1.

Compare the pathophysiological processes involved in the following types of brain attacks: *Ischemic: a clot blocks blood flow to an area of the brain; happens when a blood vessel (artery) supplying blood to an area of the brain becomes blocked by a blood clot. About 87% of all strokes are ischemic strokes. The underlying condition for this type of obstruction is the development of fatty deposits lining the vessel walls. This condition is called atherosclerosis. These fatty deposits can cause two types of obstruction: *Cerebral thrombosis: refers to a thrombus (blood clot) that develops at the clogged part of the vessel. *Cerebral embolism: refers generally to a blood clot that forms at another location in the circulatory system, usually the heart and large arteries of the upper chest and neck. A portion of the blood clot breaks loose, enters the bloodstream and travels through the brain's blood vessels until it reaches vessels too small to let it pass. A second important cause of embolism is an irregular heartbeat, known as atrial fibrillation. It creates conditions where clots can form in the heart, dislodge and travel to the brain. *Hemorrhagic: bleeding occurs inside or around brain tissue; happens when an artery in the brain leaks or bursts (ruptures). But the most common cause of hemorrhagic stroke is uncontrolled hypertension. The two types of hemorrhagic strokes are intracerebral (within the brain) hemorrhage or subarachnoid hemorrhage. Two types of weakened blood vessels usually cause hemorrhagic stroke: *Aneurysm is a ballooning of a weakened region of a blood vessel. If left untreated, the aneurysm continues to weaken until it ruptures and bleeds into the brain. Learn more about cerebral aneurysm. *arteriovenous malformation (AVM) is a cluster of abnormally formed blood vessels. Any one of these vessels can rupture, also causing bleeding into the brain.

2. Which risk factors contribute to each of the above types of brain attacks: There are 2 types of risk factors for stroke: controllable and uncontrollable: Controllable risk factors: generally fall into two categories: lifestyle risk factors or medical risk factors. Lifestyle risk factors can often be changed, while medical risk factors can usually be treated. Both types can be managed best by working with a doctor, who can prescribe medications and advise on how to adopt a healthy lifestyle. High Blood Pressure, Atrial Fibrillation, High Cholesterol, Diabetes, Atherosclerosis, Circulation Problems, Tobacco Use and Smoking, Alcohol Use, Physical Inactivity, Obesity Uncontrollable risk factors: include being over age 55, being male, being African American, Hispanic or Asian/Pacific Islander, or having a family history of stroke or transient ischemic attack (TIA). Age, Gender, Race, Family History, Previous Stroke or TIA, Fibromuscular Dysplasia, Patent Foramen Ovale 3. What signs and symptoms are associated with brain attacks? FAST: Face, Arms, Speech, Time

Face: ask the person to smile. Does one side of the face droop? Arms: Ask the person to raise both arms. Does one arm drift downward? Speech: Ask the person to repeat a simple phrase. Is their speech slurred or strange? Time: If you observe any of these signs, call 9-1-1 immediately. SUDDEN numbness or weakness of face, arm or leg - especially on one side of the body. SUDDEN confusion, trouble speaking or understanding. SUDDEN trouble seeing in one or both eyes. SUDDEN trouble walking, dizziness, loss of balance or coordination. SUDDEN severe headache with no known cause.

4. What is the goal of therapy in the treatment of patients experiencing an acute brain attack? If given within three hours of the first symptom, there is an FDA-approved clot-buster medication that may reduce longterm disability for the most common type of stroke. There are also two other types of stroke treatment available that might help reduce the effects of stroke. The goal for the acute management of patients with stroke is to stabilize the patient and to complete initial evaluation and assessment, including imaging and laboratory studies, within 60 minutes of patient arrival. Critical decisions focus on the need for intubation, blood pressure control, and determination of risk/benefit for thrombolytic intervention. 5. Describe the components of a full neurological assessment: Should be a comprehensive exam covering several critical areas: level of consciousness and mentation, cranial nerves, movement, sensation, cerebellar function, and reflexes. Pupils are another important component of the neuro exam. Assessing them is especially important in a patient with impaired LOC. Like a change in LOC, a change in pupil size, shape, or reactivity can indicate increasing intracranial pressure (ICP) from a mass or fluid. *LOC: Alert and oriented to person, place, and time. If there is a decreased LOC, use following terms: Full consciousness. The patient is alert, attentive, and follows commands. If asleep, she responds promptly to external stimulation and, once awake, remains attentive. Lethargy. The patient is drowsy but awakensalthough not fullyto stimulation. She will answer questions and follow commands, but will do so slowly and inattentively. Obtundation. The patient is difficult to arouse and needs constant stimulation in order to follow a simple command. She may respond verbally with one or two words, but will drift back to sleep between stimulation. Stupor. The patient arouses to vigorous and continuous stimulation; typically, a painful stimulus is required. She may moan briefly but does not follow commands. Her only response may be an attempt to withdraw from or remove the painful stimulus. Coma. The patient does not respond to continuous or painful stimulation. She does not moveexcept, possibly, reflexivelyand does not make any verbal sounds. *Assessing for signs of motor dysfunction: With the patient in bed, assess motor strength bilaterally: Have the patient flex and extend her arm against your hand, squeeze your fingers, lift her leg while you press down on her thigh, hold her leg straight and lift it against

gravity, and flex and extend her foot against your hand. Grade each extremity using a motor scale like the one below: +5 - full ROM, full strength +4 - full ROM, less than normal strength +3 - can raise extremity but not against resistance +2 - can move extremity but not lift it +1 - slight movement 0 - no movement *Evaluating sensation and cerebellar function: Begin with the feet and move up the body to the face, comparing one side with the other. Assess sensation to light touch using your fingertips or cotton. Test superficial pain sensation with a clean, unused safety pin. Be sure not to break the skin, and discard the pin appropriately after you've finished using it on the patient. If you prefer to use something less invasive, snap a wooden, cotton-tipped swab in two and use one of the broken ends; again, take care not to scratch or puncture the skin. Also, test sensation using a dull object. The patient should be able to distinguish sharp from dull. If the patient is in bed, you may not be expected to assess her balance and gait. In that case, limiting testing to coordination is acceptable. Hold up your finger and have the patient quickly and repeatedly move her finger back and forth from your finger to her nose. Then have her alternately touch her nose with her right and left index fingers. Finally, have her repeat these tasks with her eyes closed. The movements should be precise and smooth. To assess the lower extremities, have the patient bend her leg and slide that heel along the opposite shin, from the knee to the ankle. This movement, too, should be accurate, smooth, and without tremors.

*Deep tendon, superficial, and brain stem reflexes: Deep tendon reflexes include the triceps, biceps, brachioradialis, patellar, and the Achilles tendon . The plantar reflex is the only superficial reflex that's commonly assessed and should be tested in comatose patients and in those with suspected injury to the lumbar 4 5 or sacral 1 2 areas of the spinal cord. Stimulate the sole of the foot with a tongue blade or the handle of a reflex hammer. Begin at the heel and move up the foot, in a continuous motion, along the outer aspect of the sole and then across the ball to the base of the big toe. Assess brain stem reflexes in stuporous or comatose patients to determine if the brain stem is intact. (You'll check for the protective reflexescoughing, gagging, and the corneal responseas part of the cranial nerve assessment.) To test the oculocephalic, or doll's eye, reflex, turn the patient's head briskly from side to side; the eyes should move to the left while the head is turned to the right, and vice versa. If this reflex is absent, there will be no eye movement. 6. How are the results of a head CT used to determine therapy in the patient with a brain attack? Once stroke is suspected, imaging technology is used to determine what type the patient has suffereda critical distinction that guides therapy. A noncontrast computed tomography scan (CT scan) can reliably identify hemorrhagic strokes, caused by uncontrolled bleeding in the brain. Magnetic resonance imaging (MRI), on the other hand, particularly diffusion-weighted imaging, can detect ischemic strokes, caused by blood clots, earlier and more reliably than CT scanning.

7. Discuss the use of rt-PA, including the indications for use, potential complications and exclusion criteria? *Indications: The only FDA approved treatment for ischemic strokes is tissue plasminogen activator (tPA, also known as IV rtPA, given through an IV in the arm). tPA works by dissolving the clot and improving blood flow to the part of the brain being deprived of blood flow. If administered within 3 hours(and up to 4.5 hours in certain eligible patients), tPA may improve the chances of recovering from a stroke. A significant number of stroke victims dont get to the hospital in time for tPA treatment; this is why its so important to identify a stroke immediately. *It is contraindicated in patients with hemorrhagic stroke. * Potential complications can include: bleeding into the brain, other types of serious bleeding (e.g., gastrointestinal), and death. SEE GUIDELINES ATTACHED

8. Discuss the management of the patient who deteriorates neurologically due to a brain attack. Neurological deterioration in the post-thrombolytic patient requires prompt attention and intervention. Immediate neurological examination and comparison to the baseline, followed by a non-contrasted CT scan of the head are the first steps in investigating potential causes. Causes of neurological decline in postthrombolysis patients are several. However, the single most important cause mandating frequent neurological assessment in the setting of reperfusion therapy (with possible administration of IV or IA rtPA) is hemorrhagic transformation (HT) of the infarct or frank intraparenchymal hematoma (IPH). Historically, the rate of HT leading to neurological deterioration in post-IV rtPA patients has been estimated at about 6.7 percent, although this rate has declined over the years with increasing experience with this medication. Risk factors for HT after IV rtPA include large area of infarction, increasing age, hyperglycemia, uncontrolled hypertension, congestive heart failure and prior treatment with aspirin. Strict monitoring and management of blood pressure (BP) is essential in patients who have undergone thrombolytic therapy. The ASA guidelines recommend hourly BP monitoring for the first 24 hours with a goal systolic (SBP) of less than 180 mmHg and diastolic less than 105 mmHg.1 Persistent (more than 15 minutes) BP above these values requires more frequent monitoring and implementation of continuous infusion of IV antihypertensive medications. 9. What potential complications may result in a patient following an acute brain attack? How would the nurse manage each complication? A stroke can sometimes cause temporary or permanent disabilities, depending on how long the brain suffers a lack of blood flow and which part was affected. Complications may include: *Paralysis or loss of muscle movement. Sometimes a lack of blood flow to the brain can cause you to become paralyzed on one side of your body, or lose control of certain muscles, such as those on one side of your face or one arm. This can cause difficulty with several daily activities, including walking, eating and dressing. With physical therapy, you may see improvement in muscle movement or paralysis. Nurses can perform ROM exercises. *Difficulty talking or swallowing. A stroke may cause you to have less control over the way the muscles in your mouth and throat move, making it difficult for you to talk, swallow or eat. For example, some people may experience slurred speech (dysarthria), due to incoordination of muscles in your mouth. You also may have difficulty with language (aphasia), including speaking or understanding speech, reading or writing. Therapy with a speech and language pathologist may help you improve your skills.

*Memory loss or thinking difficulties. Many people who have had strokes experience some memory loss. Others may have difficulty thinking, making judgments, reasoning and understanding concepts. These complications may improve with rehabilitation therapies. *Emotional problems. People who have had strokes may have more difficulty controlling their emotions, or they may develop depression. *Pain. Some people who have had strokes may have pain, numbness or other strange sensations in parts of their bodies affected by stroke. For example, if a stroke causes you to lose feeling in your left arm, you may develop an uncomfortable tingling sensation in that arm. Some people may be sensitive to temperature changes, especially extreme cold. This is called central stroke pain or central pain syndrome (CPS). This complication generally develops several weeks after a stroke, and it may improve over time. But because the pain is caused by a problem in your brain, instead of a physical injury, few medications may treat CPS. *Changes in behavior and self-care. People who have had strokes may become more withdrawn and less social or more impulsive. They may lose the ability to care for themselves and may need a caretaker to help them with their grooming needs and daily chores. Nurses can refer families to the social worker for home care agencies.

10. What nursing interventions are designed to prevent each complication? *Swallowing: Keep the patient NPO until evaluated by Speech Pathology, Keep head of bed 20-30 degrees and keep head midline. If drooling, turn patient to the unaffected side. *Immobile: Reposition the patient frequently and perform active and passive range of motion exercises. 11. Why is it critical to obtain a serum glucose level when ruling out a brain attack? Diabetes can seriously harm blood vessels throughout the body, including those in the brain, which increases the risks of stroke. High blood glucose levels cause hardening of the arteries (atherosclerosis), thicken capillary walls and make blood stickier all significant risk factors for ischemic stroke. The disease also can cause small vessels to leak, reducing blood flow to the body tissue. If blood sugar (glucose) levels are high at the time of a stroke, brain damage may be more severe and extensive. This occurs because, when the brain is deprived of oxygen, the body breaks down glucose differently. The byproducts of this process, which can be found in and around the area of dead tissue, are toxic to the brain tissue. If blood circulation is restored to the area, these products will continue to break down, further increasing the size of the dead/damaged tissue area. 12. What nursing interventions are required for the patient with possible swallowing deficits? Keeping the patient NPO, elevate the HOB 20-30 degreed and keep head midline, and if drooling, turn head to unaffected side. 13. What nursing interventions are required for the patient with peripheral visual deficits? Approach patients on the side that they can see, and talk to the patient when moving to other side of bed or out of visual field range. 14. What action must the nurse take if the patient demonstrates signs and symptoms of neurological deterioration? See question 8 above

Guidelines: Intravenous t-PA Administration Inclusion/Exclusion Criteria for Ischemic Stroke This Inclusion/Exclusion Criteria listing is a tool to be used in the assessment of a patient in the acute setting. The final decision to use or not use t-PA is at the discretion of the treating physician. Patient Inclusion Criteria (all must be YES before treatment) 1. Age 18 years or older 2. Clinical diagnosis of Ischemic Stroke 3. Measurable neurological deficit 4. Clearly defined time of stroke onset (within 180 minutes of stroke onset) 5. Informed consent (if possible) 6. May extend treatment window to 4.5 hours if patient does not meet additional exclusion criteria: Patient Exclusion Criteria (all must be NO before treatment) 1. Evidence of intracranial hemorrhage on pretreatment CT scan 2. Minor or rapidly improving symptoms 3. Symptoms of subarachnoid hemorrhage, even with normal head CT 4. Active internal bleeding: Gastrointestinal or urinary bleeding within last 21 days or known bleeding risk, including but not limited to: a. Platelet count less than 100,000/mm3 b. Heparin during the preceding 48 hours associated with elevated aPTT c. Currently taking oral anticoagulants (e.g. Warfarin sodium) or recent use with an elevated prothrombin time (PT) greater than 15 seconds or INR greater than 1.7 d. Major surgery or other serious trauma during preceding 14 days e. Stroke, serious head trauma or intracranial surgery during preceding 3 months f. Recent arterial puncture at a non-compressible site g. Recent lumbar puncture during preceding 7 days 5. Systolic BP greater than 185 mm of Hg or diastolic BP greater than 110 mm of Hg at the time of t-PA infusion and/or patient requires aggressive treatment to reduce blood pressure to within these limits 6. History of intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm 7. Recent Acute Myocardial Infarction 8. Observed seizure at stroke onset Relative Contraindications: 1. Early signs of a large cerebral infarction: edema, hypodensity, mass effect, and obliteration of sulci in more than 1/3 of middle cerebral artery territory on CT scan. 2. NIHSS greater than 22 3. Glucose less than 50 mg/dL or greater than 400 mg/dL. 4. Pregnant female 5. Difficult to control hypertension 6. Age greater than 75 Additional Exclusion Criteria for 4.5 hour window: 1. Patient older than 80 years of age 2. Patient with a history of both diabetes AND stroke 3. Coumadin (warfarin) use regardless of INR 4. NIHSS greater than 25