A CVA also known as stroke or brain attack occurs when sudden decrease in the cerebral blood circulation as a result of thrombosis, embolus or hemorrhage leads to hypoxia of brain tissues ,causing swelling and death. When circulation is impaired or interrupted the small area of the brain becomes infracted and this changes membrane permeability ,resulting in increased edema and intracranial pressure. the clinical symptoms vary depending on the area and extend of the injury.
Thrombosis of small arteries in the white mater of the brain account for the most common cause of strokes.
A history of hypertension, diabetes mellitus,
vascular disease or atherosclerosis may lead to thrombosis ,which cause ischemia
He part of the brain supplied by the vessel involved.
Risk factors that predisposes the patients to stroke
Increase with age, resulting in the greatest incidence of the disease in the elderly population and the aged are least likely to seek medical attention in a timely manner. People over the age of 75 have the greatest risk of strokes but are the least aware of signs and symptoms of brain attack.
Embolism is the second common cause of CVA and happens when a blood vessel is suddenly occluded with blood, air, fat, or septic particulate. The embolus migrate to the cerebral arteries and obstructs circulation causing edema and necrosis.
When hemorrhage occurs it is usually the sudden result of ruptured aneurysms, tumors or AV malformations or involve problems with hypertension or bleeding dyscrasias. The cerebral bleeding decreases the blood supply and compresses neuronal tissue.
Serum Osmolality – to detect oncotic pressures and permeability, electrolytes, glucose levels and urinalysis performed to identify problems and imbalances that may be responsible for changes in condition.
Ineffective Airway Clearance related to decrease decreased level of consciousness, tracheobronchial obstruction, potential for aspiration.
Ineffective cough, tachypnea, dyspnea, abnormal breath sounds, respiratory rate and dept changes ,decreased response to stimuli, choking, ineffective swallowing.
Ineffective Tissue Perfusion
Related to: Occlusion, hemorrhage, interuption of cerebral blood flow, vasospasm, edema.
Inability to move at will, muscle incoordination, decreased range of motion, decrease muscle strength, paralysis, muscle atrophy, flacidity,deformity,contracture.
Patient will have improved or normal cerebral perfusion with no mental status changes or complications.
Measure blood pressure in both arms and each vital signs check.
Maintain head of bed in elevated position with head in neutral position.
Provide calm, quiet environment with adequate rest periods between activities.
Administer meds as ordered.
Instruct the patient on the use of stool softener and avoidance of straining of stool evacuation.
Prepare patient for surgery as warranted.
Instruct patient/family regarding signs and symptoms of stroke, importance of seeking medical attention promptly, and modifying lifestyle risk factors.
Impaired Cerebral verbal communication
Related to :CVA ,weakness, loss of muscle control, cerebral circulation, impairment.
Inability to speak, inability to identify objects, inability to comprehend language, inability to write, iaability to choose and use appropriate words dysarthia.
Patient will be able to communicate normally or will be able to make needs known by some form of communication.