Stroke for Progressive Care Certified Nurse (PCCN)

Stroke

Definition/Etiology:

• Definition
  • Stroke/CVA/Brain Attack
  • A loss of blood flow to part of the brain, which damages brain tissue. CVAs are caused by blood clots and broken blood vessels in the brain.
  • 85% are caused by Blood Clots
  • Hemorrhagic Strokes are CCRN material
• Etiology/Cause
  • Anything that causes Atherosclerosis
    • Smoking, HTN, DM, Hyperlipidemia
  • Undiagnosed Afib
  • Clotting issues
    • Sepsis/DIC
  • Nonmodifiable risk factors
    • Same as cardiac. Example: Age, gender, race, etc

Pathophysiology:

• Approximately 85% of all strokes are ischemic. A cerebral artery becomes narrowed or occluded, interrupting CBF and oxygen delivery and causing brain ischemia in that vascular territory.
• Perfusion problem = Clogged Hose!
  • Perfusion = Cerebral arteries are a hose. No water, no garden. No blood, no life.
• Thrombotic – most common
  • Blockage formed in a vessel
  • TIAS are associated with these
  • Usually caused by Atherosclerosis
• Embolic – Second most common
  • piece of a thrombus moved to a NEW place a lodged there
    • Example: Think of DVT to PE (leg to lung)
    • Afib: Heart to brain
    • Anything that disrupts clotting cascade
      • Sepsis/DIC

Noticing: Assessment & Recognizing Cues:

• FAST
  • NCLEX material , but great to review
• TIA
  • Stroke like symptoms that resolve within 24 hours.
  • ZERO deficits
  • Cannot see on imaging
• Thrombotic/Embolic
  • Symptoms persist more than 24 hours
  • Deficits
  • Can see damage on imaging
• Right vs Left symptoms are extensive.
  • Right
    • Left-sided weakness or neglect
    • Dysarthria – inability to control the muscles used in speech
    • Dysphagia – difficulty swallowing
    • Flat affect
  • Left
    • Right sided weakness or neglect
    • Aphasia (expressive/receptive/global)
• Lobes of brain
  • Frontal- Memory & behavior
  • Parital – Language
  • Temporal – Hearing
  • Occipital -Seeing
  • Cerebellum – Coordination

Interpreting: Analyzing & Planning:

• Labs
  • SO MANY!
    • Usually rule out conditions that mimic stroke
  • Platelet count, PT, PTT, INR
    • Can they have TPA
• Diagnostics
  • STAT CT with no contrast
    • 25 min door/20 min read
    • Rules out a brain bleed/mass
    • Confirms Ischemic Stroke
  • MRI
    • Location and extent of damage
  • EKG
    • Undiagnosed Afib = #1 cause Embolic CVA

Responding: Patient Interventions & Taking Action:

• STROKE ALERT + ABCs + Underlying Cause
  • 02 Support <94% /HOB
  • Fluids = Maintain normovolemia
• Pharmacological Interventions
  • Alteplase/TPA
    • Breaks up clot = Blood Flow
    • 4.5 hours MAX of KNOWN onset
    • Other criteria = no anticoagulation
  • Antihypertensives – Calcium Channel Blockers
    • Watch carefully
    • Keep below 180/105
    • Balance
      • Perfuse damaged area but prevent brain bleed
  • Insulin
    • Glucose goal < 200
      • Hyperglycemia grows infarct and edema
• Non-Pharmacological Interventions
  • Avoid Shivering = poorer outcomes
• Adjunct Medical Therapy
  • Neurologist and SPEECH therapy initially

Reflecting: Evaluating Patient Outcomes:

• Adequate brain perfusion is maintained to minimize ischemia
  • BP 180/105
    • Too high = bleed
    • Too low = no perfusion
• Optimal recovery of neurologic function occurs
  • Are Deficits improving?
• Potential complications are prevented or are recognized and appropriately managed
  • Monitor signs of symptoms of hemorrhage
  • Heart monitor (Afib)
  • Glucose (edema)

Linchpins (Key Points):

• Notice -Symptoms
  • Deficits and TIMING
• Interpret
  • CT no Contrast/MRI
• Respond
  • TPA ,BP , & BS
• Reflect
  • Complication Watch
    • Bleeding and Blood sugar
    • IMPROVING?