Stroke Cerebrovascular Accident CVA | Ischemic, TIA and Hemorrhagic Stroke Symptoms, Treatment, and

In this video, we're diving into the different types of cerebral vascular accidents, aka CVAs or strokes and we'll cover stroke pathophysiology, the treatment and the symptoms so that you can pass your nursing school exams. Let's dive in. Now before we dive in, I wanted to make sure that you knew about the free critical thinking cheat sheet that I have for you. We will put the link in the description below for you to snag that and use it while you study in nursing school. It will be so, so helpful you as you go through your program and it will help you be more prepared for your nursing school exams and get more questions right. So be sure to snag that. Now let's dive into stroke. There are three types of stroke that you need to know about in nursing school. An ischemic stroke, a transient ischemic attack or TIA for short, and hemorrhagic strokes. Let's first talk about ischemic stroke. This is when there is a blood clot in one of the vessels supplying the brain with blood which causes decreased increase blood perfusion to that area. Now there are two types of an ischemic stroke, thrombotic stroke, which means that a clot has formed in a blood vessel supplying the brain with blood flow in the brain. Or it could be an embolism or an embolic stroke where there is a traveling blood clot that comes from another part of the body and then it lands in the brain. So this clot breaks off from somewhere else in the body, travels to the brain and it blocks one of those vessels in the brain. The second type is a transient ischemic attack or TIA for short. These are small mini ischemic strokes that can be sometimes a precursor to a larger stroke. There is still a clot that blocks the vessel, but the clot disappears after a while and symptoms resolve after about 24 hours. A hemorrhagic stroke is another type of stroke where a blood vessel in the brain actually breaks and blood is not only leaking out into the brain, but it's also unable to properly perfuse the area of the brain that was intended to Patients will usually describe a headache that is the worst headache of their life. Now the causes of a hemorrhagic stroke could be uncontrolled hypertension, which over time will weaken the blood vessels from the constant high resistance in the pressure, older blood vessels due to aging, substance abuse, anticoagulant therapy, or if there was a previous brain aneurysm which may weaken the blood vessel Hemorrhagic stroke causes two main problems because not only is the blood leaking out of the vessel into the brain causing increased intracranial pressure and brain swelling, but the blood also isn't going to where it's supposed to go. So now that we know the different types of strokes, let's walk through the pathophysiology of it step by step. You know, I always, always love to put pathophysiology into simple step by step processes for you to follow so that you can learn it faster and easier. This is exactly how we teach pathophysiolog inside our nursing SOS membership community as well. So let's do that here too. The first step is a trigger that causes the stroke. This can be a formation of a blood clot, which would be an ischemic stroke or a tia, or a rupture of a blood vessel in the brain, which would be a hemorrhagic stroke. There are many things that may increase a patient's risk for a stroke, including hypertension, like we talked about, use of oral birth control, advanced age, cardiac rhythm changes, specifically atrial fibrillation, OBEs, obesity, and then having had a stroke in the past. Now, step number two is where blood flow is cut off in the brain with an ischemic stroke. This is because of that blocked blood flow due to a clot. There's literally a blockage in the blood vessel, so blood can't get to where it needs to go. With a hemorrhagic stroke, on the other hand, this decreased blood flow can happen in those two ways. First, that ruptured vessel, it's not intact to allow blood to pass through where it needs to go anymore. And second, that blood is accumulating around the brain, which puts that pressure on the brain and further decreases blood flow. Because of that increased pressure, it's like the brain is being squeezed so it can't get as much blood flow. Now step number three is where cell death and brain damage occurs. Since there isn't enough blood flow getting to the brain, it's going to cause damage to those areas that aren't getting enough bl. This is what leads to the symptoms of a stroke, which is step number four. The patient may experience weakness or numbness or paralysis. They might be unable to talk or understand words and have changes in their level of consciousness. Now we're going to dive into the signs and symptoms more in just a minute. We're going to do an easy breakdown for you. So the key thing to know that really differentiates the different kinds of strokes is that ischemic stroke happens with a blood clot. Transient ischemic attacks are many strokes caused by a blood clot that go away after a while. And then hemorrhagic strokes happen when a blood vessel actually ruptures in the brain. Now that we know the pathophysiology of what's happening here, let's walk through the signs and symptoms in more detail so you know them really well for your nursing school exams. Now, if you're a Nursing ESSENCE member, then you know from our four core method for studying in nursing school that we are always want to be connecting the signs and symptoms of a disorder back to the pathophysiology of that disorder. This is the best way to learn them. I promise you my friend, you do not want to just memorize a list of signs and symptoms for a disorder and call it a day. Because what will happen is you'll get to your exam and all of the things that you memorized will just get jumbled up in your mind and you won't be able to critically think on your exam. Nursing exams do not not test you on how well you memorize things. Right? They test you on how well you critically think, which is why we spend so much time breaking these things down and giving you the key critical thinking points to these disorders inside the Nursing SOS Membership community. So if you want to learn things faster and easier in nursing school and you want me to teach you everything that you need to know to pass your exams, definitely check out the Nursing SOS Membership community. The link is down below in the description for you to get all the details. So we'll connect the signs and symptoms back to the pathophysiology for stroke so you can actually understand it and critically think about it. So here's a key thing to remember when you're learning the signs and symptoms of a stroke and the stroke path. Pathophysiology connecting it all back it will depend on what side of the brain the stroke occurred and how much damage there is. If the patient had a ischemic stroke on the right side of the brain, they may present with left sided weakness and impaired decision making and judgment, impaired memory and attention, attention span, emotions, spatial awareness and depth perception and they may be confused and disoriented as well. If the patient had an ischemic stroke on the left side of the brain, they may have right sided weakness, trouble speaking, which is called aphasia, trouble swallowing, which is called dysphagia, trouble writing or reading, and difficulty problem solving and planning. They may also be more cautious than usual. The biggest takeaway here is to remember that the brain and the body are opposites. If the stroke affected the left side of the brain, then the right side of the body is affected. If the stroke affected the right side of the brain, then the left side of the body is affected. The patient may also have hemiparesis, which is a big fancy word for one sided weakness. And because the body and the brain are flipped, then the stroke happened on the right side, the patient would have weakness on the left side of the body and vice versa. Aphasia is another common symptom of stroke, and it has two types, expressive aphasia and receptive aphasia. Expressive aphasia happens mostly when the stroke occurs on the left side of the brain in Broca's area. The patient can comprehend what is being said but is unable to respond back verbally. Receptive aphasia happens when Wernicke's area on the left side of the brain is compromised and the patient is unable to comprehend speech but is able to verbally speak, or can verbally speak but cannot formulate the correct words. A key point that you may be tested on in nursing school is that a stroke on the right side of the brain causes impaired judgment and impulsiveness, whereas a stroke on the left side of the brain causes the patient to be more cautious. So you'll need to make sure that your patient is safe, especially if they've had a stroke on the right side of their brain, because they just might be more important compulsive, which can be a big safety problem. Another key difference between left and right brain strokes is that language is more compromised in a left brain stroke than it is in the right side, because the left side of the brain controls more of the language than the right. Now, some other signs and symptoms that you might see in a stroke are changes in vital signs like their heart rate may slow down. They may have Shane Stokes respirations, which are progressively deeper and then shallower respirations, mixed with periods where breathing just stops. Now, this type of breathing pattern is caused by the damage to the respiratory center in the brain and the neurological dysfunction that's happening after a cva. And they may have increased blood pressure, they may have a headache, one side of their face may droop, they may be uncoordinated or imbalanced, and this is called ataxia. Unclear speech due to muscle weakness could happen. This is called dysarthria. And trouble swallowing, this is called dysphagia. They Also might not be able to control their bladder and their bowel functions, such as retaining too much, or maybe they have incontinence. Now, let's dive a bit deeper into some of those vital sign changes that might happen, because these are really, really important for you to know for nursing school exams, because they love to test you on this, you need to pay close attention to the patient's blood pressure. Hypertension puts more pressure on the vascular system, which is is already compromised in a CVA because of the stroke. Right. You'll specifically look for what we call Cushing's triad, which means that there's increased blood pressure, decreased heart rate, and abnormal breathing. This is Cushing's triad. It's a set of these three signs. It's the body's way of trying to combat that increased intracranial pressure and get more blood flow to the brain to improve function. The body thinks it's helping by increasing the blood flow to the brain, that control center. Right. But in reality, it actually makes things a lot worse. Throughout the body, you'll watch for an increase in systolic blood pressure and a decrease in diastolic blood pressure, resulting in a widening pulse pressure. Pulse pressure just means the difference between the diastolic and the systolic blood pressure numbers. With this widening pulse pressure, the heart then decreases the heart rate to try to bring down the systolic blood pressure. This widening pulse pressure with a decreased heart rate is a medical emergency. It signals severe brain trauma due to that increased intracranial pressure. And if you're a nursing SOS member, be sure to watch the video series that we have for you on increased intracranial pressure, because that's a really, really important topic for you to know about for your nursing school exams and as a nurse. So all of these signs and symptoms for CVA are ultimately caused by the neurological and muscle impairment. The brain isn't fully connected to the body, so the neurons and the muscles can't function as well as they should be able to. Now, real quick, let's talk about the nursing assessments that you will be doing. For patients with a stroke. The major nursing assessments that you will need to do are making sure that their airway is clear. This is your top priority. You will assess their vital signs and especially, like we talked about, their heart rate, their respirations and their blood pressure. And you'll do a full neurological assessment, including their level of consciousness, their eye responses, their mental status, their motor function, and their strength. So let's talk about these. We'll start with maintaining A patent airway, an open airway patent just means that we're keeping the airway clear. It's open and there's nothing blocking it. That means it is patent. With the neurological and the muscular damage, the airway may become compromised. The patient may also have dysphagia like we just talked about in the signs and symptoms. This means trouble swallowing, so you'll need to assess and maintain proper oxygenation and monitor their swallowing capabilities and their gag reflex closely to make sure that nothing is getting blocked in their airway, that their airway is not blocked. And because of Cushing's triad and the possible vital sign changes that we just talked about, you'll want to assess their vital signs frequently. So on top of these blood pressure and heart rate changes, the patient may have Cheyne Stokes respirations as well. These are respirations like we talked about that get progressively deeper and then shallower with periods where breathing just ceases. So now let's cover the neurological assessment. If your patient is just coming in and is experiencing a possible stroke or cva, it is imperative that you assess and treat them as fast as possible to lessen the brain damage. So you may not get through all all of these neurological assessments and assessments before they're tested. So make sure to follow your facility policy. Here are some general neurological assessments that you might do for a patient with a stroke. You'll assess their pupils and their eye reactivity using perla. This stands for pupils being equal, round, reactive to light and accommodation. You may use the Glasgow Coma Scale to assess their level of consciousness and watch for any changes in confusion or lethargy or loss of consciousness. Consciousness. The Glasgow Coma Scale measures responses to eye opening, speech and motor on a 15 point scale, 15 being the highest a normal score, and anything under 8 in a developmentally appropriate patient signals significant mental status changes. Usually, the patient would be unconscious at a 7 to 9 and the lowest score you can get is a 3, which would mean that the patient is now unresponsive. You'll assess the Glasgow Coma Scale as ordered and per your facility policy. You may also assess their bilateral strength with each of the extremities. Now, these neurological assessments will help you pinpoint what area of the brain is affected, if the patient is getting better, if they're on the rehab floor and making sure that they remain safe. Now, the key thing to remember about a stroke is that is primarily a neurological issue. And the neurological system affects just about everything else in the body. So the patient's muscles, they might be weaker, their responses may be slower and their mental status and their level of consciousness might be altered. So you will need to keep a really close eye on their progress and really keep them safe by watching for signs that they're getting worse. Things like mental status changes, changes in their level of consciousness, motor, or their vital sign changes. Now let's dive into the treatment for stroke and the nursing interventions that you will need to do. Your priority nursing interventions is to keep their airway clear like we just talked about a few minutes ago with the nursing assessment. During a stroke, the patient may have paralysis and lose feeling and control over their face and their neck muscles, which can cause that airway to become blocked. So you'll always need to make sure that their airway stays clear. It's your top priority. Now, some medications, such as antihypertensives, they might be given to control their blood pressure and make sure that the least amount of stress possible possible is placed on their vascular system. Tpa, or tissue plasminogen activator, is basically a clot buster. It is used only for ischemic strokes. Okay. And it must be given within three to four hours of onset of an ischemic stroke. Since TPA dissolves and prevents blood clotting, it is never given for a hemorrhagic stroke because then the blood vessels wouldn't be able to clot and the bleeding would just, just keep happening. So this is a very key point for this medication, okay? It's only given for an ischemic stroke. There are a few parameters that must be met to give tpa. The patient needs a head CT scan to show that it's not a hemorrhagic stroke and the patient's blood pressure must be well controlled. Hypertension increases the pressure and the resistance on that vascular system. Then the added stress of this clot buster medication, the TPA might rupture vessels. Lab values of clotting factors, their platelets, their ptinr, their PTT should all be within normal limits too, so that the extra clot busting medication, the TPA, won't cause systemic clotting issues. The patient's glucose level is also important to check before giving TPA because hyperglycemia tends to put added stress on the blood vessels. And you want the vascular system system to be in the best shape possible before administering TPA for an ischemic stroke. Now, once they have received tpa, continue to monitor for bleeding and monitor the patient's neurostatus. The hope is that the clot is dislodged and dissolved by that tpa. However, if the clot is not fully dissolved, it could create another blockage in the brain. So monitoring for further neurological changes is going to be really, really important. If the patient is having a hemorrhagic stroke, the blood will need to be drained from the brain, usually through an external ventricular drain or a craniotomy, and the area of that broken vessel should be patched surgically. It is critical to monitor for increased intracranial pressure in this scenario. Keep the head of the bed 30 to 45 degrees and keep the patient's head midline to facilitate that drainage. Monitor for vital signs, closely watching for Cushing's triad, that widening pulse pressure, that decreased heart rate, and the abnormal respirations. In Cushing's triad, like we talked about a few minutes ago, there is that increase in systolic blood pressure and a decrease in diastolic blood pressure resulting in that widening pulse pressure. The heart then decreases the heart rate to try to bring down that systolic blood pressure. So think widening blood pressure with a decreased heart rate. This is a medical emergency signaling severe brain trauma due to that increased intracranial pressure. You'll monitor the patient's swallowing capabilities to make sure that they are not aspirating on liquids. A speech and language pathologist will usually help with the management of this. And you may need to suction secretions if they are unable to swallow properly. And then as they progress stress and then regain function of their mouth muscles, you'll move their diet from liquids or thickened liquids to soft foods as they're able to swallow more. Now, make sure that they are always sitting up during meals and place food in the back of their mouth on the unaffected side. So let's think about this. The affected side of their mouth doesn't have normal muscle tone and movement and function right. So they won't be able to swallow food as easily on that side. So you must make sure that they are chewing from the side that is unaffected with any hemipresis. Make sure to assist the patient with ambulating or activities of daily living and perform passive range of motion exercises to keep their muscles from cramping or shortening. And this is called contractures. Encourage them to use the affected side as much much as possible to limit neglect syndrome and unilateral neglect. Now, the term neglect here means that they're basically ignoring the affected side of their body. Their brain literally doesn't realize that it's there. So we need to teach them to use it again and always make sure you approach them from their unaffected side and keep their meal tray and all of their belongings on their unaffected side. That way they can see it. Now, if you approach them from their affected side, they will see you. They may also need to turn their tray around so that they can see it all. So don't just assume that they're full. If only half of that tray is gone, they may just not have seen the other half. So make sure you're turning their tray. Another big issue with this population is pressure sores. Since they aren't able to feel or use their affected side as much, they will more easily develop pressure sores there. So if they're in a wheelchair, a bed or a side chair, make sure that you are checking those common pressure pressure points, things like their hip, their elbow and their ankle. And make sure that you're changing their position at least every two hours. And with any aphasia, make sure that you give the patient time to process and articulate and use alternate forms of communication if needed, things like writing or a picture board or pointing or things like that. And there will be a lot of change for this patient all at once. So make sure that you take the time time to help and advocate for what is best for them. That will go a long way. They will most likely have many appointments with speech, language pathology and occupational therapy. So you want to make sure to communicate and work as a team to do what's best for your patient. The key takeaways here are to keep their airway open and prevent aspiration, remember what side is affected and always make sure that you are taking special care with the that side, like placing food on the unaffected side, looking for pressure sores and then helping them to relearn how to use that affected side. Now you know how much information there is to know for your nursing school exams. Like a lot, right? So in this video I'm going to walk you through some awesome study strategies to help you learn things faster so that you can pass your nursing school exams. And if you loved this video and want to see more full breakdowns like this, this on our channel, write love in the comments below and go become the nurse that God created only you to be. And I will see you over there in that next video.