• Cerebral vascular accident (CVA) (stroke) is the
disruption of the blood supply to the brain, resulting
in neurological dysfunction.
• Results from ischemia to a part of the brain or
hemorrhage into the brain that results in death of
Atherosclerosis: major cause of CVA
Thrombus formation & emboli development
Abnormal filtration of lipids in the intimal layer of the arterial wall
Plaque develops & locations of increased insecurity of blood division
Increased turbulence of blood or a indirect area
Calcified plaques rupture or fissure
Platelets & fibrin stick to the plaque
Narrowing or blockage of an artery by thrombus or emboli
Cerebral Infarction: blocked artery with blood supply cut off
beyond the blockage
Ischemic Stroke—inadequate blood flow to the brain from partial or
complete occlusions of an artery--85% of all strokes
– Extent of a stroke depends on:
• Rapidity of onset
• Size of the lesion
• Presence of collateral circulation
– Symptoms may progress in the first 72 hours as infarction & cerebral
Types of Ischemic Stroke:
Ischemic – Embolic Stroke
Embolus lodges in and occludes a cerebral artery
Results in infarction & cerebral edema of the area supplied
by the vessel
Second most common cause of stroke – 24%
Emboli originate in endocardial layer of the heart – at, MI,
infective endocarditis, rheumatic heart disease
Rapid occurrence with severe symptoms – body does not
have time to develop guarantee circulation
Any age group
Recurrence common if underlying cause not treated
Causes of Cerebral Vascular Accidents
(1) Thrombosis--blood clot within a blood vessel in the
brain or neck.
(2) Cerebral embolism.
(3) Stenosis of an artery supplying the brain.
(4) Cerebral hemorrhage--rupture of a cerebral blood
vessel with bleeding/pressure into brain tissue.
Signs and Symptoms
(1) Highly dependent upon size and site of lesion.
(2) Motor loss--hemiplegia (paralysis on one side of the
side) or hemiparesis (motor weakness on one side of
(3) Communication loss.
(a) Receptive aphasia (inability to understand the
(b) Expressive aphasia (inability to speak).
(4) Vision loss.
(5) Sensory loss.
(6) Bladder impairment.
(7) Impairment of mental activity.
(8) In most instances onset of symptoms is very sudden.
(a) Level of consciousness may vary from lethargy, to
mental confusion, to deep coma.
(b) Blood pressure may be severely elevated due to
increased intracranial pressure.
(c) Patient may experience sudden, severe, headache
with nausea and vomiting.
(d) Patient may remain comatose for hours, days, or even
weeks, and then recover.
(e) Generally, the longer the coma, the poorer the
(9) ICP is a frequent complication resulting from
hemorrhage or ischemia and subsequent cerebral
Right Brain – Left Brain Damage
Rehabilitation of the patient with CVA
• Process of setting goals for rehabilitation must include
the patient. This increases the likelihood of the goals
• General rehabilitative tasks faced by the patient
• Learning to use strength and abilities that are intact to
compensate for impaired functions.
• Learning to become independent in activities of daily
living (bathing, dressing, eating).
• Developing behavior patterns that are likely to prevent
the recurrence of symptoms.
• Taking prescribed medications.
• Stopping smoking.
• Reducing day-to-day stress.
• Modifying diet.
4) Specific teaching, encouragement, and support are needed.
(5) Individualized exercise program involving both affected and unaffected
extremities is required.
(6) Speech therapy, as indicated by patient's condition, may be necessary.
(7) Continuous revaluation of goals and patient's ability to meet the goals
is required to maintain a realistic plan of care.
(8) Counseling and support to family is an integral part of the
(a) Both family and patient need direction and support in coping with
intellectual and personality impairment.
(b) Instruct family to expect some emotional lability such as inappropriate
crying, laughing, or outbursts of temper.
TIA (Transient ischemic attack)
A transient ischemic attack (TIA) is when blood flow to a part of the brain
stops for a brief period of time. A person will have stroke-like symptoms
for up to 1-2 hours.
A TIA is felt to be a warning sign that a true stroke may happen in the
future if something is not done to prevent it.
A signal for major stroke in future
Clinical features may be hemiparesis, aphasia, sensory disturbances etc.
Brain imaging is strongly recommended to rule out small hemorrhage.
distinguish time for implementation of secondary preventive measures
• A blood clot in an artery of the brain
• A blood clot that travels to the brain from
somewhere else in the body (for example,
from the heart)
• An injury to blood vessels
• Narrowing of a blood vessel in the brain or
leading to the brain
Causes, incidence, and risk factors
• A TIA is different than a stroke. After a TIA, the blockage breaks up
quickly and dissolves. Unlike a stroke, a TIA does not cause brain
tissue to die.
• The loss of blood flow to an area of the brain
• High blood pressure is the number one risk for TIAs and stroke. The
other major risk factors are:
• Family history of stroke
• High cholesterol
• Increasing age, especially after age 55
• People who have heart disease or poor blood flow in their legs
caused by narrowed arteries are also more likely to have a TIA or
• Symptoms begin suddenly, last only a short time (from a
few minutes to 1 - 2 hours), and go away completely. They
may occur again at a later time.
• The symptoms of TIA are the same as the symptoms of a
stroke and include sudden:
• Abnormal feeling of movement (vertigo) or dizziness
• Change in alertness (sleepiness, less responsive,
unconscious, or in a coma)
• Changes in feeling, including touch, pain, temperature,
pressure, hearing, and taste
• Confusion or loss of memory
• Difficulty swallowing
• Almost always, the symptoms and signs of a TIA will have
gone away by the time you get to the hospital. A TIA diagnosis
may be made based on your medical history alone.
• The health care provider will do a complete physical exam to
check for heart and blood vessel problems, as well as for
problems with nerves and muscles.
• Your blood pressure may be high. The doctor will use a
stethoscope to listen to your heart and arteries. An abnormal
sound called a bruit may be heard when listening to the
carotid artery in the neck or other artery. A bruit is caused by
irregular blood flow
• Your doctor may do other tests to check high
blood pressure, heart disease, diabetes, high
cholesterol, and other causes of and risk
factors for TIAs or stroke.
• The goal is to prevent a stroke.
• If you have had a TIA within the last 48 hours, you will
likely be admitted to the hospital so that doctors can
search for the cause and observe you.
• High blood pressure, heart disease, diabetes, and
blood disorders should be treated as needed.
• You may receive blood thinners, such as aspirin, to
reduce blood clotting. Other options include
dipyridamole, clopidogrel, Aggrenox or heparin,
Coumadin, or similar medications. You may be treated
for a long period of time.
Ineffective tissue perfusion r/t decreased
cerebrovascular blood flow
Ineffective airway clearance
Impaired physical mobility
Impaired verbal communication
Unilateral neglect r/t visual field cut & sensory loss
Impaired urinary elimination
Situational low self-esteem r/t actual or perceived
loss of function
Maintain stable or improved LOC
Attain maximum physical functioning
Attain maximum self-care activities & skills
Maintain stable body functions
Maximize communication abilities
Maintain adequate nutrition
Avoid complications of stroke
Maintain effective personal & family coping
Medical and Nursing Management
during the Acute Phase of CVA
• (1) Objectives of care during the acute phase:
• (a) Keep the patient alive.
• (b) Minimize cerebral damage by providing adequately
oxygenated blood to the brain.
• (2) Support airway, breathing, and circulation.
• (3) Maintain neurological flow sheet with frequent
observations of the following:
• (a) Level of consciousness.
• (b) Pupil size and reaction to light.
• (c) Patient's response to commands.
• (d) Movement and strength.
• (e) Patient's vital signs--BP, pulse, respirations, and
• (f) Be aware of changes in any of the above.
Deterioration could indicate progression of the CVA.
• 4) Continually reorient patient to person, place, and
time (day, month) even if patient remains in a coma.
Confusion may be a result of simply regaining
consciousness, or may be due to a neurological
• (5) Maintain proper positioning/body alignment.
• (a) Prevent complications of bed rest.
• (b) Apply foot board, sand bags, trochanter rolls, and
splints as necessary.
• (c) Keep head of bed elevated 30º, or as ordered, to
reduce increased intracranial pressure.
• (d) Place air mattress or alternating pressure
mattress on bed and turn patient every two hours to
maintain skin integrity.
• 6) Ensure adequate fluid and electrocyte balance.
• (a) Fluids may be restricted in an attempt to reduce
intracranial pressure (ICP).
• (b) Intravenous fluids are maintained until patient's condition
stabilizes, then nasogastric tube feedings or oral feedings are
begun depending upon patient's abilities.
• (7) Administer medications, as ordered.
• (a) Anti hypertensives.
• (b) Antibiotics, if necessary.
• (c) Seizure control medications.
• (d) Anticoagulants.
• (e) Sedatives and tranquilizers are not given because they
depress the respiratory center and obscure neurological
• (8) Maintain adequate elimination.
• (a) A Foley catheter is usually inserted during the acute
phase; bladder retraining is begun during rehabilitation.
• (b) Provide stool softeners to prevent constipation. Straining
at stool will increase intracranial pressure.
• (9) Include patient's family and significant others in plan of
care to the maximum extent possible.
• (a) Allow them to assist with care when feasible.
• (b) Keep them informed and help them to understand the
Epilepsy Scientific Background
• When the brain functions normally, millions of
fluctuating, simultaneous, tiny electrical charges
go from the nerve cells to all parts of the body.
• People who have seizures / epilepsy have these
normal electrical “patterns” interrupted by
sudden and relatively intense bursts of electrical
energy that may affect consciousness, body
movements, and sensation.
• Nerve cells normally transmit electrochemical
signals and maintain a balance of excitatory and
inhibitory neurotransmitters as well as sodium,
potassium, and other factors critical to energy
• When this balance is changed, a seizure may
Epilepsy vs. Seizures
• Do you know the difference between seizures and
• A seizure is defined by release of excessive and
uncontrolled electrical activity in the brain.
Seizures themselves are not a disease, they are
• Epilepsy (seizure disorder) is a neurological
condition, that in different times produce brief
disturbances in the electrical functions of the
brain. Seizures are a symptom of epilepsy.
• Seizures can cause different symptoms based on the
location of the source of and where the abnormal
electrical activity spreads.
• Seizures can range from tingling in a finger to grand mal
(generalized) seizures, during which people lose
consciousness, become stiff, and jerk.
• Not everything that looks like a seizure is a seizure. And
not every seizure is an epileptic seizure. Fainting,
collapsing, and confusion can also result from other
disorders or even from emotional stress. Withdrawal
from alcohol or addicting drugs can also cause seizures.
• Epilepsy is an abnormal electrical disturbance in one or more
areas of the brain. An estimated 2 to 4 million persons in the
United States are afflicted with epilepsy and more that half of
those are under 20 years of age.
• (1) The basic problem is thought to be an electrical
disturbance in the nerve cells in one section of the brain,
causing them to give off abnormal, recurrent, uncontrolled
electrical discharges that produce a seizure or convulsion.
• (2) The underlying disorder may be structural, chemical,
physiological, or a combination of all three.
Facts About Epilepsy
• There are over 2.5 million people diagnosed with
epilepsy in the United States.
• Epilepsy affects more people than other serious
conditions such as cerebral palsy, cancer, tuberculosis,
muscular dystrophy, and multiple sclerosis combined.
• The leading cause of epilepsy in adults is automobile
• All other things even, people who have epilepsy have the
same abilities and intelligence as everyone else
• The leading cause in children is birth trauma
• The leading cause for the elderly (people over 65) is
Factors that may predispose a patient
(a) Trauma to the head/brain.
(b) Brain tumor.
(c) Circulatory disorder, stroke.
(d) Metabolic disorder (such as hypoglycemia,
hypocalcemia, or cerebral anoxia).
• (e) Drug/alcohol toxicity.
• (f) Infection (meningitis/brain abscess).
Classification of Seizures
• Seizures are classified into partial and
• Partial seizures are divided into
– Simple partial - Consciousness is not
– Complex partial - Consciousness is impaired
– About 2/3 of people with epilepsy have
complex partial seizures
Different Types of Seizures
• Generalized seizures - Can be convulsive
• Absence seizures - Typical vs. Atypical
– Typical absence seizures - Non-convulsive
with muscle tone preserved. The seizure
usually lasts less than 10 seconds.
– Atypical absence seizures - Convulsive,
longer in duration, loss in muscle tone, and
tonic/clonic movements are observed.
• Tonic-clonic seizures (grand mal) - Generalized
convulsion occurring in the tonic phase and the
clonic phase. Often this is preceded by an aura.
• Tonic phase - Muscles stiffen up, person loses
consciousness, body grows rigid.
• Clonic phase- Body extremities jerk and twitch.
• Secondary generalized tonic-clonic seizures
begins locally with partial seizures
Tonic and Clonic
(Most often, these alternate)
• Photosensitive seizures - These are very
rare, even for people with epilepsy (<5%).
A light related stimulus may trigger this
seizure, hence the warning labels on
electronic devices, theme park rides, and
even video games.
• Atonic seizures - Sudden lack of muscle
tone, causing the inability to sit and stand.
They are also called akinetic seizures.
These are very rare in adults.
• Status Epilepticus - A state of recurring
seizures when consciousness does not
return between seizure events.
– Can be very serious and at times fatal. This is
a seizure that lasts for about 20 minutes, and
can cause serious brain damage, if not
– Benzodiazepines like diazepam or lorazepam
may be given to patients in the hospital for
How do Seizures/Epilepsy
• Seizures may restrict driving, working, and social
opportunities and also affect self-esteem. But
remember, you can influence how epilepsy will affect
• Most people’s epileptic seizures can be controlled.
Some people end their seizures with the first medication
they try. Others will need to partner with their NeuroOncologist or epileptologist to find the right dosage and
combination of medications, especially as brain tumors
can change geometry and location.
Take Control of Managing Seizures
• Understand your epilepsy, including your seizure
• Make sure to talk to your Neuro-Oncologist or
epileptologist about all available treatment
• Fill out a medical history and seizure calendar,
so you can become involved in your medical
• Learn how to communicate well with your
neurologist and his or her staff
• Bring your epilepsy medications or a detailed
printed list to each Neuro-Oncology visit Take
your medication regularly.
• Linking this to a routine may be helpful (when
you brush your teeth, prepare for bed, etc.).
• There are also devices that can help like a
watch that beeps when your dose is due or
special blister packaging that is pre-dosed Get
enough sleep- lack of it can bring on epileptic
Nursing Management Epilepsy
• (1) Objectives of care:
• (a) Determine and treat underlying cause of seizures if
• (b) Prevent recurrence of seizures and therefore allow patient
to live a normal life.
• (2) Institute and reinforce the importance of anticonvulsant
• (a) Drug therapy is a means of controlling the condition; it is
not a cure.
• (b) Initially, dosage will have to be monitored and altered to
provide maximum control with minimum side effects.
• 3) Instruct patient to keep record of events surrounding
his/her seizures (number, duration, time, sleep/eating
• (4) Use of multidisciplinary approach to cope with social,
emotional, and vocational pressures of the person with
(5) Place a padded tongue blade and oral airway at the patient's
bedside. Tape them to the headboard or wall above the bed. This
provides easy emergency access.
(6) Take the seizure prone patient's temperature with a rectal
thermometer; prevents possibility of patient biting an oral
thermometer if a seizure should occur.
7) Set up suction equipment at the patient's bedside.
(a) Check the equipment daily to be sure it is working properly.
(b) Use during or after a seizure to clear the patient's airway.
(8) Essential steps necessary to protect the patient during a seizure.
(a) Turn patient on his side to provide for drainage of oral
(b) Do not forcibly restrain patient during seizure.
(c) Remove objects that may obstruct breathing or cause injury to
(d) Protect patient's head from injury with pillow, blanket, etc.
• (9) Essential steps necessary to ensure safety of the
patient following a seizure.
• (a) Keep bed flat and patient turned on his side until he
• (b) Room lighting should be dim and noise kept to a
• (c) Loosen restrictive clothing (if not done during
• (d) Check vital signs immediately following seizure and
every 30 minutes (or as ordered) until patient is alert.
• (e) Check lips, tongue, and inside of mouth for injuries.
• (f) If patient is incontinent, change clothing and
bedding with as little disturbance as possible.