Stroke, CVA, Prognosis, Treatment, Medicine

1. Cerebrovascular
Accident
DR. RAJESH. T.EAPEN

3. Overview of Stroke
 About 85% of strokes are ischemic, and
about 15% are hemorrhagic.
 Approximately 795,000 strokes occur each
year.
 Stroke is the 3rd leading cause of death in the
US, and the first cause of death worldwide.
 Stroke is a leading cause of adult disability.

4. History of Stroke
 Hippocrates-2,400 yrs ago
 Names for Stroke
 Most commonly known today
 Brain Attack

5. Demographics of Stroke
 Women have about 60,000 more strokes
than men.
 Native Americans have highest prevalence.
 African Americans have almost twice the
rate compared to Caucasians.
 Hispanics have slightly higher rates
compared to non-Hispanic whites.
 Modifiable risk factors must be addressed in
our aging population with the propensity to
stroke.

6. Definition
 Ischemic stroke
 Caused by a blocked blood vessel in
the brain.
 Hemorrhagic Stroke
 Caused by a ruptured blood vessel in
the brain.

7. Nursing and Stroke
 Nurses play a pivotal role in the care
of stroke patients.
 Nursing care directed in two phases
of the acute stroke experience:
 The emergent or hyper-acute phase
 The acute phase

8. Nursing Care of the Stroke
Patient
 Stroke is a complex disease requiring
the efforts and skills of the
multidisciplinary team.
 Nurses are often responsible for the
coordination of that care.
 Coordinated care can result in:
improved outcomes, decreased LOS,
translating to decrease costs.

9. Etiology of Ischemic Strokes
 20% caused by large vessel athero-
thrombotic causes (intracranial or
carotid artery)
 25% caused by small vessel disease
(penetrating artery disease)
 20% caused by cardiac sources (cardio-
embolism)
 30% from unknown causes

10. Risk factors for Ischemic
Stroke
 Hypertension
 Diabetes
 Heart Disease
 Smoking
 High Cholesterol
 Male gender
 Age
 Ethnicity/Race

11. CT Scan–Right Occipital/Parietal
Infarction

12. Ischemic Stroke
 Most patients with ischemic stroke do
not have a decreased level of
consciousness in the first 24 hours
 May progress in the first 72 hours

13. Embolic stroke
 Majority of emboli originate in the inside
layer of the heart, with plaque breaking off
from the endocardium and entering the
circulation
 Patient with an embolic stroke commonly
has a rapid occurrence of severe clinical
symptoms

14. Transient Ischemic Attack (TIA)
 Transient ischemic attack (TIA) is
a temporary focal loss of
neurologic function caused by
ischemia
 Most TIAs resolve within 3 hours
 TIAs are a warning sign of
progressive cerebrovascular
disease

15.  Caused by a primary either intra-
cerebral hemorrhage or
subarachnoid hemorrhage.
Etiology of Hemorrhagic Stroke
SAH 3%
ICH 10%

16. Ischemic vs. Hemorrhagic

17. CT Scan Right Subcortical Intra-
cerebral Hemorrhage

18. Risk Factors for Hemorrhagic
Stroke
 Hypertension
 Bleeding disorders
 African American race
 Vascular malformation
 Excessive alcohol use
 Liver dysfunction

19. Risk Factors
Non Modifiable
 Age
 Gender
 Race
 Heredity

20. Risk Factors
Modifiable
 Obesity
 HTN
 Smoking
 Heavy alcohol
consumption
 Hypercoagulability
 Hyperlipidemia
 Asymptomatic
carotid stenosis
 Diabetes mellitus
 Heart disease, atrial
fibrillation
 Oral contraceptives
 Physical inactivity
 Sickle cell disease

21. Blood supply by arteries
 Blood is supplied to the brain by
two major pairs of arteries
 Internal carotid arteries
 Vertebral arteries

22. Blood supply by arteries
 Carotid arteries branch to supply
most of the
 Frontal, parietal, and temporal lobes
 Basal ganglia
 Part of the diencephalon
 Thalamus
 Hypothalamus

23. Blood supply by arteries
 Vertebral arteries join to form the
basilar artery, which supply the
 Middle and lower temporal lobes
 Occipital lobes
 Cerebellum
 Brainstem
 Part of the diencephalon

24. Review of Cerebral Circulation

25. Common sites for the
development of Atherosclerosis

26. Clinical Manifestations
 Affects many body functions
 Motor activity
 Elimination
 Intellectual function
 Spatial-perceptual alterations
 Personality
 Affect
 Sensation
 Communication

27. The 5 Key Stroke Syndromes:
Classic Signs Referable to
Different Cerebral Areas
 Left (Dominant
Hemisphere)
 Left gaze preference
 Right visual field deficit
 Right hemiparesis
 Right hemisensory loss
 Right (Nondominant
Hemisphere)
 Right gaze preference
 Left visual field deficit
 Left hemiparesis
 Left hemisensory loss
neglect (left hemi-
inattention)

28. The 5 Key Stroke Syndromes:
Classic Signs Referable to
Different Cerebral Areas
 Brainstem
 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 consciousness
 Hiccups, abnormal
respirations
 Cerebellum
 Truncal/gait ataxia
 Limb ataxia neck
stiffness

29. Clinical Manifestations
Motor Function
 Most obvious effect of stroke
 Include impairment of
 Mobility
 Respiratory function
 Swallowing and speech
 Gag reflex
 Self-care abilities

30. Clinical Manifestations
Motor Function
 An initial period of flaccidity may last
from days to several weeks and is
related to nerve damage
 Spasticity of the muscles follows the
flaccid stage and is related to
interruption of upper motor neuron
influence

31. Clinical Manifestations
Communication
 Patient may experience aphasia when
a stroke damages the dominant
hemisphere of the brain
 Aphasia is a total loss of
comprehension and use of language

32. Clinical Manifestations
Communication
 Dysphasia refers to difficulty related to
the comprehension or use of language
and is due to partial disruption or loss
 Dysphasia can be classified as
nonfluent or fluent

33. Clinical Manifestations
Communication
 Dysarthria does not affect the
meaning of communication or the
comprehension of language
 It does affect the mechanics of speech

34. Clinical Manifestations
Affect
 Patients who suffer a stroke may have
difficulty controlling their emotions
 Emotional responses may be
exaggerated or unpredictable

35. Clinical Manifestations
Intellectual Function
 Both memory and judgment may be
impaired as a result of stroke
 A left-brain stroke is more likely to
result in memory problems related to
language

36. Clinical Manifestations
Spatial-Perceptual Alterations
 Stroke on the right side of the brain is
more likely to cause problems in
spatial-perceptual orientation
 However, this may occur with left-
brain stroke

37. Clinical Manifestations
Spatial-Perceptual Alterations
 Spatial-perceptual problems may be
divided into four categories
1. Incorrect perception of self and
illness
2. Erroneous perception of self in space

38. Clinical Manifestations
Spatial-Perceptual Alterations
3. Inability to recognize an object
by sight, touch, or hearing
4. Inability to carry out learned
sequential movements on
command

39. Clinical Manifestations
Elimination
 Most problems with urinary and bowel
elimination occur initially and are
temporary
 When a stroke affects one hemisphere
of the brain, the prognosis for normal
bladder function is excellent

40. Emergent Stroke Workup
All patients
 Non-contrast brain CT or brain MRI
 Blood glucose
 Serum electrolytes/renal function tests
 ECG
 Markers of cardiac ischemia
 Complete blood count, including platelet
count
 Prothrombin time/INR
 aPTT
 Oxygen saturation

41. Emergent Stroke Workup
Selected patients
 Hepatic function tests
 Toxicology screen
 Blood alcohol level
 Pregnancy test
 Arterial blood gas tests (if hypoxia is
suspected)
 Chest radiography (if lung disease is
suspected)
 Lumbar puncture (if SAH is suspected and
CT scan is negative for blood)
 EEG (if seizures are suspected)

42. Collaborative Care
Prevention
 Goals of stroke prevention include
 Health management for the well
individual
 Education and management of
modifiable risk factors to prevent a
stroke

43. Collaborative Care
Prevention
 Antiplatelet drugs are usually the
chosen treatment to prevent further
stroke in patients who have had a
TIA
 Aspirin is the most frequently used
anti-platelet drug

44. Collaborative Care
Prevention
 Surgical interventions for the patient
with TIAs from carotid disease
include
 Carotid endarterectomy
 Transluminal angioplasty
 Stenting
 Extracranial-intracranial bypass

45.  Once a potential stroke is suspected,
EMS personnel and nurses must
determine the time at which the
patient was last known to be well
(last known well time).
 This time is the single most
important determinant of treatment
options during the hyperacute
phase.
Collaborative Care
Hyperacute Care

46. From the Field to the ED:
Stroke Patient Triage and Care
 EDs should establish standard operating procedures and
protocols to triage stroke patients expeditiously.
 Standard procedures and protocols should be established for
benchmarking time to expeditiously evaluate and treat
eligible stroke patients with rtPA.
 Target treatment with rtPA should be within 1 hour of the
patient’s arrival in the ED.
 Eligible patients can be treated between the 3-4.5 hour
window when carefully evaluated carefully for exclusions to
treatment.

47. EMERGENCY NURSING INTERVENTIONS IN
THE EMERGENCY/HYPERACUTE PHASE OF
STROKE:
The First 24 Hours
 Stroke symptoms can evolve over
minutes to hours.
 Nurses should be aware of unusual stroke
presentations.
 ED assessments include: Neurological
assessment, vital signs + temperature,
and should be done not less than every
30 minutes.

48. Intensive Monitoring
 30% of patients will deteriorate in the first
24 hours.
 Intensive monitoring by nurses trained in
stroke is very important
 Trained in neurological assessment
 Trained in monitoring of bleeding
complications (major and minor)
 Ongoing management of blood pressure,
temperature, oxygenation, and blood
glucose

49. Collaborative Care
Acute Care
 Assessment findings
 Altered level of consciousness
 Weakness, numbness, or paralysis
 Speech or visual disturbances
 Severe headache
 ↑ or ↓ heart rate
 Respiratory distress
 Unequal pupils

50. Collaborative Care
Acute Care
 Interventions – Initial
 Ensure patient airway
 Remove dentures
 Perform pulse oximetry
 Maintain adequate oxygenation
 IV access with normal saline
 Maintain BP according to guidelines

51. Collaborative Care
Acute Care
 Interventions – Initial
 Remove clothing
 Obtain CT scan immediately
 Perform baseline laboratory tests
 Position head midline
 Elevate head of bed 30 degrees if no
symptoms of shock or injury

52. Collaborative Care
Acute Care
 Interventions – Ongoing
 Monitor vital signs and
neurologic status
 Level of consciousness
 Motor and sensory function
 Pupil size and reactivity
 O2 saturation
 Cardiac rhythm

53. Collaborative Care
Acute Care
 Recombinant tissue plasminogen
activator (tPA) is used to
 Reestablish blood flow through a
blocked artery to prevent cell death
in patients with acute onset of
ischemic stroke symptoms

54. Collaborative Care
Acute Care
 Thrombolytic therapy given
within 3 hours of the onset of
symptoms
 ↓ disability
 But at the expense of ↑ in deaths
within the first 7 to 10 days and ↑
in intracranial hemorrhage

55. Collaborative Care
Acute Care
 Surgical interventions for stroke
include immediate evacuation of
 Aneurysm-induced hematomas
 Cerebellar hematomas (>3 cm)

56. Nursing Management during the
Acute Phase of CVA
 Objectives of care during the acute phase:
(a) Keep the patient alive.
(b) Minimize cerebral damage by providing
adequately oxygenated blood to the brain.
 Support airway, breathing, and circulation.

57.  3. Maintain neurological flow sheet with frequent
observations of the following:
(a) Level of consciousness.
(b) Pupil size and reaction to light.
(c) Patient's response to commands.
(d) Movement and strength.
(e) Patient's vital signs--BP, pulse,
respirations & temperature.
(f) Be aware of changes in any of the above.
 Deterioration could indicate progression of the
CVA.
Nursing Management during the Acute
Phase of CVA

58. Nursing Management during the Acute
Phase of CVA
 4. Continually reorient patient to person, place,
and time (day, month) even if patient remains in
a coma. Confusion may be a result of simply
regaining consciousness, or may be due to a
neurological deficit.
 5. Maintain proper positioning/body alignment.
(a) Prevent complications of bed rest.
(b) Apply foot board, sand bags, trochanter rolls,
and splints as necessary.
(c) Keep head of bed elevated 30º, or as
ordered, to reduce increased intracranial
pressure.
(d) Place air mattress or alternating pressure
mattress on bed and turn patient every two
hours to maintain skin integrity.

59. Nursing Management during the Acute
Phase of CVA
 6. Ensure adequate fluid and electrolyte balance.
(a) Fluids may be restricted in an attempt to reduce
intracranial pressure (ICP).
(b) Intravenous fluids are maintained until patient's
condition stabilizes, then naso-gastric tube feedings or
oral feedings are begun depending upon patient's
abilities.
 7. Administer medications, as ordered
(a) Anti hypertensives.
(b) Antibiotics, if necessary.
(c) Seizure control medications.
(d) Anticoagulants.
(e) Sedatives and tranquilizers are not given because
they depress the respiratory center and obscure
neurological observations.

60. Nursing Management during the Acute
Phase of CVA
 8. Maintain adequate elimination
(a) A Foley catheter is usually inserted during the
acute phase; bladder retraining is begun during
rehabilitation.
(b) Provide stool softeners to prevent
constipation. Straining at stool will increase
intracranial pressure.
 9. Include patient's family and significant others
in plan of care to the maximum extent possible.
(a) Allow them to assist with care when feasible.
(b) Keep them informed and help them to
understand the patient's condition.

61. Rehabilitation of the patient
with CVA
 Process of setting goals for rehabilitation must
include the patient. This increases the likelihood
of the goals being met.

62. Rehabilitation of the patient
with CVA
 General rehabilitative tasks faced by the patient
include:
*Learning to use strength and abilities that are
intact to compensate for impaired functions.
*Learning to become independent in activities of
daily living (bathing, dressing, eating).
*Developing behavior patterns that are likely to
prevent the recurrence of symptoms.
*Taking prescribed medications.
*Stopping smoking.
*Reducing day-to-day stress.
*Modifying diet.

63. Rehabilitation CVA
 Specific teaching, encouragement, and support are
needed.
 Individualized exercise program involving both affected
and unaffected extremities is required.
 Speech therapy, as indicated by patient's condition, may
be necessary.
 Continuous revaluation of goals and patient's ability to
meet the goals is required to maintain a realistic plan of
care.
 Counseling and support to family is an integral part of
the rehabilitation process.
-Both family and patient need direction and support
in coping with intellectual and personality impairment.
-Instruct family to expect some emotional lability
such as inappropriate crying, laughing, or outbursts of
temper.