Cerebrovascular Accident

BY
Nachinab Gilbert
M.Phil., BSc., Dip., RGN
• It is a functional abnormality of the central
nervous system (CNS) that occurs when the
normal blood supply to the brain is disrupted

• Strokes can be divided into two major categories:

ischemic (85%), in which vascular occlusion and
significant hypoperfusion occur

hemorrhagic (15%), in which there is

extravasation of blood into the brain
Types of Strokes
 Predisposing factors
• Atherosclerosis
• Diabetes mellitus
• Hypertension
• Obesity
• Smoking
• The use of contraceptives
(embolism)
• Cardiovasculr diseases
such as rheumatic heart
disease, myocardial
infarction, LVH
• Endocarditis
• Post traumatic valvular
disease
• Family history
• Open heart surgery
(haemorrhage)
• Aneurysm
• Lack of exercise
• Drug abuse eg cocaine
• Excessive alcohol
consumption
 Transient Ischemic Attack
• A transient ischemic attack (TIA or mini-stroke)
describes an ischemic stroke that is short-lived
where the symptoms resolve spontaneously

• This situation also requires emergency

assessment to try to minimize the risk of a future
stroke.

• By definition, a stroke would be classified as a

TIA if all symptoms resolved within 24 hours
 Ischemic stroke
• Large artery thrombotic strokes (20%): Results
from thrombus formation and occlusion in the
large blood vessels of the brain resulting in
ischemia and infarction

• Small penetrating artery thrombotic strokes

(25%) : Affects one or more vessels and are the
most common type of ischemic stroke. Also
called lacunar strokes because of the cavity
that is created once the infarcted brain tissue
disintegrates.
 Ischemic stroke Cont.
• Cardiogenic embolic strokes (20%): Associated
with cardiac dysrhythmias usually atrial
fibrillation. Emboli originate from the heart and
circulate to the cerebral vasculature resulting in a
stroke.

• Cryptogenic (30%)- have no known cause

• other strokes (5%), from causes such as cocaine

use, coagulopathies, migraine, and spontaneous
dissection of the carotid or vertebral arteries
Pathophysiology
• In an ischemic brain attack, there is disruption of the
cerebral blood flow due to obstruction of a blood
vessel

• This disruption in blood flow initiates a complex series

of cellular metabolic events referred to as the
ischemic cascade

• The ischemic cascade begins when cerebral blood

flow falls to less than 25ml/100 g/min

• At this point, neurons can no longer maintain aerobic

respiration
• The mitochondria must then switch to anaerobic
respiration, which generates large amounts of
lactic acid, causing a change in the pH level

• This switch to anaerobic respiration also renders

the neuron incapable of producing sufficient
quantities of adenosine triphosphate (ATP) to fuel
the depolarization processes
• Early in the cascade, an area of low cerebral blood
flow, referred to as the penumbra region, exists
around the area of infarction

• The penumbra region is ischemic brain tissue that

can be salvaged with timely intervention.
• The influx of calcium and the release of glutamate,
if continued, activate a number of damaging
pathways, vasoconstriction, and the generation of
free radicals

• These processes enlarge the area of infarction

into the penumbra, extending the stroke.
Hemorrhagic Stroke
• Patients generally have more severe deficits and a
longer recovery time compared to those with
ischemic stroke

Causes
• Intracerebral hemorrhage
• Subarachnoid hemorrhage
• Cerebral aneurysm
• Arteriovenous malformation
 Pathophysiology
• This depends on the cause and type of cerebrovascular
disorder.

• Symptoms are produced when an aneurysm or AVM

enlarges and presses on nearby cranial nerves or brain
tissue or ruptures

• Normal brain metabolism is disrupted by

 the brain being exposed to blood
 an increase in ICP resulting from the sudden entry of
blood into the subarachnoid space, which compresses
and injures brain tissue;
 secondary ischemia of the brain resulting from the
reduced perfusion pressure
 Clinical Manifestations
• Numbness or weakness of the face, arm, or leg,
especially on one side of the body
• Trouble speaking or understanding speech
• Difficulty walking, dizziness or loss of balance or
coordination
• Sudden severe headache and/or neck pain
(subarachnoid haemorrhage)
• Unconsciousness in some patients
• Initial flaccidity, but spasticity and exaggerated
reflexes occur later
 Clinical Manifestations cont.
• Diplopia (double vision)
• Dysphasia or aphasia (defective speech or loss of
speech)
• Hemianopsia (loss of half of the visual field)
• Memory loss
• Poor judgment
• Depression
• Incontinence
• Nystagmus
• Loss of consciousness
• Poor problem solving ability
• Dysphagia
 Diagnosis
• ECG
• C T scan/MRI of the head
• Chest x – ray
• Blood glucose levels
• Serum lipid profile
• Blood urea, electrolytes and creatinine
• Uric acid levels
Treatment
Objectives of treatment
• To limit the progression area of brain damage
• To protect patients from the dangers of
unconsciousness and immobility
• To treat the underlying cause if possible
• To institute measures to improve functional
recovery
• To support and rehabilitate patients who survive
with residual disability
• To prevent recurrence of cerebrovascular accident
 Treatment Cont.
• Admit patient if he is unable to walk, unconscious
or blood pressure is too high
• Establish an adequate airway in an unconscious
patient
• Put patient in the lateral position. Suction should
always be available to clear chest secretions if
necessary
• Maintain hydration with IV fluids but take care not
to over hydrate
• Prevent pressure sores by regularly turning patient
every 2 hours
 Treatment Cont.
• Monitor blood pressure regularly and treat only if
systolic pressure is persistently above 150mmHg
• Reduce blood pressure gradually over several days
irrespective of the level of blood pressure at the
presentation
• If the cause of the stroke is thromboembolic,
antiplatelet (Aspirin 75mg daily) may be
prescribed
• Treat any identifiable cause of the stroke such as
atrial fibrillation
 Drugs Therapy
• Analgesics (e.g. Acetaminophen and codeine)
• Anticoagulant – Heparin and warfarin
• Anti-hypertensive such as Nifedipine, Atenolol
• Sedatives
 Nursing management
Bed rest and comfort
• Put patient in the correct position in bed to prevent
possible contractures
• Maintain good body alignment and relieve patient of
pain
• Place a board under patient’s bed if possible to give a
firm support
• Encourage patient to remain flat in bed to prevent hip
flexion deformities
• Assist/encourage patients to engage in activities of
daily living
• Place a foot board to keep the feet dorsiflexed
especially during the flaccid periods
 Nutrition
• Maintain electrolyte balance
• Maintain hydration with IV fluids
• Pass NG tube for feeding if patient is unconscious
• Check for gag reflex before offering feeds
otherwise give small oral feedings of semi – solid
feeds
• Encourage client to eat small bites of food since it
makes swallowing easy and safer
• After eating, check the client’s mouth for
“pocketing” of food especially on the affected side
Nutrition cont.
• Limit distraction during mealtime since distraction
increases risk of aspiration
• Have suction equipment available during
mealtime. This will be needed if client start to
choke or aspirate.
• Place the food tray within the patient’s visual field
Maintenance of airway
• Ensure/establish an adequate airway in
unconscious patients
• Insert an artificial airway
• Nurse patient in the lateral position
 Observation
• Check vital signs every 15–30 minutes in the acute
phase and report any deviation
• Assess level of consciousness
• Assess patients voiding pattern
• Monitor for bladder infection
• Keep strict intake and output if patient has
catheter in situ
 Personal hygiene
• Bed bath patient
• Give your patient assisted/full bed bath
• Ensure meticulous mouth care for your patient
• Apply Vaseline to the lips to avoid cracks
• Pass urethral catheter to keep patient clean and
dry always
• Change bed linen when soiled
• Ensure urethral catheter is changed by 2 weeks
Psychological support
• Reassure patient and family members
• Explain disease process/condition to patient and
family members
• Allow family and significant others to visit patient
• The nurse should take time to communicate with
patient
• Nurse patient in a separate room if possible
Physical Rehabilitation
• Explain what the rehabilitation entail and reassure
that she is in competent hands

• Physiotherapist, speech therapist and relevant

medical personnel including patient’s family
members should be involved in the planning of
rehabilitation

• If the condition is stable, active mobilization will

begin as soon as possible within 24 to 48 hours of
admission
• Proper positioning and early passive range of motion
exercises will be done to help avoid complications at a
flaccid stage

• Encourage patient to use the unaffected part of the

body to perform activities of daily living e.g. feeding,
grooming, dressing, cleaning the mouth etc.

• Introduce patient to the use of ambulatory devices

e.g. walking sticks, wheel chair etc.

• Educate patient on bladder and bowel training using

kegel’s exercise