1.

Define Cerebrovascular Accident

2. State the types of CVA
3. State the risk factors/etiology of CVA (IS, HS)
4. Describe the Pathophysiology of CVA (IS, HS)
5. State the Clinical manifestations of CVA (IS, HS)
6. State the complication of CVA
7. Explain the appropriate investigations for CVA
8. State the treatment for patient suffering from CVA
9. Explain the nursing responsibilities on the care of
patient with CVA
Destruction or infarction of brain cells caused by a
reduction in cerebral blood flow and oxygen.

 Also called brain attack.

 Affects men more than women

1.High blood pressure.

2.Tobacco use. Tobacco use damages blood vessels. This can

lead to blockages within those blood vessels, causing a
stroke. Don’t smoke and avoid second-hand smoke.

3.Alcohol use : May increase BP and increases risk of stroke

Diabetes. Having diabetes increases the risk of stroke

4.
because it can cause disease of blood vessels in the brain.
6. Physical inactivity and obesity. Being inactive, obese, or
both, can increase your risk of cardiovascular disease.

7. Hyperlipidemia. High cholesterol increases the risk of

blocked arteries. If an artery leading to the brain
becomes blocked, a stroke can result

8. Transient ischemic attacks (TIAs). Recognizing and treating

TIAs can reduce the risk of a major stroke. TIAs produce
stroke-like symptoms but most have no lasting effects.
9. Atrial fibrillation (AFib) or other heart disease. This causes
the blood to clot, increasing the risk of stroke. AFib increases
risk of stroke five times. People with other types of heart
disease have a higher risk of stroke, too.

10. Certain blood disorders. A high red blood cell count makes
clots more likely, raising the risk of stroke.
 Increasing age. Stroke affects people of all ages. But the older you
are, the greater your stroke risk.

 Gender. In most age groups, more men than women have stroke,
but more women die from stroke.

 Heredity and race. People whose close blood relations have had a
stroke have a higher risk of stroke.

 Prior stroke. Someone who has had a stroke is at higher risk of

having another one.
1. Ischemic Stroke

 Thrombotic stroke (45%)

 Embolic stroke (20%)
 Cryptogenic stroke (30%)

2. Hemorrhagic Stroke
 Intracerebral hemorrhage
(ICH)
 Subarachnoid hemorrhage
Types of Stroke
 Disruption of blood supply to a part of the brain is
suddenly interrupted by a thrombus or emboli.
Lead to impaired in neurons metabolism. Neurons
may die if it remains blocked for up to 5 minutes.

 Severity of neurological damage depends on the

location of blockage in the brain.
 85% of stroke condition.
 1. Artery thrombosis.
Atherosclerotic plaques in the blood vessels of the
brain can cause large artery thromboses or
Small artery thrombosis.
Large artery thrombosis occurs in large arteries that
bifurcate and narrow lumens causing fibrin and
platelet stick to plaque surface
Small artery thrombosis affects one or more vessels
and is the most common type of ischemic stroke.
Incidence: at rest/sleep – less activity
2.Cardiogenic emboli:Associated with cardiac
dysarhythmias, usually atrial fibrillation. Also
associated with valvular heart disease and thrombi in
the left ventricle.

 Originate from the heart and circulate to left middle

cerebral artery, resulting in a stroke.

 May be prevented by anticoagulation therapy in

patients with atrial fibrillation
 No known cause, strokes from other causes
such as; illicit drug use, coagulopathies,
migraine, and spontaneous dissection of the
carotid or vertebral artery.
 Account for about 15% to 20% of cerebrovascular
disorders and are primarily caused by intracranial
or subarachnoid hemorrhage

 Mortality rate as high as 50% at 30 days after an

intracranial hemorrhage

 If survives, more severe deficits - long recovery

phase compared to ischemic attack.
 Ruptured intracranial aneurysm – weakening in arterial
wall
 Ruptured Arteriovenous malformations (AVM)
 Cerebral amyloid angiopathy (CAA)
 Anticoagulants
Hemorrhagic stroke
Cerebral Aneurysm
Picture of Cerebral Aneurysm: types of aneurysm
Cerebral amyloid angiopathy (CAA) is a disease of
small blood vessels in the brain in which amyloid
deposits in the vessel walls may lead to stroke,
brain hemorrhage, or dementia.
Arteriovenous malformation in the brain
 Risk factors (e.g. obesity, hyperlipidemia, hypertension)

Partial or complete obstruction cerebral blood flow due to

thrombus due to athrosclerotic plaque
Or
Platelets & fibrin adhere to the plaque forms emboli in carotid
artery moves to small cerebral artery

Impaired cerebral blood flow

cerebral edema;tissue damage and small artery damage

Infarction of brain cells

Focal death of brain cells

STROKE
 Weakening of blood vessel due to Uncontrolled hypertension,DM,
Head trauma causing rupture of blood vessel
Aneurysm ,AVM,

Leads to rupture of blood vessel and Extradural;subdural

/intracerebral hemorrhage

The hemorrhagic area occupies space

Cause pressure on surrounding brain tissue and block CSF flow

Compress and injure brain tissue

Normal brain cell metabolism disrupted by brain’s exposure to blood

and by increase ICP

Cerebral damage or brain death

 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.
 Homonymous hemianopsia. There is loss of half of the
visual field.
 Loss of peripheral vision. The patient experiences
difficulty seeing at night and is unaware of objects or
the borders of objects.
 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.
 Dysarthria. This is the difficulty in forming words.
 Dysphagia. There is difficulty in swallowing.
 Paresthesia. There is numbness and tingling of
extremities and difficulty with proprioception.
 Expressive aphasia. The patient is unable to form words
that is understandable yet can speak in single-word
responses.
 Receptive aphasia. The patient is unable to comprehend
the spoken word and can speak but may not make any
sense.
 Global aphasia. This is a combination of both expressive
and receptive aphasia.
Right brain damage : Left brain damage:
(right hemisphere) (left hemisphere)

1. Paralized left side 1. Paralized right side

2. Spatial perceptual defects 2. Speech language
deficits
3. Behavioral style – 3. Behavioral style -
slow
 quick impulsive cautious
4. Memory deficits 4. Memory deficits -
 Performance language
Stages Description

Transient Warning sign of impending CVA.

Ischemic Brief period of neurological deficit like visual
attack(TIA) loss;hemiparesis;slurred speech;aphasia;vertigo.
May last less than 30 secs but not more than 24
hours with complete resolution of symptoms.

Completed Neurological deficit remains unchanged over a

stroke period of 2-3 days .The deficit may become
permanent
1. CT scan of the Brain
2. CT cerebral Angiogram
3. MRI
4. MR angiogram
5. Trans cranial doppler
6. Carotid duplex /ultrasound
7. ECG and ECHO
Carotid duplex/ultrasound
 Painless ultrasound wave to take picture of
narrowed carotid arteries and blood supply to
brain

Transient doppler (TDC)

 Non-invasive procedure to measure blood flow
and detect microemboli
a) Immediate
b) Subsequent
 Medical management
 Surgical management

c) Rehabilitation
1. Establish airway/ensure airway patency
2. Remove dentures, loosen cloth
3. Administer medication (to treat hypoglycemic) as ordered
4. Continuous Monitoring of vital signs, oxygen saturation
5. Maintain adequate oxygen – administer oxygen at least 10L/min
via face mask or as ordered by Doctor
6. Establish IV access with normal saline
7. Perform CT scan stat - if stable, if not, intubation is required

Elevate head 30 degrees – if no symptoms of shock

9. Start thrombolytic agent STAT as ordered – ischemic stroke
Drug Therapy

1. Control of BP and hyperglycemia to maintain good

cerebral perfusion.

For Ischemic Stroke :

 Tablet methyldopa 250mg (antihypertension) is
recommended only if systolic pressure > 220 mmHg

For Diabetic Patients :

 Tablet Metformin 250mg TDS – orally or ryles tube
 Cocktail infusion – 5- unit Actrapid + 50mL Normal saline
(1 unit/1 mL) infused according to GM regime
2. Thrombolytic drug tissue e.g. tissue plasminogen activator (tPA)
Action of tPA:

 Act as fibrinolysis that able to lysis clot. Helps to establish blood flow

through a blocked artery to prevent more neurons death for acute onset

of ischemic stroke.

Assessment in relation to tPA

 Assess for recent history of trauma or bleeding disorders.

 Time of onset of current CVA : tPA must be administered within 3 hours

of onset. NOT FOR HEMORRHAGIC STROKE

 Primary goal during 24 hours after thrombolytic treatment for an

ischemic CVA is to Control BP, NO anticoagulant or antiplatelet for 24

hours after tPA treatment.

3. Anticoagulant agents

 Tablet Warfarin 0.25mg-0.5mg daily according to INR

(International Normalized Ratio 2-3.5)

 Infusion Heparin given according to Activated Coagulant

Time result (ACT).

 Subcutaneous Heparin according to doctor’s order

4. Platelet Aggregation Inhibitors

Aggregation – a mass form small particles

compact together which form blood clot or
thrombus.
 Tablet Aspirin 75mg to 150mg daily
 Able to reduce platelet’s ‘stickiness’.
1. Clipping the Cerebral Aneurysm
 Prevent recurrent stroke
Clipping the Cerebral Aneurysm
Coil embolization
2. Carotid Endarterectomy

 Removes blockages from

carotid arteries
 Recommended for 60%
obstruction.
 Prevent recurrent stroke

Surgical Treatment
 50% death after hemorrhage
 20% functionally independent
 Other patient suffered from paralysis
(paraplegic)
  Headache
 Hemiplegia
 Vomiting  Sensory loss
 Seizures  Aphasia
 Confusion  hemianopsia
 Disorientation
 Decreased LOC
 Hypertension
 Slow bounding pulse
General features Focal signs
 1. Maintain proper airway and adequate ventilation
2. Monitor vitals signs , GCS score and neuro checks .
3. Observe for signs of raised ICP
4. Take seizure precautions
5. Head up 30 -45 degree to reduce ICP
6. Provide complete bed rest
7. Turn and reposition 2 hourly to promote skin integrity
8. Passive ROM every 4 hourly
9. Maintain fluid and electrolyte balance –IV Fluids
10. Ensure adequate nutrition-NG tube if client unable to swallow.
11. Strict I/O chart – well hydrated to promote tissue perfusion.
12. Meet elimination needs. Stool softeners
13. CBD –if absolutely necessary

14. Establish a mean of communicating with the client

15. Administer medication as ordered
 Osmotic agents
 Corticosteroids
1. Administer medication as ordered

Anticonvulsants, Thrombolytic agents to dissolve clot

Tissue Plasminogen Activator (tPA), Streptokinase, urokinase(Given in

2 hours of episode)

Embolic stroke-Heparin;Warfarin;Aspirin

Antihypertensives
 Impaired physical mobility related to hemiparesis, loss
of balance and coordination, spasticity, and brain
injury.
 Deficient self-care related to stroke sequelae.
 Impaired nutrition less than body requirement related
to difficulty in swallowing.
 Disturbed sensory perception related to altered
sensory reception, transmission, and/or integration.
 Impaired urinary elimination related to flaccid
bladder, detrusor instability, confusion, or difficulty in
communicating.
 Impaired verbal communication related to brain
damage.
 Risk for impaired skin integrity related to hemiparesis
or hemiplegia and decreased mobility.
 Interrupted family processes related to catastrophic
illness and caregiving burdens.
 Sexual dysfunction related to neurologic deficits or
fear of failure.
 Improving Mobility and Preventing Deformities
 Position to prevent contractures; use measures to
relieve pressure, assist in maintaining good body alignment,
and prevent compressive neuropathies.
 Prevent adduction of the affected shoulder with a
pillow placed in the axilla.
 Elevate affected arm to prevent edema and fibrosis.
 Position fingers so that they are barely flexed; place hand in
slight supination.
 dorsal wrist splint may be used.
 Change position every 2 hours.
 Establishing an Exercise Program
 Provide full range of motion four or five times a day to maintain
joint mobility, regain motor control, prevent contractures in the
paralyzed extremity.
 Exercise is helpful in preventing venous stasis, which
may predispose the patient to thrombosis and
pulmonary embolus.
 Observe for signs of pulmonary embolus or excessive cardiac
workload during exercise period (e.g., shortness of breath,
chest pain, cyanosis, and increasing pulse rate).
 Supervise and support the patient during exercises;
plan frequent short periods of exercise, not longer
periods; encourage the patient to exercise unaffected side at
intervals throughout the day.
 Preparing for Ambulation
 Start an active rehabilitation program when
consciousness returns.

 Teach patient to maintain balance in a sitting position, then

to balance while standing.

 Begin walking as soon as standing balance is achieved (use

parallel bars and have a wheelchair available in anticipation
of possible dizziness).

 Keep training periods for ambulation short and frequent.

 Enhancing Self Care

 Encourage personal hygiene activities as soon as

the patient can sit up; select suitable self-care activities
that can be carried out with one hand.
 Help patient to set realistic goals; add a new task daily.
 As a first step, encourage patient to carry out all self-
care activities on the unaffected side.
 Make sure patient does not neglect affected side;
provide assistive devices as indicated.
 Assist with dressing activities
 Assisting with Nutrition
 Observe patient for paroxysms of coughing, food
dribbling out or pooling in one side of the mouth, food
retained for long periods in the mouth, or nasal
regurgitation when swallowing liquids.
 Consult with speech therapist to evaluate gag reflexes;
 advise patient to take smaller boluses of food, and
inform patient of foods that are easier to swallow;
provide thicker liquids or pureed diet as indicated.
 Assisting with Nutrition
 Have patient sit upright, preferably on chair, when
eating and drinking; advance diet as tolerated.
 Prepare for GI feedings through a tube if
indicated; elevate the head of bed during feedings,
check tube position before feeding, administer feeding
slowly; monitor and report excessive retained or
residual feeding.
 Attaining Bowel and Bladder Control
 Perform intermittent sterile catheterization during the
period of loss of sphincter control.
 Analyze voiding pattern and offer urinal or bedpan
on patient’s voiding schedule.
 Assist the male patient to an upright posture for
voiding.
 Provide highfiber diet and adequate fluid intake (2 to 3
L/day), unless contraindicated.
 Establish a regular time (after breakfast) for toileting.
 Improving Thought Processes
 Reinforce structured training program using cognitive,
reality orientation,.

 Support patient: Observe performance and progress,

give positive feedback, convey an attitude of
confidence and hopefulness.
 Improving Communication
 Make the atmosphere conducive to
communication, remaining sensitive to patient’s
reactions and needs and responding to them in an
appropriate manner; treat the patient as an adult.
 Provide strong emotional support
 Be consistent in schedule, routines, and repetitions.
 Maintain patient’s attention when talking with the
patient, speak slowly, and give one instruction at a
time; allow the patient time to process.
 Maintaining Skin Integrity
 Frequently assess skin for signs of breakdown, with
emphasis on bony areas and dependent body parts.
 Employ pressure relieving devices; continue regular
turning and positioning (every 2 hours minimally);
minimize shear and friction when positioning.
 Keep skin clean and dry, gently massage the healthy
dry skin and maintain adequate nutrition.
 Improving Family Coping
 Provide counseling and support to the family.
 Involve others in patient’s care.
 Give family information about the expected outcome
of the stroke, and counsel them to avoid doing things
for the patient that he or she can do.
 Encourage everyone to approach the patient with a
supportive and optimistic attitude, focusing on abilities
that remain; explain to the family that emotional
lability usually improves with time.
 Teaching points
 Teach patient to resume as much self care as possible;
provide assistive devices as indicated.

 Have occupational therapist make a home assessment

and recommend.

 Advise family that patient may tire easily, become

irritable and upset by small events, and show less
interest in daily events.
 Teaching points
 Make a referral for home speech therapy. Encourage
family involvement.

 Discuss patient’s depression with the physician for

possible antidepressant therapy.

 Encourage patient to continue with hobbies within

limits.
 End of the session