Cerebro Vascular Accident

Jesus G.Dio,RN,MD
Cerebro Vascular Accident
Caused by disruption of the blood supply
to the brain, causing neurologic deficit.
Common causes of CVA : thrombosis,
embolism, cerebral hemorrhage

Transient Ischemic Attacks (TIA) is a

transient ischemia with temporary
episodes of neurologic dysfunction.
Cerebrovascular Accident
Cerebrovascular Disease
Stroke
Cerebral Infarction
Apoplexy
 Comparison of Left and Right CVA
Left CVA Right CVA

Right Hemiplegia Left Hemiplegia

Right Visual Defect Left visual field defect

Aphasia: expressive, receptive, Spatial- perceptual field defect

global

Altered intellectual activity Increased distractability (poor

attention span)
Slow, cautious behavior Impulsive behavior, poor
judgement, lack of awareness of
deficit
ANATOMY OF
THE BRAIN
ANATOMIC DIVISION
Two cerebral hemispheres
Brain stem
◦ Midbrain
◦ Pons
◦ Medulla
cerebellum
Lobes of the cerebral hemisphere
Frontal lobe
◦ Planning and sequencing of movement
◦ Voluntary eye movement
◦ Emotional affect
◦ Broca’s area
Parietal lobe
◦ Subserve motor control and cortical sensation
◦ Dominant: governs motor program
◦ Nondominant: governs spatial orientation
Lobes of the cerebral hemisphere
Temporal lobe
◦ Subserve olfaction
◦ Memory
◦ Certain components of auditory and visual
perception
◦ Wernicke’s area
Occipital lobe
◦ Visual perception and involuntary eye
movement
Vessels supplying blood to the brain
Anterior Circulation
◦ Anterior Cerebral Artery
◦ Middle Cerebral Artery
Posterior Circulation
◦ Posterior Cerebral Artery
Anterior Circulation
anterior cerebral artery
◦ extends upward and
forward from the internal
carotid artery
◦ supplies the frontal lobes,
the parts of the brain that
control logical thought,
personality, and voluntary
movement,
◦ Stroke in the anterior
cerebral artery results in
opposite leg weakness. 
Anterior Circulation
Middle Cerebral Artery
 largest branch of the internal
carotid.
 supplies a portion:
◦ frontal lobe
◦ lateral surface of the temporal
and parietal lobes
◦ includes the primary motor
and sensory areas of the face,
throat, hand and arm and in
the dominant hemisphere, the
areas for speech.
 artery most often occluded in
stroke
lenticulostriate arteries
Small, deep
penetrating arteries
which branch from
the middle cerebral
artery
 lacunar strokes
Posterior Circulation
Posterior cerebral artery
 Originates in the
◦ basilar artery
◦ ipsilateral internal carotid
artery
 supply the temporal and
occipital lobes
 Infarction:
◦ usually secondary to
embolism
◦ vertebral basilar system or
heart.
 The most common finding is
occipital lobe infarction
leading to an opposite visual
field defect
Circle of Willis
Arterial anastomosis
of vessels that
enables the entire
brain to reliably
vascularized
World Health Organization
neurological deficit of cerebrovascular
cause that persists beyond 24 hours or is
interrupted by death within 24 hours'
Types of Stroke
Ischemic Stroke
80% of strokes are ischemic
◦ 50%: cerebral thrombosis
 30% of strokes: Large-vessel thrombosis
 (e.g., carotid, middle cerebral, or basilar arteries)
 20% involve small, deeply penetrating arteries
 (e.g., lenticulostriate, basilar penetrating, medullary): lacunar
stroke.
◦ 30%: cerebral embolism
 most frequently: heart or from the cervical portion of the
carotid artery
 more common in  younger patients
 develop rapidly
 maximum deficit usually present within seconds to minutes.
Hemorrhagic stroke
 20% of all strokes
◦ intracerebral hemorrhage
 also called a parenchymal
hemorrhage
 The major risk factor:
hypertension
 Minute dilations at small artery
bifurcation
 Occurs: basal ganglia and
thalamus
 Most signs and symptoms
 compression of brain structures
and blood vessels.
Berry Aneurysm
◦ subarachnoid
hemorrhage
 usually follows the
rupture of an aneurysm
or an arteriovenous
malformation
Systemic hypoperfusion
reduction of blood flow to all parts of the
body.
◦ all parts of the brain may be affected
most commonly due
◦ cardiac pump failure/ low cardiac output
 Cardiac arrest
 Arrhythmias
 pulmonary embolism
 pericardial effusion or bleeding
Signs and symptoms
brainstem: 12 cranial nerves
◦ altered smell, taste, hearing, or vision (total or partial)
◦ drooping of eyelid (ptosis) and weakness of ocular muscles
◦ decreased reflexes: gag, swallow, pupil reactivity to light
◦ decreased sensation and muscle weakness of the face
◦ balance problems and nystagmus
◦ altered breathing and heart rate
◦ weakness in sternocleidomastoid muscle (SCM) with inability to
turn head to one side
◦ weakness in tongue (inability to protrude and/or move from side
to side)
Signs and symptoms
 cerebral cortex
◦ aphasia
 Brocas area
 Wernicke's area
◦ apraxia (altered voluntary movements)
◦ visual field defect
◦ memory deficits
◦ Hemineglect
◦ disorganized thinking, confusion, hypersexual gestures
 cerebellum
◦ trouble walking
◦ altered movement coordination
◦ vertigo and or disequilibrium
Risk Factors

HPN
Heart Disease
DM
Obesity
Vascular Disease (atherosclerosis)
Risk Factors
Cigarette Smoking
Age
Sexor Gender
Genetics
Manifestations of TIA
Manifestations
TIA early signal
Will depend on the affected blood vessel
(usually multiple s/sx)
Severe headache may be a sign
 ICP and cerebral edema
Critical conditions
(airway patency)
Preliminary Assessment
VitalSigns
Neurological Examinations
GCS (glasscow coma scale)
S-P-E-R-M
Neurological Examination
Mental Status
Cranial Nerves
Motor
Coordination
Reflexes
Sensory
Gait and station
Level of Consciousness
Consciousness
◦ Alert
◦ Lethargic/ Drowsy- must be awaken to get the
best response.
◦ Stuporous- (+) response to painful stimuli
◦ Comatose- (-) response to painful stimuli

Attention
Concentration
Mental Status
When conscious assess for:
◦ Disorientation
◦ Confusion
◦ Behavioral abnormalities
 Psychomotor activity
 Emotional responses (Elation, sadness, anger and
flattering)
Language Testing
Repetition
Memory
 Cranial Nerves
CN I Olfactory smell
CN II Optic vision
CN III Occulomotor Pupil Constriction, elevation
of the upper eye lid
CN IV Trochlear Eye movement; Controls
superior oblique muscle
CN V Trigeminal Controls Muscle of
mastication; sensation of the
entire face and the cornea
CN VI Abducens Eye movement control of
lateral rectus muscle
 Cranial Nerves
CN VII Facial Muscles for facial expression;
anterior 2/3 of the tongue
CN VIII Acoustic Cochlear branch permits hearing;
vestibular branch helps maintain
equilibrium
CN IX Glossopharegeal Controls muscle of the throat; taste
of the 1/3 of the tongue
CN X Vagus Nerve Controls muscle of the throat,
parasympathetic Nervous system
stimulation of thoracic and
abdominal organs.
CN XI Spinal Accesory Controls sternocleidomastoid and
trapezius muscles
CN XII Hypoglossal Movement of the tongue
Pupilary Light Reflex (CN II)
Anisucuria ( unequal Pupil) – Due to CN
III Compression. Ipsilateral pupil dilation.
Pinpoint Pupils indicate Pons
involvement.
Fixed, Dilated Pupils- indicate brain
herniation. This causes compression
of the brainstem that results to
cardiopulmonary arrest.
Dolls eye sign- Brainstem function
impairment
Motor
Inspection
Tone
Power
◦ 0 no muscle contraction
◦ 1 trace contraction
◦ 2 Movement in the plane of gravity
◦ 3 Against gravity
◦ 4 Against resistance but < normal
strength
Manual Muscle Testing (MMT)
Coordination
Extrapyrimidal System
◦ Cerebellum
◦ Basal Ganglia
Reflexes
Monosynaptic (deep tendon ) reflexes
Superficial Reflexes
◦ Abdominal
◦ Cremasteric
◦ Bulbocavernosus
Monosynaptic reflexes
0- absent
1+- Diminished
2+-Normal
3+- Increased
Sensory
Primary
◦ Light touch
◦ Pin prick
◦ Temperature
◦ Joint position
◦ Vibration
Gait and Station
Natural Gait
Tandem Gait
Toe/ Heel Walking
Sitting to standing
Romberg’s test
Pull Test
Patient Related Problems:
The common calls
Sensorial Change-
◦ stupor/ coma/ delirium
Behavioral Change-
◦ Delirium/ restlessness/
combative/ bizarre
Patient Related Problems:
The common calls
Seizures
Patient Related Problems:
The common calls
Syncope
Vertigo
Patient Related Problems:
The common calls
Increased Intracranial Pressure:
(normal = 0-14 mm Hg)
It is the pressure of the intracranial
contents exerted against the cranial vault.
Intracranial contents = brain tissue, blood
and CSF and may include hematoma,
abscesses, tumors and fluid surrounding
injured area (edema)
 ◦ Monroe- Kellie Hypothesis
 3 components: Blood, Brain, CSF
 Enclosed Skull
If the intracranial contents expand, ICP
rises, compressing the brain and causing
tissue damage and dysfunction
◦ Cushing’s Triad:
 Hypertension
 Badycardia
 Irregular Respiration
Manifestations ICP
decreasing LOC
dilated pupils (2-6 mm=normal size) or
fails to react to light
widening pulse pressure(> 40mmHg)
Increased systolic BP and temp
Slow bounding pulse
Altered respiratory pattern
neurologic deficit
(hemiparesis, hemiplegia, facial paralysis,
slurred speech and abnormal posturing)
Nurse Alert:
Increase ICP is an emergency.
The cerebral cortex can only
tolerate hypoxia for only 4-6 min.
the medulla oblongata can
tolerate hypoxia only for 10 to 5
min.
Management and Prevention ICP
Prevent hypercapnea and hypoxia
Limit fluid intake as ordered
Avoid neck flexion (foramen magnum
contents may be compressed)
No valsalva’s maneuver
Avoid activity that may increase
intrathoracic and intraabdominal pressure

Complete bedrest
Control fever and avoid noise
Treatment ICP
Restriction of fluids and administration of
diuretics
Steroids (dexamethasone) to reduce
inflammation
Hyperventilate (decreases CO2 = increases
the venous return)
Osmotic diuretics (mannitol/osmitrol) to
reduce brain swelling
Barbiturates (Phenobarbital/luminal) to
combat seizures
Withdraw CSF via lumbar tap, cisternal
puncture or ventricular catheter
Surgical removal of skull or bone flap
Patient Related Problems:
The common calls
Head ache
Neuromuscular/ respiratory failure
Glasscow Coma Scale (GCS)
Scoring system used to quantify level of
consciousness
The best responses: Eye opening , verbal
and motor responses
◦E-4
◦V-5
◦M–6
↑7 good, ↓7 poor, lowest 3, highest 15
Glasscow Coma Scale (GCS)
Limitations
◦ Intubated Patients
◦ Other modifying factors other than brain
injury:
 Shock
 Hypoxemia
 Drug use
 Alcohol intoxication
 Metabolic disturbances
 Spinal Cord patient
 Severe orbital trauma
 Limited utility in children less than 36mo.
Quick Neuro Exam
S- Sensorium
P- Pupils
E- Extraocular movement
R- Respiration
M- Movement/Motor
Diagnostic and Lab
CT scan with or without c. media
MRI
Electroencephalogram (EEG)
Lumbar Tap
CSF analysis
Electromyography
Diagnostic and Lab
Myelography
Tensilon
Test
ICP Monitoring
 Medications
Antiplatelet Drugs:
◦ Aspirin
◦ Dipyridamole (Persantine)
◦ Clopidriogel(Plavix)- for theose who cannot
tolerate aspirin.

◦ Warfarin(Coumadin)- if the clots are cardiac

in origin.
 Medications
Anti Hypertensive Medications
Anticonvulsants – prevention of
seizures
Mannitol and Corticosteroids
(dexamethasone)- to decrease
cerebral edema
Nursing Diagnosis
↑ ICP
Aspiration
Injury
Sensory and Motor problem
ADL (nutrition, mobility, bowel and
bladder, hygiene, self care)
Communication
Thought Process
Coping Mechanism
Depression
Ineffective Tissue Perfusion:
Cerebral
 secondary to thrombus, embolus,
hemorrhage, edema or spasm
Outcomes:
improved cerebral tissue perfusion
 no headache, decrease in LOC,
stable or improving GCS score, ICP
less than 15mm Hg, greater than
65mm Hg cerebral perfusion pressure,
no type A waves
Interventions:
serial assessment (15mins, 2-4 hours)
manifestations of LOC, changes in
motor/sensory function, pupillary
changes, respiratory difficulty,
development of visual or perceptual
defects or aphasia
maintain BP
maintain normothermia
elevate head of the bead – 30 degrees
Deep breathing and coughing exercises
to clear airway.
Interventions:
 restraints should be avoided
 avoid Valsalva Maneuver
 mild laxatives, stool softener
administer medications:
anticoagulants/antiplatelet/calciu
m channel blocker, sedatives
Risk for Aspiration

Outcomes:

 reduced risk of aspiration

easily managing saliva, no
choking or coughing while eating,
no fever, no crackles or rhonchi
Interventions:
 assess for clinical manifestations of
aspirations: fever, dyspnea, crackles,
rhonchi, confusion, decreased PaO2
 use caution in feeding
 monitor chest x-ray results
Impaired Physical Mobility
causes: 1) loss of muscle tone
secondary to flaccid
paralysis/spasticity
2) reluctance to move
Outcomes:
 achieve maximal physical mobility within
the limitations imposed by the stroke
 more normal movements of the
affected extremity, improved muscle
strength
Interventions:
 encouraged bed exercises/ frequent
turning and reposition
◦ gluteal and quadriceps muscle setting
 help the client sit up
 teach the client how to use a
wheelchair
 promote walking
 teach bracing
Risk for Hyperthermia
 bleedingor edema of the hypothalamus can lead
to ischemia
Outcomes:
reduced risk of hyperthermia or will have a
normal temperature
Interventions:
antipyretics
use of hypothermia blanket
shivering must be avoided
keep the feet warm
Risk for Impaired Skin Integrity
causes: 1) loss of protective sensation
2) decreased ability to move
3) friction and shearing
4) inadequate nutritional
status
Outcomes:
 skin will remain intact: absence of stage
1 pressure ulcer, absence of redness
from friction or shearing
Interventions:
assess the skin every 2 hours
change the client’s position every 2
hours
develop a written turning schedule
Self-Care Deficit
Outcomes:
performs as many ADLs as possible
within limitations: use of adaptive
devices and techniques
Interventions:
encourage clients to perform as many
self-care activities as possible
Move limbs to prevent contractures.
COLLABORATIVE PROBLEM
Hemorrhage
Outcomes:
bleeding will be controlled
Interventions:
apply pressure to any compressible
bleeding sites
monitor lab results
report any manifestations of bleeding
COLLABORATIVE PROBLEM
Blood Clots formation
Outcomes:
Blood clots formation will be prevented
Interventions:
Give medications as prescribed:
Anticoagulants like low molecular
Heparin
Put elastic/ air filled support stockings
Move legs/ exercise
Risk for Contracture
Outcomes:

no development of contracture: no muscle

shortening, maintaining normal ROM
Interventions:
assess client’s ROM
perform passive ROM exercises
PREVENTS JOINT IMMOBILITY, TENDON
CONTRACTURES & MUSCLE ATROPHY
STIMULATE CIRCULATION
HELP REESTABLISH NEUROMUSCULAR
PATHWAY
Supportive Care/
Discouragement & Depression
Promote Nutrition (Enteral Feedings, TPN)
Promote activity (Turn schedules, ROM
exercises)
Promote elimination ( monitor I & O,
urinary and bowel program)
Provide emotional support/Support Groups
Assist in rehabilitation of the client.
Advance Directives
Your attitude will
determine your
altitude!

Thank you!