PATHOPHYSIOLOGY of CVA (Stroke)

Modifiable Factors Non Modifiable Factors

Smoking, Obesity, Hypertension, High Cholesterol Age, Family History of CVA,

Level, Excessive Alcohol Consumption, Drug Family History of DM, Sex
Addiction, High Dose of estrogen OC, Diabetes (Men), Race
Mellitus, Atrial Fibrillation, Type A personality,
Sedentary Life Style

Weight
Loss

Destruction of alpha and beta

cells of the pancreas

Polydipsia Polyuria Polyphagia

Failure to produce insulin

Production of
excess glucagon Inc. Ketones

Production of Acidosis
Inc. osmolarity Inc. serum glucose level glucose from protein
due to glucose and fat stores
Acetone breath

Wasting of lean
Glycoprotein cell body mass Fatigue
wall deposits
Weight loss

Impaired immune
function
(decrease level of Small vessel
morphonuclear disease
leukocytes)

Diabetic
Nephropathy
Accelerated
Neuropath atherosclerosis
y

Infection Delayed wound Diabetic

healing Retinopathy Renal
Disease
 Symmetri Hypertension
cal loss of
protective
Loss of vision
sensation
Blindness

Increase LDL levels

Numbness Autonomic
and tingling neuropathy
in the
extremities

Dry cracked skin

Wasting of Gastro paresis

intrinsic
muscle

Impotence

Charcot
changes in
joints
Neurogenic
bladder

Thrombus CEREBROVASCULAR
ACCIDENT

Emboli
Hemiparesis
Decreased Tissue
perfusion (brain)
Loss of speech

Hemisensory loss
Cerebral Hypoxia
Syncope/ Vertigo

Cerebral ischemia

Long term
Short term Eschemia
Eschemia (>10-
(<10- 15mins)
15mins)

Temporary Permanent
Deficit Deficit

No Irreversible
permanent damage
damage

MID CEREBRAL ANTERIOR POSTERIOR VERTEBROBASILAR

ARTERY CEREBRAL A. CEREBRAL A. ARTERY
Hemiparesis/ Hemiplegia Visual Changes
Dysphagia Dysarthia Horner’s
Syndrome

Aphasia Apraxia

Agnosia Hemisensory loss

Ataxia Unilarteral Neglect

Incontinence
DEFINITION OF DISEASE] Vascular Disease which includes C.V.A. is the
second leading cause of death in the Philippines with a total
Cerebrovascular accident (CVA) is the medical term for of 51,680 according to DOH 2004. Along with this are 37,092
what is commonly termed as stroke. It refers to the injury to the
who survived with it.
brai n that occurs when flow of blood to brain tissue is interrupted
by a clogged or ruptured artery, causing brain tissue to die because (http://www.doh.gov.ph/kp/statistics/morbidity)
of lack of nutrients and oxygen.
New therapies can now prevent or limit the extent
A stroke (sometimes called a cerebrovascular accident
(CVA)) is the rapidly developing loss of brain function(s) due to can now prevent or limit the extent of damage to brain tissue
disturbance in the blood supply to the brain, caused by a blocked caused by acute ischemic stroke. Thrombolytic therapy must
or burst blood vessel. This can be due to ischemia (lack of glucose
and oxygen supply) caused by thrombosis or embolism or due to a be administered as soon as possible after onset of the
hemorrhage. As a result, the affected area of the brain is unable to stroke; a treatment window 3 hours from the onset of
function, leading to inability to move one or more limbs on one
side of the body, inability to understand or formulate speech, or manifestations has been established. To convey this sense
inability to see one side of the visual field. A stroke is a medical of urgency regarding the evaluation and treatment of stroke,
emergency and can cause permanent neurological damage,
complications, and death. health care professionals now refer to stroke as brain attack.
Public education is focused on prevention, recognition of
Stroke is a term used to describe neurologic manifestation, and early treatment of brain attack. (Joyce M.
changes caused by an interruption in the blood supply to Black et al Medical Surgical Nursing 7th edition Elsevier
part of the brain. Two major types of stroke are ischemic and Suanders 2005)
hemorrhagic. Ischemic stroke is caused by thrombotic or
embolic blockage of blood flow to the brain. Bleeding into the Diabetes Mellitus is a chronic systemic disease

brain tissue or the subarachnoid space causes a characterized by either a deficiency of insulin or a decreased

hemorrhagic stroke. Ischemic strokes account for about 83% ability of the body to use insulin Diabetes mellitus is

of all strokes. The remaining 17% of strokes are sometimes referred to as “high sugars” by both clients and

hemorrhagic. health care providers. The notion of associating sugar with

diabetes is appropriate because the passage of large
Cerebrovascular disorders are the third leading amounts of sugar-laden urine is characteristic of poorly
cause of death in United States and account for about 164, controlled diabetes. However high levels of blood glucose
000 mortalities annually. An estimated 550,000 strokes are only one component of the pathologic process and
people experience a stroke each year. When second strokes clinical manifestation associated with DM. DM can be
are considered in the estimates, the incidence increases to associated serious complications, but people with diabetes
700, 000 per year in the united States alone. Stroke is a can take preventive measures to reduce the likelihood of
leading cause of adult disability and leading primary such occurrences. (Joyce M. Black et al Medical Surgical
diagnosis for long term care. More than four million stroke Nursing 7th edition Elsevier Suanders 2005)
survivors are living with varying degrees of disability in the
United States. Along with a high mortality rate, strokes Modifiable and Non Modifiable Factors

produce significant morbidity in people who survive them.

1. Modifiable
(Joyce M. Black et al Medical Surgical Nursing 7th edition
Elsevier Suanders 2005)
a. Smoking –nicotine content of cigarettes causes a. Age –Intracranial hemorrhage is most often secondary to
vasoconstriction there by resulting hypertension which may hypertension and is most common after age 50 years.
lead to CVA.
b. Family history of CVA – Family history of stroke increase
b. Hypertension –this is due to plaque deposits on the wall of one’s risk
the arteries which causes narrowing of the blood vessel
thereby causing hypertension which may lead to c. Family history of DM –Family which has history of DM
especially type 2 is high risk of having stroke due to
accelerated atherosclerosis.

d. Sex (Male) –Incidence of stroke in men is slightly higher

than that of women.
hemorrhagic stroke.

e. Race – (more prevalent among African Americans than

c. Obesity –This is due to increase cholesterol in the body
whites or Hispanics)
which may contribute plaque formation that will narrow the
blood vessel or may cause thrombus formation. SIGNS AND SYMPTOMS

d. Hyperlipidemia –too much lipid in the blood may cause DIABETES MELLITUS
increase plaque formation which may cause thrombus
formation. HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL)

e. Drug addiction –This may cause vasopasm, hypertension, Diabetes Mellitus type II may be due to lack of
hypercoagulability and cerebral eschemia which may cause physiologically active insulin that stimulates glucose uptake
CVA. in the muscles and tissues. Therefore, it leads to an
accumulation of glucose in the intravascular space. The
glucose is not utilized by the body and it remains in the blood
stream.
f. Excessive alcohol consumption –heavy alcohol
consumption increases one’s risk of a stroke, light or POLYURIA
moderate alcohol may protect against ischemic stroke.
Polyuria is an increased frequency of urination. This may be
g. High dose Estrogen Oral Contraceptives –increases the due to the osmotic diuretic effect of the glucose, wherein it
risk of stroke in women. attracts water during urination.

h. Diabetes Mellitus –The mechanism is related to When you have diabetes, excess sugar (glucose) builds up
macrovascular changes in people with diabetes mellitus. in your blood. Your kidneys are forced to work overtime to
There is an increase viscousity of blood which may cause filter and absorb the excess sugar. If your kidneys can't keep
formation of thrombus formation. up, the excess sugar is excreted into your urine along with
fluids drawn from your tissues. This triggers more frequent
i. Atrial fibrillation –pulling of blood from poorly emptying
urination, which may leave you dehydrated.
atrial which leads to formation of tiny clots in Left atrium
which can move on the cerebral circulation. POLYDIPSIA

j. Type A personality –stress causes hypertension thereby Polydipsia is an increased thirst and fluid intake. This may
increasing chance of having hemorrhagic stroke. be due to the activation of the thirst center in the
hypothalamus resulting from the intracellular dehydration or
k. Sedentary lifestyle –increase of having DM and Obesity
volume depletion caused by excessive urine production.
which one of the factors of having CVA

POLYPHAGIA
Non-Modifiable
Increased hunger and food intake. Because glucose cannot Testing the urine for microalbuminuria shows early
enter cells of the satiety center of the brain without insulin, nephropathy, long before it would be on routine urinalysis,
the satiety center in the hypothalamus is stimulated resulting
in a “hunger sensation” as if there were very little blood ANEMIA

glucose, resulting in an exaggerated appetite.

If there are renal affectations, this might bring to decrease

BODY MALAISE production of erythropoietin which brings to decrease

production of RBC from the bone marrow that may result to
This is due to the decreased glucose uptake by the tissues anemia.
leading to decreased energy production.
CEREBROVASCULAR ACCIDENT
GLYCOSURIA
Clinical Manifestations
The kidney filters the blood, making it to its normal state.
Glucose was filtered out and excreted in the urine. Due to 1. headache and vomiting – due to an increase ICP which

the excess glucose ad compared to the kidney threshold, causes cerebral

which results to the excretion of glucose in the urine.

edema, and compressing the medulla oblongata

BLURRED VISION
2. seizures – due to hyper-excitability of neurons because of

Diabetes can affect the lens, vitreous, and retina, causing irritation.

visual symptoms. Visual blurring may develop acutely as the

3. changes in mental status – affectation in the RAS
lens changes shape with marked changes in blood glucose
concentrations. This effect, which is caused by osmotic 4. fever – affectation in the hypothalamus
fluxes of water into and out of the lens, usually occurs as
hyperglycemia increases. 5. ECG changes – problem with the medulla oblongata

WEIGHT LOSS Warning Signs

Despite eating more than usual to relieve constant hunger by 1. transient hemiparesis
the stimulation of satiety center, weight loss may still exist.
2. loss of speech
Without the glucose supplies, muscle tissues and fat stores
may deplete.
3. hemisensory loss

SLOW-HEALING SORE AND FREQUENT INFECTION

4. vertigo/syncope

High levels of blood sugar impair your body's natural healing Specific Deficits
process and your ability to fight infections. For women,
bladder and vaginal infections are especially common. 1. Hemiparesis/Hemiplegia – the former means weakness of one side
of the body while the latter means paralysis of one side of the body.
TINGLING SENSATION/ NUMBNESS IN THE HAND AND
2. Aphasia – defects on using and interpreting symbols of language
FEET

3. Apraxia - a condition in which a client can move the affected part

Excess sugar in your blood can lead to nerve damage. You
but cannot use it for purposeful actions.
may notice tingling and loss of sensation in your hands and
feet, as well as burning pain in your arms, hands, legs and 4. Homonymous Hemianopsia – a defective vision or vision loss in

feet. the same half of the visual field.

5. Agnosia – a problem in interpreting visual, tactile or other sensory

PROTEINURIA
information.
6. Dysarthia – imperfect articulation condition.

7. Kinesthesia – alteration in sensation.

8. Incontinence – due to inattention, memory lapses, emotional

factors, and inability to communicate.

9. Shoulder pain – severe pain in the affected shoulder after CVA

10. Horner’s syndrome – paralysis of sympathetic nerves to the eye

causing sinking of the eyeball, ptosis of the upper eyelid, constriction
of pupil, and lack of tearing in the eye.

11. Unilateral neglect – inability to respond to stimulus on the

contralateral side.

12. Dysphagia (01/29/09 -01/31/09) – difficulty of swallowing

13. Ataxia (01/29/09 -01/31/09) –Problem with motor coordination