This powerpoint presentation will help to understand the concept of Stroke and its management.

1. STROKESTROKE
(CEREBRO VASCULAR(CEREBRO VASCULAR
ACCIDENT)ACCIDENT)
Ms Tarika Sharma
Assistant Professor
MMCON, MMU, Ambala

2. Introduction
 “ Cerebrovascular disorders” is an umbrella term
that refers to any functional abnormality of the
central nervous system (CNS) that occurs when
the normal blood supply to the brain is disrupted.
 Stroke is the primary cerebrovascular disorder in
the world.

3. Stroke/ brain attack : Definition
 The abrupt development of a focal
neurological deficit as a consequence of
disturbance in cerebral circulation , or
irreversible brain injury resulting from
cerebral ischemia.

4. Epidemiology
 Stroke is the third leading cause of death in the Western
world, after heart disease and cancer, and causes 10%
of world-wide deaths.
 It is a major health problem in India also. Overall,
ischemic strokes account for about 80% of all strokes
in India and intracranial atherosclerosis tends to be
commoner in Indian people.

5. Non Modifiable Risk factors
 Sex
– the incidence of stroke is greater in males (3:2 ratio).
 Age
– Stroke can occur in patients of all ages, including children.
– Risk of stroke increases with age, especially in patients
older than 64 years, in whom 75% of all strokes occur.

6. Non Modifiable Risk factors…
• Race: African Americans are most affected
by stroke.
• Previous history of stroke
• Family history: Heredity, positive family
history

7. Modifiable Risk factors
• Hypertension
• Heart disease
• Smoking
• Excessive alcohol
consumption
• Obesity, Stress
• Sleep apnea
• Metabolic syndrome
• Poor diet
• Drug abuse
• Oral contraceptives

8. Cerebral blood flow
 Four vessels supply the brain :
– Two vertebral arteries
– Two carotid arteries

9. Circle of willis

11. Types of stroke
– Ischemic stroke :(80-85%)
• Thrombotic stroke
• Embolic stroke
– Hemorrhagic stroke(15-20%)
• SAH
• ICH

13. Types of stroke

14. Emboli

15. Ischemic stroke
 A blood vessel becomes occluded and the
blood supply to part of the brain is totally
or partially blocked
 Ischemic stroke is commonly divided into
thrombotic stroke,
embolic stroke

16. Thrombotic stroke
 In thrombotic stroke, a thrombus-forming process
develops in the affected artery.
 The thrombus — a built up clot — gradually
narrows the lumen of the artery and impedes blood
flow to distal tissue.
 These clots usually form around atherosclerotic
plaques. Since blockage of the artery is gradual,
onset of symptomatic thrombotic strokes is slower.

17. Types of Thrombotic stroke
 Thrombotic stroke can be divided into two types
depending on the type of vessel the thrombus is
formed on:
 Large vessel disease
 Small vessel disease

18. Embolic stroke
 Embolic stroke refers to the blockage of arterial
access to a part of the brain by an embolus.
 The onset of an embolic stroke is usually sudden.

19. Types
 Large artery thrombosis (20%),
 Small penetrating artery thrombosis (25%),
 Cardiogenic embolic stroke (20%),
 Cryptogenic (30%) and other (5%)

20. Hemorrhagic stroke
 A hemorrhagic stroke, or cerebral
hemorrhage, is a form of stroke that occurs
when a blood vessel in the brain ruptures
or bleeds.
 Types: intracerebral hemorrhage, and
subarachnoid hemorrhage

21. Intracerebral hemorrhage
 Intracerebral hemorrhage (ICH) is
bleeding directly into the brain tissue,
forming a gradually enlarging hematoma
(pooling of blood).
 The hematoma enlarges until pressure
from surrounding tissue limits its growth,
or until it decompresses by emptying into
the ventricular system, CSF

22. Subarachnoid hemorrhage
 Subarachnoid hemorrhage (SAH) is bleeding into
the cerebrospinal fluid (CSF) of the subarachnoid
space surrounding the brain.
 The two most common causes of SAH are
rupture of aneurysms from the base of the brain
and bleeding from vascular malformations near
the pial surface

23. Causes of H. stroke
 Hypertension
 Bleeding disorders
 Angiopathy
 Drugs (cocaine, methamphetamines)
 Aneurysm
 Inflammatory diseases of arteries

24. 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 mts.
 Also called as “little strokes”.
 40% of the client develop stroke in 5 yrs.

25. Clinical Manifestations
 Numbness or
weakness of the face,
arm, or leg, especially
on one side of the
body
• Confusion or change
in mental status
 • Trouble speaking or
understanding speech
• Visual disturbances
• Difficulty walking,
dizziness, or loss of
balance or coordination
• Sudden severe
headache

26. Clinical Manifestations…
 Hemiplegia
Hemiparesis
flaccid paralysis, loss
of or decrease in the
deep tendon reflexes.
Dysarthria
Dysphasia or aphasia
 Homonymous
hemianopsia
 Difficulty seeing at
night
• Unaware of objects or
the borders of objects
• Double vision
Ataxia
Dysphagia

27. Clinical Manifestations…
• Feelings of isolation
• Trouble speaking or
understanding speech
• Visual disturbances
• Difficulty walking,
dizziness, or loss of
balance or coordination
• Sudden severe headache
• Altered judgment
Loss of self-control
• Emotional lability
• Decreased tolerance to
stressful situations
• Depression
• Withdrawal
• Fear, hostility, and anger

28. Clinical Manifestations…
 Paresthesia (occurs on
the side opposite the
lesion)
 Short- and long-term
memory loss
• Decreased attention
span
• Impaired ability to
concentrate
• Poor abstract
reasoning

29. Homonymous hemianopia

30. Hemorrhagic stroke (Sp. S/S)
 Sudden, unusually severe headache
 Loss of consciousness for a variable period.
 Pain and rigidity of the back of the neck (nuchal
rigidity) and spine due to meningeal irritation.
 Visual disturbances (visual loss, diplopia, ptosis) occur
when the aneurysm is adjacent to the oculomotor nerve.
 Tinnitus, dizziness, and hemiparesis may also occur.

31. Diagnosis
 Careful history, complete physical and
neurologic examination.(TIA, a bruit )
 12-lead electrocardiogram
 Carotid ultrasonography.
 CT
 MRI
 Echocardiography

32. Diagnosis…
 CSF Analysis
 Toxicology screen for illicit drug use.
cerebral angiography
 Transcranial Doppler flow studies
 Single photon emission CT

34. Emergency Management
 Oxygenation @ 2-4 l/mt
 Cardiac and pulse oximetry monitoring
 Vital sign monitoring
 IV lines
 Medications
 Radiology
 NPO

35. Medical mx of stroke
 Ischemic stroke :
– Within 3 hrs. r-tPA is given(0.9 mg/kg)
• Eligibility criteria :
– Age >18 yrs.
– Diagnosis of ischemic stroke
– Comes within 3 hrs of onset

36. Medical mx of stroke …
 Contraindications :
• Symptoms suggestive of Subarachnoid
hemorrhage
• 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

37. Medical mx
 Heparin, Streptokinase
 Antihypertensive :
– Are given rarely to reduce the BP in acute phase
 Anticoagulation :
– Anti platelets and Anti Thrombolytic e.g. Heparin, low
dose aspirin × 4 to 10 days.
– Long term anticoagulants e.g. warfarin
 Vasodilators: Nitroglycerin
 Anticonvulsants : Phenytoin

38. Surgical mx
 Craniotomy for evacuation of hematoma,
AVM repair etc.
 Carotid endarterectomy

39.  Percutaneous
transluminal
angioplasty
 Carotid stenting

40. NURSING MANAGEMENT

41. Nursing management
 Assessment :
– Neurological assessment
– Vital signs
– Careful history
– ABC
 Ongoing Monitoring

42. Ineffective cerebral perfusion
Interventions:
 Assessments-ICP,GCS,BP,MAP,bradycardia,pattern of
breathing,pupil size or response to light,head
ache,vomiting.
 Maintain BP with in prescribed range
 Normothermia
 Reduce unnecessary movements & stimulation
 Elevate head

43. Ineffective cerebral perfusion cont…
 Neutral head position
 Administer medications as prescribed
 Delirium & restlessness should be controlled
 No physical restraints
 Avoid causes of restlessness, e.g. full bladder
 Temperature regulation
 Avoid straining at stool or with excessive
coughing,vomiting

44. Risk for prolonged bleeding times
 Monitor all puncture sites and body fluids for s/s of
bleeding
 Maintain bed rest
 Monitor aPPT& INR& adjust dosage of thrombolytics
& anticoagulants
 No arterial puncture or insertion of NG tube-24hrs

45. Increased risk for aspiration
 Caution in feeding
 Assess manifestations - fever, dyspnea,
crackles,confusion & decreased PaO2
 Monitor chest X- Ray

46. Impaired physical mobility r/t
paralysis
Positioning
• Change the position 2 hrly
• Allow him to sit upright for short duration only
• Do not place a pillow under the affected knee
• Avoid acute hip flexion
• Position him in prone position for 10-15 mts
• Prevent foot drop by using footboard
• ROM exercises
• Trochanter roll to prevent external hip rotation
• Support the affected leg when changing the position

47. Impaired physical mobility r/t paralysis
– Prevent the adduction of the
affected shoulder by placing a
pillow in the axilla to keep the
arm abducted at 600
– Keep the arm in slightly in a
neutral position
– Give a ball or something to
squeez in the hand of the
patient.

48. Impaired physical mobility r/t paralysis
Contd….
 Exercises in bed :
• Initially passive exercises in bed
• Teach him to lift his affected leg by sliding the non affected
leg under that.
• Hourly gluteal and quadriceps exercises
• ROM 4 times/d
• Do not force the extremities beyond the point of initiating
pain or continuous spasm
• Encourage the client in assisted movements
• As strength improves, resisted movements strengthen the
muscles
• Support the flaccid limb in a sling while the client is
walking and on a pillow when in bed.
• Teach him to lift the affected hand with non affected hand.

49. Impaired physical mobility r/t paralysis
Contd….
 Sitting up :
– Raise the head end of the bed slowly
– Help him to sit up by supporting the affected side
 Wheel chair

50. Self care deficit r/t paralysis
– First promote all activities with unaffected
side
– Help them in using paralyzed arm as much as
possible and avoid a tendency to do everything
with affected arm.
– When they can sit up, encourage them to use
the affected limb

51. Pain r/t hemiplegia
 Painful shoulder, subluxation (incomplete
or partial dislocation) : 70% pts
 Never lift the patient from by the flaccid shoulder
 R.O.M exercises
 Avoid oversternous arm movements
 Analgesia

52. Risk for impaired skin integrity
 Assess skin 2hrly
 Pressure relieving devices
 Support the affected arm and leg when turning
 Place a pillow between legs
 Not more than 30mts on affected side
 Skin care
• Dry and clean
• Gentle massage
• Adequate nutrition

53. Risk for contracture due to flaccid
paralysis
 ROM
 Allow sit upright for short periods
 Don’t flex hip acutely
 No pillow under the affected knee when supine
 If knee hyper extended place a folded towel
under it

54. Risk for injury
Keep the side rails up
Frequent skin inspection
 Safe environment
Effective lighting
Don’t leave the client alone in bathroom
Remined pt to walk slowly,rest
adequately

55. Altered nutrition:less than body
requirements
 Intake and output
 Body weight
 Food to be served attractively & at appropriate temp
 Small meals
 To facilitate feeding
Promote head control
Assist in positioning
Promote mouth opening
Stimulate mouth closing
Help in swallowing
If necessary give NG feeding

56. Impaired verbal communication
 Speech therapy
 Picture board
 Encourage & support
 Speak at slow rate
 Give adequate time to
respond
 Keep extraneous noises to
 Listen & watch carefully
 Don’t shout, pt can hear
 Face the pt, eye contact
 Stand within 6 feet
 Use gestures & one-step
commands

57. Risk for corneal abrasion
 Protect the eye with an eye patch if not
blinking
 Do eye care 2hrly
 Instill prescribed artificial tears

58. Disturbed sensory perception
 Approach the pt from the side that is not
visually impaired
 Keep call light & telephone on that side
 Adequate lighting

59. Ineffective coping
 Be understanding & kind
 Support &praise all successes
 Client need to feel listened to &cared
about
 Arrange the envt & anticipate needs
to reduce frustration
 Break a long term goal into several
short term goals

60. Ineffective family coping r/t family
member in disease.
 Support System
 Counseling
 Tell expected outcomes

61. RehabilitationRehabilitation

62. Rehabilitation
 DISCHARGE TEACHING
 Realistic expectations
 Plan for exercise
 Provide written documentation of any
anticoagulant schedule & a list of warning signs
of bleeding
 Client to be taught to wear Medic-Alert
identification
 Provide information about community resources

63. Prevention
 Primary prevention
 Secondary prevention

64. Complications
 Cerebral edema
 Seizures
 Increased ICP
 Pulmonary embolism
 Aspiration
 Contractures
 Infections
 Respiratory depression
 Bladder and bowel
incontinence
 Depression
 Falls
 Spasticity
 Aphasia
 Deep vein thrombosis
 Coma

65. Summary
 Definition
 Epidemiology
 Blood supply to brain
 Types of stroke
 Risk factors
 Warning signs
 Sign and symptoms
 Medical management
 Nursing management

66. Conclusion
 As stroke is third leading cause of death
world wide, leads to neurological deficits
in the patients suffering from it.
 So nurses being health professionals
should use effective strategies and best
practices for prevention of complications
and rehabilitation of these patients.

67. Thank You…