CEREBROVASCULAR

ACCIDENT

CEREBROVASCULAR ACCIDENT/STROKE

• Also called “brain attack”, cerebral infarction, cerebral hemorrhage, ischemic stroke or stroke

• A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue.

DIRECT CAUSES:

• CEREBRAL THROMBOSIS– a blood clot or plaque blocks an artery that supplies a vital

brain center

• CEREBRAL HEMORRHAGE/ANEURYSM– an artery in the brain bursts, weakens the aneurysm

wall; severe rise in BP causing hemorrhage and ischemia

• CEREBRAL EMBOLISM– a blood clot breaks off from a thrombus elsewhere in the

body, lodges in a blood vessel in the brain and shuts off blood supply to that part of the brain

TYPES:• ISCHEMIC STROKE

– Occurs when a clot or a mass clogs a blood vessel, cutting off the blood flow to brain cells. The underlying condition for this type of obstruction is the development of fatty deposits lining the vessel walls. This condition is called atherosclerosis.

– Almost 85% of strokes are ischemic

ATHEROSCLEROSIS- “hardening of the arteries”- “athero” – gruel or paste- “sclerosis” – hardness

- It’s the process in which deposits of fatty substances, cholesterol, cellular waste products, calcium and other substances build up in the inner lining of an artery. This buildup is called plaque.

Fatty deposits can cause two types of obstruction:

1. CEREBRAL THROMBOSIS2. CEREBRAL EMBOLISM

TYPES:• HEMORRHAGIC STROKE

– Results from a weakened vessel that ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue.

– About 15% of all strokes but responsible for 30% of stroke deaths

2 TYPES SUBARACHNOID HEMORRHAGE (SAH)

occurs when a blood vessel on the surface of the brain ruptures and bleeds into the space between the brain and the skull

INTRACEREBRAL HEMORRHAGE (ICH)Occurs when a blood vessel bleeds into the tissue deep within the brain.

POINTS TO CONSIDER

– 2,000,000 brain cells die every minute during stroke, increasing risk of permanent brain damage,

disability or death.

– Recognizing symptoms and acting fast to get medical attention can save life and limit

disabilities.

STAGES OF CVA

Transient Ischemic Attack• sudden and short-lived attack• Is a "mini stroke" that occurs when a blood clot blocks an artery for a

short time. • What is the difference between stroke and TIA?• There's no way to tell if symptoms of a stroke will lead to a TIA or a

major stroke. It's important to call 9-1-1 immediately for any stroke symptoms.

Reversible ischemic neurologic deficit (RIND) similar to TIA, but symptoms can last up to a week

Stroke in evolution (SIE)• Gradual worsening of symptoms of brain ischemia

Completed stroke (CS) – symptoms of stroke stable over a period and rehab can begin

Signs and SymptomsIn embolism

• Usually occurs without warning• Client often with history of cardiovascular disease

In thrombosis • Dizzy spells or sudden memory loss• No pain, and client may ignore symptoms

In cerebral hemorrhage• May have warning like dizziness and ringing in the ears (tinnitus)• Violent headache, with nausea and vomiting

Sudden Onset CVA• Usually most severe• Loss of consciousness• Face becomes red• Breathing is noisy and strained

Signs and SymptomsSudden Onset CVA• Usually most severe• Loss of consciousness• Face becomes red• Breathing is noisy and strained• Pulse is slow but full and bounding• Elevated BP• May be in a deep coma

TIME IS CRTITICAL!

– The longer the time period that the person remains unresponsive, the less likely it is that the person will recover.

– The first few days after onset is critical.– The responsive person may:• Show signs of memory loss or inconsistent

behavior• May be easily fatigued, lose bowel and bladder

control, or have poor balance

• RISK FACTORS:• Being over age 55 • Being an African-American• Having diabetes• Having a family history of stroke

–MEDICAL STROKE RISK• Previous stroke• Previous episode of transient ischemic attack (TIA) or mini-

stroke• High cholesterol• High blood pressure• Heart disease

• RISK FACTORS:

– LIFESTYLE STROKE RISK• Smoking• Being overweight • Drinking too much alcohol• You can control lifestyle risks by quitting smoking,

exercising regularly, watching what and how much you eat and limiting alcohol consumption.

Common STROKE symptoms…Weakness or paralysis Numbness, tingling, decreased sensationVision changesSpeech problemsSwallowing difficulties or droolingLoss of memoryVertigo (spinning sensation)Loss of balance and coordinationPersonality changesMood changes (depression, apathy)Drowsiness, lethargy, or loss of consciousnessUncontrollable eye movements or eyelid drooping

MAJOR EFFECT of STROKE

– HEMIPLEGIA – most common result of CVA• Paralysis of one side of the body • May affect other functions, such as hearing, general

sensation and circulation• The degree of impairment depends on the part of the

brain affected• Stages:

–Flaccid – numbness and weakness of affected side

–Spastic – muscles contracted and tense, movement hard

–Recovery – therapy and rehab methods successful

MAJOR EFFECT of STROKE• Aphasia and Dysphasia • Brain Damage – extent of brain damage determines chances of

recovery• Hemianopsia – blindness in half of the visual field of one or

both eyes• Pain – usually very little; injection of local anesthetic provides

temporary relief• Autonomic Disturbances – Such as perspiration or “goose flesh” above the level of

paralysis–May have dilated pupils, high or low BP or headache– Treated with atropine-like drugs

DIAGNOSIS

• Physical Examination (neurological examination & medical history)

• Imaging (CT scan and MRI)

ISCHEMIC STROKE

HEMORRHAGIC STROKE

TRANSIENT ISCHEMIC ATTACK (TIA)

ACT F.A.S.TF – 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 sentence. Does the

speech sound slurred or strange?

T – TIME• Call 911 Immediately

ASSESSMENT– Monitor for signs and symptoms– Symptoms will vary based on the area of the brain that is

not adequately supplied with oxygenated blood– The left cerebral hemisphere is responsible for language,

mathematic skills and analytic thinking– The right cerebral hemisphere is responsible for visual

and spatial awareness and proprioception – Assess/Monitor Airway patency

ASSESSMENT– Swallowing ability/aspiration risk– Level of consciousness– Neurological status– Motor, sensory and cognitive functions– Glasgow Coma Scale score

NURSING DIAGNOSIS

– Ineffective tissue perfusion (cerebral)–Disturbed sensory perception– Impaired physical mobility–Risk for injury– Self-care deficit– Impaired verbal communication– Impaired swallowing

NURSING CONSIDERATIONSMaintain patent airwayMonitor for changes in the client’s level of consciousnessInstitute seizure precautions. Maintain a non-stimulating environment.Assist with communication skills if the client’s speech is

impaired. Assist with safe feeding.

• Assess swallowing reflexes.• Thicken liquid to avoid aspiration. • Eat in an upright position and swallow with the head and neck flexed

slightly forward.• Place food in the back of the mouth on the unaffected side.• Suction on standby.

NURSING CONSIDERATIONS– Maintain skin integrity.– Encourage PROM every 2 hr to the affected extremities

and AROM every 2 hr to the unaffected extremities.– Elevate the affected extremities to promote venous

return and to reduce swelling.– Maintain a safe environment to reduce the risks of falls.– Scanning technique (turning head from side to side)

when eating and ambulating to compensate for hemianopsia.

– Provide care to prevent deep-vein thrombosis (sequential compression stockings, frequent position changes, mobilization)

THROMBOLYTIC THERAPY–Anticoagulants: Sodium heparin, warfarin

(Coumadin)

–Antiplatelets: Ticlopidine (Ticlid), clopidogrel (Plavix)

–Antiepileptic medications: Phenytoin (Dilantin), gabapentin (Neurontin)

STROKE PREVENTION–Get screened for high BP.–Have your cholesterol level checked. LDL

should be lower than 70 mg/dL.– Follow a low-fat diet.–Quit smoking!– Exercise!– Limit alcohol intake!

THAT’S it!THANK YOU FOR

LISTENING!