2017

Objectives

By the end of the presentation you will be able to:

 Define CVA

 Discuss the incidence of CVA in Bahrain and

worldwide
 Identify the causes and pre-disposing factors of
CVA
 Objectives cont

 Discuss the pathophysilogical changes in relation

to clinical manifestations.
 Discuss the diagnostic studies for patient with
CVA
 Explain medical, surgical and nursing
management of patients with CVA.
 List complications of CVA.
 Prepare a health education plan for a client
recovering from CVA and family
 Definition

Sudden loss of brain function due to disruption of

blood supply to a part of the brain.
 Incidence

 CVA is the third leading causes of death

 Approximately 700,000 people experience a
stroke each year in the US. Among 500,000
of these are new strokes and 200,000 are
recurrent strokes.
 Ischemic stroke – 85%
 Hemorrhagic stroke – 15%
 Risk factors

 HTN
 Smoking
 DM
 Stress
 Cardiovascular
 Obesity
 Hyper lipidemia
 Alcohol
 Atrial fibrillation
 Types
 Ischemic
 Hemorrhagic
Types of Strokes
 Type (Ischemic)

 Causes
 Thrombosis
 Radiogenic emboli

 Signs & symptoms

-Numbness & weakness in face, arm ,leg
 Type (Hemorrhagic)
 Intra cerebral hemorrhage
 Subarachnoid Hemorrhage
 Cerebral Aneurysm
 Arteriovenous Malformations
 C.V.A Pathophysiology

 Cerebral circulation (normal):

Auto regulation constant blood flow
(750ml/mt) (1/5 th of cardiac output).
 Interruption to blood flow

Atherosclerosis

Thrombus

Emboli

Hemorrhage
Collateral circulation fails

Ischemia

hypoxia

anoxia

Infarction

Death of neuron
 ischemia

Energy failure

Ion
acidosis
imbalance

Glutamate Depolarization
 Intracellular calcium increased

Cell membrane and protein breakdown

Formation of free radical

Protein production

Cell injury and death

 If circulation fails
 30 seconds: neural metabolism altered
 2 minutes: metabolism ceases
 5 minutes: cellular death (irreversible cerebral
infarction)
Pathophysiology of ischemic
brain attack
 Obstruction of blood vessel

Disruption of cerebral blood flow

Ischemic cascade
 *Ischemic cascade begin when
cerebral blood flow fall to less than
25 ml/100mg/min

* Neuron can no longer maintain aerobic

respiration

* Mitochondria will switch to anaerobic

respiration
* Large amount of lactic acid
develop ( acidosis) change in ph
 The neuron will be unable to produce
sufficient amount of ATP to fuel the
depolarization process

 Electrolyte balance which maintain by

membrane pump begin to fail and cell cease
to function
 Early in cascade:
penumbra region exist around
the area of infarction
*Ischemic cascade threat the cell of penumbra
Because of what??

Depolarization of Ca
cell wall
Glutamate
release
* Initiate a damaging pathway lead to

Destru- Release
ction of ca Vasoco Free
Of cell and nstric radical
gluta- t-ion
membrane mate

Enlarge area of infarction

and extend the stroke
 Clinical manifestations

What are the early signs and symptoms of Stroke?

 Numbness & weakness in face, arm ,leg

 Confusion or change in mental status

 Trouble speaking or understanding speech

 Visual disturbances

 Difficulty walking ,dizziness ,or loss of

balance or coordination
 Sudden severe headache
 Other Clinical Manifestations

 Motor deficit
 Hemiparesis

 Hemiplegia

 Ataxia (not able to walk)

 Dysphasia

 Dysarthria (difficult in forming words)

 Sensory
 Paresthesia ( Numbness and tingling in extremity)

 Agnosia ( failure to recognize familiar objects)

 Other Clinical Manifestations

 Verbal deficit (Communication)

 Expressive aphasia
 Receptive aphasia
 Mixed aphasia
 Visual deficit
 Diplopia
 Loss of peripheral vision
 Stroke Continuum
Transient Ischemic Attack (TIA): Temporary episode of
neurological dysfunction , sudden loss of motor, sensory, or visual
function. Last a few seconds or minutes but no longer than 24 hrs
Reversible Ischemic Neurological Deficits
S&S are consistent with but more pronounced than a TIA and last
more than 24 hrs
Stroke in Evolution: Worsening of neurological S&S over several
minutes or hrs. progressing stroke
Completed Stroke : Stabilization of the neurological S&S.
No progression of the hypoxia insult to the brain from this particular
ischemic event.
 Assessment and Diagnostic findings

 HX and complete physical and neurologic

examination.

-Air patency assessment (loss of gag or cough

reflexes, altered responsibility pattern).

-The Glasgow Coma Scale

 Diagnostic Studies

 CT Scan
 EEG
 CSF
 Angiography( Cerebral)
 MRI
 ECG
 Echocardiography
 Holter monitor
 Carotid ultra sound
 Other investigations

Lab investigations
 CBC

 Biochemical parameters

 Coagulation studies
 The Glasgow Coma Scale

 Is a neurological scale which seems to

give a reliable, objective way of recording
the conscious state of a person, for initial
as well as continuing assessment.
 Mild is 13 to 15 points
 Moderate is 9 to 12 points
 Severe 3 to 8 points
 Patients with score 3 are in Coma
 Complication

 Increase of ICP
 UTI
 Aspiration pneumonia
 Complication of Immobility
 Cardiac Dysrhythmias
 Medical management (Acute phase)

 t-PA ( Thrombolytic therapy, dissolving the blood

clot)
 Anticoagulant
 Anti-platelet
 Anti-hypertensive
 Management of ICP
 Medical management cont…
 Thrombolytic therapy

Review the eligibility Criteria for t-PA
administration.

- What are the main side effects of t-PA?

- What is your role as a nurse regarding these
side effects?
 ICP (Definition)

 Cranial contents
 Brain tissues (1400 g)
 Blood (75 ml)

 CSF (75 ML)

 Three compartments in state of equilibrium

 Normal ICP is between 10 to 20 mm Hg

Changes in these compartments lead to changes in

ICP
 ICP (Pathophysiology)

 Increase ICP Lead to

 Increase of CO2

 Vasodilatation

 Increase cerebral blood flow

 increase in ICP

 Decrease cerebral blood flow Edema

 How to calculate the cerebral perfusion
Pressure?
CPP = Mean arterial pressure – ICP
- Mean arterial pressure (MAP) =

systolic BP+2 (diastolic BP)

3
Example:
Patient’s BP 125/75 mm HG.ICP 15mm Hg.

Solution:
MAP = 125 +2×75
3
= 92 mm Hg.
CPP = 92 -15 = 77 mm HG
 ICP (Pathophysiology)
 Increase in ICP

CPP < 50 mm Hg CPP >100

mm Hg

Arterial Blood Pressure

(Autoregulation)

Failure of Autoregulation ICP

 ↑ICP Manifestation

 Confusion
 Changes in mental status
 Changes in LOC
 Restless
 Coma
 Dilated pupil (fixed)
 ↑ICP (Medical Management)

 The goals are to:

 Decrease cerebral edema
 Decrease cerebral blood volume
 Lowering the volume of CSF
 Increase cerebral blood flow
(perfusion)
 ↑ICP (Medical Management)

 To decrease cerebral edema :

 Administer osmotic diuretics (Mannitol)

 Restricting fluid

 Controlling fever

 Reduce cellular metabolic demand

 Maintaining SBP

 Maintaining Oxygenation
 Surgical Management

 Carotid Endraterectomy:-
Remove of atherosclerotic plaque or thrombus
from the carotid artery to prevent stroke in patient
with occlusive disease of the extracranial cerebral
arteries.
• First of choice for client with TIA
• Cranial nerve injury & hematoma are the
main complication
 Intracranial Surgery

1. Craniotomy: Removal of a piece of the

skull to provide room for the cranial to
expand (this procedure is performed to
remove a tumor, relieve elevate ICP,
evacuate a blood clot and control
hemorrhage).
(Supratentorial, Infratentorial and
transsphenoidal approaches)
 Intracranial Surgery

Burr holes:- Circular opening made in

the skull to determine the presence of
cerebral swelling and injury and the size
and position of ventricles also to aspirate
a brain abscess and to evacuate
hematoma.
 Nursing Management
 Acute Phase
 Maintain a patient airway and administer oxygen as
prescribed.
 Monitor vital signs.
 Maintain a blood pressure of 150/100 mm Hg to
maintain cerebral perfusion
 Suction As prescribed but never nasally and for no
longer than 10 seconds, to prevent increasing ICP.
 Monitor for increasing ICP .
 Elevate the head of the bed 30 degree.
 Maintain the patient’s head and neck in neutral
alignment (no twisting ).
 Initiate measures to prevent the Valsalva maneuver
(e.g., stool softeners).
 Nursing Management Cont…
 Maintain CPP>70 mm Hg.
 Maintain normal body temperature.
 Administer O2 to maintain PaO2>90 mm Hg.
 Maintain fluid and electrolyte balance.
 Maintain a quiet environment and provide minimal
handling of the patient to prevent further bleeding.
 Insert a foley catheter as prescribed Administer IVs as
prescribed .
 Prepare to administer anticoagulants, ant platelets,
diuretics, antihypertensive, and anticonvulsants as
prescribed.
 Monitor Coma Scale, papillary response, motor and
sensory response, cranial nerve function, and reflexes.
 Nursing Diagnosis

 Impaired physical mobility

 Acute pain
 Self care deficit
 Nursing Management Cont…
 Chronic Phase:
 Approach the client from affected side.
 Place the client’s personal objects within the visual field.
 Provide eye care for visual deficits.
 Place a patch over the affect eye if the client has
diplopia.
 Increase mobility as tolerated .
 Encourage fluids and a high fiber diet.
 Administer stool softeners as prescribed.
 Encourage Independence in activities of daily living.
 Initiate physical and occupational therapy.
 Refer to the speech and language pathologist.
Nursing Management - Hemiplegic
Deformities
 Nursing Management

 Preventing joint deformity

 Correct position to prevent contractures
 Good body alignment

 Splint to prevent flexion

 Pillow between thigh to prevent adduction

 Prone position

 Changes position
 Nursing Management- cont
 Preventing Shoulder adduction
-Pillow under axilla
-Distal joint is higher them proximal to
prevent edema
Preventing shoulder pain & dislocation

- Don’t pull the flaccid shoulder

- Support the arm while seating
- Use sling
- ROM
 Nursing Management-cont

 Establish exercise program

 Passive ROM for affected side
 Don’t forget the unaffected side
Exercise in Hemiplegia
 Nursing Management-cont

 Prepare for ambulation

 Maintain balance first
 Measures to prevent falls
 Enhance self care
 Carry self activities on the non-affected side
 Start with minor activities e.g combing, teeth brushing, eating.
 Nursing Management- cont

 Managing sensory perceptual difficulties

 Approach on the side where visual perception is
intact
 All visual stimuli placed on this side

 Make eye contact with patient

 Encourage patient to move head to affected side

 Good lighting

 Eyeglasses
 Nursing Management- cont

 Improve communication
What nursing interventions you will implement
to improve the patient communication