CEREBROVASCULAR ACCIDENT (STROKE)
LEGEND
Predisposing Factors
Hemorrhagic Stroke
Ischemic stroke
Common path
Clinical Manifestations
Diagnostic Studies
Therapeutic Management
Nursing Management
thrombus or circulating debris
Injury to a blood vessel
Thrombosis
narrowing of the lumen
blocks the passage
Thrombotic Stroke
ISCHEM IC STROKE
Motor Function
impairment of mobility,
respiratory function,
swallowing and speech, gag
reflex, and self-care abilities.
DIAGNOSTIC STUDIES
Diagnosis of Stroke
(Including Extent of Involvement)
- Computed tomography (CT)scan
- CT angiography (CTA)
- Magnetic resonance imaging(MRI)
- Magnetic resonance angiography (MRA)
- CT/MRI perfusion and diffusion imaging
Cerebral Blood Flow
- Cerebral angiography
- Carotid angiography
- Digital subtraction angiography
- Transcranial Doppler ultrasonography
- Carotid duplex scanning
Cardiac Assessment
- Electrocardiogram
- Chest x-ray
- Cardiac markers (troponin,
creatine kinase-MB)
- Echocardiography
(transthoracic, ransesophageal)
THERAPEUTIC MANAGEMENT
Drug Therapy
- Platelet inhibitors (e.g., aspirin)
- Anticoagulation therapy for patients
with atrial fibrillation
Surgical Therapy
- Carotid endarterectomy
- Stenting of carotid artery
- Transluminal angioplasty
- Extracranial-intracranial bypass
- Surgical interventions for
aneurysms at risk of bleeding
PATHOPHYSIOLOGY
Past history of Transient Ischemic Attack
Atherosclerosis
NON-MODIFIABLE MODIFIABLE
Hypertension, Diabetes mellitus, Hypertension
age, gender, ethnicity or race,
increase cholesterol, obesity, excessive
and family history or heredity.
alcohol, inflammation,birth control pills
PREDISPOSING FACTORS
cerebral aneurysm
Emboli Rupture of a blood vessel
partial or complete occlusion of Bleeding into the the cerebrospinal
Bleeding into the brain tissue
a blood vessel fluid?filled space
Hematoma
Ineffective and insufficient cerebral blood flow
Increased pressure
Anaerobic respiration
Loss of function
Embolic Stroke Subarachnoid Hemorrhage
Intracerebral Hemorrhage
Infarction
HEM ORRHAGIC STROKE
CLINICAL MANIFESTATIONS
Communication Affect Intellectual Function Spatial-Perceptual Alterations Elimination
difficulty controlling impaired memory and 4 categories: incorrect perception
aphasia, of self and illness; neglects all frequency, urgency,
emotions- may be exaggerated judgment ; difficulty making
dysphasia, input from the affected side; incontinence, and constipation
or unpredictable; depression, generalizations, which
dysarthria, agnosia, and apraxia,
frustration interferes with ability to learn.
N U R S I N G M A N A G E M E N T
ASSESSMENT CARE PLAN
Primary assessment Decreased intracranial adaptive capacity r/t decreased cerebral
(1) description of the current illness with attention to initial S/S perfusion pressure
(onset and duration, nature -intermittent or continuous,)
(2) history of similar symptoms previously experienced; Independent
(3) current medications Cerebral Perfusion Promotion
(4) history of risk factors
(5) family history of CVA - Consult with physician to determine hemodynamic parameters, and
maintain hemodynamic parameters within this range.
Secondary assessment - Monitor neurologic status.
Acomprehensive neurologic examination guided with NIHSS - Calculate and monitor cerebral perfusion pressure.
(1) level of consciousness, - Monitor respiratory status (e.g., rate, rhythm, and depth of
(2) cognition respirations; PaO2, PaCO2, pH, and bicarbonate levels)
(3) motor abilities - Monitor patient?s ICP and neurologic responses to care.
4) cranial nerve function - Monitor determinants of tissue oxygen delivery (e.g., PaCO2, SaO2,
(5) sensation hemoglobin levels, and cardiac output)
(6) proprioception; - Avoid neck flexion or extreme hip or knee flexion to avoid obstruction
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(7) cerebellar function of arterial and venous blood flow.
8) deep tendon reflexes.
Dependent
- Administer and titrate vasoactive drugs
Typical Findings
General -lethargy, apathy or combativeness, fever
Respiratory - Loss of cough reflex, labored or irregular respirations,
Risk for aspiration r/t decreased level of consciousness and
tachypnea, aspiration, airway occlusion (tongue), apnea
decreased or absent gag and swallowing reflexes
Cardiovascular - Hypertension, tachycardia, carotid bruit
Aspiration Precautions
Gastrointestinal - Loss of gag reflex, bowel incontinence, decreased
- Monitor LOC cough-gag reflex, and swallowing ability.
or absent bowel sounds, constipation - Avoid liquids or use thickening agent to facilitate swallowing.
Urinary - Frequency, urgency, incontinence - Feed in small amounts until patient is no longer at risk for aspiration.
- Offer foods/ liquids that can be formed into a bolus before swallowing.
Neurologic - Contralateral motor and sensory deficits, paresis,
paralysis, anesthesia; unequal pupils, akinesia, aphasia, dysarthria Airway Management
(slurred speech), agnosias, apraxia, visual deficits, perceptual or - Auscultate breath sounds, noting areas of decreased or absent
spatial disturbances, altered LOC, and Babinski?s sign?, ? deep ventilation and presence of adventitious sounds
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tendon reflexes, flaccidity, spasticity, amnesia, ataxia, personality - Remove secretions by encouraging coughing or by suctioning.
change, nuchal rigidity, seizures. - Encourage slow, deep breathing; turning; and coughing.
- Assist with incentive spirometer.
Possible Diagnostic Findings - Positive CT, CTA, MRI, MRA, or - Keep patient NPO until swallow evaluation completed.
other neuroimaging scans showing size, location, and type of lesion;
positive Doppler ultrasonography and angiography indicating stenosis
Impaired physical mobility r/t neuromuscular and cognitive
impairment and decreased muscle strength and control
HEALTH PROMOTION General Intervention
Exercise Therapy: Muscle Control
- Health teaching (healthy lifestyle, balanced diet) - Collaborate with physical, occupational, and recreational
- Involved in BP screening, stroke risk screening. therapists in developing and executing exercise program
- Ensuring that patients adhere to medications (antihypertensive, - Determine patient?s readiness to engage in activity or exercise
anticoagulants etc.) protocol
- Inform patients and families about early symptoms associated with - Apply splints to achieve stability of proximal joints involved with
stroke or be guided with the FAST acronym. fine motor skills to prevent contractures.
- Encourage patient to practice exercises independently.
- Reinforce instructions provided to patient about the proper way
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to perform exercises.
- Provide restful environment for patient after periods of exercise
Acronym ?FAST? helps to detect common S/S to facilitate recuperation.
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: Time to call 911 if any of these symptoms are present. Impaired verbal communication r/t aphasia as evidenced by
refusal or inability to speak, difficulty forming words and
inappropriate verbalization
Communication Enhancement: Speech Deficit
- Listen attentively to convey the importance of patient?s thoughts
and to promote a positive environment for learning.
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- Provide positive reinforcement and praise.
- Use simple words and short sentences.
- Perform prescriptive speech-language therapies.
- Provide verbal prompts and reminders.
Impaired urinary elimination related to impaired impulse to void
or manage tasks of voiding as evidenced by loss of urinary
control
Urinary Habit Training
- Keep a continence specification record.
- Establish interval of initial toileting schedule.
- Assist patient to toilet and prompt to void at prescribed intervals.
- Teach patient to consciously hold urine until the scheduled toileting
time.
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- Discuss daily record of continence with staff and encourage
compliance with toileting schedule.
- Give positive feedback or positive reinforcement to patient when he
or she voids at scheduled toileting times.
Situational low self-esteem related to actual or perceived loss of
function and altered body image
Self-Esteem Enhancement
- Monitor patient?s statements of self-worth to determine effect of
stroke on self-esteem.
- Encourage patient to identify strengths.
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- Assist in setting realistic goals.
- Reward or praise patient?s progress toward reaching goals.
- Encourage increased responsibility for self.
- Monitor levels of self-esteem over time.