CEREBROVASCULAR ACCIDENT, A BRIEF NOTE

1. CEREBROVASCULAR
ACCIDENT
By
Mrs.Jasmi Manu
Head of the department(OBS/GYN) Nursing
Rama college of Nursing
Rama University, Kanpur

2. Anatomy and
Physiology
Brain is well a protected organ
 Cranium
 Meninges
 CSF

3. Consists of 4 parts
 Cerebrum
 Diencephalon
 Cerebellum
 Brain Stem

4. Brain

5. Brain Stem
 Medulla
 Pons
 Hind brain

6. Diencephalon
 Thalamus
 Hypothalamus
 Epithalamus
 Subthalamus

7. Hypothalamus
 Control of the Autonomic nervous
system.
 Production of hormones.
 Regulation of emotional and behaviour
pattern.

8.  Regulation of eating and drinking.
 Control of body temperature.
 Regulation of circardiac rythm and
states of consciousness.

9. CEREBELLUM

10. Cerebrum
 Cerebrum is divided into frontal, parietal,
temporal, and occipital lobes.
 Sensory area
 Motor area
 Associated area[somato-sensory]

11. CEREBROVASCULAR
ACCIDENT / STROKE
 Cerebrovascular accident (CVA), or stroke, is
the sudden death of some brain cells due to a
lack of oxygen when the blood flow to the brain
is impaired by blockage or rupture of an artery
to the brain. Symptoms will depend on the area
of the brain affected.

12. Incidence
 Third leading cause of death in
America, behind heart disease and
cancer
 Kills 160,000 people each year
 Leading cause of adult disability
 About 750,000 strokes will occur this
year, 500,000 of those strokes could
be prevented

13. Non-Modifiable
Factors

14. MODIFIABLE RISK
FACTORS
 • Hypertension (controlling
hypertension, the major risk factor,
 is the key to preventing stroke)
 • Cardiovascular disease (cerebral
emboli may originate in the heart)
 • Atrial fibrillation

15.  • Coronary artery disease
 • Heart failure
 • Left ventricular hypertrophy
 • Myocardial infarction (especially
anterior)
 • Rheumatic heart disease
 • High cholesterol levels

16.  • Obesity
 • Elevated hematocrit (increases the
risk of cerebral infarction)
 • Diabetes mellitus (associated with
accelerated atherogenesis)
 • Oral contraceptive use
 Smoking

17. Classification

18. Ischemic
STAGES
 Transient ischemic attack (TIA)
 Reversible ischemic neurologic deficit
 Stroke in evolution (SIE) -
 Completed stroke (CS) –

19. Pathophysiology
Etiological factors
Thrombusemboli
Decreased cerebral perfusion
Anerobic energy production

20. Inadequate ATP production
Electrolytic imbalance
Ischemia and death of cells
Calcium and glutamate release

21. Vasoconstriction
Spreading of Ischemia
Loss of neurologic functions of affected
area
CVE

22. HAEMORRAGIC
Etiologic factors
AVM Aneurism
Sub dural haematoma

23. Increased intra cranial
pressure
Meningial
irritation and
Vasoconstriction
Death
Of
Cells

24. Clinical manifestations
 Motor loss and sensory loss
 Cognitive impairment and
Psychological effects
 Communication loss
 Perceptual disturbances

25. Haemorrhagic strokes
 Severe headache
 Tinnitus
 Meningial irritation [rigidity of neck]
 Other neurologic deficits

26. LEFT HEMISPHERIC
STROKE
RIGHT HEMISPHERIC
STROKE
Paralysis or weakness on
right side of body.
Right visual field deficit
Aphasia (expressive,
receptive, or global)
Altered intellectual ability
Slow, cautious behaviour
Paralysis or weakness on
left side of body.
Left visual field deficit
Spatial-perceptual deficits
Increased distractibility.
Impulsive behavior and
poor judgment.
Lack of awareness of
deficits

28. Diagnostic evaluation
 History collection
 Physical Examination [Neurologic ]
 a noncontrast computed tomography
 12-lead electrocardiogram and a
carotid ultrasound
 cerebral angiography, transcranial
Doppler flow studies, transthoracic or
transesophageal echocardiography,
magnetic resonance imaging

29.  Phonoangiography
 Oculoplethysmography
 Single photon emission CT
 Lumbar puncture[Used to assess
presence of blood in the CSF]

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http://www.strokecenter.org/education/ais_ct_tool/index.htm

31. Medical management
Preventive management
 Control high Blood Pressure and blood
sugar
 Lower cholesterol
 Quit smoking
 Control diabetes
 Maintain healthy weight
 Exercise
 Manage stress
 Eat a healthy diet

32. A. Acute Treatment
 I. Support of vital functions—maintain
airway, breathing, oxygenation,
circulation.
 2. Reperfusion and hemodilution with
volume expanders(ldextran)
thrombolytic therapy with tissue
plasminogen activator (t-PA. Activase)
or urokinase (Abbokinase);
vasodilation with nimodipine
(Nimotop).

33.  Tissue plasminogen activator (tPA)
can be given within three hours from
the onset of symptoms
Contra indications
 Intra cranial haemorrhage
 Myocardial infarction
 Administeration of anti-
coagulants[24hrs]
 Uncontrolled BP and DM
 Recent surgeries.

34.  3. Management of increased ICP (intra
cranial pressure)
 4. Diuretic treatment to reduce
cerebral edema, which peaks 3 to 5
days after infarction.
 5. Calcium channel blockers to reduce
blood pressure and prevent cerebral
vasospasm

35. SURGICAL
MANAGEMENT

36. Complications
 Cerebral Hypoxia
 Vassopasm
 Increased ICP
 Systemic hypertension

37. Nutritional Management
Principles of diet
 Restrict total calories to reduce body
weight and maintain it at the normal for
height, age and sex.
 It is not desirable to restrict all kind of
fat. It should consist of 30% of total
calories
 Unsaturated fat is preferred and
saturated fat and animalfat is reduced.

38.  Green leafy vegetables, fruits, cereals,
skimmed milk are encouraged.
 Three or four small meals are
preferable compared to large meals.
 Regular exercise is useful.

39. Nutritional
Management
Non- Vegetarian Vegetarian
Breakfast
Fruit juice
Cereals with skimmed milk
Bread tost with tea and coffee
Mid-morning
Tea-Coffee
Fruit
Lunch
Poached cod
Peas
Potatoes toast
Curd
Mid-afternoon
Tea-coffee and biscuit
Dinner
Roast chicken
Broad beans
Fresh fruits
Breakfast
Fruit juice
Cereals with skimmed milk
Bread tost with tea and coffee
Mid-morning
Tea-Coffee
Fruit
Lunch
Lentil soup
Cottage cheese
Rice puddingChappaties
Brinjals, Rice and Dal
Mid-afternoon
Tea-coffee and biscuit
Dinner
vegetable salads
Dosa and sambhar
Straw berry jelly

40. Nursing Assessment
 1. Maintain neurologic flow sheet
during acute phase.
 2. Assess for voluntary or involuntary
movements, tone of muscles, and
presence of deep tendon reflexes
 3. Also assess mental status, cranial
nerve function, sensation /
propriception, bladder control.

41.  4. Monitor bowel and bladder function.
 5. Monitor effectiveness of
anticoagulation therapy.
 6. Frequently assess level of function
and psychosocial response to
condition.

42. Nursing Diagnoses
 A. Risk for Injury related to neurologic
deficits
 B. Impaired Physical Mobility related to
motor deficits
 C. Altered Thought Processes related
to brain damage
 D. Impaired Verbal Communication
related to brain injury
 E. Self-care Deficit (bathing. dressing,
toileting) related to hemiparesis/
paralysis

43.  F. Imbalanced Nutrition: Less Than
Body Requirements, related to
impaired self- feeding, chewing,
swallowing
 G. Impaired Urinary Elimination related
to motor/sensory deficits
 H. Altered Family Process related to
catastrophic illness, cognitive and
behavioral sequelae of stroke, and
care-giving burden

44. Nursing Interventions
A. Preventing Falls and Other Injuries
 1. Maintain bed rest during acute phase
(48 to 72 hours after onset of stroke) with
head of bed slightly elevated and side rails
in place.
 2. Administer oxygen as ordered during
acute phase to maximize cerebral
oxygenation.
 3. Frequently assess respiratory status,
vital signs, heart rate and rhythm, and
urinary output to maintain and support vital
functions.

45. Nursing Interventions
 4. When patient becomes more alert
after acute phase, maintain frequent
vigilance and interactions aimed at
orienting, assessing, and meeting the
needs of the patients.
 5. Try to allay confusion and agitation
with calm reassurance and presence

46. Nursing Interventions
B. Preventing Complications of
Immobility
 1. Use a foot board during flaccid period
after stroke to keep loot dorsiflexed; avoid
its use after spasticity develops.
 2. Avoid excessive pressure on ball of foot
after spasticity develops.
 3. Do not allow top bedding to pull affected
foot into plantar flexion.

47. Assisting for Mobility

48. Nursing Interventions
 4. Maintain functional position of all extremities.
 a. Apply splints and braces as needed—volar
splint to support functional position of wrist, sling
to prevent shoulder subluxation of flaccid arm,
high-top sneaker for ankle and foot support.
Splints support flaccid extremities and can also
be used on spastic extremities to decrease
stretch stimulation and reduce spasticity

49. Nursing Interventions
 c. Place a pillow in the axilla of the
affected side when there is limited external
rotation to keep arm away from chest and
prevent adduction of the affected shoulder.
 d. Place the affected upper extremity
slightly flexed on pillow supports with each
joint positioned higher than the preceding
one to prevent edema and resultant
fibrosis; alternate elbow extension.
 e. Place the hand in slight supination with
fingers slightly flexed.

50. Nursing Interventions
 f. Place the patient in a prone position
for 15 to 30 minutes daily and avoid
sitting up in chair for long periods to
prevent knee and hip flexion
contractures.
5.Exercise the affected extremities
passively through range of motion four
to five times daily to maintain joint
mobility and enhance circulation;
encourage active range-of-motion
exercise as able.

51. Nursing Interventions
 6. Teach patient to use unaffected
extremity to move affected one.
 7. Prepare for ambulation cautiously.
 a. Check for orthostatic hypotension.
 b. Graduate the patient from a reclining
position to head elevate, and dangle legs
at the bedside before transferring out of
bed or ambulating; assess sitting balance
in bed.

52. Exercising the affected
extremity

53. Nursing Interventions
 c. Assess the patient for excessive
exertion.
 d. Have patient wear walking shoes.
 e. Assess standing balance and have
patient practice standing
 F. Help patient begin walking as soon
as standing balance is achieved,
ensure safety with a patient waist belt.

54. Nursing Interventions
C. Optimizing Cognitive Abilities
 1. Be aware of patient’s cognitive alterations and
adjust interaction and adjust interaction and
environment accordingly.
 2. Participate in cognitive retraining program—
reality orientation, visual imagery, cueing
procedures—as outlined by occupational or
rehabilitation therapist.
 3. Use pictures of family members, clock,
calendar; post schedule of daily activities where
patient can see.
 4. Focus on patient strengths and give positive
feedback.

55. Nursing Interventions
F. Promoting Adequate Oral Intake
 1. Help patient release swallowing
sequence.
 a. Have patient attempt to suck on gloved
finger to strengthen oral musculature.
 b. Place ice on tongue and encourage
sucking.
 c. Progress to popsice and soft foods.
 d.. Make sure soft diet is provided, based
on ability to chew.

56. Nursing Interventions
 2. Encourage small, frequent meals and
allow plenty of time.
 3. Remind patient to chew on unaffected
side.
 4. Inspect mouth for food collection or injury
and encourage frequent oral hygiene.
 5. Teach the family how to assist the patient
with meals to facilitate chewing and
swallowing.

57. Nursing Interventions
 5. Teach the family how to assist the patient with
meals to facilitate chewing and swallowing.
 a. Reduce environmental distractions improve
patient concentration.
 b. Provide oral care before eating to improve
aesthetics and afterward to remove food debris.

58. Nursing Interventions
 c. Position the patient so he or she is
sitting with 90 degrees of flexion at the
hips and 45 degress of flex- ion at the
neck. Use pillows behind the back and
along the weak side to achieve correct
position.
 d. Maintain position for 30 to 45
minutes after the meals to prevent
regurgitation and aspi- ration.

59. Nursing Interventions
 E. Facilitating Communication
 1. Speak slowly, use visual cues and
gestures; be consistent and repeat as
necessary.
 2. Give plenty of time for response,
and reinforce correct responses.
 3. Minimize distractions.
 4. Use alternative methods of
communication other than verbal.

60. Nursing Interventions
F. Fostering Independence
 1.Teach patient to use nonaffected side of
activities of daily living (ADL) but not to
neglect the affected side.
 2. Adjust the environment ( call, light, tray)
to side of awareness if special neglect or
visual field cuts are present, approach the
patient from uninvolved side.
 3.Teach the patient to scan environment if
visual deficits are present.

61. Nursing Interventions
 4.Encourage family to provide clothing
that is a size larger than the patients
wears with front closure teach patient
to dress while sitting to maintain
balance
 5.Ensure that personal care items,
urinal, commode, etc. are nearby and
that patient obtains assistance with
transfers and other activities as
needed

62. SUMMARY

63. QUESTIONS
 QU