INTRODUCTION / DEFINITION
–Cerebral Vascular Accident
–Condition in which neurological deficits result from decreased
blood flow to the brain
–3rd Leading cause of death in North America
–600,000 (approx.) CVA victims per year
–At least 80% of CVA victims survive
–Many survivors are left with functional impairments.
CLASSIFICATIONS / CATEGORIES
•Two basic categories
•More specific causes
•More specific causes (cont.)
–Hemorrhage may occur:
•Outside the dura mater
•Beneath the dura mater
•In the subarachnoid space
•Within the brain substance (ICH)
CLASSIFICATIONS / CATEGORIES (continued)
–Blood supply to part of the brain is suddenly interrupted by:
•TIA’s (transient ischemic attack)
–Blood vessel breaks and spills blood into the brain
•Localized cerebral ischemia which causes temporary
•Considered to be a warning signal for ischemic CVA’s
–Inflammatory artery disorders
–Sickle cell anemia
–Atherosclerotic changes in cerebral vessels
–Subclavian Steal Syndrome
–Depend upon location and size of cerebral vessel involve
–Sudden onset with disappearance within minutes, hours or a
couple of days
–Contra-lateral numbness or weakness of hand, forearm, corner of
mouth (middle cerebral artery)
–Visual disturbances such as blurring (posterior cerebral artery)
–Occlusion of a large cerebral vessel by a thrombus
–Often seen in older people who are resting or sleeping
–Clots tend to form in:
•Large arteries that bifurcate and . . .
•Narrowed lumens as a result of atherosclerotic plaque
•Internal carotid artery
•Junction of vertebral and basilar arteries
–Thrombotic strokes which affect smaller cerebral vessels and
leave small cavities or “lakes”
–Occur rapidly but usually progress slowly
–May start as TIA and worsen (“stroke-in-evolution”)
–Maximum neurological damage usually reached in 3 days
–Affected area is edematous & may become necrotic
–Most frequent site: bifurcation of vessels (carotid and middle
–Most embolic CVA’s originate from thrombi in the left chamber of
the heart during atrial fibrillation.
–Other sources of emboli
•Defined as “intracranial hemorrhage”
•Occur when cerebral blood vessel ruptures
–Sustained increase in BP
–Erosion of blood vessels by tumors
–Blood vessel ruptures and blood enters tissues, cerebral
ventricles or subarachnoid space. This leads to . . .
•Compression of adjacent tissues causing . . .
•Blood vessel spasms and cerebral edema
–Blood in ventricles or subarachnoid space irritates meninges &
brain tissue causing . . .
•Inflammatory reaction and . .
•Impairing absorption and circulation of CSF
–Onset of S/Sx is rapid unless bleed is a slow leak.
–Depend upon location of hemorrhage
•S/Sx of increased intracranial pressure
•LOC (loss of consciousness)
TYPICAL SIGNS/SYMPTOMS OF CVA’s
–Confusion / Disorientation
–Memory impairment & other mental changes
–Sclerosis of peripheral vessels & retinal vessels
•Left Brain Injury
–Dysphasia / aphasia / agraphia
–Frequently understand more than they can speak or write.
•Right Brain Injury
–Difficulty with spatial-perceptual tasks:
•Rate of movement
•Relationship of parts to the whole
–Impaired time perception
–Errors are inconsistent
•Often unaware of deficits
•Perform unsafe activities
•May have visual field cuts
–Eat food only on one side of the plate.
–Ignore person who approaches impaired side.
–Fail to attend to one side of the body.
•Put makeup on one side of the face only.
•Arteriography of cerebral vessels
•PET (positron emission tomography)
•Doppler (transcranial ultrasound)
•Lumbar puncture (if no danger of ↑ ICP)
MANAGEMENT OF CLIENTS
WITH BRAIN ATTACKS
•Treatment depends on severity, nature and extent of
•Treatment is directed toward:
–Minimizing residual deficits.
–Reducing ICP (intracranial pressure).
–Preventing extension of manifestations.
–Preventing recurrence of brain attack.
•Frequent neuro-checks, vital signs and general assessment
•Observe for signs of progression of thrombosis or
–Increased loss of motor or sensory function
–Increased respiratory difficulty
•Ensure F&E balance
•Maintain proper positioning & alignment
•Maintain adequate elimination
•Prevent constipation / impaction
•Involve significant others in plan of care
•Provide restful, quiet environment
•Administer meds as ordered
•If eyelids remain open protect the eye:
–Sterile saline (no preservatives)
•Prevent intellectual regression
–Talk with client
–Post date, nurse’s name
–Place clock where client can easily see it
BE SURE TO REVIEW CRANIAL NERVES
(number, name, symptoms of deficits, assessment and
A & P of the