cerebrovascular accident (CVA)

By the end of this lesson the learner is expected to:

Define cerebrovascular accident (CVA)

Identify Etiology ,risk factor and classification of CVA

Describe Pathophysiology, Clinical Manifestations, Assessment &Diagnostic Finding of CVA

Recognize Management of CVA

Discuss the complication of CVA

Apply Nursing process for PT With CVA

Introduction

Stroke is the third commonest cause of death in developed countries.

It is higher in black African populations than in Caucasian.

Stroke is uncommon below the age of 40 and is more common in males.

Death rate following stroke is around 25%.

Hypertension is the most treatable risk factor.

Introduction

In the elderly, it remains a major cause of morbidity and mortality.

Definitions

Stroke

Stroke or Cerebrovascular accident is the onset and persistence of neurologic dysfunction lasting longer than 24 hours and resulting from disruption of blood supply to the brain and indicates infarction rather than ischemia.

Disrupted of normal blood supply to the brain .

Strokes can be divided into two major categories:

Ischemic (85%), in which vascular occlusion and significant hypo perfusion occur

Hemorrhagic (15%), in which there is extravasations of blood into the brain or subarachnoid space

Pathophysiology/Etiology

1.Partial or complete occlusion of a cerebral blood vessel resulting from cerebral thrombosis (due to arteriosclerosis) or embolism, thrombotic or thrombo embolism

2- strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction

- Ischemia related to decreased blood flow to an area of the brain secondary to systemic disease, such as cardiac or metabolic disease.

- Hemorrhage occurring outside the Dura (extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or within the brain substance (intracerebral).

3. an aneurysm or AVM ruptures, causing subarachnoid hemorrhage. Normal brain metabolism is disrupted by the brain’s exposure to blood; by an increase in ICP resulting from the sudden entry of blood into the subarachnoid

space, which compresses and injures brain tissue.

or within the brain substance (Intracerebral).

Risk factors for stroke

Hypertension

Smoking

Alcohol

Hypercholesterolemia.

Obesity

Diabetes

Carotid artery stenosis,

heart disease,

Clinical Manifestations Clinical manifestations vary depending on the vessel

affected and the cerebral territories it perfuse. Symptoms are usually multiple.

1. Sudden, severe headache

2. Numbness (paresthesia), weakness (paresis), or loss of motor ability (plegia) on one side of the body

Difficulty in swallowing (dysphagia)

4. Aphasia

5. visual difficulties, including loss of half of a visual field, double vision.

6. Altered cognitive abilities and psychologic affect

clinical Manifestations

A. Change in Level of Consciousness

Caused by cerebral pressure.

B. Changes in Vital Signs

Caused by pressure on brain stem.

1. Rising blood pressure or widening pulse pressure

2.Pulse changes—bradycardia.

3.Respiratory irregularities; tachypnea (early sign of increased ICP); slowing of rate .or Kussmaul’s breathing.

C. Pupillary Changes

Caused by pressure on optic and oculomotor nerves.

D. Other Changes

1.Headache—increasing in intensity; aggravated by movement/straining.

2.Vomiting—recurrent with little or no nausea; may be projectile.

3.Subtle changes—restlessness, headache, forced breathing, purposeless movements,

Diagnostic Evaluation 1. Carotid ultrasound—to detect carotid stenosis.

2. CT—to determine cause and location of stroke.

3. Cerebral angiography—to determine extent of cerebrovascular insufficiency.

4. MRI may be done to localize ischemic damage.

Management

A. Acute Treatment

1. Support of vital functions—maintain airway, breathing, oxygenation, circulation.

2. Reperfusion and hemodilution with volume expanders (dextran or pentastarch); thrombolytic therapy with urokinase (Abbokinase);

vasodilatation with nimodipine (Nimotop).

3. Management of increased ICP.

4. Diuretic treatment to reduce cerebral edema, which peaks 3 to 5 days after infarction.

5. Calcium channel blockers to reduce blood pressure and prevent cerebral vasospasm.

The goals of medical treatment for hemorrhagic stroke are:-

To allow the brain to recover from the initial insult (bleeding)

To prevent or minimize the risk of rebleeding

To prevent or treat complications

Management/Nursing Interventions

1. Establish and maintain airway, breathing, and circulation.

2. Administer osmotic diuretics such as mannitol (Osmitrol) as ordered, to remove water and fluid from areas of brain with an intact blood–brain barrier.

a. Insert an indwelling urinary catheter for management of diuresis.

3. Administer steroids such as dexamethasone (Decadron), as ordered, to reduce edema surrounding brain tumor, if present.

3. Avoid positions or activities that may increase ICP, including turning the patient’s head, prone position, flexion of the neck.

a. Minimize suctioning or other stimuli that precipitously increase ICP.

b. Keep head of bed elevated 30 degrees to reduce jugular venous pressure and decrease ICP.

4. Monitor effects of neuromuscular paralyzing agents, such as pancurmonium (Pavulon), which may be given along with mechanical ventilation to prevent sudden changes in ICP due to coughing, straining, or fighting the ventilator.

6- Treat fever as requested, because fever increases cerebral blood flow and cerebral blood volume; acute increases in ICP occur with fever spikes.

7. Administer high-dose barbiturates and other anesthetic agents, as ordered, to induce comatose state and suppress brain metabolism, which in turn reduces cerebral blood flow and ICP.

B. Subsequent Treatment

1. Anticoagulation after hemorrhage is ruled out.

2. Antiplatelet agents such as ticlopidine (Ticlid) or aspirin.

3. Antispasmodic agents for spastic paralysis.

4. Physical therapy and rehabilitation program.

5. Treatment of poststroke depression with antidepressants.

Complications

1. Aspiration pneumonia

2. Spasticity, contractures

3. Deep-vein thrombosis; pulmonary embolism

4. Post stroke depression

5. Brain stem herniation

Nursing Assessment

1. Maintain neurologic flow sheet during acute phase.

2. Assess for voluntary or involuntary movements, tone of muscles, presence of deep tendon reflexes (reflex return signals end of flaccid period and return of muscle tone).

3. Also assess mental status, cranial nerve function, sensation/proprioception, bladder control.

4- Monitor bowel and bladder function.

5. Monitor effectiveness of anticoagulation therapy.

6. Frequently assess level of function and psychosocial response to condition.

1-Risk for Injury related to neurologic deficits

Goal:-A. Preventing Falls and Other Injuries

Nursing Interventions

1. Maintain bed rest during acute phase (48 to 72 hours after onset of stroke) with head of bed slightly elevated and side rails in place.

2. Administer oxygen as ordered during acute phase to maximize cerebral oxygenation.

Frequently assess respiratory status, vital signs, heart rate and rhythm, and urinary output to maintain and support vital functions.

4. When patient becomes more alert after acute phase, maintain frequent vigilance and interactions aimed at orienting, assessing, and meeting the needs of the patient.

5. Try to allay confusion and agitation with calm reassurance and presence.

Evaluation:- No falls, vital signs stable

2-Impaired Physical Mobility related to motor deficits

Goal:-Preventing Complications of Immobility

Nursing Interventions

Maintain functional position of all extremities.

Place a pillow in the axilla of the affected side when there is limited external rotation.

Place the affected upper extremity slightly flexed on pillow.

2-Exercise the affected extremities passively through range of motion four to five times daily to maintain joint mobility and enhance circulation; encourage active range-of-motion exercise as able.

3. Teach patient to use unaffected extremity to move affected one.

4. Prepare for ambulation cautiously.

a. Check for orthostatic hypotension.

b. Graduate the patient from a reclining position to head elevated, and dangle legs at the bedside before transferring out of bed or ambulating; assess sitting balance in bed.

c. Have patient wear walking shoes.

d. Assess standing balance and have patient practice standing.

f. Help patient begin walking as soon as standing balance is achieved; ensure safety with a patient waist belt.

Evaluation;-

Body alignment maintained, no contractures

3-Impaired Verbal Communication related to brain injury

Goal:-Facilitating Communication Nursing Interventions

1. Speak slowly, using visual cues and gestures; be consistent and repeat as necessary.

2. Give plenty of time for response, and reinforce correct responses.

3. Minimize distractions.

4. Use alternative methods of communication other than verbal.

Evaluation:- Communicates appropriately

4- Self-care Deficit (bathing, dressing, toileting) related to hemiparesis/paralysis

Goal:- Fostering Independence

Nursing Interventions

1. Teach patient to use nonaffected side for activities of daily living (ADLs) but not to neglect affected side.

2. Adjust the environment (eg, call light, tray) to side of awareness if spatial.

3. Teach the patient to scan environment if visual deficits are present.

4-Encourage family to provide clothing that is a size larger

than the patient wears, with front closures, V; teach patient to dress while sitting to maintain balance.

5. Ensure that personal care items, are nearby and that patient obtains assistance with transfers and other activities as needed.

Evaluation:-

Brushing teeth, putting on shirt and pants independently

5- Altered Nutrition: Less Than Body Requirements, related to impaired self-feeding, chewing, swallowing

Goal:- Promoting Adequate Oral Intake

Nursing Interventions

1. Encourage small, frequent meals and allow plenty of time.

2. Remind patient to chew on unaffected side.

3. Inspect mouth for food collection or injury and encourage frequent oral hygiene.

4. Teach the family how to assist the patient with meals to facilitate chewing and swallowing.

a. Provide oral care before eating to improve aesthetics and afterward to remove food debris.

B- Position the patient so he or she is sitting with 90 degrees of flexion at the hips and 45 degrees of flexion at the neck. Use pillows behind the back and along the weak side to achieve correct position.

c. Maintain position for 30 to 45 minutes after the meals to prevent regurgitation and aspiration.

Evaluation:-

Feeds self two thirds of meal

6- Altered Urinary Elimination related to motor/sensory deficits

GOAL:- Attaining Bladder Control

Nursing Interventions

1. Perform intermittent or indwelling bladder catheterization during acute stage.

2. Establish regular schedule of voiding—every 2 to 3 hours—once bladder tone returns.

3. Assist with standing or sitting to void

Evaluation:- Voiding on commode at 2-hour intervals

7- Altered Thought Processes related to brain damage

GOAL:- Optimizing Cognitive Abilities

Nursing Interventions

1. Be aware of patient’s cognitive alterations and adjust interaction and environment accordingly.

2. Participate in cognitive retraining program—reality orientation, visual imagery, as outlined by occupational or rehabilitation therapist.

3. Use pictures of family members, clock, calendar; post schedule of daily activities where patient can see.

4. Focus on patient’s strengths and give positive feedback.

Evaluation:-

Oriented to person, place, and time

Altered Family Process related to catastrophic illness, cognitive and behavioral sequelae of stroke, and caregiving burden

GOAL:- Strengthening Family Coping

Nursing Interventions

1. Encourage the family to maintain outside interests.

2. Teach stress management techniques, such as relaxation exercises, use of community and church support networks.

3. Encourage participation in support group for family of stroke victim and respite program or other available resources in area.

4. Involve as many family and friends in care as possible.

5. Provide information about stroke and expected outcome.

Evaluation:-

Family seeking help and assistance from others

THANKS