Acute Biologic Crisis

CEREBROVASCULAR ACCIDENT
• CVA is the medical term for what is commonly termed stroke.

• It refers to the injury to the brain that occurs when flow of

blood to brain tissue is interrupted by a clogged or ruptured
artery, causing brain tissue to die because of lack of nutrients
and oxygen.

• The severity associated with cerebrovascular accident can

best be demonstrated by the following facts: CVA is the
leading cause of adult disability in the world. Two –thirds of
strokes appear among 65 year old and above. Stroke affects
more men than women and most of the cases are among
African American.
 The most commonly affected blood vessels
are:
Middle Cerebral Artery Internal Carotid Artery

Transient Ischemic Attacks (TIAs) refers to transient cerebral ischemia with

temporary episodes of neurological dysfunction.
 TYPES OF STROKE
Ischemic strokes occur as a result of an obstruction
It results from a weakened vessel that ruptures and
within a blood vessel supplying blood to the brain.
bleeds into the surrounding brain. The blood
The underlying condition for this type of obstruction
accumulates and compresses the surrounding brain
is the development of fatty deposits lining the vessel
tissue.
walls. This condition is called atherosclerosis. 
 PATIENTS W/ UNCONTROLLED HYPERTENSION, CEREBRAL ATHEROSCLEROSIS

I
S
BUILDING UP OF PLAQUE, LIPID DEPOSITS
C
H
E
M
I
THROMBUS EMBOLUS
C

DECREASED CEREBRAL OXYGEN SUPPLY

S
T
DECREASED CERBRAL PERFUSION
R
O
K NEUROLOGICAL DYSFUNCTION
E
 PATIENTS W/ UNCONTROLLED HYPERTENSION,
CEREBRAL ATHEROSCLEROSIS
 
DUE TO DEGENERATIVE CHANGES OF THE ARTERIAL
WALLS
 
CAUSES RUPTURE OF INTRACEREBRAL BLOOD VESSELS
 
INTRACEREBRAL HEMORRHAGE
 
INTRACEREBRAL ANEURYSMS

Hemorrhagic stroke
 PREDISPOSING FACTORS
Modifiable Nonmodifiable

Smoking
Age
Hypertension
Obesity
Hyperlipidemia Family history of CVA
Drug addiction
Excessive alcohol consumption
 Family history of DM
High dose Estrogen Oral Contraceptives
Diabetes Mellitus
Atrial fibrillation Sex (Male)
Type A personality
Sedentary lifestyle
Race
 CLINICAL MANIFESTATIONS

• Signs and symptoms of increased ICP

– Restlessness
– Nausea & vomiting
– Diplopia
– Altered LOC
– V/S changes : → Pulse Pressure, ↓ PR ↓ RR, ↕ Temp
– Pupillary changes
– Papilledema
– Brainstem function impairment
• Health Deficits
 SPECIFIC DEFICITS
• Hemiparesis/Hemiplegia
• Incontinence
• Aphasia • Shoulder pain
• Apraxia • Horner’s syndrome
• Homonymous • Unilateral neglect
Hemianopsia • Dysphagia
• Agnosia
• Ataxia
• Dysarthia
• Kinesthesia
 COMPARISON OF LEFT AND RIGHT CVA

Left CVA Right CVA

oRight hemiplegia oLeft hemiplegia

oLeft visual field effect oRight visual field effect

oAphasia: expressive, receptive, global oSpatial-perceptual field defect

oAltered intellectual activity oIncreased distractibilty

oSlow, cautious behavior oImpulsive behavior, poor judgment,

lack of awareness deficit
 DIAGNOSTICS
Confirmation of stroke is based on symptoms, a history of risk factors, and the results
of diagnostic tests.
❑ Computed tomography scan shows evidence of hemorrhagic stroke immediately but
may not show evidence of thrombotic infarction for 48 to 72 hours.
❑ Magnetic resonance imaging may help identify ischemic or infarcted areas and
cerebral swelling.
❑ Ophthalmoscopy may show signs of hypertension and atherosclerotic changes in
retinal arteries.
❑ Angiography outlines blood vessels and pinpoints atherosclerotic plaques, vessel
occlusion, or the rupture site.
❑ EEG helps to localize the damaged area.

 Other baseline laboratory studies include urinalysis, coagulation studies, complete

blood cell count, serum osmolality, and electrolyte, glucose, triglyceride, creatinine,
and blood urea nitrogen levels.
 TREATMENT
Medications useful in treating stroke include:

❑ Alteplase (recombinant tissue plasminogen activator),

effective in emergency treatment of embolic stroke.
❑ Long-term use of aspirin or ticlopidine, used as antiplatelet
agents to prevent recurrent stroke
❑ Anticoagulants (heparin, warfarin), which may be required to
treat crescendo TIAs not responsive to antiplatelet drugs
❑ Antihypertensives, antiarrhythmics, and antidiabetics, which
may be used to treat risk factors associated with recurrent
stroke.
Surgery may also be performed to improve cerebral circulation
for patients with thrombotic or embolic stroke includes:

Endarterectomy (the removal of atherosclerotic

plaque from the inner arterial wall).

Microvascular bypass (the surgical anastomosis of

an extracranial vessel to an intracranial vessel).
 SPECIAL CONSIDERATIONS
Early supportive therapy
❑ Frequently assess neurologic status, using the National Institutes of Health (NIH)
Stroke Scale to determine deficits. (See Using the NIH Stroke Scale, pages 828 and
829.)
❑ If the patient has been treated with alteplase, monitor him for signs of
hemorrhage.
❑ Monitor blood pressure frequently; give labetalol for severe hypertension.

CLINICAL TIP: Remember that because autoregulation is disrupted in patients with

stroke, it’s necessary to maintain perfusion higher than the usual blood
pressure.
❑ Use acetaminophen and hypothermia blankets to control fever.
❑ Maintain a patent airway and oxygenation status; intubate and ventilate the
patient as needed.
❑ Monitor blood glucose levels.
❑ Monitor electrocardiogram results, and treat arrhythmias as early as possible.
❑ If the patient develops a headache, administer an analgesic.
 NURSING RESPONSIBILITIES
PREVENTIVE PROMOTIVE CURATIVE REHABILITATIVE

❑ Provide ❑ Promote nutrition. ❑ Special considerations ❑ Maintain communication with

preventive care above. the patient.
❑ Promote activity. ❑Watch for signs and ❑ Provide psychological support.
through health- symptoms of pulmonary ❑ Establish rapport with the
education- ❑ Promote emboli. patient.
activities based elimination. ❑ Watch for signs of other ❑ If necessary, teach the patient
on identified complications. to comb his hair, dress, and wash.
learning needs. ❑ Promote ❑ Offer the urinal or bedpan ❑ Speech therapy
communication. every 2 hours. ❑ Reinforce teaching, involve the
❑ Identify ❑ Ensure adequate nutrition. patient’s family in all aspects of
patients with ❑ Provide emotional ❑ Prevent aspiration. rehabilitation.
support. ❑ Position the patient and ❑ Discharge teachings. Emphasize
risk factors. align his extremities correctly the importance of regular follow-
to prevent external rotation. up visits.
❑ Involve in ❑ Provide range-of-motion ❑ If aspirin has been prescribed
HEP regarding exercises throughout the day.  to minimize the risk of embolic
lifestyle   stroke, tell the patient to watch
modification.   for GI bleeding related to ulcer
formation. Make sure the patient
realizes that he can’t substitute
acetaminophen for aspirin.
ADMITTING DIAGNOSIS
Dehydration, UTI, and Pressure Ulcer

Nursing Diagnosis:

• FLUID VOLUME DEFICIT

• IMPAIRED URINARY ELIMINATION
• IMPAIRED SKIN INTEGRITY