Tca 3 1-23-07
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Tca 3 1-23-07 as PDF for free.
More details
- Words: 1,627
- Pages: 14
1-23-07
Kennedy
Stroke •
third leading cause of death in US, fourth in MS
•
#1 cause of long term disability
•
4.7 million stroke survivors today
What is a stroke? •
Blood flow to the brain is suddenly interrupted
•
Brain cells in the immediate area die
•
Loss of brain function
•
Disability
Types of Stokes •
•
Ischemic-most common o
Thrombotic –thrombus forming within the brain itself
o
Embolic-traveling, possible from DVT, heart (arrythmias)
Hemorrhagic (15%)- usually have poorer outcomes o
o
Intracerbral-most common type
Small vessel within the brain tissue ruptures
Usually caused by uncontrolled hypertension
Subarachnoid
Subarachnoid section in the brain
Most often caused by a leaking aneurysm
Arteriovenous malformation-usually develops in utero •
Risk Factors for Stroke •
Age
Arteries and veins are not formed like they are suppose to be in the brain- too much pressure on venous wall
•
Sex
•
Race
•
Heredity
•
Hypertension
•
Prior stroke
•
“TIA”
•
Smoking- doubles risk for ischemic stroke o
Women shouldn’t be on birth control
•
Diabetes
•
Carotid artery disease
•
Heart disease o
Atrial fibrillation
•
High cholesterol
•
Obesity and inactivity
•
Socioeconomic status
•
Geography
•
Alcohol abuse
•
Illicit drug use
•
Phenylpropanolamine (PPA) use [hemorrhagic stroke]
Lifespan Considerations •
Elderly at greatest risk
•
Children with sickle cell at risk o
•
Clotting of red blood cells
Anyone with multiple risk factors
Pathophysiology
1-23-07 •
•
Kennedy
Ischemic (low blood flow) o
The arteries
o
The heart
o
The blood (low cardiac output)
Hemorrhagic o
High blood pressure, atherosclerosis, vessel defect
Vessel rupture
Rapidly increasing ICP
Vasospasm
Symptoms of a stroke •
Sudden numbness or weakness of the face, arm or leg-especially on one side
•
Sudden confusion, trouble speaking, or trouble understanding speck
•
Sudden trouble with vision, especially on one side
Primary Prevention •
Teach and know risk factors
•
Practice healthy eating habits
•
Limit alcohol
•
Exercise regularly
•
Avoid cigarettes and illicit drugs
•
See MD regularly for management of chronic illness (hypertension, diabetes CVD)
Endarterectomy for Prevention of Ischemic Stroke •
Indications
•
Procedure o
•
Plaque is removed from the vessel wall
Potential complication
•
o
Obstruction
o
Cranial Nerve Damage
o
Hyperperfusion syndrome-due to permanently dilated vessels
o
Hemorrhage
o
Infection
Nursing Management o
Monitor BP
o
Cardiac monitoring
o
Monitoring for neuro changes (altered LOC)
o
Monitor for cranial nerve damage
o
Hoarseness
Swallowing problems
Have trach set at bedside
Secondary Prevention •
Know signs and symptoms of stroke
•
Call 911 if symptoms occur
•
Initial diagnosis- CT scan
•
Prompt treatment improves chances for recovery
Clinical Manifestations •
•
Motor Loss o
Hemipegia- paralysis on one side
o
Hemiparesis- weakness on one side
o
Ataxia- incoordination of movement
o
Dysphagia- trouble swallowing (difficulty with the muscles that control swallowing)
Communication loss
1-23-07
•
Kennedy o
Dysarthria- difficulty forming words due to muscle weakness or paralysis
o
Aphasia- has problems speaking, or understanding
o
Apraxia-inability to perform a previously learned action or gestures
Sensory/ Perceptiual loss o
o
o
o
Visually
Homonymous hemianopsia-loss of half of the visual field
Diploplia-double vision
Peripheral vision loss
Visual-spatial disturbance
Sensation
Paresthesia-numbness and tingling
Proprioception difficulties-position sense- not knowing where extremety is
Cognitive deficits
Memory
Attention span
Concentration
Abstract reasoning
Judgement
Emotional deficits
Emotional lability
Loss of self-control
Reduced tolerance to stress
Depression, withdrawal, isolation
Fear, hostility, anger
Diagnostic tests •
CT scan
•
MRI
•
Cerebral angiography/arteriogram o
Go in thru femoral artery
o
Inject dye into the brain
o
Looking at brain perfusion
•
Doppler flow studies (carotid, transcranial)
•
EKG
•
Echocardiogram
Treatment of an Acute Stroke •
Ischemic o
o
o
T-PA (tissue plasminogen activator)
Must meet criteria for administration
Must be given within 3 hours of onset of symptoms
Hemorrhage a risk-critical care observation
Anticoagulants
Heparin-watch PTT
Coumadin-PT and INR 2.5
Lovenox-look at platelets <100,000 HOLD
Plavix-antiplatelet
Aspirin
Other treatment measures
Elevate HOB
Secure airway
1-23-07
•
Kennedy
Monitory hemodynamics
Monitor for neuro changes
Hemorrhagic o
Will have increased ICP
o
Emergency surgery- if the bleed can be accessed
o
Manage vasospasms
o
Give calcium channel blockers (Nemotol) check BP every 4 hours
Systolic around 150 is okay
Stoke Rehabilitation •
Mobilize as early as possible
•
Physical therapy
•
Occupational therapy
•
Speech therapy
•
Treat depression
•
Educate client and caregivers
•
Determine placement options
Nursing Diagnosis R/T Stroke •
Impaired physical mobility
•
Acute pain (painful shoulder)
•
Self-care deficits
•
Disturbed sensory perception
•
Impaired swallowing
•
Incontinenece
•
Disturbed thought processes
•
Impaired verbal communication
•
Risk for impaired skin integrity
Nursing Interventions •
•
Improving mobility and preventing joint deformities o
Mobilize as early as possible
o
Proper positioning
o
Shoulder positioning
•
Put pillow under arm
Use sling when upright or walking
Enhancing self-care o
•
Want patient to be as independent as possible, but not to the point of frustration
Managing sensory-perceptual difficulties o
Approach on side where vision is intact
o
Arrange things in room where they can see it
o
Adequate lighting
Managing dysphagia o
Speech therapy
o
Thick substances
o
Chin tuck and swallow
•
Attaining bowel and bladder control
•
Improving thought processes o
•
Re-orient, re-assure
Improving communication o
Give plenty of time to express themselves
•
Maintaining skin integrity
•
Improving family coping
1-23-07
Kennedy
•
Addressing sexual dysfunction
•
Promoting home and community-base care o
Client and family education
Intracranial Aneurysm •
Localized dilation of a cerebral artery resulting from weakness in arterial wall
Causes •
Atherosclerosis
•
Congenital vessel defect
•
Hypertension
•
Head trauma
•
Advancing age
Pathophysiology •
Artery enlarges and presses on cranial nerves or brain tissue o
Aneurysm may rupture, spilling blood into the brain (subarachnoid hemorrhage) normal brain metabolism disrupted
o
Increased ICP
o
Ischemia due to reduced perfusion and vasospasm
Clinical Manifestations •
Sudden, SEVERE headache
•
Loss of consciousness
•
Nuchal rigidity- stiff neck-meningial irritation
•
Dizziness, tinnitus
•
Symptoms of stroke (motor, cognitive, visual, perceptual deficits)
•
Signs of increased ICP
•
Aneurysm may leak, clot off and have no symptoms
•
Up to 50% mortality from subarachnoid hemorrhage
Diagnostic Tests •
CT scan
•
Cerebral angiography o
•
Looks at size, location, and vessels of aneurysm
Lumbar puncture-unless they have increased ICP o
Will find blood in CSF
Medical Management •
Recover from the initial bleed
•
Prevent re-bleeding
•
o
Complete bedrest
o
Reducing stimuli
Control vasospasm o
Calcium channel blockers
o
BP around 150
•
Control hypertension
•
Monitor for and treat increased ICP o
Due to blood blocking re-absorption of CSF causing hydrocephalus
Surgical Management •
Aneurysm clipping o
Metal clips around aneurysm
•
Trapping of aneurysm
•
Wrapping of Aneurysm
•
Carotid artery clamp
1-23-07 •
Kennedy
Interventional neuroradiology o
Aneurysm coiling-not possible for everyone, aneurysm must be certain size
Nursing Diagnosis •
Ineffective cerebral tissue perfusion
•
Disturbed sensory perception
•
Anxiety
Potential Complications •
•
Vasospasm o
Worsening headache
o
Change in LOC
o
Different neuro deficit
Seizures o
•
•
Placed on prophylactic seizure med
Hydrocephalus o
Can occur weeks after aneurysm rupture
o
WET, WOBBLE, WEIRD
Re-bleeding o
Sudden SEVERE headache
o
Renewed nuchal rigidity
o
Prevention by controlling blood pressure
Hydrocephalus Overview: CSF •
Produced and reabsorbed in the arachnoid layer of the brain
•
Contained in four ventricles and circulates around the brain
What is Hydrocephalus? •
A condition caused by an imbalance in the rates of production and absorption of CSF in the ventricular system of the brain, When production is too great or absorption is inadequate, CSF accumulates in the ventricular system, USUALLY under increased pressure, producing dilation of the ventricles
•
A symptom of an underlying neurological illness
Types •
•
•
Congenital o
Abnormal fetal development
o
Genetic predisposition
Acquired o
Occurs during or sometime after birth
o
Caused by injury, infection, tumor, hemorrhage
Other types o
Hydrocephalus ex-vacuo
o
Normal pressure hydrocephalus (NPH)
Clinical Manifestations •
•
Infants and young children o
Rapid head growth, bulging fontanels, separated sutures, vomiting, setting sun sign
o
Closed sutures may re-open in children under 10-12 years
o
Later: irritability, change in LOC, seizures
Older children and Adults o
WET, WOBBLE, WEIRD
o
Urinary incontinence, ataxic gait, cognitive changes
Headache, nausea, vomiting, papilledema, blurred vision-diplopia, sun setting eyes, poor coordination, developmental delays (children), change in LOC, irritability, personality changes, cognitive changes
1-23-07
Kennedy
Diagnostic Tests •
Infants-head circumference
•
CT scan
•
MRI
•
Cisternogram-inject dye into space thru lumbar puncture and watch dye over a series of days to watch how the CSF circulates to determine if it is an absorption problem, or what the problem is to see how to fix it. Will a shunt fix the problem
Medical Management •
Medications to treat increased ICP o
•
Mannitol
Lumbar puncture or ventriculostomy to drain excess CSF
Surgical Management •
VentriculoPeritoneal Shunt- VP shunt-fed under the skin into the abdominal cavity
•
Put on non-dominant side of the brain-usually on the right hand side
•
Direct removal of the obstruction (tumor)
Nursing Management •
Care Plan: increased ICP
•
Routine craniotomy care post-op o
Position dictated by surgeon
o
Infants may be kept flat
Observe for infection
Redness
o
Observe for shunt malfunction
o
Observe for CSF leak
Long-Term Management
•
•
Considerations for Children o
Condition is life-long
o
Make life as normal as possible
Prognosis depends on o
Cause
o
Rate that it developed
o
Number of complications
Kennedy
Stroke •
third leading cause of death in US, fourth in MS
•
#1 cause of long term disability
•
4.7 million stroke survivors today
What is a stroke? •
Blood flow to the brain is suddenly interrupted
•
Brain cells in the immediate area die
•
Loss of brain function
•
Disability
Types of Stokes •
•
Ischemic-most common o
Thrombotic –thrombus forming within the brain itself
o
Embolic-traveling, possible from DVT, heart (arrythmias)
Hemorrhagic (15%)- usually have poorer outcomes o
o
Intracerbral-most common type
Small vessel within the brain tissue ruptures
Usually caused by uncontrolled hypertension
Subarachnoid
Subarachnoid section in the brain
Most often caused by a leaking aneurysm
Arteriovenous malformation-usually develops in utero •
Risk Factors for Stroke •
Age
Arteries and veins are not formed like they are suppose to be in the brain- too much pressure on venous wall
•
Sex
•
Race
•
Heredity
•
Hypertension
•
Prior stroke
•
“TIA”
•
Smoking- doubles risk for ischemic stroke o
Women shouldn’t be on birth control
•
Diabetes
•
Carotid artery disease
•
Heart disease o
Atrial fibrillation
•
High cholesterol
•
Obesity and inactivity
•
Socioeconomic status
•
Geography
•
Alcohol abuse
•
Illicit drug use
•
Phenylpropanolamine (PPA) use [hemorrhagic stroke]
Lifespan Considerations •
Elderly at greatest risk
•
Children with sickle cell at risk o
•
Clotting of red blood cells
Anyone with multiple risk factors
Pathophysiology
1-23-07 •
•
Kennedy
Ischemic (low blood flow) o
The arteries
o
The heart
o
The blood (low cardiac output)
Hemorrhagic o
High blood pressure, atherosclerosis, vessel defect
Vessel rupture
Rapidly increasing ICP
Vasospasm
Symptoms of a stroke •
Sudden numbness or weakness of the face, arm or leg-especially on one side
•
Sudden confusion, trouble speaking, or trouble understanding speck
•
Sudden trouble with vision, especially on one side
Primary Prevention •
Teach and know risk factors
•
Practice healthy eating habits
•
Limit alcohol
•
Exercise regularly
•
Avoid cigarettes and illicit drugs
•
See MD regularly for management of chronic illness (hypertension, diabetes CVD)
Endarterectomy for Prevention of Ischemic Stroke •
Indications
•
Procedure o
•
Plaque is removed from the vessel wall
Potential complication
•
o
Obstruction
o
Cranial Nerve Damage
o
Hyperperfusion syndrome-due to permanently dilated vessels
o
Hemorrhage
o
Infection
Nursing Management o
Monitor BP
o
Cardiac monitoring
o
Monitoring for neuro changes (altered LOC)
o
Monitor for cranial nerve damage
o
Hoarseness
Swallowing problems
Have trach set at bedside
Secondary Prevention •
Know signs and symptoms of stroke
•
Call 911 if symptoms occur
•
Initial diagnosis- CT scan
•
Prompt treatment improves chances for recovery
Clinical Manifestations •
•
Motor Loss o
Hemipegia- paralysis on one side
o
Hemiparesis- weakness on one side
o
Ataxia- incoordination of movement
o
Dysphagia- trouble swallowing (difficulty with the muscles that control swallowing)
Communication loss
1-23-07
•
Kennedy o
Dysarthria- difficulty forming words due to muscle weakness or paralysis
o
Aphasia- has problems speaking, or understanding
o
Apraxia-inability to perform a previously learned action or gestures
Sensory/ Perceptiual loss o
o
o
o
Visually
Homonymous hemianopsia-loss of half of the visual field
Diploplia-double vision
Peripheral vision loss
Visual-spatial disturbance
Sensation
Paresthesia-numbness and tingling
Proprioception difficulties-position sense- not knowing where extremety is
Cognitive deficits
Memory
Attention span
Concentration
Abstract reasoning
Judgement
Emotional deficits
Emotional lability
Loss of self-control
Reduced tolerance to stress
Depression, withdrawal, isolation
Fear, hostility, anger
Diagnostic tests •
CT scan
•
MRI
•
Cerebral angiography/arteriogram o
Go in thru femoral artery
o
Inject dye into the brain
o
Looking at brain perfusion
•
Doppler flow studies (carotid, transcranial)
•
EKG
•
Echocardiogram
Treatment of an Acute Stroke •
Ischemic o
o
o
T-PA (tissue plasminogen activator)
Must meet criteria for administration
Must be given within 3 hours of onset of symptoms
Hemorrhage a risk-critical care observation
Anticoagulants
Heparin-watch PTT
Coumadin-PT and INR 2.5
Lovenox-look at platelets <100,000 HOLD
Plavix-antiplatelet
Aspirin
Other treatment measures
Elevate HOB
Secure airway
1-23-07
•
Kennedy
Monitory hemodynamics
Monitor for neuro changes
Hemorrhagic o
Will have increased ICP
o
Emergency surgery- if the bleed can be accessed
o
Manage vasospasms
o
Give calcium channel blockers (Nemotol) check BP every 4 hours
Systolic around 150 is okay
Stoke Rehabilitation •
Mobilize as early as possible
•
Physical therapy
•
Occupational therapy
•
Speech therapy
•
Treat depression
•
Educate client and caregivers
•
Determine placement options
Nursing Diagnosis R/T Stroke •
Impaired physical mobility
•
Acute pain (painful shoulder)
•
Self-care deficits
•
Disturbed sensory perception
•
Impaired swallowing
•
Incontinenece
•
Disturbed thought processes
•
Impaired verbal communication
•
Risk for impaired skin integrity
Nursing Interventions •
•
Improving mobility and preventing joint deformities o
Mobilize as early as possible
o
Proper positioning
o
Shoulder positioning
•
Put pillow under arm
Use sling when upright or walking
Enhancing self-care o
•
Want patient to be as independent as possible, but not to the point of frustration
Managing sensory-perceptual difficulties o
Approach on side where vision is intact
o
Arrange things in room where they can see it
o
Adequate lighting
Managing dysphagia o
Speech therapy
o
Thick substances
o
Chin tuck and swallow
•
Attaining bowel and bladder control
•
Improving thought processes o
•
Re-orient, re-assure
Improving communication o
Give plenty of time to express themselves
•
Maintaining skin integrity
•
Improving family coping
1-23-07
Kennedy
•
Addressing sexual dysfunction
•
Promoting home and community-base care o
Client and family education
Intracranial Aneurysm •
Localized dilation of a cerebral artery resulting from weakness in arterial wall
Causes •
Atherosclerosis
•
Congenital vessel defect
•
Hypertension
•
Head trauma
•
Advancing age
Pathophysiology •
Artery enlarges and presses on cranial nerves or brain tissue o
Aneurysm may rupture, spilling blood into the brain (subarachnoid hemorrhage) normal brain metabolism disrupted
o
Increased ICP
o
Ischemia due to reduced perfusion and vasospasm
Clinical Manifestations •
Sudden, SEVERE headache
•
Loss of consciousness
•
Nuchal rigidity- stiff neck-meningial irritation
•
Dizziness, tinnitus
•
Symptoms of stroke (motor, cognitive, visual, perceptual deficits)
•
Signs of increased ICP
•
Aneurysm may leak, clot off and have no symptoms
•
Up to 50% mortality from subarachnoid hemorrhage
Diagnostic Tests •
CT scan
•
Cerebral angiography o
•
Looks at size, location, and vessels of aneurysm
Lumbar puncture-unless they have increased ICP o
Will find blood in CSF
Medical Management •
Recover from the initial bleed
•
Prevent re-bleeding
•
o
Complete bedrest
o
Reducing stimuli
Control vasospasm o
Calcium channel blockers
o
BP around 150
•
Control hypertension
•
Monitor for and treat increased ICP o
Due to blood blocking re-absorption of CSF causing hydrocephalus
Surgical Management •
Aneurysm clipping o
Metal clips around aneurysm
•
Trapping of aneurysm
•
Wrapping of Aneurysm
•
Carotid artery clamp
1-23-07 •
Kennedy
Interventional neuroradiology o
Aneurysm coiling-not possible for everyone, aneurysm must be certain size
Nursing Diagnosis •
Ineffective cerebral tissue perfusion
•
Disturbed sensory perception
•
Anxiety
Potential Complications •
•
Vasospasm o
Worsening headache
o
Change in LOC
o
Different neuro deficit
Seizures o
•
•
Placed on prophylactic seizure med
Hydrocephalus o
Can occur weeks after aneurysm rupture
o
WET, WOBBLE, WEIRD
Re-bleeding o
Sudden SEVERE headache
o
Renewed nuchal rigidity
o
Prevention by controlling blood pressure
Hydrocephalus Overview: CSF •
Produced and reabsorbed in the arachnoid layer of the brain
•
Contained in four ventricles and circulates around the brain
What is Hydrocephalus? •
A condition caused by an imbalance in the rates of production and absorption of CSF in the ventricular system of the brain, When production is too great or absorption is inadequate, CSF accumulates in the ventricular system, USUALLY under increased pressure, producing dilation of the ventricles
•
A symptom of an underlying neurological illness
Types •
•
•
Congenital o
Abnormal fetal development
o
Genetic predisposition
Acquired o
Occurs during or sometime after birth
o
Caused by injury, infection, tumor, hemorrhage
Other types o
Hydrocephalus ex-vacuo
o
Normal pressure hydrocephalus (NPH)
Clinical Manifestations •
•
Infants and young children o
Rapid head growth, bulging fontanels, separated sutures, vomiting, setting sun sign
o
Closed sutures may re-open in children under 10-12 years
o
Later: irritability, change in LOC, seizures
Older children and Adults o
WET, WOBBLE, WEIRD
o
Urinary incontinence, ataxic gait, cognitive changes
Headache, nausea, vomiting, papilledema, blurred vision-diplopia, sun setting eyes, poor coordination, developmental delays (children), change in LOC, irritability, personality changes, cognitive changes
1-23-07
Kennedy
Diagnostic Tests •
Infants-head circumference
•
CT scan
•
MRI
•
Cisternogram-inject dye into space thru lumbar puncture and watch dye over a series of days to watch how the CSF circulates to determine if it is an absorption problem, or what the problem is to see how to fix it. Will a shunt fix the problem
Medical Management •
Medications to treat increased ICP o
•
Mannitol
Lumbar puncture or ventriculostomy to drain excess CSF
Surgical Management •
VentriculoPeritoneal Shunt- VP shunt-fed under the skin into the abdominal cavity
•
Put on non-dominant side of the brain-usually on the right hand side
•
Direct removal of the obstruction (tumor)
Nursing Management •
Care Plan: increased ICP
•
Routine craniotomy care post-op o
Position dictated by surgeon
o
Infants may be kept flat
Observe for infection
Redness
o
Observe for shunt malfunction
o
Observe for CSF leak
Long-Term Management
•
•
Considerations for Children o
Condition is life-long
o
Make life as normal as possible
Prognosis depends on o
Cause
o
Rate that it developed
o
Number of complications
