CVA

Question 1

CVA: S/Sx

Answer 1

• numbness/weakness face, arm, leg
• confusion
• dysphasia
• visual disturbance in one or both eyes
• ataxia
• dizziness
• severe headache

Face drooping
Arm weakness
Speech Difficulty
Time

Question 2

Possible Hidden Causes of CVA

Answer 2

• a-fib
• heart structure problem
• heart atherosclerosis
• blood clotting disorders

Question 3

Hemiplegia

Answer 3

paralysis of one side of the body

Question 4

Hemiparesis

Answer 4

weakness of one side of the body

Question 5

Dysphasia

Answer 5

speech disorders in which there was impairment of the power of expression by speech, writing, or signs or impairment of the power of comprehension of spoken or written language

Question 6

Dysphagia

Answer 6

difficulty swallowing

impairment of cranial nerves 9 and 10

Question 7

Expressive Aphasia (Broca’s area)

Answer 7

can understand
can’t speak or write

impairment of motor speech center in frontal lobe

Question 8

Receptive Aphasia (Wernicke’s area)

Answer 8

can’t understand or follow commands

impairment of auditory association area in temporal lobe

Question 9

Types of Strokes

Answer 9

thrombotic stroke: from plaque

embolic stroke: from embolus (blood clot, fat, air)

hemorrhagic stoke: burst blood vessel (usually aneurysm)

• intracerebral hemorrhage: bleeding w/in the brain
• subarachnoid hemorrhage: bleeding into the CSF-filled space between the arachnoid and the pia mater membranes on the surface of the brain

Question 10

Penumbra

Answer 10

the area surrounding an ischemic event such as thrombotic or embolic stoke

salvageable brain area

immediately following the event, blood flow and therefore O2 is reduced locally > hypoxia of the cell near the location of the original insult

Question 11

CVA: Risk Factors

Answer 11

• female = more deaths
• male = more likely to have 2nd CVA in 5 years
• african americans = 2x risk and mortality
• > 50YO
• women taking birth control pills
• young black w/ sickle cell disease
• diabetics w/ carotid artery disease
• hx of heart disease
• hx of HTN
• high cholesterol
• obesity
• smoking
• sedentary lifestyle
• heredity
• alcohol

Question 12

Developmental Processes of Ischemic/Embolic Strokes

Answer 12

• TIA
• RIND (reversible ischemic neuro deficit)
• Stroke in evolution: recognized stroke and comes to hospital, can be treated
• Completed Stroke: stroke in sleep or unrecognized, doesn’t get tx until much later

*TIA and RIND are reversible on their own

Question 13

TIA

Answer 13

• more likely to have CVA after TIA (like a warning sign)
• last seconds to 12 hours w/o residual effect (avg = 10-20 minutes and resolve in 1 hr)
• signifies advanced atherosclerosis

-will do carotid u/s in to r/o clots and plaques, if there is significant blockage > carotid endarterectomy to prevent future stroke

Question 14

TIA and Cerebral Edema

Answer 14

cerebral edema peaks in 72 hours and remains for 2 weeks

need CT scan to look for further bleeding and cerebral edema

Question 15

RIND

Answer 15

reversible ischemic neurological deficit

small stroke

reversible by itself in 48hrs to 3wks

may have multiple over years in the same are of the brain

usually d/t to carotid artery stenosis

Question 16

Stroke in Evolution

Answer 16

progressive stroke

deficit occurs in steps

some over 24 hours, other 72 hours

Question 17

Completed Stroke

Answer 17

stable deficits w/in 1 hour

can have secondary injury up to 72 hours as a result of stroke (do NIH stroke scale and CT scan to monitor for changes)

approximately 60% occur during sleep

Question 18

Collaborative Care of Stroke

Answer 18

involve radiology, PT, OT, Speech ASAP

Question 19

tPA Therapy

Answer 19

max time frame for use - 3 hours

dosage: 0.9mg/kg; max: 90mg

Question 20

tPA Therapy: Complications

Answer 20

intracerebral hemorrhage:

• highest risk is w/in 24 after administration
• control BP to prevent (keep systolic less than 185, keep diastolic less than 105)

Question 21

tPA Therapy: Exclusion Criteria

Answer 21

• evidence of hemorrhage on CT scan
• <18 YO
• minor or rapidly improving stroke symptoms (this indicates TIA or RIND and tPA isn’t needed)
• outside 3 hour time frame
• active bleeding or hx of recent surgery (less than 8 weeks ago)
• seizure activity w/ stroke symptoms

Question 22

Mechanical Revascularization

Answer 22

used when:

• tPA therapy ineffective b/c the clot was a thrombosis (from plaque) not an embolus
• client is not a candidate for tPA

Question 23

CVA and BP

Answer 23

maintain systolic BP at 150mm Hg to perfuse brain

Question 24

CVA and Hypervolemic/hemodilution w/ NS and albumin

Answer 24

• maintain CPP
• lowers blood viscosity
• maintains slightly elevated BP
• Hct decreases from 35-33 d/t dilution of hematocrit and it’s a false reading
• vasodilates cerebral vessels = increased perfusion
• works well for subarachnoid bleeds and vasospasm
• not as well in ischemic/embolic strokes

Question 25

How do you minimize disuse syndrome?

Answer 25

- minimize time on flaccid side - use affected hand to wrist; wrist to elbow - avoid excessive pull on affected shoulder (vulnerable to subluxation and adduction contractures) - prevent external rotation of hip - heels off mattress - AROM and PROM as much as possible - hi-top sneakers to prevent foot drop - resting splint (assess skin under splint regularly) - skin care - assess frequently (decrease skin pressure in chairs) - place things on affected side to force pt to use this side - use adaptive equipment to regain ADLs - early ambulation

Question 26

Dysphagia: Sx

Answer 26

facial droop drooling weak voice

Question 27

Dysphagia: Silent Aspiration

Answer 27

silent aspiration = aspirate w/o choking (no reflexes)

Question 28

Dysphagia: Standard of Care

Answer 28

- speech therapist will do barium swallow test - evaluate swallowing before allowing PO fluids/food/meds - quiet environment for eating to concentrate on swallowing - HOB elevated - aspiration precautions - mouth care before meals (stimulate saliva flow) - position food in visual field (if necessary) - mechanical soft diet better than liquids (thickeners) - small bites (on unaffected side of mouth) - chew thoroughly - sweep mouth after each bite for "pockets" - mouth care after meals (clean out pockets w/ gauze) - accurate I&O until sufficient intake achieved - weekly weights to ensure nutritional status has not been impaired by stroke

Question 29

Cerebral Aneurysm - Subarachnoid Hemorrhage

Answer 29

dilation of wall of cerebral artery usually at arterial junction (berry aneurysm) 80% occur in circle of willis aneurysm ruptures and bleeds into subarachnoid space can be d/t trauma sx occur when aneurysm enlarges and exerts pressure on brain, or when ruptures

Question 30

Predisposing Factors that Cause Rupture of Aneurysms

Answer 30

- valsalva maneuver - sexual intercourse - physical exertion *if rupture occurred during activity, pt may be reluctant to do that activity again

Question 31

Hemorrhagic Stroke: Sx

Answer 31

Prior to rupture: - severe HA - photophobia (look at shape of pupils, may be oval) - intermittent nausea After rupture: - severe HA - unequal pupils - dysconjugate gaze - seizures - nuchal rigidity (b/c bleeding is going into CSF and causing rigidness and neck pain) - hemiparesis - loss of consciousness - increased ICP

Question 32

Hemorrhagic Stroke: Dx Tests

Answer 32

- lumbar puncture (blood in CSF = hemorrhage in brain) - cerebral angiogram - CT scan

Question 33

Hemorrhagic Stroke: Tx

Answer 33

craniotomy to clip or coil aneurysm before rupture meds: - osmotic diuretics (Mannitol): to help decrease ICP - anti-HTN goal: prevent further increase in ICP and subsequent rupture

Question 34

Craniotomy: Post-op

Answer 34

- immediate, strict bed rest - prevent valsalva maneuver - prevent anything that will increase ICP - check swallowing - HOB elevated - quiet, dim, non-stimulating environment - constant monitoring - keep BP lower (to prevent risk of re-bleed) - vasoactive meds: Ca channel blockers (vasodilators to ensure to perfusion to brain and help decrease vasospasms which will cause rebleeding) - frequent checks on pt

Question 35

Aneurysm: Complications

Answer 35

rebleed hydrocephalus (which may require ventricular shunt) vasospasm