NCM 116 | NUR1217 Medical - Surgical Nursing

Nursing Care of Clients with Neurologic Alterations

CEREBROVASCULAR ACCIDENT (STROKE) • Right hemispheric lesion– spatial

Stroke is a term used to describe neurologic disorientation
changes caused by an interruption in blood supply • Left Hemispheric lesion -
to a part of the brain. CVA results in cerebral anoxia language disturbance
and impaired cerebral metabolism, which
damages brain tissues. CVA results from occlusion CLINICAL MANIFESTATIONS
of the intracranial or extracranial artery, commonly Early Warnings
associated with atherosclerotic plaque. • Transient Hemiparesis
There are two leading causes of stroke: a blocked • Loss of speech
artery (ischemic stroke) or the leaking or bursting of
• Hemisensory Loss
a blood vessel occurs when either a blood clot or
piece of plaque blocks one of the vital blood vessels
Neurological Deficits Motor Visual
in the brain.
Hemorrhagic stroke is a stroke that leads to • Hemiparesis- weakness of one side of the
hemorrhage (too much blood in the brain) caused body or part of it
by a slow accumulation of blood. • Diplopia– double vision
Some people may have only a temporary disruption • Hemiplegia–paralysis of one side of the body
of blood flow to the brain, known as a transient or part of it
ischemic attack (TIA), that doesn't cause lasting • Homonymous Hemianopsia– blindness in
symptoms. half of the visual field in one or both eyes
Statistics • Dysphagia- difficulty in swallowing
• Dysarthria-difficulty in speaking
• Stroke is the third leading cause of death in
the United States. Of the more than
Verbal Cognitive
700,000 people affected every year, about
500,000 of these are first attacks and
• Aphasia–inability to communicate o
200,000 are recurrent. About 25 percent of Expressive Aphasia- inability to express one
people who recover from their first stroke will self
have another stroke within five years. o Receptive Aphasia- inability to
• Stroke is a leading cause of serious long- understand language
term disability, with an estimated 5.4 million o Global Aphasia (mixed)- Affects
stroke survivors currently alive today. The both comprehension & speech
American Heart Association estimates that production
in 2003, stroke cost about $51.2 billion in • Poor abstraction/Amnesia– form of memory
both direct and indirect costs in the U.S. loss
alone. Signs and symptoms of stroke include:
• Cardiovascular diseases (CVDs) – or For Ischemic stroke:
diseases of the heart and blood vessels – are
responsible for a third of death in the • Severe headache without a known cause
Philippines. According to the Philippine • Numbness or weakness of the face, arm, or
Statistics Office (PSA), CVDs are part of the leg, especially on one side of the body
larger group of noncommunicable diseases • Confusion
(NCDs), which account for 72% of deaths in • Trouble seeing in one or both eyes
the country in 2021. • Trouble walking, dizziness, loss of balance or
coordination
Risk Factors
1. Age For Hemorrhagic stroke:
Hemorrhagic strokes that result from a rupturing
2. Sex
blood vessel can have serious, immediate, and life-
3. Heart Diseases
threatening symptoms such as:
4. High cholesterol level
5. DM
• Sudden, severe headache near the
6. Cigarette smoking
back of the head. Many people have
7. Prior stroke events described this as the “worst headache
Common Sites of your life.”
• Middle Cerebral Artery– hemiparesis • Losing consciousness
• Internal carotid Artery– hemiplegia • Inability to move or feel
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Enriquez,H., Fernando,R.M., Garcia,C.J.F. @ FEU2023

 NCM 116 | NUR1217 Medical - Surgical Nursing
Nursing Care of Clients with Neurologic Alterations
• Confusion and irritability
• Muscle pain in the neck and shoulders
• Nausea and vomiting
• Sensitivity to light
• Seizure
• Vision problems
• Drooping eyelids
• One eye pupil is larger than the other
F.A.S.T. METHOD
• 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 phrase. Is the speech slurred or
strange?
• T—Time: If you see any of these signs, call 9-
1-1 right away.
Laboratory Test and Diagnostic Procedure
Initial Studies
• CT scan
• MRI
Supportive Studies
• Cerebral Angiography
• Carotid Ultrasound-PET scan
• Transcranial Doppler Flow Studies
Tissue plasminogen activator (tPA)
This clot-busting drug helps re-establish blood flow
to the brain by dissolving clots. Injected through an
IV, tPA can significantly reduce the effects of
ischemic stroke, saving lives and reducing the risk of
permanent disability.
Antiplatelets:
Platelets in the blood help to form clots. This stops or
slows bleeding when you have a cut, for example.
But if you are having a stroke, clots must be
prevented, so antiplatelet medications may be given
to keep the blood flowing. Before antiplatelets are
given, your doctor will ask you for information about
conditions that might increase your risk of bleeding.
Anticoagulants:
Often called blood thinners, anticoagulants may be
prescribed by your physician following a stroke,
especially if you suffer from a condition such as
atrial fibrillation. Reducing the ability of the blood to
clot, this help to keep blood vessels open, delivering
oxygen and nutrients to brain cells.
Minimally Invasive Procedures
Endovascular therapy:
During this non-invasive procedure, SSM Health
specialists use a device threaded through a blood
vessel in the leg to physically remove the clot lodged
in the brain or artery, restoring critical blood flow to
the brain.
Carotid stenting:
Carotid artery stenosis (narrowing) causes as many
as one in five strokes. Traditional treatment involves
open surgery to clear the narrowed arteries of
plaque. SSM Health neuro-interventionists offer a
non-surgical alternative in carotid angioplasty and
stenting to widen narrowed arteries.
Surgical Procedures
Carotid endarterectomy:
This traditional treatment is used to remove
atherosclerotic plaque from the carotid artery when
the vessel is narrowed or blocked. The surgeon
makes an incision in the neck, the artery is opened
and the plaque is removed. It has recently been
proven that for certain patients with minor strokes
or TIAs, carotid endarterectomy is highly beneficial
in preventing future strokes. This procedure is also
beneficial for some patients with blockage of the
carotid arteries who have not had previous
symptoms.
Revascularization (bypass):
This technique is used to establish a new route for
blood to reach the brain, usually by grafting another
vessel to a cerebral artery.
For Hemorrhagic Stroke:
We treat hemorrhagic stroke by locating the source
of the bleed and surgically “clipping” it, draining the
skull to decrease pressure in the brain, blocking off
any sources of bleeding, and/or performing
minimally invasive “burr hole” removal of the
intracerebral hemorrhage.
After we perform a procedure, we typically give you
medications to reduce blood pressure, pain, anxiety,
headaches, and/or seizures.
Outcome Management
• Early Detection:
o Glasgow Coma Scale
o National Institutes of Health Stroke
Scale
o Acute Stroke QuickScale
• Maintain Cerebral Oxygenation
o Mechanical ventilation
• Optimum O2-Airway patency
Enriquez,H., Fernando,R.M., Garcia,C.J.F. @ FEU2023
 NCM 116 | NUR1217 Medical - Surgical Nursing
Nursing Care of Clients with Neurologic Alterations

Cincinnati Prehospital Stroke Screening o Instruct client to swallow sustained

1. Check for facial drooping have patient smile release formulations whole without
or show teeth. crushing or chewing
2. Check for arm drift by having patient close o Prevents cerebral arterial spasm
eyes and hold arms out for 10seconds that follows subarachnoid
3. Evaluate the patient’s speech. Have the Hemorrhage that can result to
Patient say a phrase to see if there is any neurologic deficit.
abnormal speech pattern. Such as: “The Sky o Dosing (60mg every 4hrs) should be
is Blue in Cincinnati.” given within 96hrs of SAH and
continue for 21 days.
Interpretations o MUST NOT be given parenterally
• Patients with one of these 3 findings-as (e.g. IM or IV) owing to a risk of
anew event-have a 72% probability of an potentially fatal cardiovascular
ischemic stroke events.
• If all 3 findings are present, the probability of
an acute stroke is more than 85%. Major Types of Stokes
Ischemic Stroke
TERMS TO DESCRIBE MOTOR DYSFUNCTION are caused by a thrombotic or embolic
• -plegia: means stroke or paralysis blockage of blood flow to the brain. It accounts for
• -paralysis: means loss of movement about 83% of all strokes
• -paresis: means weakness • Most common cause: thromboembolism •
• -mono: one limb Possible sources of clot:
• -hemi: both limbs on one side • Heart- Large artery (to brain)
• -di or para: both upper limbs or both lower • Small artery in brain
limbs HEMORRHAGIC STROKE
• -quadri-or tetra: all four limbs caused by bleeding into the brain tissue or the
subarachnoid space. The remaining 17% of strokes
NURSING DIAGNOSES FOR CVA are hemorrhagic.
• Impaired verbal Communication Subarachnoid Hemorrhage
• Unilateral neglect r/t perceptual Disruption • Most common cause: aneurysm rupture
• Impaired swallowing r/t neuromuscular • Other causes: Vessel malformation, tumor,
impairment bleeding abnormalities
• Disturbed body image r/t actual change in
body structure, function & appearance
• Deficit knowledge: Discharge regimen r/t
lack of previous exposure to information

MEDICAL AND PHARMACOLOGIC MANAGEMENT

• Surgical clipping or ligation of aneurysm and
evacuation of blood.
• Administration of calcium channel blocker
(NIMODIPINE)
• Neuroradiology, CSF drainage
• Mannitol
• Prevent acute systemic HPM (maintain
systolic BP to 150mmHg and administer
hypertensive drugs.

NURSING RESPONSIBILITIES
• Nimodipine (Nimotop)- Produces selective
blockade of calcium channels cerebral
blood flow.
o Nimodipine is the ONLY APPROVED

Enriquez,H., Fernando,R.M., Garcia,C.J.F. @ FEU2023