D. E. Society’s Smt. Subhadra K.

Jindal
College of Nursing

ASSIGNMENT
ON
LEARNING RESOURCE
MATERIAL

SUBMITTED TO SUBMITTED BY
Mrs. Sharda Chavan Meghavarsha Lakra
Associate Professor First year MSc. Nursing

DATE OF SUBMISSION
17/04/2020
 STROKE

INTRODUCTION

The brain is arguably the most complex of all the organs in your body. These three
pounds of tissue compose the major nerve centre of the body, which coordinates all of our bodily
functions, including behaviour, thought and emotions. Because your brain is a very hard-working
organ, it requires constant supplies of oxygen and nutrients from the blood to function effectively.
The heart pumps blood throughout the cerebral arteries ("cerebral" means "related to the brain"),
delivering blood to the brain. Any significant interruption to this supply of nutrients and oxygen
will start killing brain cells. Damage to brain cells occurs almost immediately upon cessation or
even significant restriction of blood flow to the brain. Minor damage to any part of the brain can
have a serious adverse effect on the rest of the body. Significant damage to the brain can even
result in death.
One relatively common cause of brain damage and death is referred to as a stroke. A
stroke is similar to a heart attack, only in this case, blood flow to brain, rather than the heart, is
blocked. The term "stroke" comes from the once popular idea that someone had received a "stroke
of God's hand" and was therefore damaged. Strokes are also called cerebrovascular accidents
(CVA's; "cerebrum" is Latin for brain, while "vascular" refers to the blood vessels) or "brain
attacks" to emphasize the need to call 911 and get immediate medical attention when they occur.

INCIDENCE RATE :
o Stroke is the primary cerebrovascular disorder in the United States and in the world.
o Although preventive efforts have brought about a steady decline in incidence over the
last several years, stroke is still the third leading cause of death.
o Approximately 500,000 people experience a new stroke, 100,000 experience a recurrent
stroke, and approximately 160,000 die of a stroke each year.

DEFINITION :
Stroke : The sudden death of some brain cells due to lack of oxygen when the blood flow to
the brain is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as
a stroke. Also called “brain attack”, cerebral infarction, cerebral haemorrhage, ischemic stroke or
stroke. A stroke is caused by the interruption of the blood supply to the brain, usually because a
blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients,
causing damage to the brain tissue.
 TYPES OF STROKE :
Strokes are classified as ischemic or hemorrhagic based on the underlying pathophysiologic
findings.
A. ISCHEMIC STROKE
An ischemic stroke results from inadequate blood flow to the brain from partial or complete
occlusion of an artery; these account for approximately 80% of all strokes. Ischemic strokes are
further divided into thrombotic and embolic.
Thrombotic Stroke - A thrombotic stroke occurs from injury to a blood vessel wall and
formation of blood clot. The lumen of the blood vessel becomes narrowed and, if it becomes
occluded, infarction occurs. Thrombosis develops readily where atherosclerotic plaques have
already narrowed blood vessels. Thrombotic stroke, which is the result of thrombosis or
narrowing of the blood vessel, is the most common cause of stroke, accounting for about 60% of
strokes.” Two thirds of thrombotic strokes are associated with hypertension or diabetes mellitus.
Both of which accelerate atherosclerosis. In 30% to 50% of individuals, thrombotic strokes have
been preceded by a TIA.
The extent of the stroke depends on rapidity of onset the size of the lesion, and the presence
of collateral circulation. Most patients with ischemic stroke do/not have a decreased level of
consciousness in the first 24 hours, unless it is due to a brainstem stroke or other conditions such
as seizures, increased ICP, or hemorrhage. Ischemic stroke symptoms may progress in the first 72
hours as infarction and cerebral edema increase.
Embolic Stroke - Embolic stroke occurs when an embolus lodges in and occludes a
cerebral artery, resulting in and edema area supplied by the involved vessel. Embolism is the
second most common cause of stroke, accounting for about 24% of strokes. The majority of
emboli originate in the endocardia (inside) layer of the heart with plaque breaking off from the
endocardium and entering the circulation. The embolus travels upward to the cerebral circulation
and lodges where a vessel narrows or bifurcates. Heart conditions associated with emboli include
atrial fibrillation, myocardial infarction: infective endocarditis, rheumatic heart disease, valvular
prostheses, and atrial septal defects. Less common causes of emboli include air and fat from long
bone (femur) fractures.

B. HEMORRHAGIC STROKE
Hemorrhagic strokes account for approximately 15% of all strokes and result from bleeding into
the brain tissue itself (intracerebral or intraparenchymal hemorrhage) or into the subarachnoid
space or ventricles (subarachnoid hemorrhage or intraventriculur hemorrhage).
Intracerebral Hemorrhage -Intracerebral haemorrhage is bleeding within the brain
caused by a rupture of a vessel and accounts for about 10% of all strokes. The prognosis of
patients with intracerebral hemorrhage is poor; the 30-day mortality rate is 40% to 80%. Fifty
percent of the deaths occur within the first 48 hours. Hypertension is the most important cause of
intracerebral hemorrhage. Other causes include cerebral amyloid angiopathy, vascular
malformations, coagulation disorders, anticoagulant and thrombolytic drugs, trauma, brain tumors,
and ruptured aneurysms. Hemorrhage commonly occurs during periods of activity. There is most
often a sudden onset of symptoms, with progression over minutes to hours because of ongoing
bleeding. A blood clot within the closed skull can result in a mass that causes pressure on brain
tissue, displaces brain tissue, and decreases cerebral blood flow, leading to ischemia and
infarction.
Subarachnoid Hemorrhage -Subarachnoid hemorrhage occurs when there is intracranial
bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes
on the surface of the brain. Subarachnoid hemorrhage is commonly caused by rupture of a
cerebral aneurysm (congenital or acquired weakness and ballooning of vessels). Aneurysms may
be saccular or berry aneurysms ranging from a few millimeters to 20 to 30 mm in size or fusiform
atherosclerotic aneurysms. The majority of aneurysms are in the circle of Willis. Other causes of
subarachnoid hemorrhage include arteriovenous malformations (AVMs), trauma and illicit drug
(cocaine) abuse. About 35% of people who have a hemorrhagic stroke clue to a ruptured
aneurysm die during the first episode. Fifteen percent die from subsequent bleeding. The annual
incidence of subarachnoid hemorrhage caused by ruptured aneurysm is 6 to 25 per 100,000. The
incidence increases with age and is higher in women than men.

ETIOLOGY AND RISK FACTORS

Direct Causes of Stroke
 Cerebral thrombosis – a blood clot or plaque blocks an artery that supplies a vital brain
center.
  Cerebral hemorrhage or aneurysm – an artery in the brain bursts, weakens the
aneurysm wall; severe rise in BP causing haemorrhage and ischemia.
 Cerebral embolism – a blood clot breaks off from a thrombus elsewhere in the body,
lodges in a blood vessel in the brain and shuts off blood supply to that part of the brain.

Risk factors
The most effective way to decrease the burden of stroke is prevention. Awareness and control of
modifiable risk factors can contribute to reducing the incidence and burden of stroke. Risk factors
can be divided into non-modifiable and modifiable. Stroke risk increases with multiple risk
factors.
a. Nonmodifiable risk factors
 Age - Stroke risk increases with age, doubling each decade after 55 years of age. Two thirds
of all strokes occur in individuals over 65 years but stroke can occur at any age.

 Gender - Strokes are more common in men, but more women die from stroke than men.
Because women tend to live longer than men, they have more opportunity to suffer a stroke.

 Race - African Americans have a higher incidence of stroke as well as a higher death rate
from stroke than whites. This may be related in part to a higher incidence of hypertension,
obesity, and diabetes mellitus in African Americans. African American men who are from
the South are almost 4 times more likely to die from a stroke than Southern white men.
Hispanics, Native Americans/Alaska Natives, and Asian Americans also have higher death
rates from intracerebral hemorrhage than whites.

 Family history/ heredity - A family history of stroke, a prior transient ischemic attack, or a
prior stroke also increases the risk of stroke.

b. Modifiable risk factors

Modifiable risk factors are those that can potentially be altered through lifestyle changes and
medical treatment, thus reducing the risk of stroke. Modifiable risk factors include:

 Hypertension - Hypertension is the single most important modifiable risk factor, but it is
still often undetected and inadequately treated. Increases in systolic and diastolic blood
pressure (BP) independently increase the risk of stroke. Stroke risk can be reduced by up to
42% with appropriate treatment of hypertension.

 Heart disease - Heart disease, including atrial fibrillation, myocardial infarction,

cardiomyopathy, cardiac valve abnormalities, and cardiac congenital defects, is also a risk
factor for stroke. Of these, atrial fibrillation is the most important treatable cardiac-related
risk factor. The incidence of atrial fibrillation increases with age. Atrial fibrillation is
 responsible for about 15% to 20% of all strokes. Diabetes mellitus is 3 significant risk for
stroke. The risk for stroke in people with diabetes mellitus is 4 to 5 times higher than in the
general population.
 Smoking - Increased serum cholesterol and smoking are risk factors for stroke. In Canada,
the use of tobacco is the major cause of preventable death. Smoking nearly doubles the risk
of stroke. In the 2004 Health Consequences of Smoking report, the Surgeon General stated
that the risk associated with smoking decreases substantially over time after the smoker
quits. After 5 to 10 years of no tobacco use, former smokers have the same chance of stroke
as non-smokers.

 Excessive alcohol consumption - The effect of alcohol on stroke risk appears to depend on
the amount consumed. Women who drink more than one alcoholic drink per day and men
who drink more than two alcoholic drinks per day are at higher risk for hypertension, which
increases their chance of stroke. Since 1991, the prevalence of obesity has increased 75%.

 Obesity - Abdominal obesity increases ischemic stroke risk in all ethnic groups. Individuals
who are overweight or obese experience large decreases in life expectancy. In addition,
obesity is also associated with hypertension, high blood glucose, and elevated blood lipid
levels, all of which increase the risk of stroke.

 Lack of physical exercise - An association of physical inactivity increased stroke risk is

present in both men and women regardless of ethnicity. Benefits of physical activity can
occur with even light to moderate regular activity and may be in part related to the beneficial
effect of exercise on other risk factors.

 Poor diet - The effect of diet on stroke risk is not clear, although diet high in saturated fat
and low in fruit; and vegetables may increase stroke risk. Illicit drug use especially coccaine
use, has been associated with stroke risk.

 Drug abuse - The early forms of birth control pills that contained high levels of progestin
and estrogen increased a woman's chance of experiencing a stroke, especially if they also
smoked heavily. Newer, low-dose oral contraceptives have lower risks for stroke except in
those individuals who are hypertensive and smoke.

 Other conditions that may increase stroke risk include migraine headaches,
inflammatory conditions, and hyperhomocystinemia. Sickle cell disease is another
known risk factor for stroke.

 Sleep apnoea

PATHOPHYSIOLOGY
Stages of CVA

 Transient ischemic attack (TIA) – sudden and short-lived attack. Is a "mini stroke" that
occurs when a blood clot blocks an artery for a short time.
 Reversible ischemic neurologic deficit (RIND) - similar to TIA, but symptoms can last up
to a week.

 Stroke in evolution (SIE) - gradual worsening of symptoms of brain ischemia.

 Completed stroke (CS) – symptoms of stroke stable over a period and rehabilitation can
begin.
Hypertension

Increase intracranial pressure

High BP in cerebral vessels

Cerebral vessels are break down

Cerebral haemorrhage

Cerebral haematoma

Due to thrombus & emboli, ischemia to particular part

As per affected area brain functions disturbed

Hemiparesis, hemiplegia occurs

Loss of communication functions, loss of motor functions

Perceptual disturbance, bladder dysfunctions,
All signs and symptoms develops
 If not treated patient become unconscious, and coma
Death

CLINICAL MANIFESTATIONS
Act F. A. S. T.
F = Face Ask the person to smile. Does one side of the face droop?
A = Arms Ask the person to raise both arms. Does one arm drift downward?
S = Speech Ask the person to repeat a simple sentence. Does the speech sound slurred or
strange?
T = Time Call ambulance immediately!

In embolism

 Usually occurs without warning

 Client often with history of cardiovascular disease

In thrombosis

 Dizzy spells or sudden memory loss

 No pain, and client may ignore symptoms

In cerebral hemorrhage

 May have warning like dizziness and ringing in the ears (tinnitus)
 Violent headache, with nausea and vomiting

Sudden-onset CVA

 Usually most severe

 Loss of consciousness
 Face becomes red
 Breathing is noisy and strained
 Pulse is slow but full and bounding
 Elevated BP
 May be in a deep coma

Common signs and sysmptoms

  Hemiplegia : (paralysis of one side of the body )
 Hemiparesis : ( weakness of one side of the body )
 Sensory Loss : impaired touch, pain, cold & hot.
 Motor Loss : Loss of voluntary control over motor movements.
 Communication Loss : Dysfunction of language & communication.
 Aphasia : Defective speech or loss of speech.
 Alexia ( Dyslexia ) : Difficulty in reading.
 Ataxia : Difficulty in walking, Unsteady gait.
 Apraxia : Inability to perform a previously learned action.
 Agnosia : Failure to recognize familiar objects.
 Diplopia : Double vision.
 Dysphagia : Difficulty in swallowing.
 Difficulty in interpreting : visual, tactile & auditory stimuli.

Manifestations of left-sided and right-sided stroke

DIAGNOSTIC PROCEDURES
 Magnetic resonance imaging (MRI) and/or computed tomography (CT) imaging,
computed axial tomography (CAT) scan
 Used to identify edema, ischemia and necrosis

 Magnetic resonance angiography (MRA) or cerebral angiography

 To identify presence of cerebral hemorrhage, abnormal vessel structures, vessel ruptures,

and regional perfusion of blood flow in the brain
 Carotid endarterectomy

 Performed to open the artery by removing atherosclerotic plaque

 Interventional radiology

 Performed to treat cerebral aneurysm

 Angiography

 It is the "gold standard" for imaging the carotid arteries.

 Angiography can identify cervical and cerebrovascular occlusion atherosclerotic plaques,
and malformation of vessels.
Intraarterial digital subtraction angiography (DSA) reduces the dose of contrast material, uses
smaller catheters and shortens the length of the procedure compared with conventional
angiography.
 Transcranial Doppler (TCD) ultrasonography is a noninvasive study that measures the
velocity of blood flow in the major cerebral arteries. TCD has shown to be effective in
detecting microemboli and vasospasm. Other neurodiagnostic tests such as skull x-rays, brain
scan, lumbar puncture and electroencephalography (EEG) are currently used much less in the
diagnosis of stroke. A skull x-ray result is usually normal after a stroke but there may be a
pineal gland shift with a massive infarction.

 Lumbar puncture

 Used to assess presence of blood in the CSF.

 A lumbar puncture may be done to look for evidence of red blood cells in the
cerebrospinal fluid if a subarachnoid hemorrhage is suspected but the CT does not show
hemorrhage.
  A lumbar puncture is avoided if there are signs of intreased ICP because of the danger of
herniation of the brain downward leading to pressure on cardiac and respiratory centers in
the brainstem and potentially death.

MANAGEMENT
Collaborative Preventive Care
Primary prevention is a priority for decreasing morbidity and mortality from stroke. The
goals of stroke prevention include health promotion for the well individual and education and
management of modifiable risk factors to prevent a primary or secondary stroke.
Health promotion focuses on 1) healthy diet, (2) weight control, (3) regular exercise, (4) no
smoking, (5) limiting alcohol consumption and (6) routine health assessments.
Patients with known risk factors such as diabetes mellitus, hypertension, obesity, high serum
lipids, or cardiac dysfunction require close management.

Drug Management
Measures to prevent the development of a thrombus or embolus are used in patients at risk for
stroke. Anti-platelet drugs are usually the chosen treatment to prevent further stroke in patients
who have had a TIA related to atherosclerosis. Aspirin is the most frequently used antiplatelet
agent, commonly at 21 dose of 81 to 325 mg/day. Other drugs include ticlopidinc (Ticlid),
clopitlogrel (Plavix), dipyridamole (Persantine), and combined dipyridamole and aspirin
(Aggrenox). Oral anticoagulation using warfarin is the treatment of choice for individuals with
atrial fibrillation who have had a TIA.

Surgical Management
Surgical interventions for the patient with TlAs from carotid disease include

 Carotid endarterectomy - In a carotid endarterectomy (CEA), the atheromatous lesion is

removed from the carotid artery to improve blood flow.

 Transluminal angioplasty - Transluminal angioplasty is the insertion of a balloon to open a

stenosed artery and improve blood flow. The balloon is threaded up to the carotid artery via
a catheter inserted in the femoral artery.
  Stenting - Stenting involves intravascular placement of a stent in an attempt to maintain
patency of the artery. The stent can be inserted during an angioplasty. Once in place, the
system can be used with a tiny filter that opens like an umbrella. The filter is used to catch
and remove the debris that is stirred up during the stenting procedure before it floats to the
brain, where it can trigger to stroke. Stenting is a less invasive strategy for revascularization
in patients unable to withstand the CEA because of coexisting medical conditions. Initial
research has shown the procedure to be as effective as the carotid endarterectomy.

 Extracranial-intracranial (EC-IC) bypass - EC-lC bypass involves anastomosing

(surgically connecting) a branch of an extracranial artery to an intracranial artery (most
commonly, superficial temporal to middle cerebral artery) beyond an area of obstruction
with the goal of increasing cerebral perfusion. This procedure is generally reserved for those
patients who do not benefit from other forms or therapy.

Fig. Carotid endarterectorny is performed to prevent impending cerebral infarction. A. A tube is

inserted above and below the blockage to reroute the blood flow. B. Atherosclerotic plaque in the
common carotid artery is removed. C. Once the artery IS stitched closed, the tube can be removed.
A surgeon may also perform the technique without rerouting the blood flow.
Fig. Brain stent used to treat blockages in cerebral blood flow. A. A balloon catheter is used to
implant the stent into an artery of the brain. B. The balloon catheter is moved to the blocked area
of the artery and then inflated. The stent expands due to the inflation of the balloon. C. The
balloon l5 deflated and withdrawn, leaving the stent permanently in place holding the artery open
and improving the flow of blood.

Nursing Management
 Nursing Assessment

If the patient is stable, obtain

 Description of the current illness with attention to initial symptoms
 History of similar symptoms previously experienced
 Current medications
 History of risk factors and other illnesses
 Family history of stroke or cardiovascular disease

Comprehensive neurological examination

 Level of consciousness
 Cognition
 Motor abilities
 Cranial nerve function
 Sensation
 Deep tendon reflexes

 Nursing Diagnosis

1. Ineffective cerebral tissue perfusion related to interruption of blood flow secondary to

CVA.
2. Impaired physical mobility related to neuromuscular impairment secondary to CVA.
3. Impaired verbal communication related to loss of facial or oral muscle tone control.
4. Imbalanced nutrition: Less than body requirement related to impaired swallowing and
chewing.
5. Self-care Deficit: bathing/hygiene, grooming, feeding, toileting related to stroke sequel.
6. Ineffective Coping related to situational crises, vulnerability, cognitive perceptual
changes.
 7. Disturbed sensory perception: Tactile related to altered sensory reception and
transmission.
8. Risk for injury related to neurologic deficits.

 Ineffective tissue perfusion (cerebral) related to decreased cerebral blood flow

secondary to thrombus, embolus, haemorrhage, or oedema as evidenced by ICP >15
mm Hg for 15 to 30 seconds or longer, decreasing Glasgow Coma Scale (GCS) score,
and altered respiratory pattern.

Goal. Demonstrates signs of stable or improved cerebral perfusion.

Intervention.
 Monitor neurologic status to detect changes indicative of worsening or improving
condition.
 Monitor respiratory status (e.g., rate, rhythm, and depth of respirations; PaO2, PaCO2,
pH, and bicarbonate levels) to assess changes in neurologic status.
 Monitor patient‘s ICP and neurologic responses to care activities as ICP can increase
with changes in positioning and movement.
 Administer vasopressin, calcium channel blockers, anticoagulant medications,
antiplatelet medications, thrombolytic medications (as ordered) to increase tissue
perfusion.
 Administer volume expanders (as ordered) to maintain hemodynamic parameters.
 Avoid neck flexion or extreme hip/knee flexion to avoid obstruction of arterial and
venous blood flow.

 Impaired physical mobility related ta neuromuscular and cognitive impairment and

decreased muscle strength and control as evidenced by limited ability to perform gross
and fine motor skills, limited range of motion, and difficulty turning.

Goal. 1. Demonstrates increased muscle strength and ability to move.

2. Uses adaptive equipment to increase mobility.

Intervention.
 Collaborate with physical, occupational and recreational therapists in developing and
executing exercise program to determine extent of problem and plan appropriate
interventions.
 Determine patient's readiness to engage in activity or exercise protocol to assess
expected level of participation.
 Apply splints to achieve stability of proximal joints involved with tine motor skills to
prevent contractures.
  Provide restful environment for patient after periods of exercise to facilitate recuperation.
 Encourage patient to practice exercises independently to promote patient's sense of
control.

 Impaired verbal communication related to residual aphasia as evidenced by refusal or

inability to speak, word finding problems, inappropriate verbalization, inability to
follow verbal directions.

Goal. 1. Uses effective oral and written communication techniques.

2. Demonstrates congruency of verbal and nonverbal communication.
Intervention.

 Listen attentively ta convey the importance of patient's thoughts and to promote a

positive environment for learning.
 Provide positive reinforcement and praise to build self-esteem and confidence.
 Use simple words and short sentences to avoid overwhelming patient with verbal stimuli.
 Provide verbal prompts/reminders to assist patient to express self.

Stroke Prevention
o Get screened for high BP.
o Have your cholesterol level checked. LDL should be lower than 70 mg/dL.
o Follow a low-fat diet.
o Quit smoking
o Exercise
o Limit alcohol intake
 SUMMARY

An interruption of blood supply to a vital centre in the brain. Also called “brain attack”,
cerebral infarction, cerebral haemorrhage, ischemic stroke or stroke. It is the third leading cause
of death in America, behind heart disease and cancer. There are two main types of
cerebrovascular accident, or stroke: an ischemic stroke is caused by a blockage; a haemorrhagic
stroke is caused by the rupture of a blood vessel. Both types of stroke deprive part of the brain of
blood and oxygen, causing brain cells to die.
Remembering the acronym “FAST” helps people recognize the most common symptoms
of stroke:
Face: Does one side of the face droop?
Arm: If a person holds both arms out, does one drift downward?
Speech: Is their speech abnormal or slurred?
Time: It’s time to call 911 and get to the hospital if any of these symptoms are present.
Preventive measures for stroke are similar to the actions that would take to help prevent
heart disease. Here are a few ways to reduce the risk:
 Maintain normal blood pressure.
 Limit saturated fat and cholesterol intake.
 Refrain from smoking, and drink alcohol in moderation.
 Control diabetes.
 Maintain a healthy weight.
 Get regular exercise.
 Eat a diet rich in vegetables and fruits.
 BIBLIOGRAPHY

BOOK REFERENCE :
1. PR Ashalata “Textbook of anatomy and physiology for nurses”, 4 th edition 2015,
Jaypee publication, Page no.: 424 - 427
2. Smeltzer Suzanne C, Barebrenda G, Hinkle Janice L, Cheever Kerry H. “Textbook of
medical surgical nursing”, 12th edition, New Delhi: Lippincot wolter’ Skluwer; Page
no:.113-114(vol-1)
3. Lewis Sharan mantik, Heitkemper Margaret Mclean, Shannon Ruff Dirksen, Obrien
Patrical, Giddens Jean Foret, Bucher Linda. “Medical surgical nursing: Assessment
and management of clinical problems, 6th edition .Mosby; page no.: 1162 - 1173
4. Joyce M Black and Jane Hawks, “Medical-surgical nursing: Clinical management for
positive outcomes”, 8th edition, Elsevier; page no.:1342- 1348, 1401- 1406.

ONLINE REFERENCE :
1. www.strokeassociation.org
2. www.americanstroke.org
3. www.stroke.org
4. www.strokecenter.org
5. www.ced.gov
6. www.ahajournals.org