Mrs. Keerthana.

B
Assistant Professor,
MSN, PSG CON
2
Cerebro Vascular Accident (CVA) / Stroke

 A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a

sudden loss of brain function resulting from a disruption of the blood supply
to a part of the brain.
• A cerebrovascular accident is a sudden loss of brain functioning resulting
from a disruption of the blood supply to a part of the brain.
• It is a functional abnormality of the central nervous system.
• The result is an interruption in the blood supply to the brain, causing
temporary or permanent loss of movement, thought, memory, speech, or
sensation.
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 RISK FACTORS FOR STROKE
3
Hypertension
NON
Atrial fibrillation MODIFIABLE
MODIFIABLE
Hyperlipidemia
Advanced Obesity
age (older
than 55 Smoking
years) Diabetes
Gender Asymptomatic carotid
(Male) stenosis and valvular heart
Race disease (eg, endocarditis,
(African prosthetic heart valves)
American) Periodontal disease
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4 PATHOPHYSIOLOGY OF
STROKE

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5

ANATOMY OF
CEREBRAL
CIRCULATION

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 TYPES OF STROKE
9

Transient Ischemic
Ischemic stroke Hemorrhagic Stroke
Attack

Thrombic Stroke Intracerebral hemorrhagic

Ischemic stroke Subarachnoid hemorrhagic

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10

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 TRANSIENT ISCHEMIC ATTACK (TIA)
11
 A transient ischemic attack (TIA) is an episode of stroke-like symptoms. It
usually lasts less than one hour. A TIA is sometimes called a mini stroke. 

 During a TIA, circulation to a part of the brain is interrupted briefly, and

then restored. This interruption can be caused by: 

• A narrowing of a brain artery because of atherosclerosis. 

• A small floating blood clot. This clot enters the bloodstream from
somewhere else in the body, often the heart. It temporarily blocks a brain
artery. 

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12

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 SYMPTOMS OF TIA
13
 TIA symptoms usually last for less than one to two hours. Most TIAs
actually last only five to 20 minutes. 
• Symptoms of a TIA can include:  
• Dizziness or confusion  
• Weakness or paralysis on one side of the body  
• Sudden, severe numbness in any part of the body  
• Visual disturbance, including sudden loss of vision  
• Difficulty walking, including staggering or veering  
• Coordination problems in the arms and hands  
• Slurred speech or inability to speak 
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14
SYMPTOMS OF STROKE

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 General symptoms of stroke
15

• Numbness or weakness of the face. Without adequate perfusion, oxygen is also

low, and facial tissues could not function properly without them.

• Change in mental status. Due to decreased oxygen, the patient experiences

confusion.

• Trouble speaking or understanding speech. Cells cease to function as a result

of inadequate perfusion.

• Visual disturbances. The eyes also need enough oxygen for optimal functioning.

• Loss of peripheral vision. The patient experiences difficulty seeing at night and

is unaware of objects or the borders of objects. 01/03/2022
16 • Hemiparesis. There is a weakness of the face, arm, and leg on the same
side due to a lesion in the opposite hemisphere.

• Hemiplegia. Paralysis of the face, arm, and leg on the same side due to a
lesion in the opposite hemisphere.

• Ataxia. Staggering, unsteady gait and inability to keep feet together.

• Dysphagia There is difficulty in swallowing.

• Paresthesia. There is numbness and tingling of extremities and difficulty

with proprioception.

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 Clinical Manifestation
17

 Right brain and Left brain damage

 Motor function

 Communication

 Affect

 Intellectual function

 Spatial Perceptual alterations

 Elimination 01/03/2022
18 Right and Left brain damage
Right brain damage Left brain damage

Paralyzed: Left sided hemiplegia Paralyzed: Right sided hemiplegia

Spatial perceptual deficits Impaired speech/language aphasias

Short attention span Impaired left/right dicrimination

Impulsive, safety problems Slow performance

Impaired judgement Depression or anxiety

Impaired time concepts Impaired comprehension related to

language, calculation
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19
Motor Function
 Impairment of

 Mobility

 Respiratory function

 Swallowing and speech

 Gag reflex

 Self care abilities

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20  Akinesia

 Impairment of integration of movement

 Alteration of muscle tone

 Alterations of reflexes

 Hyporeflexia to hyperreflexia

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 Communication
21
 Aphasia
 Receptive aphasia (Fluent, Wernicke)
 Expressive aphasia (Non fluent, Broca)
 Global aphasia
 Dysphasia
 Dysarthria

Affect
 Unpredictable
 Difficulty in controlling the emotions
 Mostly depression
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 Intellectual function
22
 Memory and judgement problems

Spatial alterations deficit

1. Incorrect perception of self and illness
2. Neglects inputs from affected side – homonymous hemianopsia
3. Agnosia
4. Apraxia

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23 Elimination
 Increased frequency, urgency and incontinence
 Constipation

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 Diagnostic studies for stroke
24
• CT scan Demonstrates structural abnormalities, edema, hematomas, ischemia, and
infarctions. Note: May not immediately reveal all changes, e.g., ischemic infarcts are not
evident on CT for 8–12 hr; however, intracerebral hemorrhage is immediately apparent;
therefore, emergency CT is always done before administering tissue plasminogen activator
(t-PA). In addition, patients with TIA commonly have a normal CT scan

• PET scan. Provides data on cerebral metabolism and blood flow changes.

• MRI. Shows areas of infarction, hemorrhage, AV malformations, and areas of ischemia.

• Cerebral angiography. Helps determine specific cause of stroke, e.g., hemorrhage or

obstructed artery, pinpoints site of occlusion or rupture. Digital subtraction angiography
evaluates patency of cerebral vessels, identifies their position in head and neck, and
detects/evaluates lesions and vascular abnormalities.
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25

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 • Lumbar puncture Pressure is usually normal and CSF is clear in cerebral
26
thrombosis, embolism, and TIA. Pressure elevation and grossly bloody fluid
suggest subarachnoid and intracerebral hemorrhage. CSF total protein level
may be elevated in cases of thrombosis because of inflammatory process. LP
should be performed if septic embolism from bacterial endocarditis is
suspected.

• Transcranial Doppler ultrasonography. Evaluates the velocity of blood flow

through major intracranial vessels; identifies AV disease, e.g., problems with
carotid system (blood flow/presence of atherosclerotic plaques).

• EEG. Identifies problems based on reduced electrical activity in specific areas

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of infarction; and can differentiate seizure activity from CVA damage.

27
• Skull x-ray. May show a shift of pineal gland to the opposite side from an
expanding mass; calcifications of the internal carotid may be visible in
cerebral thrombosis; partial calcification of walls of an aneurysm may be
noted in subarachnoid hemorrhage.

• ECG and echocardiography To rule out cardiac origin as source of

embolus (20% of strokes are the result of blood or vegetative emboli
associated with valvular disease, dysrhythmias, or endocarditis).

• Laboratory studies to rule out systemic causes: CBC, platelet

and clotting studies, VDRL/RPR, erythrocyte sedimentation rate (ESR),
chemistries (glucose, sodium).
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28

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29 Preventive therapy

 Healthy diet

 Weight control

 Regular Exercise

 No smoking

 Limitation on alcohol consumption

 Routine health assessment

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30
Preventive Drug and Surgical Therapy
 Drug:
 Antiplatelet therapy
 Aspirin (81 – 325 mg/day)
 Other drugs (Ticlopidine, Clopidogrel, and dipyridamole)
 For patients with atrial fibrillation include warfarin, rivaroxaban and
dabigatran.
 Surgery:
 Carotid endarterectomy
 Transluminal angioplasty
 Stenting
 Extracranial-Intracranial bypass. 01/03/2022
 CAROTID ENDARTERECTOMY
31

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32
STENTING

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 TRANSLUMINAL ANGIOPLASTY
33

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 Management of Ischemic Stroke
34
 Emergency Management:

 Maintaining adequate oxygenation (Oxygen administration, artificial airway insertion,

intubation and mechanical ventilation).

 Fibrinolytic therapy

 IV Antihypertensive drugs such as labetalol and nicardipine

 Fluid and Electrolyte replacement therapy

 Management of ICP

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 Drug therapy for Ischemic stroke
35
 Fibrinolytic therapy

 Recombinant tissue plasminogen activator (tPA)

 IV administration/ intraarterial

 3-4 hours of onset of clinical signs of ischemic stroke

 Screening of contrast MRI or CT, Glucose level, Gastrointestinal

bleeding, stroke or head trauma within past 3 months or any surgery
within 14 days.

 Aspirin 325 mg can be initiated within 24 to 48 hours

 For patients with atrial fibrillation include warfarin, rivaroxaban and 01/03/2022
 Surgical therapy for Ischemic stroke
36

 Stent retrievers

 Mechanical embolus removal in cerebral Ischemia (MERCI)

 Research:

 Mechanical thrombectomy devices (acute balloon angioplasty,

stenting, snare devices, ultrasonic aspirators) 01/03/2022
 Management of Hemorrhagic stroke
37
 Drug Therapy for hemorrhagic stroke:

 Anticoagulants and platelet inhibitors are contraindicated

 Calcium channel blocker (Nimodipine)

 Management of hypertension

 Seizure prophylaxis

 Surgical therapy:

 Immediate evacuation of aneurysm induced hematomas

 Clipping or coiling, hyperdynamic therapy

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38

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 NURSING MANAGEMENT FOR
39
CVA/STROKE
 Respiratory system
 Neurologic system
 Cardiovascular system
 Musculoskeletal system  Urinary system
 Integumentary system  Nutrition
 Gastrointestinal system  Communication
 Sensory Perceptual
alterations
 Coping
 Rehabilitation
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 NURSING MANAGEMENT FOR
40
CVA/STROKE
1. Decreased intracranial capacity related to decreased cerebral perfusion pressure of less than
50 – 60 mm Hg and sustained increase in ICP as evidenced by baseline ICP greater than 15
mm Hg, elevated systolic blood pressure, bradycardia and widened pulse pressure.

2. Risk for aspiration related to level od consciousness and decreased or absent gag and
swallowing reflexes

3. Impaired physical mobility related to neuromuscular and cognitive impairment and

decreased muscle strength and control as evidenced by limited ability to perform gross and
fine motor skills, limited range of motion and difficulty turning.

4. Impaired verbal communication related to aphasia as evidenced by refusal or inability to

speak, difficulty forming words and sentences to express thoughts and inappropriate 01/03/2022

verbalization.
41 5. Unilateral neglect related to visual field cut and loss on one side of body and brain
injury from cerebrovascular problem as evidenced by consistent inattention to stimuli
on affected side

6. Impaired urinary elimination related to impaired impulse to void or inability or

inability to reach toilet or manage tasks of voiding as evidenced by loss of urinary
control and involuntary loss of urine at unpredictable times

7. Impaired swallowing related to weakness or paralysis of affected muscles as

evidenced by drooling, difficulty in swallowing, choking

8. Situational low esteem related to actual or perceived loss of function and altered
body image as evidenced by refusal to participate in self care and expressions of
helplessness and uselessness. 01/03/2022
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