2. INTRODUCTION
• CVD or CVA refers to a functional abnormality of the central
nervous system that occurs when the normal blood supply to
the brain is disrupted.
• Brain & cerebral nerve cells extremely sensitive to a lack of
oxygen
• severity of the loss of function varies according to the
location and extent of the brain involved.
3. INCIDENCE
• The stroke is the leading cause of death and disability in India. The
estimated prevalence rate of stroke in India is (84-262 per 1,00,000)
in rural areas as compared to (334-424 per 1,00,000 population) in
urban areas. There is also a wide variation in case fatality rates with
the highest being 42% in Kolkata(2018).
• World: 1 in 6 persons gets a stroke in their lifetime.
• India has reported 1.6 million stroke cases per year(2015.)
4. ANATOMY OF BRAIN AND ITS BLOOD SUPPLY
•Four vessels supply nutrient and oxygen rich blood to the
brain :
•Two internal carotid arteries (anterior circulation: most of
the frontal, parietal &temporal lobes, basal ganglia, part of
diencephalon.)
•Two vertebral arteries (posterior circulation: middle &
lower part of temporal lobes, occipital lobes, cerebellum,
brain stem and part of diencephalon.)
7. DEFINITION OF STROKE
Stroke, Cerebrovascular Accident (CVA) or “Brain
Attack” defined as sudden loss of brain function resulting
from disruption of blood supply to a part of brain, which
results in infarction or death of brain tissue.
-WHO
A stroke is a medical emergency in which the blood
supply to any portion of the brain is interrupted or reduced
11. TRANSIENT ISCHEMIC ATTACK
• These are brief, transient and focal disturbances of neurological
function that clear with little or no residual deficit within 24 hrs.
• Most of them last for only 7 to 10 minutes.
• Also called as “little strokes” or “mini stroke”.
• 40% of the client develop stroke in 5 yrs.
• Accounts for 80-85% of all strokes.
• Results from partial or complete occlusion of an artery.
12. Ischemic stroke can be:-
Due to
systemic hypo
perfusion OR
Watershed
stroke( 15% )
Embolic stroke
(24%)
Thrombotic
stroke
(61%)
13. RISK FACTORS
Non modifiable risk factors:
Age- 60% - 65% of all strokes occur in persons over 65
yrs. of age.
Gender- men>women
Race- African, Americans are twice likely to develop
thrombotic stroke & 3 times more likely for
haemorrhagic one.
Genetics- Those with family history of CVA have
greater risk.
14. Modifiable Risk Factors
Lifestyle risk factors
•Being overweight or obese
•Physical inactivity
•Heavy or binge drinking
•Use of illicit drugs such as
cocaine and
methamphetamines
Medical risk factors
•High blood pressure
•Cigarette smoking or
exposure to secondhand
smoke.
•High cholesterol.
•Diabetes.
•Obstructive sleep apnea
•Cardiovascular disease
14
http://chicagostrokemd.com/stroke-risk-factors/
15. Etiology
•A stroke occurs when the blood supply to your brain is
interrupted or reduced. This deprives your brain of
oxygen and nutrients, which can cause brain cells to die.
• A stroke may be caused by a blocked artery (ischemic
stroke) or a leaking or burst blood vessel (hemorrhagic
stroke).
•Some people may experience a temporary disruption of
blood flow through their brain (Transient ischemic
attack).
18. SIGN AND SYMPTOMS
SYMPTOMS
Facial drooping
Arm weakness
Slurred speech
Blurred vision or blindness in one or both the eyes.
Severe headache
Sudden loss of balance, dizziness or falling without any apparent reason.
19.
20. Left and Right Hemisphere Stroke:
Left (Dominant) Hemisphere
Stroke: Common Pattern
• Aphasia
• Right hemiparesis
• Right-sided sensory loss
• Right visual field defect
• Poor right conjugate gaze
• Difficulty reading, writing,
or calculating
Right (Non-dominant) Hemisphere
Stroke: Common Pattern
• Neglect of left visual field
• Extinction of left-sided
stimuli
• Left hemiparesis
• Left-sided sensory loss
• Left visual field defect
• Poor left conjugate gaze
• Dysarthria
• Spatial disorientation
21.
22. SPECIFIC DEFICITS AFTER CVA
•Visual field deficits
•Motor deficits
•Sensory deficits
•Perceptual deficits
•Cognitive deficits
•Emotional deficits
25. Clinical features: Altered Mental Status
• Change in intelligence and personality
• Altered thought process
• Poor reasoning and judgment
• Emotional liability
• Memory loss
36. Evaluation by DOCTOR/RN
•History of event
•Vitals
•Time of onset : Accurate
eg. 3:19 PM.
•Initiate Lab work
•Neurological assessment
using NIHSS.
36
37. National Institutes of Health Stroke Scale(NIHSS)
•Useful in determining suitability for thrombolysis.
•Useful for post thrombolysis monitoring.
37
41. Thrombolysis: Golden Hour
Intra venous Thrombolytic Therapy
Inj. tPA (clot busting drug)
Dosages: 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with 10%
of the dose given as a bolus over 1 minute
42. Eligibility criteria
• Age >18 yrs.
• Diagnosis of ischemic stroke
• Comes within 4½ hrs of onset
• No seizure at onset of stroke
• Not taking warfarin
• Prothrombin time ≤15 sec
• Not receiving heparin during the past 48 hours with elevated thromboplastin
time
• No prior intracranial haemorrhage
• No major surgical procedure within 14 days
43. Exclusion criteria
•Symptoms suggestive of SAH.
•Stroke or serious head trauma within 3 months
•Major surgery or serious bodily trauma within 2 weeks
•History of a prior ICH, thrombocytopenia
•Use of oral anticoagulants
•Patient with an NIHSS score of greater than 22.
44. Pre thrombolysis management
• Vitals
• NIHSS(national Institute of health stroke scale)
• 2 IV Cannula 18 G. Preferably in Brachial Veins.
• Blood tests
• Stat Blood Sugar
• Stat PT and INR
• Urinary Catheterization.
• RT Insertion.
• NCCT Head and CT Angio of neck and cerebral vessels
• Pt./Relatives Counseling For event, prognosis, available Best
Treatment Modalities.
• Informed written consent from pt./close relative.
44
45. BLOOD PRESSURE
•If Systolic BP is >180 mm of Hg or Diastolic BP is >110
mmHg
•Confirm with 2 readings 5-10 minutes apart
•If persistent, Inj Labetalol 10-20 mg IV over 1-2 mins.
•Repeat every 10-20 mins to a total dose of 300mg or
bradycardia.
45
47. Therapy for patients with ischemic stroke
not receiving t-PA
• Intra arterial thrombolytics: e.g. Heparin
• Antihypertensive : Are given rarely to reduce the BP in acute
phase, as it acts as a compensatory mech. to perfuse the brain.
• Anticoagulation : Anti platelets and Anti Thrombotic e.g.
Heparin, low dose aspirin × 4 to 10 days.
• Analgesic:-if headache e.g. codeine, stronger narcotics are
avoided
48. Cont..
• Anticonvulsants : Phenytoin (dilating), phenobarbital
• Elevate the head end of the bed to promote venous drainage and to lower
increased ICP.
• Intubation with an endotracheal tube to establish patent airway if
necessary
• Continuous hemodynamic monitoring. Systolic pressure should be
maintained at < 180 mm hg, diastolic pressure at <100 mm hg to reduce
the potential for additional bleeding.
50. EMERGENCY MANAGEMENT
• Oxygenation @ 2-4 l/min
• Assess the level of consciousness
• Maintain the patent airway
• Call a stroke code or stroke team
• Cardiac and pulse oximetry monitoring
• IV lines
• Vital sign monitoring and GCS
• Anticipate thrombolytic therapy for ischemic stroke
• obtain CT scan immediately
• NPO
• Management of blood glucose abnormalities (hyperglycemia associated
with poorer prognosis)
• Management of fever and infections (ischemia worsened by
hyperthermia, improved by hypothermia
54. Post stroke care and quality measures
Post stroke care consist of following continuum:
•Phase 1: 3hrs-24hrs (Emergency/ Hyperacute phase) pre-
hospital and emergency care protocols
•Phase 2: 24-72 hrs (Acute Care) Clarifying the cause of
stroke, preventing medical complications, preparation for
discharge
•Phase 3: Rehabilitation and secondary prevention
55. Intensive management
PREVENTION OF COMPLICATIONS:-
•Symptoms related to presence of intracranial bleed in the
patient after tPA.
•Cardiac monitoring.
•If spo2 <92%, supplement oxygenation 2-4L/min
•If saturation persistently below 92%, ABG, CXR
recommended
•Treat cerebral edema, if present
•Evaluate for hypoxia, hypothermia
•Avoid hypotonic fluids
•IV mannitol (0.25-0.50g/kg) q6h
56. Cont...
•Anticonvulsants for patients who have had >1 seizure
•Some patients may develop infections in the
rehabilitation phase of the stroke
•Causes 15-25% of deaths associated with strokeMost
common cause:
•Aspiration secondary to dysphagia
•Early mobility, good pulmonary care
•Prophylactic intubation
•Patients may develop incontinent bladder after the
stroke
•Restrict fluids in the evening
57. MOBILIZATION OF PATIENT:-
• Keep the patient mobile after 24 hrs from the occurrences of the
stroke.
• Mobilize early when hemodynamically stable
• Reduces atelectasis, pneumonia, DVT, PE
• Nurse should monitor the first transfer from bed to upright
position
PREVENTION FROM DVT:-
• Patient may develop DVT(2.5% and pulmonary embolism
(1.2%)
• Pneumatic compression devices and compression stockings
• LMWH/ UFH
58. SKIN CARE AND POSITIONING:-
•Skin care should be done to prevent the bed sores.
•Loss of sensation, impaired circulation, old age, inability
to move, depressed consciousness
•Major pressure areas: heels, sacrum, Scapula.
•Change position q2h
•Skin- clean and dry
•Special mattresses
59. FEEDING:-
•Swallow assessment. Gagging Swallow Screen
•During swallowing- choking, coughing, wet voice, delay in
initiation, uncoordinated chewing or swallowing, loss of food
from mouth
•50% of stroke patients malnourished at 2-3 weeks after
stroke
•Assess- diet history, BMI, Mid arm circumference, triceps
skin fold thickness
•Monitor weight changes and dietary intake
•Prolonged dysphagia anticipated >6 weeks: early
gastrostomy feed.
60. PREVENTION OF RE-OCCURANCE
•It is seen that the patients have the 50% more chances of
developing the second stroke after the first attack so
secondary precautions is important to decrease the
chances of the stroke.
•Explaining stroke
•Risk factors- modifiable
•Compliance to medication
•Lifestyle modification-DASH diet, Exercise, Moderate
alcohol, smoking cessation
•Warfarin use: INR 2.0-3.5, weekly-monthly INR,
bleeding risk
61. REHABILITATION
•Stroke rehabilitation is a progressive, dynamic,
goal orientated process
•enabling a person with impairment to reach their
optimal physical, cognitive, emotional,
communicative and/or social functional level.
•“Getting back on own feet is likely one of top concerns
after a stroke”
62. REHABILITATION
Stroke rehabilitation may include some or all of the following activities:
• Therapy for communication disorders
• Strengthening motor skills
• Mobility training
• Range of motion therapy
• Constraint-induced therapy
• Electrical stimulation
• Virtual reality.
65. NURSING MANAGEMENT
ABC
Cerebral perfusion
Aphasia Management
Swallowing technique
Care of unilateral neglect
Bedsore prevention
Measures to prevent bleeding (Antiplatelets/ Anticogulants)
Speech therapy
Coma stimulation program
Physiotherapy
Occupational therapy
Preventive measures
66. Nursing Diagnosis:-
• Ineffective airway clearanc nrelated to (R/T) unconsciousness or ineffective
cough reflex
• Ineffective cerebral tissue perfusion related to interruption of cerebral
blood flow as evidenced by altered level of consciousness, changes in
motor/sensory responses, restlessness, sensory, language, and changes in
vital signs
• Impaired Physical Mobility related to Neuromuscular involvement:
weakness, paresthesia; flaccid/hypotonic paralysis, Perceptual/cognitive
impairment as evidenced by Inability to purposefully move within the
physical environment; impaired coordination; limited range of motion;
decreased muscle strength/control.
• Impaired verbal Communication related to Impaired cerebral circulation;
neuromuscular impairment, loss of facial/oral muscle tone/control;
generalized weakness/fatigue as evidenced by dysarthria, Inability to
modulate speech, and Inability to produce written communication.
67. Nursing Diagnosis
• Altered body temperature: hyperthermia related to disease process as
evidenced by increase in temperature
• Risk for impaired skin integrity, immobility and mechanical factors(
shearing , friction)
• Fluid and Electrolyte Imbalances related to fluid loss secondary to diarrhea
• Ineffective Coping related to Situational crises, vulnerability, unknown
disease pathology as evidenced by Inappropriate use of defense
mechanisms, Inability to cope/difficulty asking for help, Change in usual
communication patterns, Inability to meet basic needs/role expectations.
• Self care deficit related to paralysis of right side of body secondary to
cerebrovascular accident as evidenced by inability of patient to perform the
activities of daily life.
68. Ineffective airway clearance related to (R/T)
unconsciousness or ineffective cough reflex
• Position to facilitate drainage oropharyngeal
secretions.
•Turn side to side every 2 hours.
•Elevate the head of the bed to 30 degrees.
•Clear secretions from the airway using suction, as
necessary; provide for pulmonary hygiene.
•Provide for chest physical therapy.
69. Ineffective cerebral tissue perfusion related to interruption of
cerebral blood flow as evidenced by altered level of consciousness,
changes in motor/sensory responses, restlessness, sensory, language,
and changes in vital signs
• Monitor vital and neurological signs.
• Maintain cerebral venous outflow by elevating the head of the bed 30
degrees.
• Maintain head in neutral position.
• Avoid positions that increase intra-abdominal/intrathoracic pressure
(hip flexion, prone position, etc.
• Maintain normothermia.
• Maintain blood pressure within targeted range set for sufficient
cerebral perfusion pressure.
• Monitor peripheral oxygenation with pulse oximeter.
70. Impaired physical mobility R/T
neurological deficits
• Assess type and degree of impairment.
•Provide slings, braces, support shoes, etc., as necessary.
•Support alternative methods of mobility.
•Collaborate with physical therapist to support exercise
and mobility.
71. Impaired verbal Communication related to Impaired cerebral
circulation; neuromuscular impairment, loss of facial/oral muscle
tone/control; generalized weakness/fatigue as evidenced by dysarthria,
Inability to modulate speech, and Inability to produce written
communication.
• Assess type of communication deficit present.
•Develop and establish appropriate alternative
methods for communication.
72. Sensory/perceptual R/T altered consciousness,
impaired sensation, or impaired vision
•Assess impact of deficits on function and safety.
•Develop compensatory strategies to meet particular
patient needs.
•Provide for patient safety to prevent burns, injury, or
falls.
•For double vision, patch one eye.
•Approach patient from unaffected side if
homonymous hemianopsia is present.
•Provide appropriate stimulation to involved areas of
sense.
73. Risk of aspiration R/T inability to protect
airway or unconsciousness
• Maintain on nothing by mouth (NPO) status.
• Clear with a swallow assessment before beginning oral
intake.
• When oral intake is resumed, take precautions to prevent
aspiration (elevate head of bed, hold head up, etc.).
74. Risk of Infection R/T use of invasive devices and
hospitalization
• Follow aseptic technique.
•If urinary catheter is in place, remove as soon as possible.
•Monitor intravascular device sites for infection.
•Monitor chest x-ray and blood chemistries for evidence of
infection.
75. RESEARCH STUDY
• Dyslipidaemia in stroke
• Aims and objects of study: To study the association of
dyslipidaemia with stroke.
• Study design- Retrospective cross-sectional descriptive
study
• Method of collection of data- A hundred patients between
30 to 90 years of age ,with first ever stroke, during a 12-
month period were included in the study. History and
physical examination details were collected from patient
records. Laboratory investigations were also obtained .
• Data Analysis- Data collected was analysed by frequency,
mean, standard deviation and chi-square test.
76. Results: The lipid profile of the study sample was analysed
according to the ATP III classification for identification of
dyslipidemia. The findings revealed that 56% of the patients had
dyslipidemia . 40% had high total cholesterol, 7% had high
triglycerides and only 3% had high LDL. However, 28% of the
patients showed low HDL levels.10% had both high total cholesterol
and low HDL.
Conclusion: This study showed a significant association of 56%
between dyslipidemia and stroke. Although high LDL is usually held
responsible for cerebrovascular accidents, our study showed a
significant proportion of patients with low HDL. Thus, besides
generating Indian evidence to correlate dyslipidemia with stroke, this
study upholds that primary prevention is the key to overcoming the
burden of stroke in our country.
77. REFERENCES
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management for positive outcomes. 7th ed. Elsevier publishers:2005;
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• Kasper DL, Braunwald E, Fauci AS, et al, editors. Harrison’s principles of
internal medicine, 16th ed. [monograph on the Internet]. New York (NY):
The McGraw-Hill Companies, Inc.; 2004-2005
• Smeltzer Suzanne C, Bare Brenda G. Brunner & Suddarth’s Textbook of
medical-surgical nursing. 11th ed. lippincott williams & wilkins:2009;
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