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Saturday, September 1, 2007

Cardio Vascular Accident CVA

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Contemporary Medicines Slideshow Transcript

Slide 1: Critical Care Situations in Neurological Nursing Increased Intracranial Pressure Delirium CVA

Slide 2: Increased Intracranial Pressure: Skull as a “closed box” Brain tissue is 78%  Intravascular blood is 12%  Cerebrospinal fluid is 10 %  About 1900 mL in adults  Normally volume in = volume out 

Slide 3: Normal ICP is 5-15 mmHg in pt. With HOB at 30 degrees. If sustained pressure above 20 mmHg  herniation of the brain is likely, compressing the brainstem Body compensates for minor increases  in ICP by increasing CSF absorption, decreased CSF production, as well as changing intracranial blood volume through increased venous outflow

Slide 4: Cerebral Perfusion Pressure: CPP This is the pressure of the blood flow  into the cerebrum, which must be above 30 CPP = MAP - ICP  Note the pressure-volume curve: 

Slide 5: What are the factors that raise the ICP? Increased arterial blood pressure (note: MAP  is the mean arterial pressure) Maximal constriction of vessels occurs at MAP  of 150, maximal dilation at 50 Increased intra-abdominal and intrathoracic  pressure (eg valsalva, cardiac) Posture (how high head is in relation to  heart)

Slide 6: More factors that influence ICP Hyper and hypothermia  Brain injury = swelling  Low oxygen tension = cerebral vessel dilation  Increased PaCO2 = cerebral vessel dilation  Infection  Masses  Toxic substances in blood/brain tissue 

Slide 7: Signs and Symptoms of Increased ICP Change in LOC: orientation, restlessness,  clouded sensorium. Subtle or dramatic Change in Vital Signs: most important is  watching for pattern. Cushing’s Triad (late sign): widening pulse  pressure, bradycardia with full bounding pulse, and irregular respirations

Slide 8: More Signs and Symptoms Changes in pupil size, vision, symmetry,  reactivity, as well as ocular and lid movement. Hemiparesis, or other changes in motor  function Review decerebrate and decorticate  posturing. Both serious, decerebrate is more ominous. Vomiting, headache. 

Slide 9: Brief overview of treatment of Increased ICP Frequent assessment, with attention to subtle  changes in LOC and neuro exam Very important to ACT EARLY when  symptoms emerge, by the time symptoms are overt, pressure may be hitting the dangerous part of the curve. Maintain calm and non-stimulating  environment (think: similar to “aneurysm precautions”) PaO2 at 100%, some physicians will aim for  hyperventilatory state, some not. Do avoid

Slide 10: Increased ICP Care, continued Team will want to address the cause, and  treat it whenever possible (discuss) Debate about use of sedation (discuss pros  and cons, situational considerations) Diuresis: osmotic and loop diuretics, watch I  & O, note SIADH as serious problem Corticosteroids 

Slide 11: Even More ICP care Maintain normothermia  Avoid skin breakdown  Maintain nutrition (discuss why)  Maintain adequate CPP with BP stable  and fairly normo-tensive (physician may have specific boundaries in mind) Maintain ICP as near normal as  possible, moniter it.

Slide 12: CVA: Epidemiology CVA affects over 730,000 people in US yearly  One of the top 3 causes of death in US  Costs us (in indirect and direct cost) about 41  billion yearly Incidence doubles after age 55, CVA affects  more men than women, and African Americans are at a higher risk as well.

Slide 13: More Epidemiology About 50% Stroke victims in US die  About ½ Strokes in US are associated  with hypertension 85% strokes occur at home  About 50% stroke victims travel to ED  by ambulance

Slide 14: Risk Factors for CVA~Mostly Modifiable Use of Oral Hypertension   Contraceptives Heart disease  History of Migraine  Diabetes  Headache High cholesterol  Elevated  homocysteine Smoking  Obesity and physical Alcohol and other   inactivity drug use, esp Diet cocaine 

Slide 15: Cerebrovascular Disease that Predisposes to Stroke Cerebral Vessel Abnormalities:  arteriosclerosis, aneurysms, arteritis, hypertension*, vasoconstriction Blood Flow Abnormalities: Stenosis,  thrombi, emboli Blood Property Abnormalities:  coagulation problems, viscosity

Slide 16: CVA Symptoms Sudden onset of focal neurological  deficits, the deficits relate directly to the area of the brain that is affected: visual, motor, sensory, speech most common Talk about stroke scales and their  usefulness: NIH full and short scale, the LAPSS—why it matters

Slide 17: Mini NIHSS Facial assessment: able to smile,  grimace, show teeth equal bilaterally? Extremity assessment: can hold  affected arm up at 45 degrees for 10 seconds? Can hold affected leg up at 30 degrees for 5 seconds? Language: Speak clearly and  appropriately?

Slide 18: Pathophysiology of Stroke Brain requires nearly constant supply of  Oxygen and Glucose to function. Brain is about 2% of body mass, but  uses about 20% of the blood pumped by your heart. Brain has little reserve Oxygen/glucose-  therefore TIME IS BRAIN.

Slide 19: Ischemic Stroke (about 85%): Thrombus and Embolus (pictures) Densely ischemic central core: neuronal  tissue undergoes rapid infarction Ischemic prenumbra: larger  surrounding area that is compromised re circulation, but because of collateral circulation, tissue remains viable for a variable period of time (several hours)

Slide 20: Hemorrhagic Stroke: about 15% Hypertension, Aneurysm, malformed  vessel, drug use are implicated Assessment findings alone are not  definitive to differentiate. May find “worst HA ever, blood in CSF 

Slide 21: Parts of the Brain and Deficits in CVA (oversimplified) Frontal Lobe: judgment, foresight,  voluntary movement Parietal Lobe: Language comprehension  Temporal Lobe: Hearing  Occipital Lobe: Primary visual area  Cerebellum: Coordination  Brain Stem: Swallowing, breathing,  heart rate, wakefulness

Slide 22: A Few More Broca’s Area: speech  Wernicke’s Area: speech comprehension  Sensory Cortex: pain, heat, and other  sensations Motor Cortex : movement 

Slide 23: Diagnosis in Stroke: Essential to be correct~treatment differs Physical Assessment CT scan is important  Labs: may see elevated Evaluation needs to  Hgb and Hct if stroke is be rapid. severe, EKG NURSE should be  Blood sugar and patient advocate electrolytes and make sure Stroke mimics things are going on hypoglycemia, migraine, seizure time:Because time is brain.

Slide 24: Guidelines for Emergency Stroke Management On arrival: EKG, blood sugar, Vital signs  Physician evaluation: 10 minutes  Stroke team notification: 15 minutes  CT scan : 25 minutes  CT interpreted: 45 minutes  Drug administration: 60 minutes  Monitored bed: 3 hours 

Slide 25: Most Common Nursing Diagnoses (not all) Self care deficits – all  Immobility  Situational Low Self Esteem  Injury, risk for  Aspiration, risk for & Impaired swallow  Body temp, risk for imbalanced  Communication, impaired  Unilateral Neglect 

Slide 26: Thrombotic or Embolic Stroke tPA Activase to dissolve Manage BP Goal:   clot. 3 hour time window 140/80 to 150/90 and not for hemorrhagic If hypertensive  stroke. 0.9 mg/kg up to labetrol used (20-40 90 mg. First 10% as mg over 2 min), or bolus, rest given over 60 minutes. sodium nitroprusside No ASA or heparin right  now (discuss controversy)

Slide 27: Other Medications: ASA, heparin, anticonvulsants ASA, persantine: Heparin and low   molecular weight Some studies find that  heparin ASA given early prevents early recurrence of Some controversy in  th/emb. research findings: the little decrease in Should be given if no  thrombus or embolus clear diagnosis is may be canceled out by possible (even at home the increased risk of before coming in) intracranial bleeding. Anticonvulsants to  Review the use of these prevent seizure (which  drugs, including would compound injury appropriate lab values to monitor

Slide 28: Nursing Care Issues in Acute Treatment Keep temperature Assess for depression   normal (discuss why) (common) Prevent aspiration and Keep patient calm-avoid   choking while not abrupt increases in ICP starving the patient Aim for good CPP and  Prevent and assess for ICP as close to normal  thromboembolism as possible (discuss) Prevent seizures, seizure Neuro assessment,   precautions report changes

Slide 29: Hemorrhagic Stroke Care Once this type of stroke is diagnosed, there are a few  key differences in medical care. First, tPA, ASA, heparin, etc. are contraindicated (a  main issue). Later, since 50% of hemorrhagic stroke victims go on to have a thrombotic or embolic stroke, they may be used with caution. Second, depending on the case, surgery may be  indicated Third: a medication such as Amicar (an antifibrinolytic)  may be used to facilitate a good clot at site of ruptured aneurysm

Slide 30: Nursing Care Consider many of the same issues as for  thrombotic or embolic stroke—temperature, aspiration, blood pressure, preventing DVT (but without heparin!), maintaining blood glucose. Add aneurysm precautions  Research suggests that organized stroke  teams/units do a better job with some of these nursing care issues, and have better patient outcomes.

Slide 31: Aneurysm precautions Limit TV HOB up   No very hot or cold Bedrest   liquids Quiet  No Valsalva  Dark  maneuver No caffeine Patient may be   sedated with Limit visitors  medication Rationale: 

Slide 32: Prevention Issues Primary Prevention: work with public to  facilitate limiting the modifiable risk factors prior to any illness developing Secondary Prevention: (early detection)  Teach public that time is brain and symptoms of stroke to seek treatment for right away. Talk about ASA.

Slide 33: Tertiary Prevention ASA up to 300 mg/day, Carotid endarterectomy   or persantine. (discuss especially useful if over research) 70% blockage Coumadin therapy esp if  ACE inhibition  person has A fib. (not Pravastatin or good if hemorrhagic  Simvastatin to decrease stroke) hypercholesterol states Antihypertensive therapy  Stop smoking Improve diet and   exercise

Slide 34: Delirium: Basic Characteristics Disturbance of consciousness or  cognition Usually reversible, with acute onset  Usually secondary to some other  condition or problem, such as intoxication, withdrawl, medical condition, severe stressors

Slide 35: Delirium: Assessment concerns Review MMS exam. In Ability to converse   text. Level of Consciousness  Scrutinize for underlying (alert, drowsy,  causes stuporous, etc) Orientation to time (1st Illusions, hallucinations   to go) (type, specific, timing) Orientation to place Awareness of own   deficits Orientation to person  (last to go) Distractability 

Slide 36: Nursing Intervention: Delirium Do what is appropriate to eliminate cause,  includes careful assessment Safety: falls, wandering, Ivs/ NGs pulled out  easily, may strike out in fear Meet physiologic needs: nutrition, hydration,  sleep, appropriate level of stimulation, pain relief Judicious use of antipsychotic,antianxiety  meds

Slide 37: Communication with Confused Person Short questions, instructions, with no  “big” words. Be patient. Check for comprehension, give  instructions more than once, not in condescending manner Face to face, normal tone, good light  No “honey” “dearie” etc 

Slide 38: Reality Orientation with Confused Person Clocks, calendars, cues placed  prominently. Talk about it. Names on doors, big.  Familiar routine, structure, staff  Verbal reorientation to PPT as a natural  part of conversation Read text for more interventions!! 





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