Stroke Nursing (CVA) Cerebrovascular Accident Ischemic Hemorrhagic Symptoms Treatment tPA

this is cereth registered nurse re and calm and in this video i'm going to be going over stroke in this video is part of an in clicks review series over the neuro system and as always after you watch this youtube video you can access the free quiz that will test you on this condition so let's get started first let's start out talking about what is a stroke it is where blood rich in oxygen cannot reach brain cells and when this happens cells begin to die after a certain amount of time now what can cause this what can limit blood flow to the brain tissue those cells well number one a blockage of some type in those vessels that feed the brain tissue you can get a blockage and that will stop blood flow from going to that part of the brain and if it's stopped so long that brain tissue can die leading to severe consequences or that blood vessel can rupture leading to bleeding where all the Bloods being spilled inside the brain instead of going to the tissue where it should be now there are different types of strokes and we're going to talk about ischemic stroke hemorrhagic and we're also going to hit a little bit on TI age which are transient ischemic attacks so first let's talk about ischemic strokes an ischemic stroke is where you can have a blood clot within the vessel or you have stenosis which is narrowing of an artery and it's not able to feed the brain tissue and this limits the blood that can reach those brain cells now this can happen due to a couple reasons first let's talk about an embolism type ischemic stroke this is where a claw has left a part of the body example the heart maybe the patient has a heart valve problem or they're in a rhythm called atrial fibrillation where those maitreya Mar just quivering the blood is pulling in there too long it can claw and then it can leave the heart and travel to the brain which will stop blood flow and another type that can happen is a thrombosis type of ischemic broke and this happens when a clot forms within the artery wall within the neck or the brain and this is seen in patients with hyperlipidemia high cholesterol or atherosclerosis now let's look at hemorrhagic stroke okay this happens when there is bleeding in the brain due to a break in a blood vessel and this will lead to no blood to be perfused to the brain cells and you'll get excessive swelling from the leakage of the blood in the brain now what can cause this one thing that can cause us is a brain aneurysm they have weakening of the vessel it's bulging out and it just bursts also uncontrolled hypertension so much force of blood going to the brain can weaken those vessels also older age as a person ages the vessels aren't as resilient as they used to be which leads to decrease in the integrity and they can break now let's talk about T IAS okay this is an ischemic type stroke and its origin so there's some type of blockage in that vessel preventing blood from getting to that brain tissue now what makes it different is that it's a mini type of stroke so it's not a full-blown stroke yet it's one of those warning signs that hey something big is about to happen so whenever a patient has this they will have the signs and symptoms of a stroke however they own those symptoms only tend to last for a few minutes two hours and will resolve so the patient just doesn't need to ignore this and think oh well that could have been something else they need to go they need to get evaluated to make sure that hey this may be a stroke and we can treat it appropriately so they won't have those long-term consequences that could happen if they ignored it nella switch gears and let's talk about the brain function and Anatomy this part of the lecture is really going to lay that framework for helping us understand those signs and symptoms and nursing interventions that we do for a patient with a stroke and what I want to be doing is I'm going to be talking about the function of each lobe or each area of the brain along with the right hemisphere the left hemisphere because test questions love to ask questions like your patient had a stroke they're having vision changes what part of the brain is responsible for vision or they like to say your patient has language issues they can't communicate with you efficiently which side the brain the right or the left side is responsible for that so you want to be keeping that in mind as I'm going over that material so first let's look at blood supply what supplies the brain with all of its fresh rich blood because in stroke that's the issue there's not enough blood getting to a specific part of the brain and it's causing the patient issues most of the blood supply that comes to the brain is through the carotid or vertebral arteries and these arteries will branch off into other arteries and will feed these sections and each area of the brain has specific functions and you want to know what those functions are in order to be able to get those tests questions right on those exams now brain cells are super sensitive they cannot go very long without that fresh rich oxygenated blood and within as little as five minutes these brain cells start to become affected and the longer they go without that rich oxygenated blood the more effective they become they can die and it can be irreversible there's no replacing those brain cells so now let's look at the brain and let's look at each section and see what its function is okay we'll start in the front so we'll go with the frontal lobe which is represented in red and it is responsible for our thinking speaking memory and movement and then right behind that and blue is the parietal lobe and it's responsible for our language and processing touch them a little bit below that in yellow we have our temporal lobe and it's responsible for hearing learning and processing our feelings and then right behind that in green is the occipital lobe and it is response for vision and how we perceive color so color perception and then a little bit below that and orange is the cerebellum and it's responsible for balance and coordination and then underneath that in purple we have the brain sin and it's very important it helps with our breathing heart rate and temperature now let's look at the right side of the brain versus the left side okay our right side of the brain is responsible for our creativity so it helps us be creative like with music and arts and things like that on the contrary our left side is our logical side so it helps us with logic and it helps us with things like reading writing speaking and things like that now how do you remember the two how I remember is that left starts with L logic starts with L so I know that the left side of the brain is our logic side and the other side is the creative side so let's look at the right side what does it help us do well it helps us maintain an attention span it also helps us show emotions and gives us the ability to solve everyday problems by making those quick decisions and those plans also it helps us with reasoning which gives us the ability to understand jokes and read them between the lines whenever we're conversing with people also making judgment calls having memory recall and helps us with music / our awareness and it controls the left side of our body now let's look over on the left side it helps us with speaking writing reading math skills analyzing information and planning so what happens when a patient has a right brain injury based on all those normal functions we just seen well our left side is going to be affected so what you're going to find is that the patient's going to have some left side weakness called hemiplegia also they can have impairment their creativity because that's our creative side of our brain so they'll have issues with understanding interpreting art and music they will be confused on date/time in place they won't be able to recognize familiar faces or the person's name that goes with that face they'll have loss of depth perception and trouble staying on topic while talking because remember they have they're gonna have a short attention span in addition they're not gonna be able to see the things on the left side of their body and this is going to lead to I want you to remember this left side neglect and this is where they ignore the left side of their body they're also going to have trouble with maintaining proper grooming haven't habits they can also be unstable emotionally they're not going to think things through they're going to be very impulsive and they're gonna have the poor ability to make decisions and assessing the spatial elements like shapes furthermore they're gonna be in denial about their limitations which is gonna put them at risk even more for injury because they're impulsive and they really don't realize how they're limited with this stroke they're not gonna be able to interpret nonverbal language very well or understand the hidden meaning of things and like I said they're gonna have a very short attention span so you need to keep that in mind when you're providing education or asking the patient to do something who has a right brain injury now let's talk about if a patient has a left brain injury so again the opposite side is gonna be affected the right side so some findings you'll see is right side Keima plea gia also they'll have aphasia and this is where they have trouble formulating words and comprehending them and there's different forms of aphasia like expressive and receptive and we're gonna talk in detail about those a little bit later on also these patients are going to be aware of their limits on the contrary the patient with a brunt the right brain injury was not aware but this patient will be aware of them and they can experience severe depression anger and frustration along with having trouble understanding written text when they look at those words they do not make sense to them also issues with looking at numbers and interpreting math like the Third Point they'll have impaired math skills also they will have issues with writing so agraphia and their memory will be intact and they can have issues with seen on the right side of the body now let's look at the risk factors that increase a patient's chances of developing a stroke and as I go through these be asking yourself which one of these are modifiable something that a patient can change or unmodifiable something that a patient cannot really change because exams love to ask those questions and they also love to ask about which patient is most at risk for developing a stroke for instance like smoking is a modifiable thing that a patient can stop doing to decrease their chances of stroke however if they had a family history of it they really can't change that they're stuck with that unfortunately because it's in their genetic code so to help us remember all those risk factors let's remember the mnemonic strokes happen okay s4 smoking smoking makes those blood vessels decreases their integrity so they don't work as well as they should which can increase the chances of a stroke t4 thinners specifically blood thinners if a patient gets their blood way too thin that increases the risk of one of those vessels busting in the brain r4 rhythm changes and this can happen in those rhythms such as atrial fibrillation or a flutter and the heart is not contracting properly blood is pulling in the heart and we don't want blood to conquer hate together long enough because if it does can form a clot and that clot can leave the heart and go to the brain so it's important when patients are in those rhythms that they're mean anticoagulated so they don't develop a blood clot oh for oral contraceptives birth control k for kin the family history they have a history of that efore excessive way being obese increases the risk of it because remember hyperlipidemia is one of those risk factors for developing stroke so patients who are overweight tend to have high cholesterol among other things as for senior citizens these are your patients who are elderly in age remember advanced age those vessels are not as resilient as they used to be so that increases the risk age for hypertension uncontrolled high blood pressure a for atherosclerosis P for physical inactivity another P for previous T IA remember we talked about that about mini stroke but they're having those signs and symptoms but they're resolving they still need to get it checked out because it can be a warning sign that hey a big stroke may be happening efore elevated blood glucose and this is specifically in patients who have diabetes and this really traces back to how diabetes that elevated blood sugar is so hard on those vessels it in a sense just sticks to those vessels hardens them up they're not as resilient as they used to be and it can lead to stroke and then in the end in aneurysm brain aneurysm and this is where the brain vessels are outpouching in a sense and they can rupture it so if the patient has brain aneurysm not really aware and they have uncontrolled hypertension all that pressure hitting that vessel that has really lost its integrity can just rupture open and lead to that hemorrhagic stroke now let's talk about those signs and symptoms that a patient can experience whenever they're having a stroke one thing it's important to know is that these signs and symptoms are going to happen suddenly so as the nurse you want to act fast because acting fast is going to help save as many brain cells as possible so if you are in the hospital setting and you start seeing these signs and symptoms you'll want to call a rapid response or whatever your Hospital has in place or if you're outside of the hospital you would want to call I'm one one that's here for us in the United States another thing it's super important to do is to note the time when these signs and symptoms started so if you don't know ask the patient or if you were there observing them you want to take a look at your watch and you want to look at the time because the first question that's going to be asked is what time do these signs and symptoms happen because if this is an ischemic stroke where there's a clot blocking the flow of blood to the brain they can give a drug called TPA which will dissolve that clot but they only have a three hour window from the time of those signs and symptoms started so you want to note the time now what exactly are those signs and symptoms of a stroke okay the National Stroke Association suggests using the term fast to help you recognize common stroke symptoms because remember they can come on suddenly without a warning so the S is for face so you'll want to look and notice a droop or an uneven smile on the person's face tell them to smile if it's not symmetrical that's a warning sign a look at their arms and no any arm numbness or weakness and ask the patient to raise their arm and if they can't raise their arm it drops down like an arm drift or it's an unsteady pad as a big warning sign and then s for speech difficulty ask the patient to repeat something notice how does their speech sound is it slurred which can be indicated of the person having a stroke and then t is for time it's time to act and also look at your watch look at the clock and note what time those signs and symptoms happen and then notify the appropriate personnel now in addition to those signs and symptoms that we just seen with the fast mnemonic the patient can also have these unique signs and symptoms that is really geared to patients who've had some type of brain injury like with stroke now as I go over these signs and symptoms of these terms commit their definition to memory and know they mean because I can remember on nursing lecture exams the professor would ask specific things maybe about aphasia the different types and we would have to know where maybe this type of aphasia was coming from what area of the brain or be able to describe how a patient with this type of problem would communicate with you so just commit this summary okay so the first topic I want to talk about is aphasia this is where they are unable to speak or comprehend the speech that you're speaking to them or producing speech and there's various types the first type is called receptive aphasia and this is where the patient is unable to comprehend the speech spoken to them and this affects the Warnick Khazaria and so whenever you're talking to the patient they're not really being receptive to your speech they're not really understanding it then we have a different type which is called expressive and the problem is is that they can comprehend what you're saying but they can't respond back with speech appropriately or even at all depending on how severe it is and the area in the brain that's affected with this leading to expressive aphasia is called Broca's area then you can also have a combination of both expressive and receptive and this would be called mix and then there's global where there's just a complete inability to understand speech or produce it and this is in really severe cases of stroke the patient can also have dysarthria which is where they will be unable to speak clearly due to weak muscles so they will be hard to understand and that goes back to the slurred speech in the ass of the mnemonic fast they can also have apraxia where they can't perform voluntary movements even though their muscle function is normal and this could be like winking or they need to move their arm just scratch their other arms something like that like a purposeful movement they can't really do but our muscle function is fine they can also have a graph iya which is where they've lost the ability to write and Alexia which they've lost the ability to read they don't understand the text or they really can't see the words and notice that that word also comes from the word dyslexia but this is Alexia furthermore the patient can also experience agnosia which is where they don't understand sensations or really recognize known objects or people for instance you can show them a pencil and say what is this and they don't have the ability to connect the word pencil with that object they may call it something else or just not even be familiar with it they can also have dysphagia which is where they have issues swallowing so as a nurse we've really have to watch out for this because they are a major risk for aspiration which can lead to pneumonia and lastly they can experience a condition of the eyes called hemianopia and this is where they have limited vision and half of the visual field and below this is a little example of hemianopia and for instance this is just a certain type the patient maybe is looking and they only see in each eye half of the object that they're looking at and the other part they can't see so whenever you look at this word just dissect it cameo means half off Mia deals with the eyes so know that this is an issue with the eyes and as the nurse we really have to watch out for them with injury and teach them how to scan their environment whenever they have this type of condition which will really talk about more in our nursing interventions so now let's talk about how a stroke can be diagnosed and what can be ordered by the physician because as a nurse you need to know what can be ordered what we should be looking out for okay so the patient's having those signs and symptoms we have just talked about so what can happen is that the physician can order a CT scan of the head one reason they like to do this whenever that patient comes in almost immediately is because they want to rule out if a patient has bleeding in the brain like a hemorrhagic stroke because if they do they're not a candidate for TPA so they can't receive this because this will make them bleed even worse also they can have what's called an MRI look at the brain see what lobes and areas of the brain have been affected by the stroke that can help with diagnosing it so let's talk about TPA this is tissue plasminogen activator and this is used only for ischemic strokes so again those were the type of strokes that were caused from a clot of some type that's maybe broke off from the heart or is formed in the brain and it's stopping blood flow to a certain area of the brain it is not for him hemorrhagic type strokes so how does this medication work it works by dissolving the clot that is found within that vessel by activating the protein that causes fibrinolysis so you get the breakdown of that clot and when that happens bloods gonna go back to that brain tissue that's severely means if however there's a catch with this drug it can only be given within three hours from the onset of those signs and symptoms so it's very important the patient knows or as a nurse who was there whenever the patient started having those signs and symptoms what time they occurred now there are some exceptions within the three to four and a half hour range if the patient meets strict criteria they may be able to receive this but the physician will have to analyze that so what are some criteria that a patient should meet before they receive TPA and as a nurse I would remember these okay first they need to have a CT scan of their and it needs to be negative for any bleeding which could be a hemorrhagic stroke we don't want to go in and throw more of this type of medication in there because we will increase their chances of bleeding out also their labs need to be within normal limits and labs that aren't normal they can be corrected before this medications given like glucose should be within a certain parameter they shouldn't be hypoglycemic or hyperglycemic also there claudine levels like inr and platelets should be within normal range and their blood pressure needs to be under control a lot of times when a patient comes in with stroke symptoms their blood pressure is through the roof so they need that to be under control so as a nurse you're going to be giving some antihypertensives to bring that down you want this is solid to be less than 185 and their dialogue to be less than 110 before giving TPA and while they're getting TPA you want to keep that blood pressure within a good range also it's important that they haven't received recently any drugs like heparin or any other anticoagulants because we're gonna throw some more type of drugs in there and we don't want to increase their chances of bleeding now let's talk about nursing interventions okay say you have a patient they receive TPA what are you going to be doing as a nurse what are you going to monitor them for you want to monitor them for bleeding and you will be doing around-the-clock neuro checks checking their neuro status using the NIH Stroke Scale which is what we're going to be looking at here in a second you're also going to be giving them blood pressure medications if they need it to keep their blood pressure within a certain parameter and looking at those other bottle signs monitoring their glucose and making sure that they're on bed rest they don't get up fall because if they fall while they receive this it could lead to intense bleeding and we want to prevent an injury also know I am injections and avoid unnecessary IV sticks drawing blood things like that and most cases patients will go to the some care unit ICU to be monitored usually the first 24 hours after they have received this medication now as a nurse caring for a patient who's experiencing a stroke you're going to be assessing them using some type of stroke scale and a common one is the NIH Stroke Scale and it assesses eleven different areas such as the patient's level of consciousness their gaze their visual their facial palsy motor function of extremities sensory best language dis are three a' and extinction slash and attention and the scores range from zero to forty two with zero being no stroke symptoms at all and the worst score is 21 to forty two with that being severe stroke symptoms along with that you're also going to be monitoring for a lot of things and especially in that acute stage you want to be monitoring their vital signs looking at their blood pressure making sure they're not hypertensive their heart rate their respirations because their risk in those first several hours for developing increased intracranial pressure so you want to make sure they're not having that and that can present with an increased blood pressure decreased heart rate decreased respirations the patient can also suddenly start having nausea and vomiting their level of consciousness can change and their pupils will not respond at all so you want to be looking for all that another thing is you want to be monitoring that airway very closely because remember they're gonna have issues depending on what type of stroke they've had with swallowing so all those oral secretions or just hanging out in there they're not gonna be able to swallow them so they're at risk for aspiration so you want to make sure that you have suction hooked up and ready to go for whatever you need it assessing those cranial nerves as well like the pupils their ability to swallow the facial nerves their gag reflex and things like that you're not familiar with how this has those cranial nerves you can check down below in the description for a link to a video with the head-to-toe assessment that will show you how to do that also you want to assess their bladder and bowel function because patients can either have incontinence or retention so you want to be making sure you offer them the bedpan that's I commode if they can even get up also they may need a Foley catheter if they're retaining urine and an easy way to check if they're retaining urine is that you can use a bladder scanner and scan the bladder with put a little bit of ultrasound jelly and get your little bladder scanner and it'll can tell you if there is urine in the bladder and how much also you want to be maintaining skin and limb integrity if they have where they can't move one side of the body you need to be positioning them every two hours performing those passive range of motion techniques with their arms their legs and making sure that they have proper body alignment because they can't really do this and one thing you want to watch out for and I want you to remember this it's in orange I have it right here called neglect syndrome and it's also sometimes called unilateral and neglect we talked a little we talked a little bit about this earlier and this happens when there is a right side injury and this is literally where the patient ignores that affected side and it's usually the left side so some nursing interventions to help with this you want to monitor the patient for to see if they're having this and you want to constantly remind the patient to make a conscious effort to use and to touch that affected side of the body that they are neglecting and also to constantly scan the environment to look all around to look for any type of injury that they could do to that effective side and this leads to another thing that the patient could experience called hemianopsia and this is what it looks like notice whenever you're looking this image you can see that half of the visual field is gone but they can see the other part this is just one type of hemianopsia that a patient can experience so as you can see if you don't have good vision there's a chance that the patient can't injure themselves so to assess for this you want to show a patient of something and help tell them to describe what they see see if they are having abnormal vision and teach them to prevent injury to always scan the head side to side to always look in all the visual fields to make sure they're not gonna run into something or fall or something like that now next diet because what is one of those things a lot of patients with strokes can experience difficulty swallowing and as you're gonna see whenever you work in the hospital taking care of patients with strokes this is a multidisciplinary thing you're gonna have speech therapy involved physical therapy occupational therapy and as the nurse you're going to be receiving treatment plans from them and you'll be following them out so this just isn't all nursing it's all of us working together to care for this patient along with their family one thing I want to note is that the patient has family with them you really want to incorporate the family in the patient's care as much as possible because a lot of times these patients are going home with the family and the family needs to know what to expect and what's going on so diet they will be evaluated by the speech-language pathologist who's going to do a swallow study on them see how they're swallowing also they're gonna work with them if they have difficulty with their speech helping them be able to communicate more effectively a lot of times are recommended to have thickened liquids no thin liquids so always remember this whenever giving medications or helping them with their food do they need honey fig nectar thick and if you're gonna need to crush medications and put them in applesauce also a lot of patients are going to follow a mechanical soft diet where the foods are soft easy to swallow and a lot of times you're going to be a just seen these patients with eating their food so as the nurse you want to watch out for yourself or your CNA who may be assisting with us or the family member to watch out for the patient pouching food in their cheat on that effective side that's weak because a lot of times it can just fill up with food and if you're not aware of this this can cause aspiration from where that food contents can go down into the lungs because they've just kept it in the cheek and also if the patient has a lot of trouble swallowing to prevent them from choking and gagging things like that they can tuck their chin to their chest while they swallow and that will help assist in God that food down now let's talk about communication specifically how to communicate with a patient who has aphasia one thing you want to remember about a patient who has difficulty communicating with you is that they don't have a mental deficit they're not an unintelligent they don't have something like that wrong with them it's just that they can't properly communicate with you or understand you as fast as they used to be able to before they had the stroke so as the nurse what we can do is we can help in a sense bridge that gap a little bit and make it less frustrating for our patients so if they have receptive aphasia that is where they are unable to comprehend what we're saying so we may be saying things to the end and those words are just not coming to them to make them understand what we're saying so sometimes it just there's a delay in their ability to understand our question so what can we do well whenever we communicate with them we can use short fat phrases and simple details don't go on and on also use gestures and point to things that we're talking to them about because if we want them to use the bedpan we can show them the bedpan and they may not understand that word we're saying but since we're pointing to it and using that they'll get the idea they want me to use the bedpan be patient with them don't rush then or just walk off because you think that they can't understand you take your time with them in addition remove any distractions because a lot of times these patients have short attention spans or they hear words coming from the television along with the words coming out of your mouth and it just too much to decipher and another great thing is repeat and repeat repeat those questions over and over those commands rephrase then or just keep repeating them over and over and eventually it'll click and they'll be able to comprehend now with expressive what do we do this is where they can comprehend what you're saying so they know what you're saying but they're having trouble putting the words of how they want to respond back to you some patients can't respond at all or and some patients don't use the right words to respond so with these patients again be patient with them and let them speak don't rush them or try to fill out the sentence of what they're trying to say let them say it another thing is ask one question at a time don't ask them 50 questions where they have to give you 50 responses one question at a time and let those questions be direct and ask the question in a way where they have to give a simple response to you not a huge descriptive response and another great thing with these patients I've found is to use a communication like dry race for a pencil piece of paper and that will help them communicate what they need to tell you okay so that wraps up this video over stroke thank you so much for watching don't forget to take the free quiz and to subscribe to our channel for more videos

Channel: RegisteredNurseRN

Views: 1,186,551

Rating: 4.7520409 out of 5

Keywords: stroke, stroke nursing. stroke symptoms, ischemic stroke, hemorrhagic stroke, brain stroke symptoms, stroke treatment, types of stroke, brain stroke treatment, cva pathophysiology, cva nursing, cerebrovascular accident, tia nursing, transient ischemic attack, tpa stroke, stroke nursing care, stroke nursing management, #nclex, #nursing, #nurse

Id: U8s427-tv58

Length: 36min 58sec (2218 seconds)

Published: Sat Dec 09 2017