CVA and ICP
Case Study
& content
N232 2022
CVA learning outcomes
Identify risk factors, signs & symptoms, and
nursing care for CVA
Describe the prevention and early recognition of a
TIA and an evolving CVA
Compare the differences between an ischemic and
hemorrhagic CVA
Develop a plan of care for a patient in the recovery
phase of a CVA (case study)
Who is
at risk?
•Non-Modifiable
Risk Factors
•Age
•Male
•Race
•
•Modifiable
•
Risk Factors
HTN,
•A-Fib,
•Hyperlipidemia,
•Obesity
•Smoking,
•Diabetes
What is a
CVA/Stroke
?
A stroke occurs when blood
flow to the brain is interrupted
by a blocked (ischemic – 80%)
or burst (hemorrhagic – 20%)
blood vessel
The duration, severity, and
location of cerebral ischemia
determine the extent of brain
function and thus the severity
of stroke.
Hot
Stroke
Code Stroke:
Time is Brain
YouTube CLIC
K HERE
This Photo by Unknown author is licensed under CC BY-SA-NC.
Types of
Strokes
Ischemic
Stroke – Blood
clot or
blockage of
Large flow
arteryto
blood
thrombotic
brain
tissue
Small penetrating
artery thrombotic
Cardiogenic
embolic
Cryptogenic
Other
Hemorrha
gic stroke
How do the symptoms differ?
ISCHEMIC MAIN
PRESENTING
SYMPTOMS
•
NUMBNESS OR
WEAKNESS OF THE
FACE, ARM, OR LEGESPECIALLY ON ONE
SIDE OF THE BODY
HEMORRHAGIC MAIN
PRESENTING
SYMPTOMS
•
“EXPLODING
HEADACHE”
•
DECREASED LEVEL
OF CONSCIOUSNESS
Transient
Ischemic
Attack
(TIA)
What
assessme
nt do you
do if you
suspect a
CVA?
Suspected stroke priority
interventions on the ward
Get help and assess the patient•
Vital Signs, BG, GCS, and neurological
symptoms
•
Note the Last Time Normal (LTN)- when last
seen without symptoms/are they on
anticoagulants?
•
Physician must be notified immediately (SBAR)
•
What diagnostic test will they be sent for?
Treatment for
hemorrhagic
stroke
Emergency
treatment of
hemorrhagic stroke
focuses on
controlling the
bleeding and
reducing pressure in
the brain caused by
the excess fluid.
Tissue Plasminogen Activator
(TPA) AKA Alteplase
Tissue plasminogen activator is a protein involved
in the breakdown of blood clots.
It catalyzes the conversion of plasminogen to
plasmin, the major enzyme responsible for clot
breakdown.
•
Rapid diagnosis of ischemic CVA and initiation
of TPA within 3-4.5 hours leads to a decrease in
the size of the stroke and an overall improved
functional outcomes.
TPA questions
In an ischemic
stroke, when would
it be
contraindicated to
administer TPA?
What is the priority
assessment during
and postadministration?
Diagnostics for CVA
CT Scan
• A computed
tomography scan is a
medical imaging
technique used to
obtain detailed
internal images of the
body. The personnel
that perform CT
scans are called
Angiography
• Cerebral angiography
is a procedure that
uses a special dye
(contrast material)
and x-rays to see how
blood flows through
the brain.
• What procedure could
they do here to return
Angiograph
y
Magnetic Resonance Imaging
(MRI)
A magnetic resonance imaging (MRI) is an imaging
test that uses powerful magnetic forces,
radiofrequency (RF) waves and a computer to
make detailed 3-dimensional pictures of the
organs, bones and tissues inside your body. Some
MRI scans require a. contrast medium.
MRI scanning can be challenging to obtain urgently in
an Emergency Department setting. This must be
considered in decision-making and not delay decisions
CVA
diagnostics
Carotid
continued
Ultrasound
Carotid
ultrasound is a
safe, painless
procedure that
uses sound
waves to examine
the blood flow
through the
Carotid
ultrasound and
endarterectomy
(CEA)
Most common surgical
procedure for patients
with TIA’s and mild
stroke that are caused
by carotid artery
stenosis
Used to prevent stroke
in patients with
Pharmacological Interventions
Antihypertensives
Anticoagulants
Platelet-inhibiting medications: clopidogrel
All stroke patients should be assessed for their risk of developing
venous thromboembolism (deep vein thrombosis and pulmonary
embolism). Patients at high risk include those who are unable to
move one or both lower limbs; those who are unable to mobilize
independently; a previous history of venous thromboembolism;
dehydration; and comorbidities such as cancer
Stroke
deficit
Terminolog
y
•
•
Hemiplegia
Hemiparesis
Stroke
Deficit
Terminology
con’t
Ataxia
Stroke
deficit
terminology
con’t
DYSPHAGIA
Stoke
deficit
terminolo
gy Con’t
Dysphasia/Aph
asia
Hemianop
sia
Case study
76 years old admitted with CVA
three day ago. Patient was at home
sitting at the table about to eat
breakfast when the patient suddenly
couldn’t move the left arm, speech
became slurred and had a facial
droop. Patient's spouse noticed
these changes and called 911. Upon
arrival to ER, Patient had slurred
gobbled speech, left facial droop, no
movement to left arm and left leg.
Vital Signs
BP: 220/120, HR:89 irreg, RR:26
O2sat:94% R/A, Temp 36.5
Hyperlipidemia
HTN
Past
medical
history
A-fib
MI
COPD
smoked 1 pkg a day X 60 yrs
Father had HTN, CAD and died
of an MI at age 45.
Family
History
Mother Type II Diabetes and
HTN and died of stoke at age
70.
Brother has HTN and CAD
Medications
Home Meds
Hydrochlorothiazide (HCTZ) 25mg PO OD,
Ramipril 2.5mg PO OD,
Warfarin 1mg,
Atorvastatin 10mg PO OD,
Advair 2 puffs BID
Hospital meds
HCTZ 25mg OD,
ASA 81mg OD,
Metoprolol 25mg PO BID,
Ramipril 5mg PO OD,
Atorvastatin 10mg PO OD,
Enoxaparin 60mg SC OD,
Warfarin 3mg PO OD,
Clopidogrel 75mg PO OD,
Pantoprazole 40mg PO OD,
Advair 2 puffs BID,
Ventolin neb Q4hr PRN,
Morphine 5-10mg SC Q4h PRN,
Risperidone ODT 0.5mg TID
PRN,
Risperidone 0.5mg PO TID
PRN,
Dimenhydrinate 50mg IV PO
Q4hr PRN,
Metoclopramide 10mg IV Q6hr
PRN
What needs to
happen before our
patient is allowed
to eat or drink or
take oral meds?
What Diagnostic Test
is priority in hot
stroke? Why?
CT of Head
from case
study
indicates
Small area of focal
cerebral cortical
infarction in posterior
Right frontal vertex in
pre-central gyrus. Patchy
deep and subcortical
white matter ischemic
change in both cerebral
hemispheres.
A able to speak in one word
answer with slurred speech
Priority
Assessmen
t
B chest expansion equal with
SOB
C radial pulses weak and
irregular @ 76bpm
D drowsy no complaints of
pain
Neuro: Confused, oriented only to person, drowsier than yesterday, PERLA, Lt arm very weak and
no movement in Lt leg. RT arm and leg moderate. No pain at present. Patient is hard to
understand, sounds like the patient is saying, “let me go home”.
Res: Anterior/posterior chest auscultated Lt clear but decreased A/E to bases, Rt Coarse crackles
Mid lobe posterior with decreased A/E to base. Productive wet cough – pt’s cough weak and not
able to bring up sputum. Increased work of breathing, shown by use of abdominal muscles RR
28 O2 Sat 87% on R/A.
CVS: Apex irregular rhythm, HR 76 BP 198/98, Rd +1, DP and PT via Doppler. Pitted edema +1 to
bilateral ankles. Cap refill <2 seconds. Skin pale, feet and hands cool.
Assessment data
Assessment Data
GI: LBM 1 day ago. Pt incontinent of stool. Bowel sounds present X4. Abdomen
round, soft, non-tender to palpate, mucus membranes dry. Pt is on a thickened diet.
GU: Foley catheter insitu draining clear amber urine.
Musculoskeletal/Mobility: Left sided weakness, 2 PA with sitting at side of bed, OHL
to chair
Psychosocial: Lives with wife Lucy, two son’s live out of town.
What are the
actual and
potential
problems?
Actual Problems
Decreased O2 sat/ SOB/Increased RR R/T
COPD, or possible aspiration pneumonia/chest
infection
Increased BP 198/98 R/T HTN
Potential problems
At risk for further stokes, MI R/T increased BP, Hx of stroke, hyperlipidemia
At risk for bleed R/T Warfarin and Enoxaparin
At risk for ICP R/T recent CVA
At risk for UTI R/T Foley catheter
At risk for systemic infection R/T possible lung or urinary infection
At risk for delirium R/T infection, CVA, narcotic use, constipation, immobility
At risk for aspiration pneumonia R/T swallowing deficit, drowsiness – not able to cough (weak)
At risk for skin breakdown R/T decreased mobility, Left sided weakness
At risk for nutritional deficit R/T inadequate nutritional intake
At risk for constipation R/T decreased mobility and nutrition/fluid intake
Based on the
actual and
potential
problems,
what lab/diag
nostics do
you
think should
be order? Ra
tionale?
At risk for bleed
R/T Warfarin
and Enoxaparin
and clopidogrel
What lab tests?
Risk
for ICP
R/T
CVA
What
diagnostics
do we need?
What
assessments
can we do?
Signs and
symptoms
of ICP
Risk for
pneumonia/chest
infection
Which tests
do we need?
Risk for UTI R/T
Foley catheter
What
diagnostic
tests?
What test to rule
out sepsis?
Risk the patient
had another
stroke?
What test is
priority?
the
nursing
interventi
ons for
YOUR
TOP
ACTUAL
PROBLEM
S?
Nursing interventions
- Position
John in a high fowlers position, apply O2 and pulse oximetry on finger to monitor
--Take vitals & BG to rule out hypoglycemia/hyperglycemia
- Ensure suction is set-up at the bedside
- Use of suction to remove sputum/phlegm
-Administer PRN Ventolin (bronchodilator)
If deteriorating- have someone stay with him (if safe to leave-->bed alarm ON)
-Call doctor – inform about respiratory status, decreased O2 sats, increased RR, high
BP, increased WBC and Neutrophils- current drowsy LOC and confusion- receive orders
for diagnostic tests/meds- Physician may want to come and see the patient
Hold breakfast and move it out of way
Our patient is now stable
and will be transferred to
neuro-rehab when a bed
is available. What
nursing interventions
would be helpful for a
patient who had a right
sided CVA?
How is this
different from
the left?
Right vs Left Sided Stroke
Right Hemispheric Stroke
Left Hemispheric Stroke
Paralysis/weakness L side=Left
side neglect
Left visual field deficit
Spatial perceptual deficit (prob w
depth perception
up/down/front/back
Inability to localize/recog body
parts
Inability to understand maps/find
objects/clothing
Impulsive behavior/poor judgment
no concern about situations,
inappropriate, depression
Paralysis/weakness R side of body
Behavior change, depression
Right visual field deficit
Aphasia (prob w speech/understanding language)
-expressive/receptive/or global
Increased distractibility
Altered intellectual ability
Deficits in math/organization/reason
Deficits in reading/writing, learning new info
Slow cautious behavior/hesitant
Nursing priorities for patient
recovering from stroke
•
•
•
•
•
•
Impaired physical
mobility
Unilateral neglect
Acute Pain (painful
shoulder)
Self-care deficits
(hygiene/toileting/dres
sing)
Impaired sensory
perception
Impaired swallowing
•
•
•
•
•
•
Impaired nutritional
status
Impaired urinary
elimination
Impaired bowel
function
Disturbed thought
process
Impaired verbal
communication
Impaired skin integrity
Care planning continued
Higher risk of injury to the weakened side- due to
decrease in function and sensation
-monitor bony prominences and L side limbs to
get caught or squeezed in chair/bed/tight socks or
anything that can cause damage to limb
-refrain from IV/BP on L side
Mentation:
-Change in emotions, depression, impulsive,
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class ICP
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