1. CVA/Stroke/ Brain Attack
Dr. RS Mehta, BPKIHS

2. • C V A common : middle or late
years of life.
• Incidence ↑ With age.
• Now referred to as strokes or
brain attacks
• Acute and treatable condition
• Third leading cause of death in
Developed Countries.
• Leading cause of disability
Dr. RS Mehta, BPKIHS

3. Brain Blood Supply
•
•
•
•
Brain 2% of body weight
15-20% of Cardiac output
20% of Total body oxygen
Neurons: predominantly Aerobic
Dr. RS Mehta, BPKIHS

4. Dr. RS Mehta, BPKIHS

5. Dr. RS Mehta, BPKIHS

6. Circle of wills
Dr. RS Mehta, BPKIHS

7. Dr. RS Mehta, BPKIHS

8. • A stroke is a clinical syndrome
consisting of group of neurologic
findings.
• Cerebrovascular accident (CVA/stroke)
is the infarction (death) of brain tissue
caused by the disruption of blood flow to
the brain.
• It is characterized by focal neurological
deficits specific to the area of the brain
involved.
Dr. RS Mehta, BPKIHS

9. Classification:
• Transient ischemic attack (TIA)
(<24).
• Reversible ischemic neurologic
deficit (RIND). (complete >24 hrs)
• Partial non-progressing stroke
(PNS).
• Progressing stroke.
• Completed stroke (Stabilized).
Dr. RS Mehta, BPKIHS

10. Infarct Stages:
• Immediate – 6 hours
– No Change both gross & microscopic
• Acute stage – 2 days
– Oedema, loss of grey/white matter border.
– Inflammation
• Intermediate stage – 2 Weeks
– Demarcation
– Liquifactive necrosis
• Late stage – After Weeks
– Fluid filled cysts with dark grey margin
– Proliferation of glia, loss of architecture (Gliosis) .
Dr. RS Mehta, BPKIHS

11. CVA
•
•
•
•
Thromboetic infraction: 80%
Cerebral Haemorrhage: 10%
Sub-arrhochonoid hemorrhage: 5%
Others
Dr. RS Mehta, BPKIHS

12. Dr. RS Mehta, BPKIHS

13. Cerebral edema
Dr. RS Mehta, BPKIHS

14. Local infarction:
Dr. RS Mehta, BPKIHS

15. Dr. RS Mehta, BPKIHS

16. Cerebral Infarct - 1 Week
Dr. RS Mehta, BPKIHS

17. Cerebral Infarct - 2 Weeks
Dr. RS Mehta, BPKIHS

18. Cerebral Infarction - Late
Dr. RS Mehta, BPKIHS

19. Dr. RS Mehta, BPKIHS

20. Causes:
•
•
•
Thrombosis.
Embolus.
Hemorrhage (HTN. Rupture).
Dr. RS Mehta, BPKIHS

21. Risk factors
• Modifiable risk factors
– High BP
– Cigarette smoking
– Alcohol intake
– Uncontrolled Heart disease
– Atrial fibrillation
– Uncontrolled Diabetes
– Carotid congestion
Dr. RS Mehta, BPKIHS

22. •
•
•
•
•
High blood cholesterol
Sedentary lifestyle
Obesity
Seasons
Stress
Dr. RS Mehta, BPKIHS

23. Risk Factors Unable to Control
•
•
•
•
•
•
Age
Gender
Race
Prior strokes
Heredity
Sickle Cell Disease
Dr. RS Mehta, BPKIHS

24. Risk factors for stroke:
• Non-modifiable: Age, Gender, Race,
Prior CVA and Heredity.
• Modifiable: HTN, DM, cardiac
diseases, cigarette smoking,
excessive Avenal intake, drug abuse,
↑ cholesterol.
• Other factors: Obesity, migraines,
oral contraceptives, hyper coagulation
state.
Dr. RS Mehta, BPKIHS

25. THREE STROKE TYPES
Focal Brain Dysfunction
Ischemic
Stroke
Intracerebral
Hemorrhage
85%
Clot occluding
artery
Subarachnoid
Hemorrhage
10%
Bleeding
into brain
5%
Bleeding
around brain
Diffuse Brain Dysfunction
Dr. RS Mehta, BPKIHS

26. Pathophysiology
Brain
Very sensitive to loss of blood supply.
Cannot resort anaerobic metabolism in the
absence of oxygen and glucose.
Hypoxia develop.
Cerebral ischemia.
Short term ischemia
Temporary or TIAS
Permanent infraction of
cerebral cells.
Dr. RS Mehta, BPKIHS
(Permanent changes occur within 3-10 minutes).

27. Early warning signs:
• Headache
• Vomiting
• Seizures
• fever etc.
Silent Stroke: do not cause Symptoms
Dr. RS Mehta, BPKIHS

28. Signs and Symptoms of
STROKE
• Hemorrhagic
– Sudden and dramatic
– Violent explosive headache
– Visual disturbance
– Nausea and vomiting
– Neck and back pain
– Sensitivity to light
– Weakness on one side
Dr. RS Mehta, BPKIHS

29. Signs and Symptoms of
STROKE
• Ischemic Stroke
– Harder to detect
– Weakness in one side
– Facial drooping
– Numbness and tingling
– Language disturbance
– Visual disturbance
Dr. RS Mehta, BPKIHS

30. Left Brain Damage
•
•
•
•
Right side paralysis
Speech and language disturbance
Behavioral changes
Swallowing problems
Dr. RS Mehta, BPKIHS

31. Right Brain Damage
• Left side paralysis
• Coordination
• Perception
Dr. RS Mehta, BPKIHS

32. Specific deficits after CVA:
• Hemiparesis and hemiplegia.
• Apraxia (moves the part but not function
properly).
• Aphasia (difficulty in swallowing).
• Visual changes:
• Agnosia- recognition problem
(object/person).
• Incontinence.
Dr. RS Mehta, BPKIHS

33. Clinical Manifestations
• Affects many body functions
• Motor activity
• Elimination
• Intellectual function
• Perceptual alterations
• Personality
• Sensation
• Communication
Dr. RS Mehta, BPKIHS

34. Use a “FAST” STROKE Assessment
• Face
• Arm
• Speech
• Time of onset
Dr. RS Mehta, BPKIHS

35. FACE
• Look for Facial Droop
– Have the patient smile or show his/her teeth
– NORMAL Both sides of the
face move equally
– ABNORMAL One side of
the patient’s face droops
or does not move
Dr. RS Mehta, BPKIHS

36. ARMS
• Motor Weakness: Look for arm drift by asking
the patient to close eyes and lift arms, palms up
• NORMAL- arms remain
extended equally or drift
downward equally
• ABNORMAL – One arm
drifts down compared
to the other
Dr. RS Mehta, BPKIHS

37. SPEECH
• Ask the patient to say “You can’t teach an
old dog new tricks”
• NORMAL –Phrase repeated clearly and
plainly
• ABNORMAL – Words slurred, abnormal or
unable to speak
Dr. RS Mehta, BPKIHS

38. Abnormal Speech
•
•
•
•
Slurring of speech
Unable to think of words
Inappropriate words
Expressive aphasia – unable to speak
words
• Receptive aphasia – unable to understand
words
Dr. RS Mehta, BPKIHS

39. TIME OF ONSET
• The window of opportunity to effectively
treat STROKE is 3 hours (180 minutes)
– May be extended to 4 ½ hours
• Need to know “ last known well”.
• Difficult when
– Patient lives alone
– Woke up with symptoms
Dr. RS Mehta, BPKIHS

40. Inv: •
•
•
•
X-ray skull, CT, MRI
L.P. contra indicated if ↑ ICP
ECG
PET Scan: activities of brain and tissue
damage
• Angiography: visualize blood vessels
Dr. RS Mehta, BPKIHS

41. Medical management: Aim:
–Preserving life.
–Minimizing residual deficits.
–Reducing ICP.
–Preventing extension or
recurrence.
Dr. RS Mehta, BPKIHS

42. Pharmacological management:
• Anti coagulants, Anti-platelet therapy:
(Heparin, Warfarin, Asprin, Tilcopidin).
• Edema control: (steroid, osmotic diuretics
(Mannitol) loop diuretics e.g. lasix).
• Antihypertensive, mild analgesics: (avoid
strong analgesic & sedative).
• Seizure control: phenytoin / phenoharbitone.
• Antibiotic (open HI).
• Thrombolytic Agents (if blood Clot)
Dr. RS Mehta, BPKIHS

43. Rx
A.
1.
CVA: Ischemic
Tab. Asprin 150 mg, Po/NGT OD (Asprin allergy: Clopidogel 300mg
stat,75mg/day)
2. Ranitidine/Ocid/Pantop: decrease gastric ulcer
3. Antihypertensive
4. O2 support: based on ABG, ABC
5. NGT feeding/IV infusion
6. Chest physiotherapy and passive exercise
7. DVT prophylaxis and Seizure control
8. Laxative
9. Catheter: Foleys early
10. Steroid: if Meningitis/ Inflammation / Swelling
B. Clot:
11. anti-hypertensive
12. Mannitol-20%
13. Tissue Plasminogen Activator: t-PA (clot buster): previously STK was
Dr. RS Mehta, BPKIHS
used

44. tPA (Tissue Plasminogen Activator)
– is a clot-busting drug
– Ischemic strokes, the most
common type of strokes,
can be treated with a drug
called t-PA, that dissolves
blood clots obstructing
blood flow to the brain.
Dr. RS Mehta, BPKIHS

45. Surgical approaches:
• Epidural (Clot): Excision & Drain
• External ventrisculotomy drainage
• Craniotomy: Flap of skull out- if
cerebral decompression.
• Extra / Intra-cranial bipass
• Aneurysm: Clip
• Internal Carotid Endarterectomy
Dr. RS Mehta, BPKIHS

46. Dr. RS Mehta, BPKIHS

47. Dr. RS Mehta, BPKIHS

48. Internal Carotid Endarterectomy
Dr. RS Mehta, > 70%)
(if StenosisBPKIHS

49. Nursing Management
Dr. RS Mehta, BPKIHS

50. Nursing management:
Assessment
• Initial assessment essential, includes:
LOC, papillary reaction and movement of
eye, changes in speech, sensory changes,
reflexes, (planter: UMN / LMN), headache,
and vital signs.
• Recorded and scored in GCS (pupil
movement response. / eye, motor, verbal).
• Reports of: LP, CT, MRT etc.
Dr. RS Mehta, BPKIHS

51. Nursing diagnosis:
• Altered cerebral tissue perfusion R/T ↓
cerebral blood how (thrombus, embolus,
hemorrhage, edema, spasm).
Expected outcome:
• The client will have improved cerebral tissue
perfusion as evidenced by ICP less than 15
mm Hg, no report of headache and ↓ loc,
stable, ↑ GCS score.
Dr. RS Mehta, BPKIHS

52. Implementations:
• Assessment of unstable client hourly.
• Analyze data, if detorating inform physician.
• Administer drug →
asprin, heparin, tilcopidine.
• Delirium or restlessness should be
controlled with sedatives, if necessary. (Be
sure restlessness is not due to: hypoxia, full
bladder, bowel impaction, pain etc).
• Restraints should be avoided, became they
often increase agitation and ↑ ICP.
Dr. RS Mehta, BPKIHS

53. • Straining at stool, or with excessive
coughing, vomiting, lifting of the arms to
change position should be avoided. (↑
ICO).
• Mild laxatives and stool softeners are often
prescribed.
• The client who is a wade and alert should
be taught about the pathologic process and
instructed to inform you about any changes
in: Sensation, movement, or function,
regardless of how minor a change may
seem.
Dr. RS Mehta, BPKIHS

54. • Impaired physical mobility R/T
loss of muscle tone secondary to
flaccid paralysis or spasticity or
reluctance to move associated
with fear of self – injury or prolong
disuse.
Dr. RS Mehta, BPKIHS

55. Risk for impaired skin integrity R/T
loss of protective sensation and
decreased ability to move.
• Expected Outcome: The client’s skin will
remain intact as evidenced by no stage I
pressure ulcer development and no signs
of redness from friction or shearing.
Dr. RS Mehta, BPKIHS

56. Risk for contracture R/T flaccid
paralysis or spasticity.
• Expected Outcome: The client will have
absence of contractures joint, ankylosis,
muscle shortening as evidenced by
maintaining normal Rom.
Dr. RS Mehta, BPKIHS

57. Impaired verbal communication R/T
loss of the function of muscle, which
produces speech or ischemia of the
dominant cerebral hemisphere.
• Expected Outcome: The client will
be able to effectively communication.
Dr. RS Mehta, BPKIHS

58. Ineffective individual coping RT
physiologic changes and frustrations.
• Expected Outcome: The client will
develop effective coping strategies, as
evidenced by appropriate life-style
modifications, use of the assistance of
others, and appropriate social interactions.
Dr. RS Mehta, BPKIHS

59. Long term care of stroke patient
(Rehabilitation):
Aims:
• To prevent further impairment.
• Jo maintain existing abilities and
• To restore highest level of function possible.
– TRF → bed to wheel chair. (Hemiplegia).
– Assess daily living activities (ADL => score (0-100).
• => Bowel, bladder, grooming, toilet use, transfer,
mobility, dressing, stairs, bathing. (0, 5, 10) =>
evaluate prognosis.
– Glasgow coma scale: Eye open (4), Verbal (5), Moter (6).
Dr. RS Mehta, BPKIHS

60. Nursing care of the Patient
undergoing intracranial surgery:
•
•
•
•
Potential for ineffective breathing pattern RT post
operative cerebral edema.
Potential for alteration in fluid volume RT ↑ ICP or
dieresis.
Alteration in sensory perception RT periorbital
edema and head dressing.
Monitor and manage complication: Cerebral
edema, intracranial hemorrhage, seizures,
infection, venous thrombosis, leakage of CSF,
(G.I. ulceration: monitor S/S of hemorrhage,
perforation or both).
Dr. RS Mehta, BPKIHS

61. Short and long term effects
• The physical damage stroke causes to the
brain can have a wide range of effects that
will depend on the type of stroke and its
severity, the part of the brain affected the
extent of brain damage and how quickly
other brain cells take over the function of
those that are damaged or dead. Around a
third of strokes are fatal.
• Effects may include: next page
Dr. RS Mehta, BPKIHS

62. Effects
•
•
•
•
•
•
•
•
•
•
•
•
Weakness or paralysis
Lack of feeling
Swallowing difficulties
Speech or language difficulties
Problems of perception
Cognitive difficulties
Behaviour changes
Difficulties with bowel or bladder control
Fatigue
Mood changes
Post-stroke pain
Epilepsy: (7-20%) Mehta, BPKIHS
Dr. RS

63. Rehabilitation: (Nurses role)
• Exercise.
• Diet.
• Regular follow up.
• Family support.
• Psychological support.
• Occupational therapy.
Dr. RS Mehta, BPKIHS

64. Nursing Care of Bed Ridden Patients
( Summary)
1.Regular change of position.
2.Care of skin and pressure sore,
3.Bladder management.
4.Care of bowel.
5.Management of diet.
6.Chest physiotherapy.
7.Rehabilitation & physiotherapy.
8.Recreational and Divertional therapy.
9.Occupational therapy.
Dr. RS Mehta, BPKIHS

65. Primary Prevention:
Decrease Risk Factors
1. Treatment of HTN
2. Avoid Smoking
3. Active Life Style
4. Avoid Alcohol
5. Decrease LDL Cholesterol
6. Anticoagulant in Atrial Fibrillation
Dr. RS Mehta, BPKIHS

66. Dr. RS Mehta, BPKIHS

67. Dr. RS Mehta, BPKIHS

68. Thank you
Dr. RS Mehta, BPKIHS