CEREBROVASCULAR ACCIDENT

1. CEREBROVASCULAR
ACCIDENT
LULAKA, RNM, BSCN, MSC

2. LEARNING OUTCOMES
• Define Cerebral Vascular Accident
(CVA)
• Describe the types and causes
• Explain the pathophysiology
• Describe the diagnostic studies
• Explain the medical and nursing
management
• Describe the complications

3. INTRODUCTION
• 2,000,000 brain cells die every minute
during stroke, increasing risk of
permanent brain damage, disability
or death.
• Recognizing symptoms and acting
fast to get medical attention can
save life and limit disabilities.

4. DEFINITION
• An interruption of blood supply to a
vital center in the brain.
• Also called “brain attack”, “Stroke”
• Brain cells die due to nutrients and
oxygen deprivation to the brain
• Leading cause of long-term disability

5. THE HUMAN BRAIN

6. BRAIN ATTACK

7. TYPES OF CVA
Hemorrhagic
•About 15% of all strokes but responsible for
30% of stroke deaths.
Ischemic
• Almost 85% of strokes are ischemic.

8. HEMORRHAGIC CVA
• Occurs when blood vessel in the brain
burst due to high blood pressure,
atherosclerosis, or congenital
abnormality.
• Burst vessel causes bleeding into the
brain and decreased blood flow in the
damaged vessels. Blood build-up
increases pressure in the brain,
damaging nerve cells and collapsing
smaller vessels.

9. TYPES OF HEMORRHAGIC CVA
A. Intracerebral/
parenchymal
hemorrhage
• Occurs when a
diseased artery
within the brain
ruptures, flooding the
surrounding brain
tissue with blood

10. B. Subarachnoid
hemorrhage
• Bleeding into the
skull or cranium
that occurs when
a blood vessel on
the surface of the
brain ruptures and
bleeds into the
meninges.

11. ISCHEMIC CVA
• Occurs when
arteries are
blocked by
blood clots or by
gradual build up
of plaque and
other fatty
deposits

12. CATEGORIES OF ISCHEMIC
CVA
A. Thrombotic
•Occurs when
flow in a blood
vessel in the brain
is obstructed by
arteriosclerosis

13. B. Thromboembolic
•Occurs when a clot breaks off from an
arteriosclerotic plaque, and lodges in
a downstream vessel, blocking blood
flow.

14. CATEGORIES OF
ISCHEMIC CVA
C. Thrombolic
•Occurs when a clot travels to the brain from
elsewhere in the body.
•Patients with atrial fibrillation or who have
suffered a heart attack are at high risk of
embolic stroke. This is because slow,
irregular, or interrupted blood flow has a
tendency to clot.

17. PATHOPHYSIOLOGY OF ISCHEMIC
STROKE
• Partial or complete occlusion of a cerebral
blood flow to an area of the brain due to:
• Thrombus (most common) due to
arteriosclerotic plaque in a cerebral artery,
usually at bifurcation of larger arteries;
occurs over several days.
• Embolus a moving clot of cardiac origin
(frequently due to atrial fibrillation) or from
a carotid artery that travels quickly to the
brain and lodges in a small artery; occurs
suddenly with immediate maximum
deficits.

18. • Area of brain affected is related to the
vascular territory that was occluded. Subtle
decrease in blood flow may allow brain cells
to maintain minimal function, but as blood
flow decreases focal areas of ischemia
occur, followed by infarction to the vascular
territory.

19. PATHOPHYSIOLOGY OF ISCHEMIC
STROKE
• An area of injury includes edema, tissue
breakdown, and small arterial vessel
damage. The small arterial vessel
damage poses a risk of hemorrhage.
The larger the area of infarction, the
greater the risk of hemorrhagic
conversion.
• Ischemic strokes are not activity
dependent; may occur at rest

20. PATHOPHYSIOLOGY OF
HEMORRHAGIC STROKE
• Leakage of blood from a blood vessel and
hemorrhage into brain tissue, causing
edema, compression of brain tissue, and
spasm of adjacent blood vessels.
• May occur outside the dura (extradural),
beneath the dura mater (subdural), in the
subarachnoid space (SAS or
subarachnoid), or within the brain
substance (intracerebral).

21. PATHOPHYSIOLOGY OF
HEMORRHAGIC STROKE
• Causal mechanisms include:
• Increased pressure due to hypertension.
• Head trauma causing dissection or rupture or
vessel.
• Deterioration of vessel wall from chronic
hypertension, diabetes mellitus.
• Congenital weakening of blood vessel wall
with aneurysm or arteriovenous malformation
(AVM).

22. PATHOPHYSIOLOGY OF
HEMORRHAGIC STROKE
• The intracranial hemorrhage becomes a space-
occupying lesion within the skull, further
compromising brain function.
• The mass effect causes pressure on brain tissue.
• The hemorrhage irritates local brain tissue
leading to surrounding focal edema.
• SAH or hemorrhage into a ventricle can block
normal CSF flow, leading to hydrocephalus.
• Hemorrhage commonly occurs suddenly while a
person is active.

23. STAGES OF CVA
1. Transient ischemic attack (TIA)
• Sudden and short-lived
• Attack lasts less than 30sec but no more than
24 hours with complete resolution of
symptoms.
• Sudden numbness or weakness of the face, arm or leg,
especially on one side of the body.
• Sudden confusion.
• Sudden trouble speaking.
• Sudden trouble seeing in one or both eyes.
• Sudden trouble walking.
• Sudden dizziness, loss of balance or coordination.
• Sudden, severe headache with no known cause

24. 2. Reversible ischemic neurologic deficit
(RIND)
•Similar to TIA.
•Lasts more than 24 hours and settles within a
week

25. 3. Stroke in
evolution
(SIE)
•Gradual
worsening
of
symptoms
of brain
ischemia

26. 4. Completed stroke (CS)
• Neurologic deficit remains
unchanged for a 2-3 day period

27. SIGNS AND SYMPTOMS
 In embolism
 Usually occurs without warning
 Client often with history of cardiovascular
disease
 In thrombosis
 Dizzy spells or sudden memory loss
 No pain, and client may ignore symptoms
 In cerebral hemorrhage
 May have warning like dizziness and ringing
in the ears (tinnitus)
 Violent headache, with nausea and vomiting

28. SIGNS AND SYMPTOMS
• Sudden-onset CVA
• Usually most severe
• Loss of consciousness
• Face becomes red
• Breathing is noisy and strained
• Pulse is slow but full and bounding
• Elevated BP
• May be in a deep coma

29. TIME IS CRITICAL!
• The longer the time period that the
person remains unresponsive, the less
likely it is that the person will recover.
• The first few days after onset is critical.
• The responsive person may:
• Show signs of memory loss or inconsistent
behavior
• May be easily fatigued, lose bowel and bladder
control, or have poor balance.

30. COMMON STROKE SYMPTOMS
• Weakness or paralysis
• Numbness, tingling, decreased
sensation
• Vision changes
• Speech problems
• Swallowing difficulties or
drooling
• Loss of memory
• Vertigo (spinning sensation)
• Loss of balance and
coordination
• Personality changes
• Mood changes (depression,
apathy)
• Drowsiness, lethargy, or loss of
consciousness
• Uncontrollable eye
movements or eyelid drooping

31. ACT F.A.S.T.
• F = Face Ask the person to smile. Does
one side of the face droop?
• A = Arms Ask the person to raise both
arms. Does one arm drift
downward?
• S = Speech Ask the person to repeat a simple
sentence. Does the speech sound
slurred or strange?
• T = Time Call for help immediately!

32. RISK FACTORS
• Being over age 55
• Being an African-American
• Having diabetes
• Having a family history of stroke

33. MEDICAL STROKE RISKS
• Previous stroke
• Previous episode of transient ischemic attack (TIA) or
mini-stroke
• High cholesterol
• High blood pressure
• Heart disease
• Atrial fibrillation and carotid
artery disease

34. LIFESTYLE STROKE RISKS
• Smoking
• Being overweight
• Drinking too much alcohol
• You can control lifestyle risks by quitting
smoking, exercising regularly, watching
what and how much you eat and
limiting alcohol consumption.

35. MAJOR EFFECTS OF
STROKE
 Hemiplegia - most common result of CVA
 Paralysis of one side of the body
 May affect other functions, such as hearing,
general sensation and circulation
 The degree of impairment depends on the part
of the brain affected
 Stages:
 Flaccid – numbness and weakness of affected side
 Spastic – muscles contracted and tense, movement
hard
 Recovery – therapy and rehab methods successful

36.  Aphasia and Dysphasia
 Brain Damage – extent of brain damage determines
chances of recovery
 Hemianopsia – blindness in half of the visual field of
one or both eyes
 Pain – usually very little; injection of local anesthetic
provides temporary relief
 Autonomic Disturbances
 Such as perspiration or “goose flesh” above the level of
paralysis
 May have dilated pupils, high or low BP or headache
 Treated with atropine-like drugs
 Personality Changes – either functional or organic

37. DIAGNOSTIC PROCEDURES
• MRI and/or CT imaging, computed axial
tomography (CAT) scan
• Used to identify edema, ischemia and
necrosis
• Magnetic resonance angiography (MRA) or
cerebral angiography
• To identify presence of cerebral
hemorrhage, abnormal vessel structures,
vessel ruptures, and regional perfusion of
blood flow in the brain

38. • Lumbar puncture
• Used to assess presence of blood in the
CSF
• Carotid endarterectomy
• Performed to open the artery by
removing atherosclerotic plaque
• Interventional radiology
• Performed to treat cerebral aneurysm

39. ASSESSMENT
History
Assess for
Baseline level of function
Hx of HBP and its mangement, coronary artery
disease, diabetes, and TIA or previous stroke
Medications in use
Smoking, alcohol or other drug use
Circumstances surrounding the stroke
Onset, nature, and location

40. ASSESSMENT
• Headache, nature and location
• Visual acuity, diplopia, blurred vision, field
cuts
• Ability to concentrate and follow
commands, memory
• Emotional and affective response
• Family and social support network, current
living situation, financial status

41. ASSESSMENTS (PHYSICAL
EXAM)
 Monitor for signs and symptoms
 Symptoms will vary based on the area of
the brain that is not adequately supplied
with oxygenated blood
 The left cerebral hemisphere is
responsible for language, mathematic
skills and analytic thinking
 The right cerebral hemisphere is
responsible for visual and spatial
awareness and proprioception

42.  Assess/Monitor
 Airway patency
 Swallowing ability/aspiration risk
 Level of consciousness
 Neurological status
 Motor, sensory and cognitive functions
 Glasgow Coma score

43. NURSING DIAGNOSES
• Ineffective tissue perfusion (cerebral)
• Disturbed sensory perception
• Impaired physical mobility r/t motor deficit
• Risk for injury r/t neurologic deficit
• Disabled Family Coping related to
catastrophic illness, cognitive and
behavioral sequelae of stroke, and
caregiving burden

44. NURSING DIAGNOSES
• Self-care deficit (bathing, dressing, toileting
r/t hemiparesis/paralysis
• Impaired verbal communication r/t brain
injury
• Imbalanced nutrition less than body
requirements rt impaired self feeding,
swallowing and chewing

45. NURSING
CONSIDERATIONS
• Maintain patent airway.
• Monitor for changes in the client’s level of
consciousness (increased intracranial
pressure sign-IICP).
• Elevate the client’s head to reduce IICP
and to promote venous drainage. Avoid
extreme flexion or extension, maintain the
head in a midline neutral position and
elevate the head of bed to 30 degrees.
degrees.
• Institute seizure precautions.

46. • Maintain a non-stimulating environment.
• Assist with communication skills if the client’s
speech is impaired.
• Assist with safe feeding.
• Assess swallowing reflexes.
• Thicken liquid to avoid aspiration.
• Eat in an upright position and swallow with
the head and neck flexed slightly forward.
• Place food in the back of the mouth on the
unaffected side.
• Suction on standby.

47.  Maintain skin integrity.
 Encourage PROM every 2 hr to the affected
extremities and AROM every 2 hr to the
unaffected extremities.
 Elevate the affected extremities to promote
venous return and to reduce swelling.
 Maintain a safe environment to reduce the
risks of falls.
 Scanning technique (turning head from side
to side) when eating and ambulating to
compensate for hemianopsia.

48.  Provide care to prevent deep-vein thrombosis
(sequential compression stockings, frequent
position changes, mobilization).
 Administer medications as prescribed.
 Systemic or catheter directed thrombolytic
therapy restores cerebral blood flow. It must
be administered within hours of the onset of
symptoms. It is contraindicated for
treatment of hemorrhagic stroke and for
clients with an increased risk of bleeding.
Rule out hemorrhagic stroke with an MRI
prior to initiation of thrombolytic therapy.

49. THROMBOLYTIC THERAPY
• Anticoagulants: Sodium heparin, warfarin
(Coumadin)
• Antiplatelets: Ticlopidine (Ticlid), clopidogrel
(Plavix)
• Antiepileptic medications: Phenytoin
(Dilantin), gabapentin (Neurontin)

50. MAINTAINING CEREBRAL
PERFUSION
• Immediately after admission, nursing care
focuses on monitoring the patients
neurologic status and preventing
complications.
• Put the patient in bed rest with the head of
the bed elevated about 30 degrees to
maintain patent air way hence support
oxygenation and perfusion
• Monitor vital signs and neurological checks
to rule increased ICP

51. PREVENTING FALLS AND
OTHER INJURIES
• Maintain bed rest during acute phase (24 to
48 hours after onset of stroke) with head of
bed slightly elevated and side rails in place.
• Administer oxygen as ordered during acute
phase to maximize cerebral oxygenation.
• Frequently assess respiratory status, vital
signs, heart rate and rhythm, and urine
output to maintain and support vital
functions.

52. FALLS AND OTHER
INJURIES
• When patient becomes more alert after
acute phase, maintain frequent vigilance
and interactions aimed at orienting,
assessing, and meeting the needs of the
patient.
• Try to allay confusion and agitation with
calm reassurance and presence.
• Assess patient for risk of falls.

53. OPTIMAZING COGNITIVE
ABILITIES
• Be aware of the patient's cognitive
alterations, and adjust interaction and
environment accordingly.
• Participate in cognitive retraining program
reality orientation, visual imagery, cueing
procedures—as outlined by rehabilitation
nurse or therapist.

54. OPTIMIZING COGNITIVE
ABILITIES
• In patients with increased awareness, use
pictures of family members, clock,
calendar; post schedule of daily activities
where patient can see it.
• Focus on patient's strengths, and give
positive feedback.
• Be aware that depression is common and
therapy should include psychotherapy and
pharmacological agents.

55. FACILITATING
COMMUNICATION
• Speak slowly, using visual cues and
gestures; be consistent, and repeat as
necessary.
• Speak directly to the patient while facing
him.
• Give plenty of time for response, and
reinforce attempts as well as correct
responses.

56. FACILITATING
COMMUNICATION
• Minimize distractions.
• Use alternative methods of communication
other than verbal, such as written words,
gestures, or pictures

57. FOSTERING
INDEPENDENCE
• Teach patient to use non-affected side for
activities of daily living (ADLs) but not to
neglect affected side.
• Adjust the environment (eg, call light, tray)
to side of awareness if spatial neglect or
visual field cuts are present; approach
patient from uninvolved side.

58. FOSTERING
INDEPENDENCE
• Teach the patient to scan environment if visual
deficits are present.
• Encourage family to provide clothing a size
larger than patient wears, with front closures, ,
and stretch fabric; teach patient to dress while
sitting to maintain balance
• Make sure personal care items, urinal, and are
nearby and that patient obtains assistance
with transfers and other activities as needed.
• .

59. FOSTERING
INDEPENDENCE
• Be aware that ADLs require anticipatory
(automatic coordination of multiple muscle
groups in anticipation of a specific
movement) and reactive (adjustment of
posture to stimuli) postural adjustments.
• Be aware that patients usually have clear
goals in relation to functional abilities,
against which all success and forward
progress will be measured; help them set
realistic short- and long-term goals

60. PROMOTING ADEQUATE
ORAL INTAKE
• Initiate referral for a speech therapist for
individuals with compromised LOC, or
speech difficulties, to evaluate swallowing
function at bedside to demonstrate safe
and functional swallowing mechanisms
before initiation of oral diet.

61. PROMOTING ADEQUATE
ORAL INTAKE
• Help patient relearn swallowing sequence
using compensatory techniques.
• Place ice on tongue and encourage sucking.
• Progress to ice pops and soft foods.
• Make sure mechanical soft or pureed diet is
provided, based on ability to chew.
• Encourage small, frequent meals, and
allow plenty of time to chew and swallow.
Dietary consults can be helpful for selection
of food preferences

62. PROMOTING ADEQUATE
ORAL INTAKE
• Remind patient to chew on unaffected side.
• Encourage patient to drink small sips from a
straw with chin tucked to the chest,
strengthening effort to swallow while chin is
tucked down.
• Inspect mouth for food collection and
pocketing before entry of each new bolus of
food.
• Inspect oral mucosa for injury from biting
tongue or cheek.

63. PROMOTING ADEQAUTE
ORAL INTAKE
• Teach the family how to assist the patient
with meals to facilitate chewing and
swallowing.
• Reduce environmental distractions to
improve patient concentration.
• Provide oral care before eating to
improve aesthetics and afterward to
remove food debris.

64. PROMOTING ADEQUATE
ORAL INTAKE
• Position the patient so he is sitting with 90
degrees of flexion at the hips and 45
degrees of flexion at the neck. Use pillows
to achieve correct position.
• Maintain position for 30 to 45 minutes after
meals to prevent regurgitation and
aspiration

65. STRENGTHENING FAMILY
COPING
• Encourage the family to maintain outside
interests.
• Teach stress management techniques,
such as relaxation exercises, use of
community and faith-based support
networks.
• Encourage participation in support group
for family respite program for caregivers, or
other available resources in area.

66. STRENGTHENING FAMILY
COPING
• Involve as many family and friends in
care as possible.
• Provide information about stroke and
expected outcome.
• Teach family that stroke survivors do
show depression in the first 3 months
of recovery

67. • Administer oxygen
• Monitor ABGs

68. COMPLICATIONS
• Aspiration pneumonia
• Dysphagia in 25% to 50% of patients after
stroke
• Spasticity, contractures
• Deep vein thrombosis, pulmonary embolism
• Brain stem herniation
• Post stroke depression

69. STROKE PREVENTION
• Get screened for high BP.
• Have your cholesterol level checked. LDL
should be lower than 70 mg/dL.
• Follow a low-fat diet.
• Quit smoking!
• Exercise!
• Limit alcohol intake!

70. REFERENCE
• Unnithan AKA, M Das J, Mehta P. Hemorrhagic Stroke.
[Updated 2023 May 8]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2023 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK559173/