Cerebrovascular Accident
Sarah Brader
Tori Kuhn
Jessie Van Wijk
March 23, 2016
Scenario
John Gates, 59 y/o male who was at work when he had sudden onset of
right-sided weakness, right facial droop, and difficulty speaking (dysarthric
speech). He was transported to the ED where these symptoms persisted.
During transport, he had increased agitation and became confused to place
and time.
Medical hx: HTN, DM II, hyperlipidemia, gouty arthritis, 1 pack/day 40y
Medications:
Lisinopril
Indocin
Aspirin
Metformin
Simvastatin
Johns Social History
John lives with his wife in their own home in a small rural community. He owns his
own hardware store where he remains active and involved in the day-to-day
operations. Johns wife is with him along with his son who also works in the
hardware store. His wife insists on being by his side and talking to John despite
Johns frustration in not being able to answer her questions. John has been trying
to quit smoking over the past week and began using a nicotine patch. John has
been complaining of pain on the right foot for the past week according to his wife.
Pathophysiology of CVA
1. Ischemic Stroke
a.
b.
Thrombotic (60%) - injury to blood vessel wall and formation of a clot
Embolic (24%) - Lodged embolus occludes cerebral artery
2. Hemorrhagic Stroke
a.
b.
Intracerebral (10%) - bleeding within the brain caused by rupture
Subarachnoid - intracranial bleeding into the CSF filled space (between
arachnoid and pia mater)
https://www.youtube.com/watch?v=pcmrgwNCPwM
Ischemic Stroke
Causes and risk factors:
Non-modifiable: Age, gender,
ethnicity/race, and family history
Modifiable: HTN, heart disease,
DM, smoking, alcohol, obesity,
sleep apnea, metabolic syndrome,
birth control pills, poor physical
exercise/diet, transient ischemic
attack and drug abuse
S/S: Usually no loss of consciousness
in first 24hrs, headache, neurologic
deficits. Onset quicker in embolic.
Hemorrhagic Stroke
Causes and risk factors: HTN,
vascular malformation, coagulation
disorders,
anticoagulant/thrombolytic therapy,
drugs, trauma, brain tumors, and
aneurysm.
S/S: Neurologic deficits,
headache, nausea, vomiting,
decreased level/loss of
consciousness, HTN, often no
warning signs noted for aneurysm
Clinical manifestations cont.
Important: Manifestations do not differ much between ischemic and hemorrhagic
stroke; they are more related to the location of the stroke
In the ED
It has been 30 minutes from the onset of his neurologic symptoms when he presents
to the ED.
Identified as a non-hemorrhagic stroke within the three-hour onset window, tissue
plasminogen activator (TPA) was administered with some improvement in neurological
deficits.
He was also found to have new onset atrial fibrillations during this hospitalization.
NEURO ASSESSMENT: Confused to place and why he is in the hospital, is notably
anxious, restless and agitated, speech is currently slurred and difficult to understand,
facial droop present on right side, pupils equal and reactive to light (PEARL), both right
upper extremity (RUE) and right lower extremity (RLE) notably weak in comparison to
left which is strong, right pronator drift present, unable to hold right arm up, right visual
deficit cut present.
Diagnostic testing
Noncontrast CT or MRI Distinguish between ischemic and hemorrhagic
stroke, determine size and location
CT angiography Visualization of cerebral blood vessels to estimate
perfusion, filling defects
Magnetic resonance angiography MRA Detect vascular lesions and
blocks
Cardiac imaging Check for blood clots from the heart
Intraarterial digital subtraction angiography DSA Visualize blood
vessels in neck and large vessels of the circle of Willis
Transcranial Doppler TCD ultrasonography Measure velocity of blood
flow in major cerebral arteries, to detect microemboli/vasospasm
Treatment during hospitalization
Admission to the neuro unit from ED:
New med regimen: Lisinopril, Indocin, Aspirin, Metformin and Simvastatin,
Clopidogrel (Plavix), aspirin, simvastatin.
GCS Assessment: Dependent for ADLs, difficulty swallowing, fall risk
Consults: OT, PT and ST
Day 5: Still no independence in ADLs, pureed foods, assistance needed for
feeding, limited speech (yes/no answers)
Transfer to rehab hospital
Rehab unit
Assessment: Expressive aphasia, left facial droop,
left-sided hemiparesis, mild dysphagia
Interdisciplinary team:
Occupational therapist: Relearn fine motor skills
Speech language pathologist: PT has
expressive aphasia
Barium swallow study: Assess functional
abnormalities of pharynx and esophagus
Registered dietitian: Dysphagia requires special
diet
Nursing Diagnoses: Rehab
Risk for aspiration related to decreased swallowing reflexes as evidenced by
problems swallowing (Barium test)
Impaired swallowing related to mild dysphasia as evidenced by difficulty
swallowing
Impaired physical mobility related to left-sided hemiparesis as evidenced by
inability to perform ADLs
Impaired verbal communication related to aphasia as evidenced by patient
only being able to pronounce a limited amount of words, difficulty forming
words
Patient and Family Teaching
Home Maintenance Assistance:
1.
2.
3.
Safety Hazards
a. Adaptive equipment, prevent falls etc.
Family understanding patients Plan of Care
a. Diet: Pureed Food, Thickened Liquids
b. Bladder Program to prevent incontinence
c. Communication Aids such as flashcards and call lights
Realistic Expectations of family members assisting w caregiving
a. Who is going to help him with shower/bath etc at home?
Ericksons stages of development
ACTUAL:
CURRENT:
Middle-age Adult
School-age Child
Generativity vs. Self-absorption
Industry vs. Inferiority
Care Stage: Contribution to family,
society, personal accomplishments
and responsibilities ie. owner and
manager at hardware store, son is
now the only one able to work
Competence Stage: Frustration of not
being able to communicate needs
and thoughts ie. dysphagia, wife
jumping to conclusions, dependent
on someone else for ADLs
Teaching Plan
Length of the teaching session? The length of the teaching plan should progress through the
entire duration of the clients stay in the hospital. The content should be closely related to the areas
of improvement the patient is focused on. The home assessment should be done pre-discharge to
anticipate any physical or educational needs that the family may have.
Appropriate learning environment? It is important to facilitate an environment that does not
isolate the patient but includes him in the teaching. Explain all the resources available to the family
such as respite, home care and identify supportive people in the community who can help.
Possible challenges to the teaching situation? I potentially foresee the wife wanting to be the
sole caregiver and it would be important to offer counseling and explain all the resources that she
has. Explain the disease process of CVA, signs of progress and recovery and assist her in
identifying ways she can focus on taking care of herself too.
Outcomes
Short-term Goal:
COMMUNICATION ENHANCEMENT: Patient will use
alternative methods of communicating effectively by
phase end.
Long-term Goal:
HOME MAINTENANCE: Patient will utilize community
resources to assist with home care needs within one
week after discharge.
Evaluation
Describes methods that would be used to evaluate patient learning.
Short term Progress: GOAL MET - Patient is employing speech therapist
alternative techniques, is aware of his expressive aphasia and limitations in
communicating, and using both verbal and nonverbal communication techniques.
Long-term Progress: GOAL MET - Patient and family have contacted Home Care
services prior to discharge to prevent anxiety for wife when he returns home. She
has also identified two supportive people in their community who will support her.
Progress in rehab, 21 days
Ambulation with a short leg brace and quad cane
ADLs: Bathing, feeding, dressing, walking up and down stairs with adaptive
equipment and help of wife
Improved bladder and bowel control and function.
Wife helps with clothing while toileting
Expressive language improved, short sentences.
Comprehension intact
Swallowing improved, moved to normal diet
Patient is ready for outpatient therapy.
Wife will drive him to outpatient visits.
Discharge Plan
With the Teaching Plan in place, the majority of the work is already done! The
discharge plan is to verify that the patient and family understand the next step of
rehabilitation at home and the safety measures they have already been doing.
Identify the different multidisciplinary team members who would be involved in his
care and why? He still needs speech therapy, occupational therapy visits, and
potentially homecare for the first part of the transition. When wife is overwhelmed,
respite is also a good resource for short-term rehabilitation.
Patients GOAL: To remain in his own home and resume his passion for gardening.
Community Support Resources
Stroke Survivors Support Groups - SHARP Memorial Rehabilitation Center
The Young Enthusiastic Stroke Survivors (YESS) and American Heart Association
sponsor community group meetings at SHARP Memorial various Friday
afternoons 12:30-1:30pm. This service is free for patients and family to attend.
http://www.sharp.com/health-classes/stroke-survivors-support-group-114
National Stroke Association - free online educational materials, can start local
support group in your area as well.
http://www.stroke.org/stroke-resources/stroke-support-groups/join-our-stroke-supp
ort-group-registry
Journal Article 1: Intravenous tPA for ischemic stroke team performance
over time, safety, and efficacy in a single-center, 2-year experience
The only FDA approved treatment for ischemic
strokes is tissue plasminogen activator (tPA). tPA
works by dissolving the clot and improving blood flow
to the part of the brain being deprived of blood flow.
75 patients studied over 2 years
Mean age: 68
Average time of tPA administration after symptoms:
144 minutes
Results: 2 cerebral hemorrhages occurred (2.7%),
good outcome in 40% of patients, moderate in 32%,
and poor in 13%. Mortality rate was 15%.
Journal Article 2: Ischemic stroke prognosis in adults
A wide variety of factors affect stroke prognosis, including: age, stroke severity,
stroke mechanism, infarct location, comorbid conditions, clinical findings, and
related complications. This meta-analysis focused on the major predictors of
outcome, which are stroke severity (degree of neurologic impairment, size, etc.)
and patient age.
The greatest proportion of recovery after stroke occurs in the first 3-6 months.
A study analyzed showed that those who had a mild disability recovered within 2 months, those who
had moderate disability recovered in 3. Patients with severe disability recovered in 4, and those with the
most severe disability within 5 months from onset. Functional outcome at 3 months after stroke predicats
survival at 4 years, and functional status at 6 months predicts long-term survival.
Class questions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Why is diabetes considered a modifiable risk factor for CVA?
Why did patient experience foot pain prior to presenting with ischemic stroke?
Why does having Atrial Fibrillation increase your risk of developing a stroke?
Was it nerves or muscle disconnect that caused the urinary incontinence?
What are the benefits of Range of Motion (ROM) exercises for recovery?
What are the two most important predicting factors on a stroke patients
prognosis?
How might social resources have an impact (positive or negative) on a
patients recovery?
What is the only FDA approved drug for treatment of an ischemic stroke?
What is a major complication with this drug?
What are some things we can do as nurses to help stroke patients get back to
their pre-stroke activities? (ie. managing a garden)
References
Edwardson, M. A., Dromerick, A. W. (2015). Ischemic stroke prognosis in adults.
UpToDate. Retrieved from:
http://www.uptodate.com/contents/ischemic-stroke-prognosis-in-adults
Koennecke, H., Norh, R., Leistner, S., Marx, P. (2001). Intravenous tPA for ischemic
stroke team performance over time, safety, and efficacy in a single-center, 2-year
experience. Stroke. 31, 1074-1078.
