Cerebrovascular Accident (CVA)(stroke)

Prepared by:Nour el-dien khalaf

By the end of the Lecture each Student should be able:

Discus brain anatomy and its function.

Identify the stroke.

List the risk factors of stroke.

Mention the causes of stroke.

Describe signs and symptoms of stroke

:Objectives

List types of stroke.

Differentiate between the types of stroke.

Identify the Transient ischemic attack(TIAs).

List warning signs of stroke.

Discus complications of stroke.

Apply nursing care for stroke patients.

Cont.,

Introduction.

The definition of Stroke.

Risk factors of stroke.

Causes of stroke.

Signs and Symptoms of Stroke.

Types of Stroke.

Outlines:

Transient ischemic attack(TIAs).

Stroke warning signs.

Complications of stroke.

Diagnosis of stroke.

management of stroke.

Con.,

Stroke is a form of cardiovascular disease affecting the blood supply to the brain.

Stroke is a major health problem in the country.Stroke as a disease of elderly but also affects younger individuals. If 100 persons have stroke:10% are able to return to previous level of activity.50% return home and carry on with only limited assistance. 40% require significant assistance in caring for themselves.

Introduction:

Anatomy of the brain

Brain

Brain stem

Cerebrum Left hemispheres Right hemispheres

Frontal

Temporal

Parietal

OccipitalCerebellum

The brain

Stroke is the sudden death of a portion of the brain cells

due to a lack of oxygen.

Stroke occurs when blood flow to the brain is damage

resulting in abnormal function of brain.

It causes by blockage or rupture of an artery to the brain.

Stroke

Controllable Medical Risk Factors:1) High blood pressure(Hypertension).2) Heart disease3) Diabetes.4) High cholesterol5) Atherosclerosis6) Carotid bruit.

Risk factors

Controllable Lifestyle Risk Factors:1) Smoking.2) Obesity and Physical Inactivity.

Uncontrollable Risk Factors:1) Age2) Heredity and family history3) History of TIAs.

Cont.,

1-High blood pressure(Hypertension) :Making the arteries more vulnerable to thickening or

narrowing to rupture.

Controlling hypertension is the key to preventing stroke.

Controllable Medical Risk Factors:

2-Heart disease:

Damage to the heart more likely to form clots within heart and it can travel to the brain.

If the blood vessels feeding the heart are diseased, it is likely that arteries to the brain are also affected.

Patients with A.F, heart failure, and C.H.F, have increase in the risk of stroke.

Cont.,

3-Diabetes:Major risk factor for ischemic stroke.

Increased susceptibility to atherosclerosis and hypertension,

obesity, and abnormal blood lipids.

Many people with diabetes also have high cholesterol,

increasing their risk for stroke.

Cont.,

Con.,

Risk of stroke increase

Blockage of arteries

Increase cholesterol

4-High cholesterol:

5-Atherosclerosis:is the progressive buildup of plaque – fatty deposits and

other cells – in artery walls.

Cont.,

6-Carotid bruit:A bruit is a noise made by turbulent flow in blood vessel that

usually can be heard only by stethoscope.

The most common cause is carotid stenosis due to atherosclerosis.

Carotid bruit increase to have a stroke by 5% .

May need surgical procedure called carotid endarterectomy.

Cont.,

1-Smoking:The more you smoke, the more this risk increases.Smoke 20 cigarettes a day, you are six times more likely

to have a stroke compared to a non-smoker.

Controllable Lifestyle Risk Factors:

If you have had a stroke, it is strongly

recommended that you stop smoking to

help prevent any further strokes. Research

has shown that you are at greatest risk

of another stroke shortly after the first.

2-Obesity and in activity:Obesity increase the risk of HTN,HD and DM and they also stroke risk factor

Cont.,

1-AgeAge is a significant risk factor for stroke.

About 75% of strokes occur in individuals ≥ 65 yrs.

Uncontrollable Risk Factors:

2-Heredity and family history The chance of having a stroke is higher for people who have a

family history of this disease.

3-History of TIAs? Is localized neurological problem caused by ischemia(decreased

blood flow)resolves within24hours.

Cont.,

1-Cerebral thrombosis(blood clot within blood vessel of the brain or neck)

2-Cerebral embolism(blood clot or other material carried to the brain from another part of the body)

Causes of stroke:

3-Cerebral ischemia(insufficiency of the blood supply to the brain)

4-Cerebral hemorrhage(rupture of a cerebral vessel with bleeding into the brain tissue or spaces around the brain)

Cont.,

Types of stroke

Stroke

Ischemic stroke70%

Thromboticstroke 15%

Embolic stroke25%

Lacunar stroke30%

Others

5%

Hemorrhagic stroke

25%Intracerebral hemorrhag

e15%

Subarachnoid

hemorrhage

10%

1-Ischemic stroke 70 % Insufficiency of the blood supply to the brain.

Types of stroke:

Thrombotic stroke 15%Is caused by a clot that blocks blood flow in an artery.

B-Embolic stroke 25%Is caused by a wandering clot that forms in one part of

the body, and travel in the bloodstream until lodges in an artery.

C-Lacunar stroke 30%Is caused by occlusion of arterioles, the very small ends

of the arteries that penetrate deep into the Bain .

Subcategories of Ischemic stroke:

Bleeding within the brain tissue either the brain itself(intracerebral hemorrhage)or the space around the brain(subarachnoid hemorrhage)

2-Hemorrhagic stroke 25%

Intracerebral Hemorrhage:Blood leaks from small vessels at the base of brain.

Subarachnoid Hemorrhage :Blood leaks from small vessels at the space around the brain.

Intracerebral Hemorrhage andSubarachnoid Hemorrhage

1. High blood pressure(hypertension).

2. Aneurysm.

3. Trauma.

4. Tumors.

5. Abnormalities in blood vessels (arteriovenous malformations).

Causes of hemorrhagic stroke

Cont.,

Sudden severe headache with unknown cause.

Seizures.

Stiff neck.

Sensitivity to light.

Change in consciousness.

Nausea and Vomiting.

The classic signs and symptoms ofICH and SAH

Others 5%

Is localized neurological problem caused by ischemia(decreased blood flow)resolves within24hours.

Most TIAs are due to either an embolus(blood clot)or restricted blood flow often causes by narrowing in the carotid artery(carotid stenosis).

Transient ischemic attack(TIAs)

Sudden weakness or numbness of the face, arm ,and leg on one side of the body.

Sudden onset of blurred or double vision.

Sudden confusion, trouble speaking or understanding..

Sudden trouble walking, dizziness, lack of balance or coordination.

Sudden severe headache with no known cause.

Stroke warning signs

Hemiplegia:The total paralysis of the arm, leg, and trunk on one side of the body.

Hemiparesis:Is weakness on one side of the body. It is less severe than hemiplegia.

Signs and Symptoms of Stroke

Dysarthria:Difficulty in forming words but not lose any speech comprehension or writing skills. Aphasia:Difficulty in producing or comprehending spoken or written language. Apraxia:Is the inability to execute learned purposeful movements spite having the desire and the physical capacity to perform the movements.

Con.,

Dysphagia:Difficulty in swallowing.

Homonymous hemianopsia:Loss of the half of the visual field (left or right side of the vertical midline) It can affect one eye but usually affects both eyes.

Con.,

Amorphosynthesi:The patient’s head turns away from the affected side of the body and he tend to neglect that side.

Limited attention span. Depression , hostility, resentment and frustration.

Con.,

1)Systemic thrombotic complications: Deep venous thrombosis(DVT)The risk of deep vein thrombosis (DVT) after stroke is increased in patients with restricted mobility.

pulmonary embolismPulmonary embolism in patients with acute stroke can be a cause of early mortality (during the first month after the ictus).

Complications:

2)Pulmonary complicationsAspiration Pneumonia .3. Cardiac complicationsSinus tachycardia.

Sinus bradycardia.

A.F

Con.,

4. genitourinary complicationsurinary incontinence.

urinary tract infection.most common organism : Escherichia coli

5.Gastrointestinal complication

GI bleeding.

Con.,

6-Miscellaneous complications:

Falls.

skin breakdown.

Depression.

Con.,

1-History and Examination:Vital signs.

Carotid Bruit.

Cardiac Exam .

Signs of trauma.

Past history.

History oh TIAs.

Diagnosis of stroke

3 Simple Questions:Ask the person to smile.

Ask the person to raise both arms.

Ask the person to say a simple sentence “The sky is blue in Assiout”.

Recognize the Symptoms of a Stroke

The sky is blue in assiout

Neurologic Exam Level of consciousness/GCS.

Language/Speech.

Orientation, vision, and hearing.

memory, motor skills, and emotional control.

Visual deficits.

Weakness/Paralysis.

Con.,

Glasgow Coma Scale(GCS)

2-Imaging studies:Brain computed tomography(CT) Is a painless test that uses x rays to take clear, detailed pictures of

your brain.Can show bleeding in the brain or damage to the brain cells from

a stroke.

Con.,

Magnetic Resonance Imaging(MRI): Is a painless test that uses magnets and radio waves to create

pictures of the organs and structures in your body. Computed Tomography Arteriogram and Magnetic Resonance Arteriogram.(CTA &MRA)Can show the large blood vessels in the brain.

Carotid Ultrasound: is a painless and harmless test that uses sound waves to create

pictures of the insides of your carotid arteries.

Doppler ultrasound: is a special test that shows the speed and direction of blood

moving through your blood vessels.

Con.,

Carotid Angiography: is a test that uses dye and special x rays to show the insides of

your carotid arteries.Contraindications?

Con.,

EKG (Electrocardiogram): Is a simple, painless test that records the heart's electrical activity. Can help detect heart problems that may have led to a stroke. For

example, the test can help diagnose atrial fibrillation or a previous heart attack.

Con.,

Echocardiography(Echo.): Is a painless test that uses sound waves to create pictures of your

heart.Gives information about the size and shape of your heart and

how well your heart's chambers and valves are working.

Con.,

Blood Tests:

PT and PTT tests These tests show whether your blood is clotting normally.

Nutritionists

Social Workers

CaseManagers

Occupational

Therapists

Nurses

Medical Doctors

Physiotherapists

Neurologist

Pharmacologist

Patient

Neurosurgeon

Multidisciplinary in Stroke

A-Firstly1-Prevention of Stroke: Public Awareness and health teachingThrough the mass media to raise awareness about the

health .Public should be able to recognize signs and symptoms

of stroke, and sudden signs and symptoms.Health teaching should emphasize stroke is a medical

emergency act as FAST.Education should include that stroke can affect persons

of any age.

management of stroke

Easy way to remember the sudden signs and symptoms of a stroke:

Know your blood pressure, have it checked at least annually, if it is elevated, work with your doctor to control it.

If you smoke, stop.

Know your cholesterol number. If it is high, work with your doctor to control it.

If you are diabetic, follow your doctor’s recommendations carefully to control your diabetes.

Con.,

Include exercise in your daily routine.

Enjoy a lower sodium (salt) and lower fat diet.

If you have circulation problems, work with your doctor to improve your circulation.

If you experience any stroke symptoms please, go to

doctor rapidly Every minute matters.

Con.,

Giving basic information for all patients with stroke or at risk of stroke and their families Includes:

About meaning of stroke.

Stroke is a medical emergency act as FAST.

About Transient ischemic attack(TIAs).

Sudden signs and symptoms of stroke.

Con.,

Who are the risk factors.

Care of stroke.

Post-stroke complication.

Rehabilitation process.

Con.,

B-Secondary:A-Medical treatment:Reduce blood clots formation by preventing the smallest blood cells (platelets) from sticking together and forming blood clots.Anticoagulants drugs (warfarin, heparin).Antiplatelet drugs(Aspirin, Plavix).Antihypertensive drugs(Capoten, Norvasc, Cardura, etc..).

management of stroke

Warfarin.

Heparin.

Anticoagulants drugs:

Aspirin.

Plavix.

Antiplatelet drugs:

Clexane gropes:

Glucose control Hyperglycemia is an independent risk factor for hemorrhage. Drugs as insulin and Amaryl.

Antiepileptic Drugs

Seizures are common after hemorrhagic . Drugs as phenytoin

Con.,

TPA to treat ischemic stroke in the first three hours after the onset of symptoms.

Tissue plasminogen activator (TPA)The magician

0.9 mg/kg – Do not exceed the 90 mg max dose

Mix 100 mg in 100 ml of sterile water, subtract pt dose from 100

ml and discard the difference. Final concentration 1mg/1ml

Withdraw 10% and give IV bolus over 1 minute, followed by the

remainder over 60 min.

Double check for correct dose (MD, RN)

Document bolus dose and drip dose over 1 hr

Calculation and Documentation of tPA

Example of tPA Calculation

Patient wt – 80 kg

Chart:

0800 tPA bolus 7.2 mg

0801 tPA infusion 64.8 mg in 64.8 ml given over 60 minutes

0.9mg/kg = 72

72mg in 72 ml (total dose)

- 10% = 7.2 mg or ml (bolus dose)

72 -7.2 = 64.8mg (infusion dose)

Check BP every 15 min for 2 hours.Treat hypertension/hypotension as ordered.Monitor Neuro status every 30 min.Watch for bleeding – puncture sites, urine, stool

etc.Know signs/symptoms of Intracerebral

Hemorrhage.

Nursing interventionsDuring tPA Administration

Stop TPA infusion.Call MD immediately.Stat head CT without contrast.Draw blood for PT, PTT, plt ct, fibrinogen, and

type and hold.Prepare for administration of cryo and or

platelets .

Hemorrhage Suspected

Continue to monitor for signs/symptoms of intracerebral hemorrhage.

No unnecessary blood draws or invasive procedures for 12 hours after tPA.

Repeat CT scan 24 hours after tPA to evaluate for bleeding

No aspirin, heparin, warfarin, or other antithrombotic or antiplatelet drugs 24 hours after tPA.

Post tPA

carotid endarterectomy for carotid stenosis

B-Surgical intervention

Bypass surgery for ischemic stroke:

Coil embolizationSurgical clipping for aneurysm

Evacuation for hemorrhage and hematoma

1-Monitor vital signs for changes.2-Asses neurological status, perform neurological checks at least every 4hours by using GCS.3-Monitor for signs of increased ICP.4-Turning position every 2hours.5-Assess the patient in the feeding process.

important for people to understand stroke warning signs and get to a hospital FAST in case they are eligible to receive tPA

C-Nursing intervention:

6-keep skin clean and dry.

7-massage to maintain skin integrity.

8-Using footboard used during flaccid period to prevent sores.

9-Perform passive ROM 4 to 5 times.

10-Apply care to the patient to promote health.

Con.,

Recovery and RehabilitationNo program can succeed without a strong desire.1-physica therapy: Help patient to learn to walk again (walking, range of motion)

C-Thirdly

2-Occupational therapy: Help the patient to perform basic activity by muscular

coordination. (Taking care of one’s self ,bathing, dressing)

Con.,

3-speech therapy:Help the patient to regain to speech and communicate.

Con.,

Summery:

myth

Not preventable

cannot be treated

only strikes the elderly

Stroke happens in the heart

reality

80%are preventable

requires emergency

Anyone can have a stroke

Stroke is a “Brain Attack”

stroke

Check Up Quiz

At a family gathering, your cousin tells you that your uncle has had a stroke. Your cousin says you should not worry about it happening to either of

you because stroke is caused by old age. Is his statement true or false?

Check Up Quiz

What is a stroke?A. A blood clot stops the flow of blood in a limb.B. The heart slows and nearly stops functioning.C. Blood flow to the brain is interrupted, or a blood vessel in the

brain bursts D. All of the Above.

Check Up Quiz

What are risk factors for stroke?A. High blood pressureB. DiabetesC. Heart disease D. All of the Above

Check Up Quiz

What are the symptoms of stroke?A. Sudden weakness or numbness on one side of the body,

and/or sudden, severe headaches.B. Sudden confusion, difficulty speaking, and/or blurred vision.C. Sudden dizziness or problems moving or walking.D. All of the Above.

Check Up Quiz

What therapy is used to prevent a second ischemic stroke?A. Surgery to remove carotid artery plaqueB. Angioplasty in the carotid arteryC. Anticoagulant medicationD. All of the Above

Brunner and sudderth’s.(2011).text book of medical surgical nursing,9th edition, Lippincott, page(1725-1735).

www.medicalnewstoday.com

www.stroke.org

www.strokeassociation.org

www.strokenetwork.org

References