Valuable presentation

2. PRESENTED BY –
Shubhrima Khan
Assistant Professor
Royal Institute of Nursing & Medical Sciences

3. INTRODUCTION
 The terms brain attack and cerebrovascular accident (CVA)
also used to describe stroke.
 Stroke occurs when there is (1) ischemia to a part of the brain
or (2) hemorrhage into the brain that results in death of brain
cells.
 Functions such as movement, sensation, or emotions that were
controlled by the affected area of the brain are lost or impaired.
 The severity of the loss of function varies according to the
location and extend of the brain damage.

4. RISK FACTORS OF STROKE
Nonmodifiable Risk Factors
 Age: Two thirds of all strokes occur in individuals older than
65 years of age but stroke can occur at any age.
 Gender: more common in men, but more women die from
stroke than men
 Ethnicity or race
 Heredity

5. CONT..
Modifiable Risk Factors
Modifiable risk factors are those that can potentially be altered
through lifestyle changes and medical treatment. These includes:
 Hypertension: untreated or inadequately treated increases 50%
risk of stroke
 Heart disease: atrial fibrillation responsible for 20% of all
stroke
 Diabetes mellitus: five times higher than in general population.
 Others: smoking, excessive alcohol consumption, obesity,
sleep apnea, metabolic syndrome, lack of physical exercise,
poor diet. and drug abuse.

6. CONT..
Transient Ischemic Attack
 Another risk factor associated with stroke is a past history of a
transient ischemic attack (TIA).
 A TIA is a transient episode of neurologic dysfunction caused
by focal brain, spinal cord or retinal ischemia, but without
acute infarction of the brain.
 TIAs may be due to micro emboli that temporarily block the
blood flow. TIAs are a warning sign of progressive
cerebrovascular disease.

7. TYPES OF STROKE
Ischemic Stroke
 Thrombotic Stroke
 Embolic stroke
Hemorrhagic stroke
 Intracerebral hemorrhage
 Subarachnoid hemorrhage

8. ISCHEMIC STROKE
An ischemic stroke results from inadequate blood flow to the
brain from partial or complete occlusion of an artery. Nearly 80%
of strokes are ischemic.

9. CONT..
1. Thrombotic Stroke
 It occurs from injury to a blood vessel wall and formation of
a blood clot.
 Thrombosis develops readily where atherosclerotic plaques
have already narrowed blood vessels.
 Thrombotic stroke is the most common cause of stroke,
accounting for about 60% of all strokes.
 Two thirds of thrombotic strokes are associated with
hypertension or diabetes mellitus, both of which accelerate
atherosclerosis. In 30% to 50% of individuals, thrombotic
strokes are preceded by a TIA.

10. CONT..
2. Embolic Stroke
 It occurs when an embolus lodges in and occludes a cerebral
artery.
 Embolism is the second most common cause of stroke,
accounting for about 24% of strokes.
 Most emboli originate in the endocardial layer of the heart,
with plaque breaking off from the endocardium and entering
the circulation.
 The embolus travels upward to the cerebral circulation and
lodges where a vessels narrows or splits.
 Heart conditions associated with emboli include atrial
fibrillation, myocardial infraction, endocarditis, rheumatic
heart disease, valvular prostheses and septal defects.

13. HEMORRHAGIC STROKE
Hemorrhagic strokes account 15% of all strokes and result from
bleeding into the tissue itself (intracerebral hemorrhage) or into
the Subarachnoid space or ventricles.

14. CONT..
1. Intracerebral Hemorrhage
 It is bleeding within the brain caused by a rupture of a
vessel.
 Accounts for 10% of all stroke.
 The Prognosis is poor with the 30-day mortality rate at 40%
to 80%. 50% of deaths occur within the first 48 hours.
 Hypertension is the most common cause. Other causes
include vascular malformation, coagulation disorders,
anticoagulant and thrombolytic treatment, brain trauma,
brain tumors, and ruptured aneurysms.

15. CONT..
2. Subarachnoid Hemorrhage
 It occurs when there is intracranial bleeding into the
cerebrospinal fluid filled space between the arachnoid and
pia mater membranes on the surface of the brain.
 SAH is most commonly caused by rupture of a cerebral
aneurysms.
 Other causes of SAH include trauma and illicit drug
(cocaine) abuse.
 About 40% of people a stroke due to a ruptured aneurysm
die during the first episode.
 The incidence increases with age and is higher in women
than men.

18. CLINICAL MANIFESTATIONS
Motor function
 Motor deficits include impairment of (1) mobility. (2)
respiratory function. (3) swallowing and speech, (4) gag reflex
and (5) self-care abilities.
 Symptoms are caused by the destruction of motor neurons in
the pyramidal pathway (nerve fibers from the brain that pass
through the spinal cord to the motor cells).
 The characteristic motor deficits include loss of voluntary
movement (akinesia), alterations in muscle tone and alterations
in reflexes.

19. CONT..
Communication
 Language disorders involve expression and comprehension of
written and spoken words.
 The patient may experience aphasia & dysphasia.
1. receptive aphasia (loss of comprehension)
2. expressive aphasia (inability to produce language)
3. global aphasia (total inability to communicate).
 Dysphasia refers to impaired ability to communicate.

20. CONT..
Sensory
 Pins and needles or reduced sensation of touch
 Blurred vision, double vision, sudden visual loss, or temporary
loss of vision in one eye
 Incorrect perception of self and illness
Affect
 Difficulty in controlling emotions
 Frustration
 Depression
Intellectual function: impaired memory and judgement

21. CONT..
Elimination
 Initially. the patient may experience frequency, urgency and
incontinence
 Patients are frequently constipated. Constipation is associated
with immobility, weak abdominal muscles, dehydration &
diminished response to the defecation.
Whole body
 Fatigue
 light-headedness
 vertigo

22. DIAGNOSTIC STUDIES
Extent of involvement
 Computed tomography (CT) scan
 CT angiography (CTA
 Magnetic resonance imaging (MRI)
 Magnetic resonance angiography
Cerebral Blood Flow
 Cerebral angiography
 Carotid angiography
 Digital subtraction angiography
 Transcranial Doppler ultrasonography
 Carotid duplex scanning

23. CONT..
Cardiac Assessment
 Chest x-ray
 Cardiac markers (troponin. creatine kinase – MB)
 Echocardiography
Additional Studies
 Complete blood Count, including platelet
 Coagulation studies: prothrombin time, activated partial
thromboplastin time
 Electrolytes, blood glucose
 Renal and hepatic studies
 Lipid profile
 Cerebrospinal fluid analysis (contraindicated in increased ICP)

24. COLLABORATIVE THERAPY
Prevention
 Reduce salt and sodium intake.
 Maintain a normal body weight.
 Maintain a normal blood pressure.
 Control of diabetes mellitus
 Increase level of physical exercise.
 Avoid cigarette Smoking or tobacco products.
 Limit consumption of alcohol to moderate levels.
 Follow a diet that is low in saturated fat, total fat and dietary
cholesterol and high in fruits and vegetables.
 Treatment of underlying cardiac problems.

25. COLLABORATIVE THERAPY
Drug Therapy
 Platelet inhibitors (e.g.. aspirin)
 Anticoagulation therapy (warfarin) for patients with atrial
fibrillation

26. CONT..
Surgical Therapy
 Carotid endarterectomy:
the atheromatous lesion
is removed from the
carotid artery to improve
blood flow.

27. CONT..
Surgical Therapy
 Stenting of carotid artery: intravascular placement of stent in
an attempt to maintain patency of the artery.

28. CONT..
Surgical Therapy
 Transluminal angioplasty: insertion of a balloon to open a
stenosed artery in the brain and improve blood flow.

29. CONT..
Surgical Therapy
 Extracranial-intracranial
bypass: anastomosing a
branch of extracranial artery
to an intracranial artery for
increasing cerebral perfusion.

30. CONT..
Surgical Therapy
 Surgical interventions for aneurysms at risk of bleeding

31. ACUTE CARE /EMERGENCY MANAGEMENT
Initial
 Ensure patent airway.
 Remove dentures.
 Perform pulse oximetry.
 Maintain adequate oxygenation (SaO2>95%) with supplemental O2 if
necessary.
 Establish IV access with normal saline.
 Maintain BP according to guidelines
 Remove clothing.
 Obtain CT scan or MRI immediately
 Perform baseline laboratory tests (including blood glucose) immediately.
And treat if hypoglycemic.
 Position head in midline.
 Elevate head of bed 30 degrees if no symptoms of shock or injury
 Institute seizure precautions.
 Anticipate thrombolytic therapy for ischemic stroke.
 Keep patient NPO until swallow reflex evaluated.

32. CONT..
Ongoing Monitoring
 Monitor vital signs and neurologic status. including level of
consciousness, motor and sensory function, pupil size and
reactivity, SaO2 & and cardiac rhythm.
 Reassure patient and family.

33. CONT..
Rehabilitation
 Focus on helping patient achieve independence and functional
recovery.

34. NURSING INTERVENTIONS
 Maintain a stable or improved level of consciousness
 Attain maximum physical functioning
 Attain maximum self care abilities and skills
 Maintain stable body functions (e.g., bladder control).
 Maximize communication abilities
 Maintain adequate nutrition
 Avoid complications of stoke
 Maintain effective personal and family coping.