A transient ischemic attack (TIA) is a short episode of symptoms resembling a stroke. A TIA or “mini-stroke” only lasts a few minutes and doesn’t harm the brain permanently. However, a TIA may be a warning sign of a future stroke.
In this article:
- Overview
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Ineffective Cerebral Tissue Perfusion
- Risk for Injury
- Unilateral Neglect
Overview
With a TIA, blood flow to the brain is only temporarily obstructed and does not cause lasting effects. Symptoms of a TIA are similar to those of a stroke but usually resolve within minutes.
Atherosclerosis, the accumulation of cholesterol-containing fatty deposits in an artery, is the underlying cause of a transient ischemic attack. Plaques of cholesterol can cause a clot to form or reduce the blood flow through an artery. A TIA may occur from a blood clot traveling from another body part to an artery that supplies the brain.
Additionally, TIAs may result from various modifiable and nonmodifiable risk factors.
The primary goal of TIA therapy is to reduce the risk of another TIA or stroke and may include medications, preventative surgery, and lifestyle changes.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to a transient ischemic attack.
Review of Health History
1. Ask about the patient’s symptoms.
The following are common warning signs of a TIA:
- Unilateral weakness, numbness, or paralysis
- Altered balance and coordination
- Slurred speech
- Difficulty swallowing (dysphagia)
- Double vision or vision loss
- Dizziness or vertigo
- Confusion
2. Obtain a thorough history.
Closely examine the onset, duration, and severity of symptoms. Include the following questions during history taking:
- Onset of symptoms
- Duration of symptoms
- Time of occurrence
- Neurological symptoms
- Related symptoms
- Any aggravating or alleviating factors
3. Identify the patient’s risk factors.
Risk factors for a TIA include modifiable and nonmodifiable factors, such as:
- Personal or family history of hypercoagulability disorders, stroke, or transient ischemic attack
- Age greater than 55
- Male gender
- Smoking
- Excessive alcohol use
- Drug abuse
- Obesity
- Sedentary lifestyle
- Poor diet
4. Review the patient’s medical history.
The following comorbidities increase the incidence of a TIA:
- Cardiovascular disease
- Atrial fibrillation
- Obstructive sleep apnea
- Previous strokes or TIAs
- Central nervous system infections
- Peripheral vascular disease
- Coagulopathy
- Migraines
- Diabetes mellitus
- Dyslipidemia
- Hypertension
- Sickle cell disease
- Covid-19
5. Review the patient’s medications.
Check the patient’s treatment regimen and use of over-the-counter (OTC) medications. Assess for signs of misuse and abuse of substances.
6. Interview the witness.
Ask witnesses, the patient’s family, and emergency medical services (EMS) staff about the patient’s sudden change in cognition and movement. Document the interview findings, such as changes in the following:
- Behavior
- Speech
- Gait
- Memory
- Movement
Physical Assessment
1. Assess the risk factors through recommended evaluation tools.
TIA risk can be predicted using the ABCD2 score. The following factors are included in the ABCD2 score:
- Age (≥ 60)
- Blood pressure
- Duration
- Clinical symptoms
- History of diabetes
2. Perform a neurological assessment.
Localized neurological impairments and speech abnormalities should be the main focus of a physical examination when patients present with TIA symptoms. Examine the cranial nerves, motor strength, sensations, and gait.
3. Assess the patient’s motor system.
Monitor the reflexes, posture, and muscle strength for spasticity, clonus, and rigidity.
4. Conduct a cardiac examination.
Conduct a cardiac examination and carotid auscultation to check for a carotid bruit. Examine for any irregular heart rhythms and rates, murmurs, or rubs that could indicate heart conditions.
5. Utilize the stroke scale.
The National Institutes of Health Stroke Scale (NIHSS) is the most widely used tool to determine stroke severity and location and should be performed in the setting of a TIA.
6. Monitor the patient’s vital signs and general status.
Closely monitor the vital signs for alterations and changes in overall health, such as attentiveness, language, and ability to follow commands.
Diagnostic Procedures
1. Perform initial tests.
The initial evaluation is to rule out other causes (hypoglycemia, seizures, or cerebral hemorrhage) that can mimic a TIA. Obtain blood for coagulation tests, serum electrolyte values, and a complete blood count and perform a fingerstick blood glucose test.
2. Obtain an ECG.
Obtain a 12-lead electrocardiogram (ECG) to monitor for ischemia or symptomatic arrhythmias. Atrial fibrillation can lead to the formation of clots, which may subsequently pass through carotid arteries and into the brain, causing a TIA.
3. Prepare the patient for an imaging scan.
Prepare the patient for brain imaging that should occur within 24 hours after symptoms appear. Noncontrast computed tomography (CT) of the head or MRI (preferred) is recommended.
4. Consider brain vessel imaging.
Consider imaging of the cerebral vasculature via a Doppler ultrasound, CT angiography (CTA), or magnetic resonance angiography (MRA) to identify occlusions or stenosis.
5. Investigate other possible causes.
An electroencephalogram (EEG) can check for seizure activity, while a lumbar puncture can assess for subarachnoid hemorrhage or central nervous system (CNS) infections.
6. Monitor for cardiac anomalies.
Echocardiogram/TEE can assess for cardioembolic causes. Consider inpatient telemetry or an outpatient Holter monitor if a diagnosis is not clear.
7. Draw blood for additional blood tests.
Perform the following blood tests to assess underlying causes:
- Prothrombin Time and International Normalized Ratio (PT/INR)
- Lipid panel
- Urine drug screen
- Cardiac enzymes
- Erythrocyte Sedimentation Rate (ESR)
- Coagulation factors (fibrinogen, D-dimer)
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a transient ischemic attack.
1. Initiate stroke prevention.
After a TIA, prompt medical attention can significantly lower the chance of having a stroke soon after. There is a 20% chance of having a stroke within three months after a TIA (with 50% of these strokes happening within the first two days following the initial onset).
2. Manage the underlying cause of a TIA.
Treatments should address the cause and avoid a full-blown stroke and may include:
- Medication to lessen the risk of blood clotting
- Surgery
- Stent placement
3. Stabilize the blood pressure.
The American Heart Association recommends only initiating antihypertensive medication for blood pressure greater than 220/120 mm Hg or mean arterial pressure greater than 130 mmHg to allow for optimal cerebral perfusion pressure unless there is a coexisting cardiac or other condition.
4. Start medications immediately.
Following a TIA, administer medications immediately as ordered to reduce the risk of a stroke. Anticipate for the following orders:
- Antiplatelet drugs
- Aspirin
- Clopidogrel
- Anticoagulants
- Heparin
- Warfarin
- Blood pressure medications
- Calcium channel blockers
- Angiotensin-converting enzyme (ACE) inhibitors
- Angiotensin II receptor blockers (ARBs)
- Diuretics
- Cholesterol-lowering medications
- Statins
5. Prepare for surgery.
Prepare for a carotid endarterectomy if the carotid artery is moderately or severely occluded. Patients with a patent foramen ovale may require surgery to close the hole between the heart’s chambers.
6. Consider angioplasty.
Carotid angioplasty, also known as stenting, uses a thin wire tube (stent) inserted into the obstructed artery that widens the artery using a balloon-like device.
7. Decrease the risk of another TIA or stroke.
Educate the patient on lowering their risk by adhering to preventive measures:
- Maintain blood pressure below 140/90 mmHg
- Maintain total cholesterol below 200 mg/dL
- Maintain glucose levels within an optimal range
- Adhere to medications prescribed for the above conditions
- Eliminate heavy alcohol consumption
- Maintain weight within a healthy range
- Participate in an exercise regimen
- Reduce sodium intake
- Do not smoke
8. Encourage follow-up with a specialist.
Patients who experience a TIA should follow up with their primary care physician as soon as possible. If cardiac or neurological causes are identified, referrals to these specialists should occur.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for a transient ischemic attack, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for a transient ischemic attack.
Acute Confusion
Patients who experience a transient ischemic attack may exhibit sudden reversible confusion.
Nursing Diagnosis: Acute Confusion
Related to:
- Disease process
- Cerebral hypoxia
- Ineffective cerebral tissue perfusion
- Brain injury or trauma
As evidenced by:
- Altered psychomotor performance
- Difficulty initiating purposeful behavior
- Cognitive dysfunction
- Altered level of consciousness
- Neurobehavioral manifestations
Expected outcomes:
- Patient will remain oriented to person, place, and time.
- Patient will demonstrate appropriate motor behavior.
Assessment:
1. Conduct a mental status assessment.
The nurse should gather information about the client’s cognition through a comprehensive neurological examination. The nurse can quickly assess the patient’s orientation by asking their name, where they are, and what day it is.
2. Assess the extent of the patient’s impairment in communication, attention, and ability to follow directions.
Patients experiencing a TIA may exhibit inattention, disorganized thinking, difficulty with speech, and an inability to follow commands.
3. Ask a caregiver or family member about the client’s usual level of cognition.
If available, the nurse should ask the person accompanying the patient about their baseline level of cognitive functioning. Someone familiar with the patient will be able to provide background information about memory loss, changes in mood, or language alterations.
Interventions:
1. Orient the patient to their surroundings and activities as needed.
Frequent reorientation is essential to promote safety, cooperation, and a trusting relationship with a patient who is confused.
2. Provide a calm environment and eliminate unnecessary environmental stimuli.
Excessive environmental stimuli can cause anxiety or agitation in the patient who is confused. Reduce noise and bright lighting when possible.
3. Encourage sleep.
Sleep is crucial to allow the brain to recover after a TIA, repairing neural connections and improving confusion and cognitive symptoms.
4. Continuously monitor the patient’s level of consciousness.
While the symptoms of a TIA may resolve quickly, there is an increased risk of stroke following a TIA. Continuous monitoring of the patient’s level of consciousness and overall mental status allows prompt treatment and reduces complications.
Deficient Knowledge
Deficient knowledge associated with a transient ischemic attack can result in delayed recognition of symptoms and the development of a future stroke.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Unfamiliarity with TIA symptoms
- Lack of information about when to seek medical attention when having a TIA
- Misunderstanding how lifestyle factors affect the risk for a TIA
- Misconceptions about TIA treatments
- A sudden change in health status
- Poor health literacy
- Anxiety
As evidenced by:
- Questions about TIA symptoms and treatments
- Ineffective lifestyle modification
- Recurrence of a TIA
- Development of major stroke
- Nonadherence with prevention and management recommendations
Expected outcomes:
- Patient will be able to verbalize the differences between a TIA and a stroke
- Patient will be able to describe “F.A.S.T” symptoms
- Patient will implement two strategies to prevent a future TIA or stroke
Assessment:
1. Discuss what a TIA is and how it happens.
The nurse must first assess what the patient knows about TIA—having this baseline data can help the nurse focus on what is unknown or misunderstood.
2. Assess the patient’s understanding of their risk factors.
The patient may not realize that their chronic health conditions or lifestyle choices influence the risk of a TIA.
3. Distinguish misconceptions and false beliefs about TIA.
The nurse must assess the patient’s beliefs to distinguish between facts and myths. The nurse must stress that a TIA is not “just” a small or minor stroke but a warning sign of an impending full stroke.
4. Assess the patient’s knowledge about the signs and symptoms.
Symptom-free strokes are much more prevalent than those with symptoms. Emphasize that not all strokes exhibit symptoms. Silent strokes can be observed when patients get MRI scans for other reasons. Silent strokes are more likely to develop into dementia, cognitive impairment, and subsequent symptomatic strokes.
Interventions:
1. Ask the patient to describe F.A.S.T.
Remembering the acronym F.A.S.T.—for face, arms, speech, and time—will help the patient recognize the signs of a TIA and a stroke. Explain to the patient that “time is tissue” when dealing with a TIA or stroke.
2. Ask the patient to differentiate between a TIA and a stroke.
A TIA often called a “mini-stroke,” differs from other forms of stroke in that blood supply to the brain is interrupted for a brief period, typically no longer than five minutes.
3. Teach the patient about cholesterol numbers.
Since atherosclerosis is a significant cause of TIA and is heavily influenced by cholesterol in the arteries, the nurse can explain and teach patients what their cholesterol numbers should be.
4. Have the patient verbalize the preventive measures of a TIA/stroke.
The nurse can evaluate if the patient is learning effectively by having them list preventative steps to decrease the risk of a TIA/stroke. These include not smoking, limiting fatty foods and sodium, exercising, and controlling their weight.
5. Advise the patient to wear a medical alert bracelet.
Patients should be advised to carry identification or wear a medical alert bracelet when taking anticoagulants following a TIA, due to the risk of bleeding.
Ineffective Cerebral Tissue Perfusion
Ineffective cerebral tissue perfusion associated with a transient ischemic attack (TIA) can be caused by blood flow cessation and vasospasm, resulting in a lack of oxygen to the brain.
Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral)
Related to:
- Blood clot
- Lack of blood supply
- Atherosclerosis
- Sickle cell disease
- Vasospasm
As evidenced by:
- Change in mental status
- Alteration in behavior
- Speech difficulty
- Inability to communicate
- Motor weakness
- Change in sensory response
Expected outcomes:
- Patient will remain alert with orientation to person, place, and time
- Patient will not experience lasting motor weakness or paralysis
- Patient will not experience a cerebrovascular accident (CVA)
Assessment:
1. Rapidly assess F.A.S.T.
F.A.S.T. stands for “face, arm, speech, and time.” The symptoms of a TIA include facial drooping, weakness in one arm, and slurred speech. The last known time of wellness is crucial as this can limit interventions.
2. Determine neurovascular status.
Lack of blood flow due to a TIA causes the brain to receive insufficient oxygen. It will affect vision, speech and language, and motor and sensory function.
3. Monitor vital signs.
Vital signs should be evaluated, including blood pressure in both arms, to rule out subclavian artery stenosis. This will show a significant difference in the readings of both arms.
4. Auscultate the heart and neck.
Auscultation of the heart and neck should be performed. Carotid artery stenosis in TIA may present as positive carotid bruits.
5. Perform ECG.
Atrial fibrillation (AFib), an abnormal ECG rhythm, may develop after a TIA. This can cause a blood clot that originates in the heart and travels to the brain.
6. Obtain neuroimaging scans.
Within 24 hours of the initiation of the symptoms, neuroimaging scans (MRI and diffusion-weighted MR imaging) are advised. A head CT with CT angiography is performed as a backup if an MRI is not possible.
Interventions:
1. Keep the blood pressure manageable.
Elevated blood pressure (BP) can damage arteries. Maintain the desired BP parameters as ordered by the healthcare provider to preserve brain perfusion.
2. Activate the Rapid Response Team (RRT).
Patients at risk of developing fatal conditions (like TIA developing into full-blown stroke) will benefit from the Rapid Response System (RRS). Activation of RRT provides immediate professional assistance and monitoring to decrease the mortality rate.
3. Administer antiplatelet medications as prescribed
Antiplatelet medications stop platelets from adhering to one another and reduce the risk of developing a clot that obstructs blood flow to the brain. Aspirin and clopidogrel may be prescribed following a TIA.
4. Provide anticoagulants as ordered.
A clot causing a TIA or stroke can be fatal. Anticoagulants cannot dissolve a clot but can prevent it from getting bigger or prevent more from developing. A client with AFib may be prescribed an anticoagulant for long-term use.
5. Control cholesterol levels.
One of the causes of TIA is hypercholesterolemia—lower cholesterol with statin medications and diet and exercise modifications.
6. Advise the patient about following the recommended diet.
A poor diet can increase the chance of developing a TIA through hypertension and high cholesterol. Advise following a low-fat, low-sodium, high-fiber diet with daily fruit, vegetables, and whole grains.
7. Prepare for possible surgery.
A carotid endarterectomy procedure creates an incision in the carotid artery to remove plaque. Carotid angioplasty places a stent into the artery to keep the artery open.
Risk for Injury
Safety issues can cause risk for injury associated with a transient ischemic attack due to altered cognitive, sensory, and motor function.
Nursing Diagnosis: Risk for Injury
Related to:
- Altered sensations
- Motor weakness
- Poor decision-making
- Uncoordinated movements
- Paralysis
- Disorientation to person, place, and time
- Inability to communicate
- Impaired swallowing
- Poor concentration
As evidenced by:
A risk for diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will utilize assistive devices as needed.
- Patient will remain free from any injury, wound, or fall.
- Caregivers will create a safe environment and assist the patient as needed.
Assessment:
1. Determine the affected part of the brain.
The patient may manifest symptoms that can affect the patient’s safety depending on the part of the brain involved in the TIA. Right-sided brain affectation can cause spatial-perceptual issues leading to poor decision-making and concentration in activities such as walking and driving. In comparison, left-sided brain affectation can cause problems with speech, communication, and vision.
2. Observe the patient’s motor function.
Impaired motor functions such as gait disturbances, limb paralysis, lack of coordination, and unilateral motor weakness can lead to falls that injure the patient.
3. Assess sensory function.
The patient is more likely to sustain skin damage and breakdown if they cannot distinguish between pain, heat, or sharp sensations.
4. Check the communication capabilities of the patient.
The inability to communicate pain or symptoms can place the patient at risk for injuries.
Interventions:
1. Orient the patient to their surroundings.
To avoid injuries, the patient must be familiar with their surroundings. The nurse can reduce the risk of injuries by keeping frequently used items and the call bell within the patient’s reach.
2. Prevent aspiration.
Patients with dysphagia may need pureed meals and thickened beverages. Assess their chewing and swallowing capabilities and monitor for signs of difficulty swallowing, like gagging, coughing, and pocketing food.
3. Advise scanning with vision changes.
The patient with hemianopia, often caused by a cerebral infarct, experiences a loss of vision in one-half of their visual field. Instructing them to scan the environment by moving their head from left to right or right to left can ensure they are aware of furniture, stairs, and hazards, such as vehicles in their path before ambulating.
4. Protect the skin.
The nurse must protect the patient’s skin integrity if there is paralysis and loss of sensation. Maintain appropriate alignment of the extremities, turn the patient every two hours, assess water temperature before bathing, and ensure devices and tubes are not pressing into the patient’s skin.
Unilateral Neglect
Unilateral neglect is less severe in a TIA since symptoms often only last for minutes but may still occur, especially if the right hemisphere is affected.
Nursing Diagnosis: Unilateral Neglect
Related to:
- Disease process
- Cerebral hypoxia
- Ineffective cerebral tissue perfusion
- Brain injury or trauma
As evidenced by:
- Hemianopsia
- Weakness on one side of the body
- Paralysis or numbness on one side of the body
- Altered safety behavior on the neglected side
- Unilateral visuospatial neglect
- Unawareness of the positioning of the neglected limb
- Failure to notice people approaching from the neglected side
- Failure to move head/limbs in the neglected hemisphere
Expected outcomes:
- Patient will demonstrate the ability to visualize information on both sides of the body.
- Patient will care for both sides of the body and will remain free from injury.
Assessment:
1. Assess for symptoms of unilateral neglect.
Signs and symptoms of unilateral neglect include neglecting to provide self-care to one side of the body, not responding to stimuli on the opposite side, and failing to look to one side of the body.
2. Assess the patient’s functional ability and deficits.
This can help plan appropriate interventions for managing and caring for patients experiencing unilateral neglect after a TIA.
Interventions:
1. Implement fall precautions.
Unilateral neglect significantly increases the risk of falls, especially with right hemisphere brain damage. Ensure the bed is in the lowest position with the alarm activated. Remind the patient to call for help if needing to get up from the bed or chair.
2. Collaborate with rehabilitation specialists.
PT, OT, SLP, neuropsychologists, and other professionals should be consulted to promote coping with unilateral neglect and encourage attention to the neglected side.
3. Ensure the environment setup enables activities on the unaffected side.
Position the bed so that the patient is approached on the unaffected side and place the patient’s items within view of the unaffected side to decrease visual neglect.
4. Educate the family and caregivers on unilateral neglect.
While symptoms should resolve quickly with a TIA, caregivers should be aware of symptoms and complications of unilateral neglect to ensure patient safety and comfort.
References
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