all Account for approximately 15% of all strokes strokes Result from bleeding into the brain Result from bleeding into the brain tissue itself or into the subarachnoid tissue itself or into the subarachnoid space or ventricles space or ventricles
- 22. Hemorrhagic Stroke Hemorrhagic Stroke Intracerebral hemorrhage Intracerebral hemorrhage – Bleeding within the brain caused by a Bleeding within the brain caused by a rupture of a vessel rupture of a vessel – Hypertension is the most important Hypertension is the most important cause cause – Commonly occurs during activity Commonly occurs during activity
- 23. Hemorrhagic Stroke Hemorrhagic Stroke Intracerebral hemorrhage Intracerebral hemorrhage – Often a sudden onset of symptoms Often a sudden onset of symptoms that progress over minutes to that progress over minutes to hours b/c of ongoing bleeding hours b/c of ongoing bleeding – Manifestations include neurologic Manifestations include neurologic deficits, headache, N & V, decreased deficits, headache, N & V, decreased levels of consciousness, and HTN levels of consciousness, and HTN
- 24. Hemorrhagic Stroke Hemorrhagic Stroke Subarachnoid hemorrhage Subarachnoid hemorrhage – Bleeding into cerebrospinal space Bleeding into cerebrospinal space between the arachnoid and pia mater between the arachnoid and pia mater – Commonly caused by rupture of a Commonly caused by rupture of a cerebral aneurysm cerebral aneurysm
- 25. Clinical Manifestations of Stroke Clinical Manifestations of Stroke Affects many body functions Affects many body functions Motor activity Motor activity Elimination Elimination Intellectual function Intellectual function Spatial-perceptual alterations Spatial-perceptual alterations Personality Personality Affect Affect Sensation Sensation Communication Communication
- 26. Clinical Manifestations Clinical Manifestations Motor Function Motor Function Most obvious effect of stroke Most obvious effect of stroke Can include impairment of : Can include impairment of : – Mobility Mobility – Respiratory function Respiratory function – Swallowing and speech Swallowing and speech – Gag reflex Gag reflex – Self-care abilities Self-care abilities
- 27. Clinical Manifestations Clinical Manifestations Motor Function Motor Function Characteristic motor deficits (contra- Characteristic motor deficits (contra- lateral) lateral) – Loss of skilled voluntary movement Loss of skilled voluntary movement – Impairment of integration of movements Impairment of integration of movements – Alterations in muscle tone (flaccid Alterations in muscle tone (flaccid → → spastic) spastic) – Alterations in reflexes (hypo Alterations in reflexes (hypo → hyper) → hyper)
- 28. Clinical Manifestations Clinical Manifestations Communication Communication Patient may experience aphasia when Patient may experience aphasia when stroke damages the dominant stroke damages the dominant hemisphere of the brain hemisphere of the brain – Aphasia: total loss of comprehension Aphasia: total loss of comprehension and use of language and use of language – Dysphasia: difficulty with Dysphasia: difficulty with comprehension and use of language comprehension and use of language Classified as nonfluent or fluent Classified as nonfluent or fluent
- 29. Clinical Manifestations Clinical Manifestations Communication Communication Dysarthria Dysarthria – Disturbance in the muscular control Disturbance in the muscular control of speech of speech – Impairments in pronunciation, Impairments in pronunciation, articulation, and phonation; NOT articulation, and phonation; NOT meaning or comprehension meaning or comprehension
- 30. Clinical Manifestations Clinical Manifestations Affect Affect May have difficulty controlling their May have difficulty controlling their emotions emotions Emotional responses may be Emotional responses may be exaggerated or unpredictable exaggerated or unpredictable Depression , impaired body image and Depression , impaired body image and loss of function can make this worse loss of function can make this worse May be frustrated by mobility and May be frustrated by mobility and communication problems communication problems
- 31. Clinical Manifestations Clinical Manifestations Intellectual Function Intellectual Function Memory and judgment may be Memory and judgment may be impaired impaired Left-brain stroke: more likely to result Left-brain stroke: more likely to result in memory problems related to in memory problems related to language language
- 32. Manifestations of Right-Brain and Left-Brain Manifestations of Right-Brain and Left-Brain Stroke Stroke Fig. 56-6
- 33. Clinical Manifestations Clinical Manifestations Spatial-Perceptual Alterations Spatial-Perceptual Alterations Stroke on the right side of the brain is Stroke on the right side of the brain is more likely to cause problems in spatial- more likely to cause problems in spatial- perceptual orientation perceptual orientation However, this may occur with left- However, this may occur with left- brain stroke brain stroke
- 34. Clinical Manifestations Clinical Manifestations Spatial-Perceptual Alterations Spatial-Perceptual Alterations Spatial-perceptual problems may be Spatial-perceptual problems may be divided into four categories divided into four categories 1. 1. Incorrect perception of self and Incorrect perception of self and illness (may deny illness or body illness (may deny illness or body parts) parts) 2. 2. Erroneous perception of self in Erroneous perception of self in space (e.g., neglect all input from space (e.g., neglect all input from affected side; distance judgement) affected side; distance judgement)
- 35. Clinical Manifestations Clinical Manifestations Spatial-Perceptual Alterations Spatial-Perceptual Alterations 3. 3. Inability to recognize an object by Inability to recognize an object by sight, touch, or hearing sight, touch, or hearing 4. 4. Inability to carry out learned Inability to carry out learned sequential movements on sequential movements on command command
- 36. Clinical Manifestations Clinical Manifestations Elimination Elimination Most problems with elimination occur Most problems with elimination occur initially and are temporary initially and are temporary Prognosis for normal bladder function Prognosis for normal bladder function is excellent when only one hemisphere is excellent when only one hemisphere of brain is affected. of brain is affected.
- 37. Common signs and symptoms of Common signs and symptoms of TIA, and ischemic stroke: TIA, and ischemic stroke: 1- Carotid (Anterior) circulation:- 1- Carotid (Anterior) circulation:- *unilateral paralysis: weakness or heaviness *unilateral paralysis: weakness or heaviness involove hand, arm, face, or leg, alone or in involove hand, arm, face, or leg, alone or in combination. The invloved body parts are combination. The invloved body parts are opposite the side of the diseased artery. opposite the side of the diseased artery. *Numbness:sensory loss, tingling, or abnormal *Numbness:sensory loss, tingling, or abnormal sensation usually occures simultaneously and on sensation usually occures simultaneously and on the same side as weakness. the same side as weakness. *Visual disturbance:opposite the side of the *Visual disturbance:opposite the side of the diseased artery. diseased artery.
- 38. * lunguage disturbance:- aphasia or * lunguage disturbance:- aphasia or dysarthria. dysarthria. * monocular blindeness: partially or * monocular blindeness: partially or completely may occurs on the same side. completely may occurs on the same side.
- 39. 2- Vertebral( posterior) circulation:* *vertigo. 2- Vertebral( posterior) circulation:* *vertigo. *- visual disturbance: involve both eyes *- visual disturbance: involve both eyes simultaneously. simultaneously. * Diplopia. * paralysis: can involve one half * Diplopia. * paralysis: can involve one half or infrequently all four limbs, the face can or infrequently all four limbs, the face can be involved on one side and the limbs on the be involved on one side and the limbs on the other. other. * numbeness: can involve one half of the body * numbeness: can involve one half of the body or all four limbs. or all four limbs.
- 40. * dysarthria. * dysarthria. * ataxia: poor balance, stumbling gait, * ataxia: poor balance, stumbling gait, uncoordination of one side of the body. uncoordination of one side of the body.
- 41. Signs and symptoms of hemorrhagic stroke: Signs and symptoms of hemorrhagic stroke: * generaly patient with hemorrhagic stroke * generaly patient with hemorrhagic stroke appear seriously ill, and have a more rapid appear seriously ill, and have a more rapid course of deterioration than those of course of deterioration than those of ischemic stroke. ischemic stroke. * headache, disturbances in consciousness, * headache, disturbances in consciousness, nausea, and vomiting are more prominent nausea, and vomiting are more prominent with hemorrhagic stroke. with hemorrhagic stroke.
- 42. 1- Subarachnoid hemorrhage:- 1- Subarachnoid hemorrhage:- the most Common symptom is a sudden severe the most Common symptom is a sudden severe headache, transient loss of consciousness, headache, transient loss of consciousness, assiciated with headache, seizer, or assiciated with headache, seizer, or arrhythmia, nausea, vomiting, neck pain, arrhythmia, nausea, vomiting, neck pain, intolerance of noise and light, and altered intolerance of noise and light, and altered mental status. mental status. Rupture of an intracranial aneurysm is in Rupture of an intracranial aneurysm is in cause in one fourth of the of patients cause in one fourth of the of patients
- 43. 2- Intracerebral hemorrhage:- 2- Intracerebral hemorrhage:- Like ischemic stroke, more ever, they have a Like ischemic stroke, more ever, they have a decreased in level of consciousness, decreased in level of consciousness, headache, and vomiting. headache, and vomiting.
- 44. Diagnostic Studies Diagnostic Studies When symptoms of a stroke occur, When symptoms of a stroke occur, diagnostic studies are done to diagnostic studies are done to – Confirm that it is a stroke Confirm that it is a stroke – Identify the likely cause of the stroke Identify the likely cause of the stroke CT is the primary diagnostic test used CT is the primary diagnostic test used after a stroke to detet the type of stroke, after a stroke to detet the type of stroke, and guide the treatment. and guide the treatment.
- 45. Diagnosis of stroke Diagnosis of stroke *Neurological examination:the diagmosis of *Neurological examination:the diagmosis of stroke is clinical from acute facial paresis, arm stroke is clinical from acute facial paresis, arm drift, or abnormal speech. drift, or abnormal speech. *Imaging techniques: determine the type and *Imaging techniques: determine the type and cause of stroke as:- cause of stroke as:- -CTscans without contrast. -CTscans without contrast. - MRI. - MRI. -ultrasound /doppler study of the -ultrasound /doppler study of the carotides. carotides. -Angiography of the cerebral vasculature. -Angiography of the cerebral vasculature.
- 46. Contin....... Contin....... -ECG and echocardiography. -ECG and echocardiography. -Blood test for hyperlipidemia,blood -Blood test for hyperlipidemia,blood suger, bleeding diathesis. suger, bleeding diathesis. -Holter: to determine intermitent -Holter: to determine intermitent arrythmias. arrythmias.
- 47. - Management:- - Management:- 1- lschemic stroke:- 1- lschemic stroke:- * emergency diagnosis:- clinically and CT scan * emergency diagnosis:- clinically and CT scan without contrast to exclude hemorrhagic without contrast to exclude hemorrhagic stroke and guide treatment. stroke and guide treatment. * differential diagnosis:- * differential diagnosis:- . Persistent focal defecit:- . Persistent focal defecit:- ◐ ◐ischemic stroke. hemorrhagic stroke. ◐ ischemic stroke. hemorrhagic stroke. ◐ partial seizer with postictal(todd, s) ◐partial seizer with postictal(todd, s) ◐ paralysis paralysis .. ..
- 48. ◐ ◐hypoglysemia. hyperglysemia. ◐ hypoglysemia. hyperglysemia. ◐ ◐ ◐subdural hematoma. brain tumor. ◐ subdural hematoma. brain tumor. ◐ ◐ ◐metabolic dysorder. drugs ◐ metabolic dysorder. drugs ◐ overdose. brain abscess with seizere. ◐ overdose. brain abscess with seizere. ◐ ◐ ◐meningitis and encephalitis. meningitis and encephalitis. *transient focal deficit:- *transient focal deficit:- ◐ ◐TIA. migrain with aura. ◐ TIA. migrain with aura. ◐ ◐ ◐partial seizere. partial seizere.
- 49. * stroke severity and prognosis:- * stroke severity and prognosis:- - Glasgow coma scale( GCS) :- - Glasgow coma scale( GCS) :- -Eye opening. Score -Eye opening. Score . Spontaneous. 4 . Spontaneous. 4 .in response to speech. 3 .in response to speech. 3 . In response to pain. 2 . In response to pain. 2 . None. 1 . None. 1
- 50. - Best verbal response: - Best verbal response: .oriented conversation. 5 .oriented conversation. 5 .confused conversation. 4 .confused conversation. 4 .inappropriate words. 3 .inappropriate words. 3 .incomprehensible sounds. 2 .incomprehensible sounds. 2 .none. 1 .none. 1
- 51. - Best motor response: - Best motor response: . obeys. 6 . obeys. 6 . localize. 5 . localize. 5 .withdraws. 4 .withdraws. 4 . abnormal flexion. 3 . abnormal flexion. 3 . abonrmal extention. 2 . abonrmal extention. 2 . None 1 . None 1 GCS of (8) or less has a very poor prognosis. GCS of (8) or less has a very poor prognosis.
- 52. * thrombolytic therapy as (T-PA) :- * thrombolytic therapy as (T-PA) :- can be given within (3) hours of stroke onset, can be given within (3) hours of stroke onset, if cerebral hemorrhage is excluded, and if cerebral hemorrhage is excluded, and there is no contraindications for their used. there is no contraindications for their used. * intravenous heparin in patients who will * intravenous heparin in patients who will require chronic warfarin for secondary require chronic warfarin for secondary prevention. prevention. * asprin (325 mg) within 48 hours of onset, * asprin (325 mg) within 48 hours of onset, may decreased the risk of recurrent stroke may decreased the risk of recurrent stroke and death. and death.
- 53. * if patient receives thrombolytic * if patient receives thrombolytic theraby:asprin and heparin should be theraby:asprin and heparin should be delayed for at least (24) hours. delayed for at least (24) hours. * hypertension should not be treated unless * hypertension should not be treated unless the patient has another condition that the patient has another condition that requires lowering the pressure as acute requires lowering the pressure as acute myocardial infarction, acute CHF, aortic myocardial infarction, acute CHF, aortic dissection, or acute renal failure. dissection, or acute renal failure. * hyperglycemia:- damages the ischemic * hyperglycemia:- damages the ischemic
- 54. Penumbra by increasing local lactic acidosis. Penumbra by increasing local lactic acidosis. Glucose containing solutions and hypotonic Glucose containing solutions and hypotonic solutions should be avoided since they solutions should be avoided since they worsen cerebral edema, insulin is used to worsen cerebral edema, insulin is used to maintion normoglysemia, glucose is only maintion normoglysemia, glucose is only given if the hypoglysemia is the cause of the given if the hypoglysemia is the cause of the focal neurological deficit. focal neurological deficit.
- 55. * prevension of aspiration pneumonia:- * prevension of aspiration pneumonia:- . elevation of the patient head at 30 degree . elevation of the patient head at 30 degree . Prohibiting oral intake. . Prohibiting oral intake. . lateral decubitus position if emesis occurs. . lateral decubitus position if emesis occurs. * intubation is needed in patient with * intubation is needed in patient with compromised airway. compromised airway. * prevention of DVT :- * prevention of DVT :- . Pneumatic compressing stockes. . Pneumatic compressing stockes.
- 56. . early mobility and rehabilitation. . early mobility and rehabilitation. low dose heparin(5000) U. sabcutaneous / low dose heparin(5000) U. sabcutaneous / 12 h. 12 h. * secondary prevention of ischemic stroke: * secondary prevention of ischemic stroke: . risk factors control. . risk factors control. . antiplatelets agents as: . antiplatelets agents as: .asprin (75-325) mg/ d. .asprin (75-325) mg/ d. . Clopidogril (75) mg / d. . Clopidogril (75) mg / d.
- 57. * carotid endarterectomy for carotid artery * carotid endarterectomy for carotid artery stenosis. stenosis. * warfarin( INR 2-3):- in hypercoagulable * warfarin( INR 2-3):- in hypercoagulable state and cardiac embolism. state and cardiac embolism.
- 58. 2- treatment of hemorrhagic stroke:- 2- treatment of hemorrhagic stroke:- A- intracerebral hemorrhage:- A- intracerebral hemorrhage:- . The most important risk factors are . The most important risk factors are advanced age and hypertention. advanced age and hypertention. . Control of blood pressure to a moderate . Control of blood pressure to a moderate range. . Control of Intracranial pressure as range. . Control of Intracranial pressure as by manitol. by manitol. . Intravenous normal salin and ringer. . Intravenous normal salin and ringer. . Surgical intervension in same cases. . Surgical intervension in same cases.
- 59. B- subarachnoid hemorrhage:- B- subarachnoid hemorrhage:- . Is a medical emergency requiring accurate . Is a medical emergency requiring accurate and early diagnosis. and early diagnosis. . General management include care and . General management include care and monitoring in intensive care unit. monitoring in intensive care unit. . Ruptured aneurysm treated either by . Ruptured aneurysm treated either by surgical clipping or endovascular coiling. surgical clipping or endovascular coiling. . Nimodipine drug reduce the vasospasm and . Nimodipine drug reduce the vasospasm and inproves clinical outcome. inproves clinical outcome.
- 60. . The major complicstions are increased . The major complicstions are increased intracranial pressure, obstructive intracranial pressure, obstructive hydrocephalus, seizures, and vasospasm. hydrocephalus, seizures, and vasospasm.
- 61. Collaborative Care Collaborative Care Prevention Prevention Education and management of Education and management of modifiable risk factors to prevent a modifiable risk factors to prevent a stroke stroke Close management of patients with Close management of patients with known risk factors known risk factors
- 62. Collaborative Care Collaborative Care Prevention Prevention Antiplatelet drugs (usually Aspirin) to Antiplatelet drugs (usually Aspirin) to prevent stroke in those with history of prevent stroke in those with history of TIA TIA
- 63. Collaborative Care Collaborative Care Prevention Prevention Surgical interventions for those with Surgical interventions for those with TIAs from carotid disease: TIAs from carotid disease: – Carotid endarterectomy Carotid endarterectomy – Transluminal angioplasty Transluminal angioplasty – Stenting Stenting – Extracranial-intracranial bypass Extracranial-intracranial bypass
- 64. Add Figure 56-7, p. 1533 Add Figure 56-7, p. 1533
- 65. Collaborative Care Collaborative Care Acute Care Acute Care Assessment findings Assessment findings – Altered level of consciousness (See GCS, p. Altered level of consciousness (See GCS, p. 1500) 1500) – Weakness, numbness, or paralysis Weakness, numbness, or paralysis – Speech or visual disturbances Speech or visual disturbances – Severe headache Severe headache – ↑ ↑ or ↓ heart rate or ↓ heart rate – Respiratory distress Respiratory distress – Unequal pupils Unequal pupils
- 66. Collaborative Care Collaborative Care Acute Care Acute Care Assessment findings Assessment findings – Hypertension Hypertension – Facial drooping on affected side Facial drooping on affected side – Difficulty swallowing Difficulty swallowing – Seizures Seizures – Bladder or bowel incontinence Bladder or bowel incontinence – Nausea and vomiting Nausea and vomiting – Vertigo Vertigo
- 67. Collaborative Care Collaborative Care Acute Care Acute Care Interventions – Initial: ABC Interventions – Initial: ABC – Ensure patient airway Ensure patient airway – Remove dentures Remove dentures – Perform pulse oximetry Perform pulse oximetry – Maintain adequate oxygenation Maintain adequate oxygenation – IV access IV access – Maintain BP according to guidelines Maintain BP according to guidelines (treat if SBP > 220 or MAP > 130) (treat if SBP > 220 or MAP > 130)
- 68. Collaborative Care Collaborative Care Acute Care Acute Care Interventions – Initial Interventions – Initial – Immediate CT scan to determine cause Immediate CT scan to determine cause (ischemic vs hemorrhagic) (ischemic vs hemorrhagic) – Measures to control ICP Measures to control ICP Head & neck in alignment (avoid flexion) Head & neck in alignment (avoid flexion) Elevate HOB 30 Elevate HOB 30 ° ° if no symptoms of shock or if no symptoms of shock or injury injury Avoid hip, knee flexion Avoid hip, knee flexion Pain management, euvolemia, diuretics if Pain management, euvolemia, diuretics if needed needed
- 69. Collaborative Care Collaborative Care Acute Care Acute Care Interventions – Initial Interventions – Initial – Institute seizure precautions Institute seizure precautions – Avoid hyperthermia ( Avoid hyperthermia ( ↑s ↑s cerebral cerebral metabolism) metabolism) – Anticipate thrombolytic/fibrinolytic Anticipate thrombolytic/fibrinolytic therapy for ischemic stroke therapy for ischemic stroke
- 70. Collaborative Care Collaborative Care Acute Care Acute Care Thrombolytic/fibrinolytic therapy with Thrombolytic/fibrinolytic therapy with recombinant tissue plasminogen recombinant tissue plasminogen activator (tPA) is used to activator (tPA) is used to – Reestablish blood flow and prevent Reestablish blood flow and prevent cell death in patients of cell death in patients of ischemic ischemic stroke stroke
- 71. Collaborative Care Collaborative Care Acute Care Acute Care Thrombolytic/fibrinolytic therapy given Thrombolytic/fibrinolytic therapy given within 3 hours of the onset of symptoms within 3 hours of the onset of symptoms – ↓ ↓ disability disability – But at the expense of But at the expense of ↑ in deaths ↑ in deaths within the first 7 to 10 days and ↑ in within the first 7 to 10 days and ↑ in intracranial hemorrhage intracranial hemorrhage
- 72. Collaborative Care Collaborative Care Acute Care Acute Care For ischemic strokes (24 hr after tPA): For ischemic strokes (24 hr after tPA): – Antiplatelets Antiplatelets – Anticoagulants (Heparin, coumadin) Anticoagulants (Heparin, coumadin) Must maintain therapeutic levels Must maintain therapeutic levels – PTT, INR PTT, INR
- 73. Collaborative Care Collaborative Care Acute Care Acute Care Interventions – Ongoing Interventions – Ongoing – Monitor vital signs and neurologic Monitor vital signs and neurologic status status Level of consciousness Level of consciousness Motor and sensory function Motor and sensory function Pupil size and reactivity Pupil size and reactivity O2 saturation O2 saturation Cardiac rhythm Cardiac rhythm
- 74. Collaborative Care Collaborative Care Acute Care Acute Care Approximately 10-15% of patients who Approximately 10-15% of patients who experience a stroke will have seizures, experience a stroke will have seizures, usually within 24 hours usually within 24 hours
- 75. Collaborative Care Collaborative Care Acute Care Acute Care Surgical interventions: Surgical interventions: – Immediate evacuation of hematomas Immediate evacuation of hematomas that result from hemorrhagic stroke that result from hemorrhagic stroke – Clip, wrap or coli aneurysm to Clip, wrap or coli aneurysm to prevent rebleed prevent rebleed
- 76. Collaborative Care Collaborative Care Rehabilitation Care Rehabilitation Care After the stroke has stabilized for 12-24 After the stroke has stabilized for 12-24 hours, collaborative care shifts from hours, collaborative care shifts from preserving life to lessening disability preserving life to lessening disability and attaining optimal functioning and attaining optimal functioning
- 77. Nursing Management Nursing Management Nursing Nursing Assessment Assessment Assess for: Assess for: – Clinical manifestations Clinical manifestations – Risk factors Risk factors – Complications Complications
- 78. Nursing Management Nursing Management Nursing Diagnoses Nursing Diagnoses Ineffective tissue perfusion (cerebral) Ineffective tissue perfusion (cerebral) Ineffective airway clearance Ineffective airway clearance Impaired physical mobility Impaired physical mobility Impaired verbal communication Impaired verbal communication Unilateral neglect Unilateral neglect Impaired urinary elimination Impaired urinary elimination
- 79. Nursing Management Nursing Management Nursing Diagnoses Nursing Diagnoses Impaired swallowing Impaired swallowing Situational low self-esteem Situational low self-esteem
- 80. Nursing Management Nursing Management Planning Planning Physiotherapy :Goals Physiotherapy :Goals – Maintain a stable or improved level Maintain a stable or improved level of consciousness of consciousness – Attain maximum physical functioning Attain maximum physical functioning – Attain maximum self-care abilities Attain maximum self-care abilities and skills and skills – Maximize communication abilities Maximize communication abilities
- 81. Nursing Management Nursing Management Planning Planning Goals Goals – Maintain adequate nutrition Maintain adequate nutrition – Avoid complications of stroke Avoid complications of stroke – Maintain effective personal and Maintain effective personal and family coping family coping
- 82. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Health Promotion Health Promotion – Teaching patients and families about Teaching patients and families about early symptoms associated with early symptoms associated with stroke or TIA and when to seek stroke or TIA and when to seek health care for symptoms health care for symptoms
- 83. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Respiratory System Respiratory System – Management of the respiratory system Management of the respiratory system is a nursing priority is a nursing priority – Risk for aspiration pneumonia (why?) Risk for aspiration pneumonia (why?) – Risks for airway obstruction Risks for airway obstruction – May require intubation and ventilation May require intubation and ventilation
- 84. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Neurologic System Neurologic System – Monitor closely for deterioration or Monitor closely for deterioration or improvement improvement
- 85. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Cardiovascular System Cardiovascular System – Monitor closely Monitor closely – Risk for DVT Risk for DVT
- 86. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Musculoskeletal System Musculoskeletal System – Prevent joint contractures and Prevent joint contractures and muscular atrophy muscular atrophy – In the acute phase, range-of-motion In the acute phase, range-of-motion exercises and positioning exercises and positioning – Trochanter roll at hip to prevent Trochanter roll at hip to prevent external rotation external rotation
- 87. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Musculoskeletal System Musculoskeletal System – Hand cones to prevent hand Hand cones to prevent hand contractures contractures – Arm supports with slings and lap Arm supports with slings and lap boards to prevent shoulder boards to prevent shoulder displacement displacement
- 88. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Musculoskeletal System Musculoskeletal System – Avoid pulling patient by arm to avoid Avoid pulling patient by arm to avoid shoulder displacement shoulder displacement – Posterior leg splints, footboards or Posterior leg splints, footboards or high-topped shoes to prevent foot high-topped shoes to prevent foot drop drop – Hand splints to reduce spasticity Hand splints to reduce spasticity
- 89. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Integumentary System Integumentary System – Skin is susceptible to breakdown Skin is susceptible to breakdown related to loss of sensation, ↓ related to loss of sensation, ↓ circulation, and immobility circulation, and immobility – Compounded by age, poor nutrition, Compounded by age, poor nutrition, dehydration, edema, and incontinence dehydration, edema, and incontinence
- 90. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Integumentary System Integumentary System – Pressure relief by position changes, Pressure relief by position changes, special mattresses, wheelchair cushions special mattresses, wheelchair cushions – Good skin hygiene Good skin hygiene – Emollients for dry skin Emollients for dry skin – Early mobility Early mobility – Position patient affected side for only 30 Position patient affected side for only 30 minutes minutes
- 91. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Gastrointestinal System Gastrointestinal System – May require nutrition support May require nutrition support – Assess gag and swallowing before first Assess gag and swallowing before first feeding feeding – Scrupulous oral hygiene after meals (food Scrupulous oral hygiene after meals (food collects) collects) – Place food on unaffected side Place food on unaffected side – Foods with texture are more easily Foods with texture are more easily swallowed swallowed
- 92. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Gastrointestinal System Gastrointestinal System – Constipation is common Constipation is common – Manage with Manage with Physical activity Physical activity Adequate fluid intake Adequate fluid intake Laxatives, suppositories, stool softeners Laxatives, suppositories, stool softeners
- 93. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Urinary System Urinary System – In the acute stage poor bladder In the acute stage poor bladder control is the primary urinary control is the primary urinary problem, resulting in incontinence problem, resulting in incontinence – Avoid indwelling catheters Avoid indwelling catheters
- 94. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Communication Communication – Assess ability to speak and Assess ability to speak and understand understand – Speak slowly and calmly, using Speak slowly and calmly, using simple words or sentences simple words or sentences – Provide time to express self Provide time to express self
- 95. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Sensory-Perceptual Alterations Sensory-Perceptual Alterations – Blindness in the same half of each visual Blindness in the same half of each visual field is a common (homonymous field is a common (homonymous hemianopsia) hemianopsia) Difficult to distinguish from unilateral Difficult to distinguish from unilateral neglect neglect Initially approach from, and place needed Initially approach from, and place needed objects on “good” side. Later, teach to scan objects on “good” side. Later, teach to scan and pay attention to affected side and pay attention to affected side
- 96. Homonymous Hemianopsia (food on left side Homonymous Hemianopsia (food on left side is not seen) is not seen) Fig. 56-8
- 97. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Coping Coping – A stroke is often a family disease, A stroke is often a family disease, affecting the family emotionally, affecting the family emotionally, socially, and financially socially, and financially – Changing roles and responsibilities Changing roles and responsibilities occur occur
- 98. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Coping Coping – Clear explanations about what has Clear explanations about what has happened, diagnostic and therapeutic happened, diagnostic and therapeutic procedures procedures
- 99. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Ambulatory and Home Care Ambulatory and Home Care – The patient is usually discharged The patient is usually discharged from the acute care setting to home, from the acute care setting to home, an intermediate or long-term care an intermediate or long-term care facility, or a rehabilitation facility facility, or a rehabilitation facility – Discharge planning should begin Discharge planning should begin early early
- 100. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Ambulatory and Home Care Ambulatory and Home Care – The nurse initially emphasizes the The nurse initially emphasizes the musculoskeletal functions of musculoskeletal functions of Eating Eating Toileting Toileting Walking Walking
- 101. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Ambulatory and Home Care Ambulatory and Home Care – Most patients begin to show signs of Most patients begin to show signs of spasticity with exaggerated reflexes spasticity with exaggerated reflexes within 48 hours following the stroke within 48 hours following the stroke – Balance training, transferring Balance training, transferring – Supportive/assistive devices for Supportive/assistive devices for mobilizing mobilizing
- 102. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Ambulatory and Home Care Ambulatory and Home Care – Interventions to promote self-feeding Interventions to promote self-feeding Using the unaffected upper extremity Using the unaffected upper extremity Employing assistive devices such as Employing assistive devices such as rocker knives, plate guards, and nonslip rocker knives, plate guards, and nonslip pads for dishes pads for dishes
- 103. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Ambulatory and Home Care Ambulatory and Home Care – A bowel management program is A bowel management program is implemented for problems with bowel implemented for problems with bowel control, constipation, incontinence control, constipation, incontinence – A high-fiber diet and adequate fluid A high-fiber diet and adequate fluid intake intake
- 104. Nursing Management Nursing Management Nursing Implementation Nursing Implementation Ambulatory and Home Care Ambulatory and Home Care – Family members must cope with 3 Family members must cope with 3 aspects of the patient's behavior aspects of the patient's behavior 1. 1. Behavioral changes resulting from Behavioral changes resulting from neurologic deficits neurologic deficits 2. 2. Responses to multiple losses Responses to multiple losses 3. 3. Behaviors that may have been Behaviors that may have been reinforced during the early stages of reinforced during the early stages of stroke as continued dependency stroke as continued dependency