Medical Surgical Nursing - Cerebro-Vascular Accidents

1. CEREBROVASCULAR
ACCIDENT

2. CEREBROVASCULAR ACCIDENT/STROKE
Also called “brain attack”, cerebral infarction, cerebral hemorrhage, ischemic stroke or stroke
A stroke is caused by the interruption of the blood supply to the brain, usually because a blood
vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing
damage to the brain tissue.

3. BY AMERICAN STROKE ASSOCIATION
A stroke occurs when a blood vessel that carries
oxygen and nutrients to the brain is either blocked
by a clot or bursts (or ruptures).
When that happens, part of the brain cannot get the
blood (and oxygen) it needs, so it and brain cells die.

4. DIRECT CAUSES:
• a blood clot or plaque blocks an artery that
supplies a vital
• brain center
CEREBRAL THROMBOSIS
• an artery in the brain bursts, weakens the
aneurysm wall; severe rise in BP causing
hemorrhage and ischemia
CEREBRAL
HEMORRHAGE/ANEURYSM
• a blood clot breaks off from a thrombus
elsewhere in the body, lodges in a blood vessel
in the brain and shuts off blood supply to that
part of the brain
CEREBRAL EMBOLISM

5. WHAT ARE
THE TYPES
OF STROKE?
Stroke can be caused either by a clot
obstructing the flow of blood to the brain
(called an ischemic stroke) or by a blood
vessel rupturing and preventing blood flow
to the brain (called a hemorrhagic stroke).
A TIA (transient ischemic attack), or "mini
stroke", is caused by a temporary clot.

8. TYPES:
ISCHEMIC STROKE
• Occurs when a clot or a mass clogs a blood vessel, cutting off the blood flow to brain cells. The underlying condition
for this type of obstruction is the development of fatty deposits lining the vessel walls. This condition is called
atherosclerosis.
• Almost 85% of strokes are ischemic
ATHEROSCLEROSIS - “hardening of the arteries”
“athero” – gruel or paste , “sclerosis” – hardness
It’s the process in which deposits of fatty substances, cholesterol, cellular waste products,
calcium and other substances build up in the inner lining of an artery. This buildup is called
plaque.

9. TYPES:
HEMORRHAGIC STROKE
• Results from a weakened vessel that ruptures and bleeds into the surrounding brain. The
blood accumulates and compresses the surrounding brain tissue.
• About 15% of all strokes but responsible for 30% of stroke deaths
2 TYPES
• SUBARACHNOID HEMORRHAGE (SAH)
• occurs when a blood vessel on the surface of the brain ruptures and bleeds into the
space between the brain and the skull
• INTRACEREBRAL HEMORRHAGE (ICH)
• Occurs when a blood vessel bleeds into the tissue deep within the brain.

10. POINTS TO CONSIDER
– 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.

11. STAGES OF CVA
Transient Ischemic Attack
• sudden and short-lived attack
• Is a "mini stroke" that occurs when a blood clot blocks an artery for a
• short time.
• What is the difference between stroke and TIA?
• There's no way to tell if symptoms of a stroke will lead to a TIA or a major stroke. It's important to call 9-1-1
immediately for any stroke symptoms.
Reversible ischemic neurologic deficit (RIND) similar to TIA, but symptoms can last up to a
week
Stroke in evolution (SIE)
• Gradual worsening of symptoms of brain ischemia
Completed stroke (CS) – symptoms of stroke stable over a period and rehab can begin

12. PATHOPHYSIOLOGY

13. Injures the brain tissue or by Secondary ischemia of the brain resulting from the reduced perfusion
presssure
Increase ICP resulting from the sudden entry of blood into Subarachnoid space
Causing Subarachnoid Haemorrhage
Compresses on nearby nerves and brain tissue
Etiological Factors

14. SIGNS AND SYMPTOMS

15. • Usually occurs without warning
• Client often with history of cardiovascular
disease
In embolism
• Dizzy spells or sudden memory loss
• No pain, and client may ignore symptoms
In thrombosis
• May have warning like dizziness and ringing in the
ears (tinnitus)
• Violent headache, with nausea and vomiting
In cerebral
hemorrhage
• Usually most severe
• Loss of consciousness
• Face becomes red
• Breathing is noisy and strained
Sudden Onset
CVA

16. 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

17. TIME IS
CRTITICAL!
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

18. RISK FACTORS:
• Being over age 55
• Being an African-
American
• Having diabetes
• Having a family history
of stroke
MEDICAL STROKE RISK
• Previous stroke
• Previous episode of
transient ischemic
attack (TIA) or mini-
stroke
• High cholesterol
• High blood pressure
• Heart disease

19. RISK FACTORS:
•LIFESTYLE STROKE RISK
•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.
This Photo by Unknown Author is licensed under CC BY-ND

20. COMMON STROKE SYMPTOMS…
Weakness
or paralysis
Numbness,
tingling,
decreased
sensation
Vision
changes
Speech
problems
Swallowing
difficulties
or drooling

21. COMMON STROKE SYMPTOMS…
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

23. MAJOR
EFFECT 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

24. MAJOR EFFECT
OF STROKE
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

25. DIAGNOSIS
• Physical Examination (neurological
examination & medical history)
• Imaging (CT scan and MRI)

26. ISCHEMIC
STROKE

27. HEMORRHAGIC
STROKE

28. TRANSIENT
ISCHEMIC
ATTACK (TIA)

29. 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 911
Immediately

31. ASSESSMENT
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
Assess/Monitor Airway patency

32. ASSESSMENT
Swallowing ability/aspiration risk
Level of consciousness
Neurological status
Motor, sensory and cognitive functions
Glasgow Coma Scale score

33. Ineffective tissue perfusion (cerebral)
Disturbed sensory perception
Impaired physical mobility
Risk for injury
Self-care deficit
Impaired verbal communication
Impaired swallowing
NURSING DIAGNOSIS

35. NURSING CONSIDERATIONS
Maintain patent airway
• Monitor for changes in the client’s level of consciousness
Institute seizure precautions.
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.

36. NURSING CONSIDERATIONS
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.
Provide care to prevent deep-vein thrombosis (sequential compression stockings, frequent position
changes, mobilization)

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

38. 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!