Basic Stroke for the New Recruit

Transcription

1 Basic Stroke for the New Recruit Authors Erin Conahan MSN, RN, ACNS-BC, CNRN, SCRN Julie FussnerBSN, RN, CPHQ, SCRN The authors have nothing to disclose. 1

2 Objectives List causes of small vessel stroke vs large vessel stroke and differences in treatment Describe inclusion/exclusion criteria for tpa and endovascular treatment List elements of acute stroke work-up to identify risk factors Stroke Facts Each year 795,000 strokes occur in the United States Stroke is the 5 th leading cause of death in the United States Stroke is the leading cause of adult disability Up to 80% of strokes are preventable During a stroke ~32,000 brain cells are lost per second ~2 million brain cells lost per minute. The brain ages 3.6 years for each hour untreated Time is Brain 2

3 What is stroke? Stroke occurs when a blood vessel to the brain is blocked or ruptured causing brain cells in the blood vessel territory to die. What does it look like? Ischemic Stroke Hemorrhagic Stroke 3

4 Cerebral Circulation Circle of Willis Located at the base of the skull Provides collateral circulation Anterior Circulation Carotid arteries Anterior cerebral Middle cerebral Anterior communicating Posterior Circulation Vertebral Basilar Posterior cerebral Posterior communicating 5 Stroke Syndromes 1. Left Hemisphere 2. Right Hemisphere 3. Cerebellar 4. Brainstem 5. Hemorrhage 4

5 Left Hemisphere Signs: Aphasia Right side weakness Right side sensory loss Right visual field cut Left gaze Right Hemisphere Signs: Neglect Left side weakness Left side sensory loss Left visual field cut Right gaze 5

6 Cerebellar Signs: Ataxia Gait disturbance Vertigo Nystagmus Ipsilateral Findings Brainstem Retrieved on 9/25/15 from: pdf 6

7 Brainstem The5 D s Dizziness Diplopia Dysarthria Dysphagia Dystaxia Retrieved 9/25/15 from: IntracranialHemorrhages 4 Types Epidural (trauma) Subdural (trauma) Subarachnoid (traumatic or stroke) Intracerebral hemorrhages (stroke) Note difference between intracranialand intracerebral both abbreviated ICH 7

8 Hemorrhage Meninges (Outer to Inner) Dura Mater thick, fibrous covering of brain (and spinal cord) Arachnoid Mater thin web-like membrane between duraand pia, below which flows the CSF in the subarachnoid space Pia Mater delicate covering of the brain and directly adherent to tissue Retrieved from: Source: Medical Disability Advisor SAH Etiology Traumatic (fall, blow to head) Aneurysmal (ruptured aneurysm) AVM (burst of AV malformation) Signs and symptoms occur suddenly Worst headache of my life (thunderclap HA) Decrease/loss of consciousness/confusion N/V Photophobia Hemiparesis/hemiplegia Meningeal irritation 8

9 Intracerebral Hemorrhage Clinical Presentation SBP often >220 mmhg HA N/V Ataxia Dizziness/Vertigo Dysarthria Nuchal Rigidity Alterations in LOC Stroke Assessments Support airway/breathing/circulation Vital signs POC Glucose CT NIHSS Labs, EKG, CXR CTA or MRA assess vessels LP for SAH 9

10 NIH Stroke Scale Systematic assessment tool that provides a quantitative measure of stroke used world wide 42 point scale Higher the number the worse the stroke NIHSS 2 or greater tpagiven Too good to treat research NIH Stroke Scale Level of Consciousness Questions & Commands Visual Fields Facial Palsy Motor arm & leg Limb ataxia Sensory Best Language Dysarthria Neglect 10

11 What type of stroke did your patient have? Large vessel occlusion Lacunar Infarct Transient Ischemic Attack Stroke mimics AIS: Large Artery Atherosclerosis Thrombosis Plaque narrows the vessel lumen resulting in turbulent blood flow. The atherosclerotic plaque becomes unstable and ruptures, clotting factors are attracted and a thrombus forms. Carotids / Aorta Afib 11

12 AIS: Small Vessel Atherosclerosis Small-vessel ischemia occurs when plaque occludes small perforating vessels. Typically results in lacunar strokes which accounts for ~ 25% of ischemic strokes. Chronic medical conditions such as DM, HTN, HLD and smoking increases risk of small vessel disease. TIA Mini stroke -Avoid term Brief episode of neurological dysfunction lasting < 1 hour Symptoms usually last mins Old Definition: less than 24 hours New Definition: Evidence on MRI imaging Important determinant of stroke risk 3-10% pts stroke within 2 days 9-17% pts stroke within 90 days Within 1 year of TIA =12% will die 12

13 Stroke Mimics Hypoglycemia Seizures Migraine Tumor Abscess Subdural Hematoma Imaging: CT vs MRI Why do they order the scan? CT better for seeing acute blood or skull fractures MRI better for ischemic stroke and tumor CTA/MRA looking for blood vessel abnormalities ( A means angio) 13

14 Treatment options: Time is brain Blood pressure control for all types!! IV tpa Endovascular Pharmacologic Mechanical Neurosurgery Aneurysmal SAH Clipping and Coiling External Ventricular Device Decompressive Hemi craniotomy Research Neuroscience ICU / Stroke unit **Find the cause to prevent future events! tpa Inclusion/Exclusion Criteria Contraindications ICH, SAH, active internal bleeding Recent intracranial or intraspinal surgery or head trauma Presence of intracranial conditions that may increase risk of bleeding Bleeding diathesis Uncontrolled hypertension INR >1.7 or use of NOAC hour window >80 years old Any anticoagulant use History of CVA anddiabetes 14

15 Modifiable Risk Factors Cardiovascular disease (CVD) Hypertension (HTN) Asymptomatic carotid stenosis A Fib Diabetes mellitus (DM) Dyslipidemia Cigarette smoking Drug use ( cocaine) Alcohol Obesity Physical inactivity Sickle cell disease Postmenopausal hormone therapy Hypercoagulable states Stroke Work-Up Cardiac monitoring Angiography (CTA, MRA, angio) Carotid duplex Echocardiogram/TEE FLP, HgA1C, Hypercoag panels Patient History!! 15

16 Importance of Nursing Assessment Ongoing neuro exam: 30% of stroke patients deteriorate in 1 st 24 hours Bleeding, edema, stroke in evolution; seizures; side effects of treatment VS trending BP goals, temperature management, cardiac monitoring, oxygenation, blood glucose monitoring Nursing Role of Preventing Complications VTE, Pneumonia Nutritional deficiency Aspiration Bowel or bladder dysfunction, UTI Contractures/joint abnormalities Skin breakdown Depression Falls 16