detail about CVA

1. CEREBRO VASCULAR
ACCIDENT / STROKE
MS. SAHELI CHOWDHURY.
1ST YEAR , M.SC NURSING.
RINER

2. INTRODUCTION :-
 Brain is the largest and most complex part of the
nervous system. It is composed of more than 100
billion neurons and associated fibers.
 Any deterioration to brain function leads to a
number of deficits in body specially in case of
disruption of blood supply.
 “Circle of willis” is responsible for blood supply to
brain, rupture of any of the artery or occlusion may
lead to CVA

7. DEFINITION:
 Cerebro vascular accident is the sudden death of
brain cells due to lack of oxygen, caused by
blockage of blood flow or rupture of an artery to the
brain.
 CVA or stroke is a term used to describe the
neurologic changes caused by an interruption in the
blood supply to a part of the brain.

8.  According to WHO “stroke is a focal neurological deficit
due to local disruption in blood supply to brain. Its onset
is usually abrupt but may extend over a few hours or
longer”
 If neurological deficits exists for > 24 hours, only then it is
termed as STROKE or CVA.
 If neurological deficits exist < 24 hours, it is called as
Transient Ischaemic Stroke (TIA)

9. INCIDENCE :-
 Stroke is a frequent cause of death .
 It is the 3rd biggest killer in India after heart attacks and
cancers.
 A Stroke happens every 40 seconds and every 4
minutes, someone dies of stroke.
 The incidence of stroke increases with age. Mainly
people between 40-60years are affected.
 Brain infarct or stroke occurs 30 percent more frequently
in men then in women.
 It is projected that by 2020 the number of cases of stroke
would increase to 1.6 million in the country.

10. GENDER DIFFERENCES :-
Men :-
 Stroke is more
common in men than
women.
 More likely to have a
thrombotic stroke.
 More likely to have a
embolic stroke.
 Have better chance of
surviving from a stroke.
Women :-
 At all ages , more
women than men die
from strokes.
 More likely to have a
hemorrhagic stroke.
 Oral contraceptive use
and pregnancy
contribute to stroke
risk.

11. RISK FACTORS:
Modifiable risk factors:-
 Hypertension
 Heart disease.
 Smoking .
 Excessive alcohol
consumption.
 Obesity.
 Sleep apnoea.
 Metabolic syndrome.
 Lack of physical exercise.
 Poor diet.
 Drug abuse.
Non-modifiable risk factors :-
 Age
 Gender
 Race .
 Family history
 Heredity .

12. CAUSES :-
1) Cerebral thrombosis: Atheromatous plaque of hard
fatty degenerative material may form in the artery
of brain, resulting in clot formation. It may
increase in size, finally blocking the blood vessels
completely.
2) Cerebral embolism: a clot may have formed in
vessel outside the brain such as one of big
vessels in neck or thorax, or heart itself. Piece of
clot may break and moved by blood until it lodge
in a vessel which is too small to allow them to
pass further.

13. 3) Cerebral hemorrhage: wall of the cerebral vessel
ruptures and blood rushes into and through the brain
destroying the brain tissue by its sheer force. It occurs
due to;
 Weakness in vessel wall (atheromas)
 High BP
 Age of 55 years or more
 Cerebral aneurysm
 Arterio venous malformations.

14. TYPES :-
1)Ischaemic stroke
It accounts for 83% of all
types of stroke.
It is of two types;
a) Embolic
b) thrombotic
2) Hemorrhagic stroke
It accounts for 17% of all
types of stroke
It is of two types;
a) Intra cerebral
b) Sub arachonoid

16. PATHOPHYSIOLOGY

17. CLINICAL MANIFESTATIONS :
 Warning signs
 General signs and symptoms
 Symptoms specific to blood vessel affected
 Hemisphere involvement

21. LOBES OF BRAIN

23. DIAGNOSIS:-
 History collection
 Physical examination
 CT head plain, rarely MRI
 Cerebral angiography (optional)
 Lumbar puncture (optional, during recovery phase
to look for chronic meningitis)
 Other routine investigations i.e. blood
investigations, triglyceride level, urine examinations

24. MANAGEMENT :-
 Medical management
 Surgical management
 Nursing management

25. MEDICAL MANAGEMENT:-
 Aspirin. Aspirin is an immediate treatment given in the
emergency room to reduce the likelihood of having
another stroke. Aspirin prevents blood clots from forming.
Tab aspirin 325mg/ od is given orally
 Intravenous injection of tissue plasminogen activator
(TPA). Some people can benefit from an injection of a
recombinant tissue plasminogen activator (TPA), also
called alteplase. An injection of TPA is usually given
through a vein in the arm. This potent clot-busting drug
needs to be given within 4.5 hours after stroke symptoms
begin if it's given in the vein

26.  The recommended dose of t-PA for acute ischemic stroke
is 0.9 mg/kg (maximum 90 mg) infused over 60 minutes
with 10% of the total dose administered as an initial
intravenous bolus over 1 minute.
 In cerebral venous thrombosis, low dose heparin as 5000
IU subcutaneously is given 8 hourly for 7 days.

27. SURGICAL MANAGEMENT :-
 For ischaemic stroke,
Carotid end arterectomy: surgical procedure to
open or clean blockage in carotid artery
Bypass graft: in case of patient with intracranial
occlusion such as of internal carotid artery or
middle cerebral artery.
Thrombectomy: for patients with an identified
thrombus, inorder to restore circulation.

28.  For hemorrhagic,
 In case of aneurysm:
Surgical clipping: clip is placed in neck of aneurysm to
stop bleeding.
Surgical coiling: a long thin tube is inserted through the
tube into the aneurysm “baloon” to fill the space and seal
off the bleeding.
 In case of hematoma,
caniotomy may be required.

29. NURSING MANAGEMENT :-
 Nursing management of patient with stroke varies
according to specific stroke syndrome and
neurological and functional deficits.
A) Care during acute phase
B) Care during post acute phase
C) Meeting psychological needs
D) Rehabilitation
E) Discharge planning and continuity of care

30. A) CARE DURING ACUTE PHASE (FIRST 24-48
HOURS)
 Early treatment and nursing care is recognized as a key
factor in optimizing outcomes.
 Patient during acute phase may be unconscious/ having
altered sensorium and may be unable to maintain airway.
 Damage to brain tissue and raised ICP inhibits the
respiratory center resulting inadequate ventilation so
 Maintain clear airway for adequate ventilation and to
prevent hypoxia.
 Observe and record vital signs and neurological status
as frequently as necessary

31.  Draw blood for necessary investigations
 Provide necessary care for patient on mannitol drip and
heparin therapy
 Provide necessary personal hygiene as per patient
condition
 If patient is in altered sensorium, maintain NPO status,
ryles tube feeding to be given to compensate for
nutritional needs.
 Assess type of communication deficits and develop
appropriate methods for communication.
 Use strict aseptic technique while doing any procedures.

32. B) CARE DURING POST ACUTE PHASE
 Even after returning to conscious level, couging and
swallowing reflexes may be impaired for sometime so,
 Maintain clear airway to prevent hypoxia
 Maintain safe environment
 Establish effective communication
 Encourage mobilization/ prevent contractures
 Meet nutritional needs
 Assess elimination pattern and perform necessary
interventions
 Maintain general personal hygiene
 Provide diversion from hospital anxiety

33. C) PSYCHOLOGICAL NEEDS
 Reassure patient and family
 Control the environment and maintain routines as much
as possible, remove stimuli that are upsetting
 Anticipate needs and meet them in time
 Clarify any misconceptions.
 Allow patient to verbalize his/her feelings
 Provide positive feedback.

34. D) REHABILITATION
 Rehabilitation begins once the patient is stabilized.
 Encourage the patient to do as much of his/her work as
possible with increased independence
 Teach activities of daily living (ADL) with respect to ways
to compensate patient’s disability. ADL includes bathing,
dressing, toileting, gait training and so forth.
 Teach patient transfer techniques (e.g. bed to chair, chair
to bed)
 Encourage family participation.

35. E) DISCHARGE PLANNING AND CONTINUITY OF
CARE
 Stress importance of follow up care.
 Make patient and family members aware of community resources
which they can utilize for rehabilitation.
 Depression is comon after stroke (40-50% of patients) so patient’s
family should be prepared for this possibility and assess the
psychological status of patient.
Advice family to;
 Avoid doing things for patient that he/she can do himself/herself
 Be supportive, optimistic but firm and direct.
 Install hand rails in toilet and shower and safety rails in bed
 Encourage patient to adhere to exercise program
 Explain that patient becomes fatigued easily so see to that patient
has rest periods.
 To bring patient for regular follow up.

36. COMPLICATIONS
 Deep vein thrombosis
 Pulmonary embolism
 Aspiration pneumonia
 Spasticity
 Joint contractures with associated pain
 Post stroke depression
 Recurrent stroke
 Bed sore
 Hospital acquired sepsis