stroke presentation.ppt

Brain
• The brain is divided into three major areas: the cerebrum,
the brain stem, and the cerebellum.
• The cerebrum is composed of two hemispheres, the
thalamus/ the hypothalamus and the basal ganglia.
• The brain stem includes the midbrain, pons, and medulla.
• The cerebellum is located under the cerebrum and behind
the brain stem

-wrinkled appearance –gyri
-right and left hemispheres-corpus callosum.
-The external or outer portion of the hemispheres (the cerebral cortex) made up of gray contains
billions of neuron
-The cerebral hemispheres are divided into lobes

BRAIN LOBES

Brainstem

Brainstem
• Brain Stem consists of the midbrain, pons, and medulla oblongata
• The midbrain connects the pons and the cerebellum with the cerebral
hemispheres; it contains sensory and motor pathways and serves as the center
for auditory and visual reflexes. Cranial nerves III and IV originate in the
midbrain.
• The pons is bridge between the two halves of the cerebellum, and between the
medulla and the midbrain. Cranial nerves V through VIII originate in the pons.
The pons also contains motor and sensory pathways. Portions of the pons help
regulate respiration.
• Medulla, Motor fibers from the brain to the spinal cord and sensory fibers from
the spinal cord to the brain are located in the medulla. Most of these fibers
cross, or decussate, at this level. Cranial nerves IX through XII originate in the
medulla. Reflex centers for respiration, blood pressure, heart rate, coughing,
vomiting, swallowing, and sneezing are also located in the medulla.

Strokes can be divided into two major categories:
• ischemic in which vascular occlusion and significant
hypoperfusion occur, and hemorrhagic in which there is
extravasation of blood into the brain or subarachnoid space
• Although there are some similarities between the two types of
stroke, differences exist in etiology, pathophysiology, medical
management, surgical management, and nursing care.

Ischemic Stroke
ischemic stroke, also known as a
cerebrovascular accident (CVA), or “brain
attack” is a sudden loss of function
resulting from disruption of the blood
supply to a part of the brain.

Types of plegia

Glossary of Neurosurgical Terminology
• ACOUSTIC NEUROMAS - Benign tumor of the hearing nerve (eighth nerve).
• AGNOSIA - Absence of the ability to recognize the form and nature of persons
and things.
• AGRAPHIA - Inability to write due either to muscular coordination issues or to
an inability to phrase thought.
• AMNESIA - Loss of memory caused by brain damage or by severe emotional
trauma.
• ANGIOGRAM - A medical imaging report that shows the blood vessels leading
to and in the brain, obtained by injecting a dye or contrast substance through a
catheter.

• APHASIA - Difficulty with or loss of use of language in any of
several ways, including reading, writing or speaking, not related
to intelligence but to specific lesions in the brain.
• ATAXIA - A loss of muscular coordination, abnormal clumsiness.
• BELL'S PALSY - Paralysis of facial muscles (usually one side)
due to facial nerve dysfunction ( 7th cranial nerve )of unknown
cause.
• BRADYKINESIA - Slowness in movement.
• BROWN-SEQUARD'S SYNDROME - Loss of sensation of touch,
position sense and movement on the side of a spinal cord lesion,
with loss of pain sensation on the other side. Caused by a lesion
limited to one side of spinal cord.

• CHOREA - A disorder, usually of childhood, characterized by
irregular, spasmodic involuntary movements of the limbs or facial
muscles.
• CONCUSSION - A disruption, usually temporary, of neurological
function resulting from a blow or violent shaking.
• CRANIECTOMY - Excision of a portion of the skull.
• CRANIOTOMY - Opening of the skull, usually by creating a flap
of bone.
• DIPLOPIA - Double vision, due usually to weakness or paralysis
of one or more of the extra-ocular muscles.
• DYSESTHESIA - A condition in which ordinary touch,
temperature or movement produces a disagreeable sensation.

• DYSPHASIA - Difficulty in the use of language due to a brain
lesion without mental impairment.
• Dysphagia is the medical term for swallowing
difficulties.
• Dystonia is a movement disorder that causes the
muscles to contract involuntarily.
• ELECTROENCEPHALOPGRAHY (EEG) - The study of the
electrical currents set up by brain actions; the record made is
called an electroencephalogram.
• ELECTROMYOGRAPHY (EMG) - A method of recording the
electrical currents generated in a muscle during its contraction.
• ENDARTERECTOMY - Removal of fatty or cholesterol plaques
and calcified deposits from the internal wall of an artery.

• EPILEPSY - Disorder characterized by abnormal electrical
discharges in the brain, causing abnormal sensation, movement
or level of consciousness.
• HEMIANOPIA - Loss of vision of one-half of the visual field.
• HYDROCEPHALUS - A condition, often congenital, marked by
abnormal and excessive accumulation of cerebrospinal fluid in
the cerebral ventricles. This dilates the ventricles and, in infants
and young children, causes the head to enlarge.
• HYPERESTHESIA - Excessive sensibility to touch, pain or other
stimuli.
• MENINGITIS - An infection or inflammation of the membranes
covering the brain and spinal cord.

• MYELOPATHY - Any functional or pathologic disturbance in the
spinal cord.
• MYOPATHY - Any disease of muscle.
• NEURALGIA - A paroxysmal pain extending along the course of
one or more nerves.
• NEUROPATHY - Any functional or pathologic disturbance in the
peripheral nervous system.
• NYSTAGMUS - Involuntary rapid movement of the eyes in the
horizontal, vertical or rotary planes of the eyeball.
• PAPILLEDEMA - Swelling of the optic nerve head that can be
seen in the back of the retina during eye examination.

• PROPRIOCEPTION - Sensation concerning movements of joints
and position of the body in space.
• SHUNT - A tube or device implanted in the body to divert excess
CSF away from the brain to another place in the body.
• STRABISMUS - Deviation of eye movement that prevents the
two eyes from moving in a parallel fashion.
• TRIGEMINAL NEURALGIA - Paroxysmal pain in the face. Pain
may be so severe that it causes an involuntary grimace or "tic".
Also called Tic Douloureux. 5th cranial nerve dysfunction
• VERTIGO - An abnormal sensation of rotation or movement of
one's self or the environment

Stroke assessment

Los Angeles Prehospital Stroke Screen
Screening criteria
• No history of seizures or epilepsy
• Age 45 years or older
• At baseline, patient is not wheelchair bound or bedridden
• Blood glucose between 60 and 400 mg/dL
• Obvious asymmetry-unilateral weakness with any of the following motor exams:
• Facial Smile/Grimace
• Grip
• Arm Strength
• If all of the above criteria are met (or not ascertainable) the LAPSS is positive
for stroke. Patients may still be experiencing a stroke even if LAPSS criteria are
not met.

NIH SCALE
• NIHSS (National Institute of Health Stroke Scale)
– Standardized method used by health care professionals to measure the
level of impairment caused by a stroke
– Purpose
• Main use is as a clinical assessment tool to determine whether the
degree of disability is severe enough to warrant the use of tPA
• Another important use of the NIHSS is in research, where it allows
for the objective comparison of efficacy across different stroke
treatments and rehabilitation interventions
– Scores are totaled to determine level of severity
– Can also serve as a tool to determine if a change in exam has occurred

Transient Ischemic Attack (TIA)
• Temporary neurologic deficit resulting from a temporary
impairment of blood flow
• “Warning of an impending stroke”
• Diagnostic workup is required to treat and prevent
irreversible deficits

Manifestations of Ischemic Stroke
Symptoms depend on the location
and size of the affected area

Medical Management
• Prevention: control of hypertension
• Diagnosis: CT scan, cerebral angiography, lumbar
puncture if CT is negative and ICP is not elevated to
confirm subarachnoid hemorrhage
• Care is primarily supportive
• Bed rest with sedation
• Oxygen
• Treatment of vasospasm, increased ICP, hypertension,
potential seizures, and prevention of further bleeding

ICP management

Treatment of cerebral spasms
Calcium Channel Blockers
Nimodipine (Nimotop, Nymalize)
Nimodipine has been recommended as first-line medical treatment for preventing post-aSAH cerebral
vasospasm. It is usually given orally at a dosage of 60 mg every 4 hours for 21 days after the initial
subarachnoid hemorrhage.
Fasudil – anti spasm and vasodilator
Statins
atorvastatin (Lipitor),
• fluvastatin (Lescol),
• lovastatin (Mevacor, Altocor)
• pravastatin (Pravachol),
• rosuvastatin (Crestor),
• simvastatin (Zocor ), and.
• pitavastatin (Livalo).
Magnesium

t-PA Can be Administered Within 4.5 hours After the Onset of Stroke
t-PA is truly a silver bullet for cerebral infarction (ischemic stroke).
It works by dissolving the blood clot that formed in the brain and
restores blood flow. It is usually given through a vein in the arm
(intravenous injection).

Eligibility Criteria for Tissue Plasminogen
Activator Administration
• Age ≥18 years
• • Clinical diagnosis of ischemic stroke
• • Time of onset of stroke known and is within center guidelines
• • Systolic blood pressure ≤185 mm Hg; diastolic ≤110 mm Hg
• • No minor stroke or rapidly resolving stroke
• • No seizure at onset of stroke
• • Not taking warfarin (Coumadin)
• • Prothrombin time ≤15 seconds or international normalized ratio ≤1.7
• • Not received heparin during the past 48 hours with elevated partial
• thromboplastin time
• • Platelet count ≥100,000/mm3
• • No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or
• aneurysm
• • No major surgical procedures within 14 days
• • No stroke, serious head injury, or intracranial surgery within 3 months

Dosage and Administration
The patient is weighed to determine the dose of t-PA.
Typically, two or more IV sites are established prior to
administration of t-PA (one for the t-PA and the other for
administration of IV fluids).
The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90
mg. Ten percent of the calculated dose is administered as an
IV bolus over 1minute. The remaining dose (90%) is
administered IV over 1 hour via an infusion pump
Intracranial bleeding is a major complication

Cerebral circulation ( circle of Willis )

• The circle of Willis is a part of the cerebral circulation and is
composed of the following arteries:
• Anterior cerebral artery (left and right)
• Anterior communicating artery
• Internal carotid artery (left and right)
• Posterior cerebral artery (left and right)
• Posterior communicating artery (left and right)
• The middle cerebral arteries, supplying the brain, are not
considered part of the circle of Willis.

Epidural hemorrhage

Subdural hemorrhage

Intraventricular hemorrhage

Subarachnoid hemorrhage

Preventive Treatment and Secondary
Prevention
• Health maintenance measures including a healthy diet,
exercise, and the prevention and treatment of
periodontal disease
• Carotid endarterectomy
• Anticoagulant therapy
• Antiplatelet therapy: aspirin, dipyridamole plus aspirin
(Aggrenox), clopidogrel (Plavix)
• “Statins”
• Antihypertensive medications

Medical Management: Acute Phase of
Stroke
• Prompt diagnosis and treatment:
• Assessment of stroke: assessment tools
• Thrombolytic therapy
– Criteria for tPA
– IV dosage and administration
– Patient monitoring
– Side effects: potential bleeding
• Elevate head of bed (HOB) unless contraindicated
• Maintain airway and ventilation
• Continuous hemodynamic monitoring and neurologic
assessment

Nursing Process: The Patient Recovering
From an Ischemic Stroke—Assessment
• Acute phase
– Ongoing, frequent monitoring of all systems,
including vital signs and neurologic assessment—
LOC, motor symptoms, speech, eye symptoms
– Monitor for potential complications, including
musculoskeletal problems, swallowing difficulties,
respiratory problems, and signs and symptoms of
increased ICP and meningeal irritation
• After the stroke is complete
– Focus on patient function; self-care ability, coping,
and education regarding needs to facilitate
rehabilitation

From an Ischemic Stroke—Diagnoses
• Impaired physical mobility
• Acute pain
• Self-care deficits
• Disturbed sensory perception
• Impaired swallowing
• Urinary incontinence
• Disturbed thought processes
• Impaired verbal communication
• Risk for impaired skin integrity
• Interrupted family processes
• Sexual dysfunction

Communicating With the Patient With Aphasia
• Face the patient and establish eye contact.
• Speak in a usual manner and tone.
• Use short phrases, and pause between phrases to allow the
patient time to
understand what is being said.
• Limit conversation to practical and concrete matters.
• Use gestures, pictures, objects, and writing.

Improving Mobility and Preventing Joint
Deformities
• Turn and position in correct alignment every 2 hours
• Use of splints
• Passive or active ROM four or five times day
• Positioning of hands and fingers
• Prevention of flexion contractures
• Prevention of shoulder abduction
• Do not lift by flaccid shoulder
• Measures to prevent and treat shoulder problems

From an Ischemic Stroke—Planning
• Major goals may include
– Improved mobility
– Avoidance of shoulder pain
– Achievement of self-care
– Relief of sensory and perceptual deprivation
– Prevention of aspiration
– Continence of bowel and bladder
– Improved thought processes
– Achieving a form of communication
– Maintaining skin integrity
– Restored family functioning
– Improved sexual function
– Absence of complications

Improving Mobility and Preventing Joint
Deformities
• Encourage patient to exercise unaffected side
• Establish regular exercise routine
• Quadriceps setting and gluteal exercises
• Assist patient out of bed as soon as possible; assess and
help patient achieve balance; move slowly
• Ambulation training

Interventions
• Enhancing self-care
– Set realistic goals with the patient
– Encourage personal hygiene
– Ensure that patient does not neglect the affected side
– Use of assistive devices and modification of clothing
• Support and encouragement
• Strategies to enhance communication
• Encourage patient to turn head, look to side with visual
field loss

Interventions (cont’d)
• Nutrition
– Consult with speech therapy or nutritional services
– Have patient sit upright, preferably out of bed, to eat
– Chin tuck or swallowing method
– Use of thickened liquids or pureed diet
• Bowel and bladder control
– Assessment of voiding and scheduled voiding
– Measures to prevent constipation: fiber, fluid,
toileting schedule
– Bowel and bladder retraining

Nursing Process: The Patient With a
Hemorrhagic Stroke—Assessment
• Complete and ongoing neurologic assessment; use
neurologic flow chart
• Monitor respiratory status and oxygenation
• Monitoring of ICP
• Patients with intracerebral or subarachnoid hemorrhage
should be monitored in the ICU
• Monitor for potential complications
• Monitor fluid balance and laboratory data
• All changes must be reported immediately

Hemorrhagic Stroke—Diagnoses
• Ineffective tissue perfusion (cerebral)
• Disturbed sensory perception
• Anxiety

Collaborative Problems and Potential
Complications
• Vasospasm
• Seizures
• Hydrocephalus
• Re-bleeding
• Hyponatremia

Hemorrhagic Stroke—Planning
• Goals may include:
– Improved cerebral tissue perfusion
– Relief of sensory and perceptual deprivation
– Relief of anxiety
– The absence of complications

Aneurysm Precautions
• Absolute bed rest
• Elevate HOB 30 degrees to promote venous drainage or
flat to increase cerebral perfusion
• Avoid all activity that may increase ICP or BP; Valsalva
maneuver, acute flexion or rotation of neck or head
• Exhale through mouth when voiding or defecating to
decrease strain
• Prevent constipation

Interventions
• Relieving sensory deprivation and anxiety
• Keep sensory stimulation to a minimum for aneurysm
precautions
• Realty orientation
• Patient and family education
• Support and reassurance
• Seizure precautions
• Strategies to regain and promote self-care and
rehabilitation

Home Care and Education for the Patient
Recovering from a Stroke
• Prevention of subsequent strokes, health promotion, and
follow-up care; refer to Chart 67-6
• Prevention of and signs and symptoms of complications
• Medication education
• Safety measures
• Adaptive strategies and use of assistive devices for ADLs
• Nutrition: diet, swallowing techniques, tube feeding
administration
• Elimination: bowel and bladder programs, catheter use
• Exercise and activities, recreation and diversion
• Socialization, support groups, and community resources

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