What Every Patient Wants Their Nurse to Know…

Presented by: Mary Kay Bader RN, MSN, CCNS, CCRN, CNRN, FAHA [email protected] Disclosures

• Bader – American Association Neuroscience Nurses • President – Honorarium • Bard – Medical Advisory Board • Neurooptics and Trauma Foundation Objectives

• Identify the cerebrovascular anatomy of the brain and differentiate between in the various cerebral vessels • Describe the pathophysiology of occlusion and the importance of collateral blood flow and BP • Differentiate between the management of BP in patients receiving tPA and those who do not receive tPA • Describe the major nursing priorities in caring for the acute stroke patient. What is a stroke?

• Sudden development of a focal neurologic deficit caused by blockage in an artery feeding the brain or a rupture of the artery in the brain Introduction • Statistics – 795,000 new strokes each year • 610,000 1 st stroke • 6.4 million stroke survivors in US • 130,000 deaths each year (decrease of 18.4% between 1996 and 2006) with 25% reduction by 2008 • 20% survivors institutional care after 3 months • 25-30% permanently disabled

– 4th leading cause of death in US

CDC Prevalence of Stroke in United States 2006-2010. MMWR. 2012. 61 (20): 379-382. Circulation of Brain

• Anterior circulation – Carotid arteries • Posterior circulation – Vertebral arteries What kinds of Stroke?

• Ischemic • Hemorrhagic Ischemic Stroke

• 87% – Thrombotic/atherosclerotic disease • 20% – Embolic • 20% – Lacunar or subcortical stroke • 20-25% • Small vessel disease – Cryptogenic: cause unknown • 30% Hemorrhagic Stroke

• 13% – Intracerebral – Subarachnoid Hemorrhage • Aneurysm –8 to 10 per 100,000 population »1-5% of population –10-12 million –50-80% don’t rupture over lifetime • Vascular Malformations The Anatomy of Stroke Right vs Left Brain

• If clockwise, then you use more of the right side of the brain

• If counterclockwise, then you use more of the left side of the brain

• Left Hemisphere – rational/logical reasoning, intellectual deductive/analytical thinking, science, math, , reading, writing, sequential ordering, and the ability to perform fine motor learned acts • Right Hemisphere – imagination, inductive reasoning, spatial, art, music, nonverbal ideation, spiritual, visual images, shape, recognizing faces, & facial expressions Anatomy of Cerebral Vasculature

• Anterior circulation • Posterior circulation Anatomical Assessment Arterial Syndromes

• Carotid System – Contralateral with facial asymmetry and sensory changes – HH, horner’s syndrome, & amourosis fugax – Dominant hemisphere- , dyslexia, , acalculia – Non-dominant hemisphere-loss of spatial relationships, dressing/constructional apraxia – Headache over ipsilateral eye Arterial Syndromes

• ACA: – Contralateral sensorimotor deficit > foot than arm or face; urinary incontinence;& rigidity – -slowness of all reactions – Distractibility, perseveration, cognitive impairment, personality changes – Expressive aphasia – Apraxia – Contralateral grasping reflex & sucking reflex Arterial Syndromes

• MCA – Contralateral paralysis & sensory loss > arm than leg & homonymous hemianopia – Dominant hemisphere- aphasia, dyslexia, agraphia, acalculia – Non-dominant hemisphere-loss of spatial relationships, dressing/constructional apraxia – Decrease in LOC with massive infarct Arterial Syndromes

• Vertebrobasilar Artery Syndrome – Ataxia, vertigo, nausea, transient global amnesia, , dysphagia, – Visual disturbances, HH, diplopia, nystagmus, conjugate gaze paralysis – Facial weakness, tinnitus, deafness – Altering hemiparesis – Drop attacks and syncope Arterial Syndromes

• Posterior cerebral arteries – Visual changes: field cuts, possible 3rd nerve palsy, visual perception, inability to recognize objects, faces, pictures, colors, or symbols – Paralysis of contralateral side if pyramidal tract is affected – Some hemi-sensory changes Arterial Syndromes

• PICA-Wallenburg’s syndrome – Ipsilateral numbness of face & horner’s syndrome (miosis, ptosis, & anhydrosis) – Contralateral loss of pain & temperature over half of the body – Dysphagia, dysphonia, decreased gag reflex, & paralysis of soft palate/larynx – Nystagmus, diplopia, vertigo, nausea & vomiting, hiccoughs Stroke Signs/Symptoms

• Key Stroke Syndromes – Left Vessels (dominant hemisphere) • Left gaze preference • Right visual field deficit • Right hemiparesis • Right hemisensory loss – Right Vessels (non-dominant hemisphere) • Right gaze preference • Left visual field deficit • Left hemiparesis • Left hemisensory loss Stroke Signs/Symptoms

• Key Stroke Syndromes – (basilar-vertebral arteries) • Nausea and/or vomiting • Diplopia, dysconjugate gaze, gaze palsy • Dysarthria, dysphagia • Vertigo, tinnitus • Hemiparesis or quadriplegia • Sensory loss in hemibody or all 4 limbs • Decreased level of consciousness • Hiccups, abnormal respirations – Cerebellum • Truncal/gait ataxia • Limb ataxia/neck stiffness Pathophysiology of Ischemic Stroke Pathophysiology of Ischemic Stroke

• Dense core of dead tissue • Penumbra • Interruption of blood flow Pathology of Occlusion

• Once vessel is occluded – Systemic arterial BP influences CPP and collateral blood flow during ischemia – Permanent ischemic cell death ensues after 30 minutes • Continued ischemia (< 50% of baseline CBF) will kill the rest of the vessel territory • What can save this area around core? Collateral Flow

• Example MCA occlusion – Leptomeningeal arteries – Cross perfusion from internal system • Opposite side • Posterior circulation Pathophysiology of Ischemic Stroke

• Cellular Responses to reduced Flow • Disturbances in calcium homeostasis • Buildup of lactic acidosis • Oxygen free radical production Pathophysiology of Ischemic Stroke

• Three Factors Affecting Outcome – Time dependent – Degree of ischemia – Collateral circulation Pathophysiological Issues Related to Stroke • Edema and Increased ICP – Occurs as natural evolution of insult – Minimized if restore perfusion – Assess for change in neurologic status • Do not medicate with sedation agents unless monitoring for increased ICP • Prepare for CT Pathophysiological Issues Related to Stroke

• Blood Pressure • Blood Glucose • Temperature Pathophysiology: BP & Stroke

• Alteration in cerebral blood flow • Brain perfusion dependent on MAP • Increases in BP – may be normal homeostatic response – usually falls spontaneously within 24 hours to several days • Do Not treat BP unless…... Pathophysiology: BP & Stroke

• Treat BP in acute ischemic stroke – No thrombolytics • Systolic > 220 mm Hg • Diastolic > 120 mm Hg • MAP > 130 mm Hg – Thrombolytics • Systolic >185 mm Hg – After tPA 180 mm Hg • Diastolic >110 mm Hg – After tPA 105 mm Hg Pathophysiology: Blood Glucose & Stroke

• Maintain blood glucose < 180 – When blood glucose level exceeds 180 begin strategies to lower serum glucose Pathophysiology: Body Temperature & Stroke

• Temperature control –Avoid hyperthermia •Stroke – normothermia

Don’t Forget the 5 Fs of Stroke Care

• Flow – (reestablish flow) • Flat – (head of bed if no edema) • Fluids – (euvolemia) • Fever – (normothermia) • Finger sticks – (control glucose) Diagnostic Tests in Stroke Diagnosis • All Patients • Selected Patients – Non-contrast CT/MRI – TT or ECT – Blood glucose – Hepatic function – Oxygen saturation – Tox screen – Serum electrolytes/ – Blood alcohol renal function tests – Pregnancy – CBC / platelets – ABG – Markers of cardiac – Chest Xray ischemia (if needed) – LP – PT/INR/aPTT – EEG – ECG Diagnostic Tests

• Non Contrast CT • CT angiogram • CT Perfusion • Cerebral Angiogram • MRI • MRA • Diffusion Weighted MRI Computerized Tomography

• CT – Technique: x-ray beam projected thru narrow section of brain or spine; detectors at opposite side measure attenuation of radiation as it passes through tissues – Produce a series of thin slices of adjacent anatomy – Hyperdense tissue (bone) absorbs more x-rays and appears whiter on image. Hypodense (air,fluid) absorb fewer xrays and appear darker Computerized Tomography Angiography • CT – Technique: Post contrast CT scan reconstructed to outline cerebral vasculature. – Useful in screening for vascular such as aneurysms or AVMs. – Enhance tissue where there is disruption of blood-brain barrier (i.e. tumors) Computerized Tomography: Perfusion

• Perfusion CT – Technique: Ct scan performed during IV bolus administration of iodinated contrast material. – Computer calculations provide measures of regional CBV, MTT, and RCBF – Used in acute stroke to determine marginally perfused areas/vulnerable potentially salvageable areas, and infarcted tissue Diagnostic Tests

• MTT Mean Transit Time – How long does it take blood to get to the capillaries – Delay in arrival of blood ---- increase MTT CT Perfusion • CBV=Cerebral Blood Volume – Think of the brain as a sponge filled with blood • If ischemic but not dead—blood still be present in the tissue (picture normal) • If completed stroke and tissue irreversible— lack of flow is visible • CBF=Cerebral Blood Flow – Flow map cc/gram/cm 3 – See Defect in flow Magnetic Resonance Imaging

• Technique: magnetic fields and radiofrequency waves create signals that generate an image • Gadolinium can be added as a contrast agent • Useful for brain (tissue contrast is better than CT) and spine (better for soft tissues and defining lesions such as cysts, vascular lesions, contusions, tumors, edema, hemorrhage or ischemia) Cerebral Angiography

• Technique: contrast material is injected into the vertebral and carotid arteries to enable radiographic visualization of intracranial and extracranial vessels • Requires trained interventional team Focus on Ischemic Stroke Care Two Effective Therapies for Stroke

• Thrombolysis –Reduces death and disability • Comprehensive Stroke Care –Multidisciplinary teamwork reduces mortality by more than 25% Nursing Priorities

• Approach through Case Studies – Airway and Breathing – Circulation: telemetry, BP, DVT prophylaxis – Deficit: neuro monitoring • Cerebral edema/ICP – Temperature control – System support • Mobility • GI/GU • Skin • Education • Emotional support Case 31 yr old Male Entry of Stroke Patient

• Hospitals must have an organized Stroke Intervention Program – rapid identification and triage – organized stroke response team – protocols for emergent work-up – nursing protocols for preparing, administering, and monitoring drug therapy Arrival of Stroke Patient in the Emergency Department

• Rapid identification and work-up – Key symptoms • Triage to acute area – Classify as emergent • Time of symptom onset is crucial Initial Management

• Primary & secondary survey – Neurologic assessment with NIHSS • Start IV and draw labs • Check Blood glucose • Monitor: ECG, SpO2, and serial manual BP assessments • CT scan of brain without contrast STAT • 12 Lead EKG and chest x-ray NIH Stroke Scale

 LOC  Motor Weakness in Legs  LOC Questions  Limb ataxia  LOC Commands  Sensory Loss  Gaze Abnormalities  Language  Visual Loss  Dysarthria  Facial Weakness  Extinction and  Motor Weakness in Inattention Arms Abbreviated NIHSS

• Level of Consciousness • Level of Consciousness Questions • Level of Consciousness Commands • Motor Weakness in Arms • Motor Weakness in Legs • Language • Cardinal Sign-dependent of patient Time is Brain 

• 911 • Door to ED Physician exam 10 minutes • Door to Stroke expertise 15 minutes • Door to CT scan of brain 25 minutes • Door to CT interpretation 45 minutes • Door to drug (tPA) 60 minutes Anatomy of the

This Case - consistent with Superior Division: Brachiofacial paralysis Sensorimotor deficit involving face and arm, leg to a lesser extent. Foot is spared. Ipsilateral deviation of head/eyes. With Left lesion may have initial -> motor aphasia. No impairment of alertness.

http://www.google.com/imgres?imgurl Medical Management

• Goal: reestablish perfusion • Rule out stroke mimics • Interventions: – Traditional interventions – Thrombolytics • IV tPA • Combination IV/IA • Intraarterial thrombolytics Intravenous tPA

• Results of NINDS trial – patients receiving tPA within 3 hours of symptoms onset had better outcomes at 3 months than those treated with placebo – increase risk of in patients treated with tPA • NIH stroke score > 20 1 • Brain edema or mass effect on CT 1

1NINDS Study Group. Stroke 1997. 28: 2109-2118. Treatment Decisions

• Treatment Options Ischemic – Acute • Within 180-270 minutes tPA unless contraindicated –IV (typical dose 60-90 mg total) given in ED then admit to ICU • Within 6 hours of presentation –IA tPA with typical dose 5-8 mg –Merci retrieval device/penumbra/solitaire Intravenous tPA

Intravenous tPA Time Window was < 3 hours   It has now moved to 4 ½ hours Intravenous tPA: Indications

• Patient symptoms < 4.5 hours from symptom onset – CT scan excludes hemorrhage – NIH stroke scale > 4 – Isolated aphasia – Age > 18 • Note exclusions for 3-4.5 hour IV tPA – Age > 80 years – Taking oral anticoagulants – NIHSS > 25 – Combination of history of prior stroke and diabetes IV tPA: Nursing Management

• Start 2nd IV for thrombolytics • Reassess neuro status using NIHSS q 15 min • Weigh patient or assess likely weight • Avoid invasive tubes: foley/NG Infusion Guidelines tPA

• Preparation of IV tPA drip – 0.9 mg/kg – 10% IV bolus over 1-2 minutes – 90% IV over 60 minutes • Administration of tPA – Monitor VS: Q 15 min x 2 hrs, Q 30 min x 6 hrs, then Q 1 hour x 16 hours – Treat BP accordingly Team Priorities

• Goal: preserve life and prevent further neurologic deterioration • Airway • Breathing • Circulation Team Priorities

• BP Management – Do not drop BP rapidly – Decision to treat is based on treatment options • Thrombolytics: –Systolic > 185 or diastolic > 110 After bolus > 180/105 • No thrombolytics –Systolic > 220 mm Hg –Diastolic > 130 mm Hg –Mean > 130 mm Hg Team Priorities

• BP Medications – Labetalol – Nicaridipine

• Never give sublingual nifedipine Team Priorities

• Fluid Management • Recheck Blood Glucose • Start 2nd IV for thrombolytics • Reassess neuro status using NIHSS q 15 min • Weigh patient or assess likely weight • Avoid invasive tubes: foley/NG Post Infusion Guidelines tPA

• Admit to ICU • Vigilant monitoring of VS and neuro checks • Avoid NG/central lines for 24 hours • If neuro condition worsens, notify MD, and prepare for stat CT of brain • Do not administer heparin, warfarin, or ticlopidine for 24 hours after tPA • Keep patient NPO until swallow assessment Case 86 year old Acute onset of stroke signs and symptoms 911 called Pre-Hospital Care Providers • EMT and/or Paramedic key role – Stabilization of airway, breathing, circulation – Recognize signs/symptoms of stroke • Rapid assessment using pre-hospital stroke scale – Place IV/ cardiac monitor – Establishing verification of last seen normal • Patient history from reliable witness – Provision of supplemental O2 if hypoxic – Checking blood glucose level – Avoiding fluids with dextrose – Load and GO • Rapid transport to a facility capable of caring for stroke patients Hyperacute Ischemic Stroke Onset 1641

• 86 year old at home when developed acute onset of aphasia, left gaze, and right facial droop/arm hemiparesis (5/5 arm/ 5/5 leg) – NIHSS 16 • Arrives in ED 1716: Code Stroke • History – Prior stroke minor – New onset Atrial fibrillation – Hypothyroidism and chronic thrombocytopenia (platelets 48,000) • Medications – Dabigatran x 1 dose – Levothyroxine ED Priorities

• Airway and Breathing adequate with 99% pulse oximetry • Circulation: BP 162/87 Afib • NIHSS 16 and GCS 11 Anatomy of the Lesion • Left middle cerebral artery M2 branch

Sylvian (M2) Segment Middle Cerebral Artery Segment divides into superior and inferior divisions which can be a site for an embolus to lodge. Branches supply: and (sensory language area of Wernicke) (Sensory cortical areas) Inferolateral . Anatomy of the Lesion

This Case - Signs and Symptoms consistent with Superior Division: Brachiofacial paralysis Sensorimotor deficit involving face and arm, leg to a lesser extent. Foot is spared. Ipsilateral deviation of head/eyes. With Left lesion may have initial global aphasia -> motor aphasia. No impairment of alertness. Treatment Options

• IV tPA 0.9 mg/kg – 10% IV bolus – 90% over one hour • To Interventional – IA tPA – Solitaire retrieval Diagnostic Pictures

• Occlusion of MCA • Reopening of vessel with complete reperfusion Post Procedural Abbreviated NIHSS

• Taken to SICU at 2300: VS and NC q 15 14 hours Post onset • Improvement in Abbreviated NIHSS • BP within correct parameters post tPA Nursing Priorities in Care

• Neuro assessment and vital signs • Parameters to call MD • O2 saturation> 92% • Monitor for major bleeding complications • ECG monitoring for 72h or more • I/O • IV fluids 75-100 ml/h 36 hours Post Intervention

• NIHSS improving to 2 NIHSS Full Score Pupillometer Assessment

• Minimal cerebral edema • NPI 4.8/4.9 • Constriction velocity normal NIHSS Full Score Patient Education

Hypertension

Diabetes Patient Education

Cholesterol

Smoking

Alcohol Patient Education

Obesity

Activity

Other recommendations related to: Interventional approaches (Extracranial carotid disease/vertebro- basilar disease), and Cardioembolic (AFib, cardiomyopathy, valvular disease) Preparing for DC/Transfer

• Make a connection with Patient and their Care Partner – Involve family in decision making – Family and team meetings to discuss progress – Encourage care partner to participate in educational and training sessions – Conduct a pre-discharge needs assessment of the home before D/C (OT or PT) – Caregiver training if aphasic, positioning, handling shoulder care, how to promote independence, and mobility Preparing for DC/Transfer

• Make a connection with Patient and their Care Partner – Provide education for patient’s family/Care Partner on stroke pathology, prevention, stroke s/s, actions to take, follow-up appointments, treatment plan, and community resources – Liaison with community providers – Review individual patient and care partner psychosocial needs and support needs – Provide information on discharge plans and post discharge management to primary care MD/community ARU Stay Patient transferred to acute rehab on Day 5 - Progress by Day 10 Outcome • Discharged home after 13 day stay in ARU – Supervised transfer to bed mobilty – Ambulating 150 feet with contact guard assist only – Cognition – minimal assist with problem solving – clear and able to communicate Outcome • Discharged home after 13 day stay in ARU – Supervised transfer to bed mobilty – Ambulating 150 feet with contact guard assist only – Cognition – minimal assist with problem solving – Speech clear and able to communicate Conclusion