Week 7 - CVA

Stroke
School of Nursing
MNU
1 Prepared by: Agleema Ahmed

Learning Outcome
After this session, you should be able to:
⚫define stroke
⚫compare and contrast the mechanisms and manifestations
of hemorrhagic and ischemic strokes.
⚫compare and contrast care of patients following
hemorrageic and ischemic shock
⚫analyze emergent management of the patient with an
ischemic stroke.
⚫critically examine lab values
⚫prioritize nursing care for a acute stroke patient
2
Review anatomy and function
⚫Blood supply to the brain
3
⚫Blood supply to the brain
4
5
6
7
Review
Functions of the lobes of the brain
8
Function of the right vs left side
9
Stroke
Stroke / cerebral vascular accident (CVA) / brain attack,
is a decrease in blood flow & oxygen to brain cells with the
subsequent loss of neurological functioning.
Classified as
⚫Ischemic (disruption of blood flow to part
of the brain due to a thrombus or embolus)

⚫Hemorrhagic (loss of blood flow due
to rupture of cerebral vessels)

10
Risk Factors
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Pathophysiology
Normally brain is metabolically active.
⚫Pathophysiologic changes begin seconds after a reduction in blood

flow and oxygen supply to the cerebral neurons.
⚫Cellular metabolism stops as glucose, glycogen, and adenosine
triphosphate (ATP) are depleted, resulting in failure of the sodium-
potassium pump.
⚫ Cerebral blood vessels swell, resulting in further decreased blood
flow. Vasospasm and increased blood viscosity can result in
12 obstruction to blood flow, even after circulation is restored.
Pathophysiology
⚫When brain cells are damaged, function of the body parts they control
is impaired or lost, causing paralysis, speech and sensory problems,
memory and reasoning deficits, coma, and possibly death. The degree
of damage to the brain cells depends on the size of the perfusion
deficit, the amount of brain tissue that is infarcted, and the type of
stroke.
⮚ Hemorrhagic stroke:-blood accumulates and compresses the
affected brain tissue, causing decreased perfusion to those
brain cells.
⮚ Ischemic stroke :- result of an obstruction to a blood vessel
supplying nutrients and oxygen to the brain.
13
The CPPS (Cincinnati Pre-hospital Stroke
Scale)
Test Findings
Facial droop: have the patient Normal: Both sides of the face
show teeth or smile move equally Facial droop
Abnormal: One side of the face
does not move as well as the
other side
Arm drift: Patient closes eye s Normal: both arms move the
and extends both arms straight same or both arms do no move at
out, with palms up for 10 seconds all
Abnormal: one arm does not
move or one arm drifts down One-sided
compared to another motor
weakness
Abnormal speech: Have patient Normal: patient uses correct ( Right arm)
say “you can’t teach an old new words with no slurring
tricks” Abnormal: Patient slurs words,
uses the wrong words or is
unable to speak
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Clinical features
Sudden onset of focal neurological deficits resulting from damage to the
injured
portion of the brain. Classic signs and symptoms include:
• Sudden confusion
• Sudden difficulty understanding or
speaking
• Sudden loss of vision out of one eye
• Sudden severe headache
• Sudden weakness of the face, arm,
or leg, especially
• affecting one side of the body
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Investigation of a patient with an acute
stroke
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Immediate Neurological Assessment by stroke team
⚫ Patient’s history, physical examination and

establish time of symptom onset
⚫ Neurologic assessment-National Institutes
of Health Stroke Scale (NIHSS)
⚫ CT scan: Hemorrhage or NO Hemorrhage
⚫ An initial non-contrast CT is important
for a patient with acute stroke
⚫ Do not give aspirin, heparin or rtPA until
the CT scan has ruled out intracranial
hemorrhage
⚫ If Hemorrhage is present: Patient is not a
candidate for fibrinolytic therapy.
⚫ If hemorrhage is not present: Patient is
a candidate for fibrinolytic therapy
Stroke management algorithm
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Stroke management algorithm (cont..)
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21
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Immediate General Assessment & Stabilization
Steps Actions
Assess ABCs Assess ABCs and evaluate baseline vital signs
Provide oxygen Provide supplementary oxygen for hypoxemic stroke (SPO2 <94%) and patients with
unknown oxygen saturation
Establish IV access For baseline blood count, coagulation studies and blood glucose. Do not let this delay a
and obtain blood CT scan of brain
samples
Check Glucose Promptly treat hypoglycemia
Perform neurologic Perform a neurologic screening assessment. Use the NIH Stroke Scale (NIHSS) or a
assessment similar tool
Activate the stroke Activate the stroke team or arrange consultation with a stroke expert based on
team predetermined protocols
Order CT brain scan Order an emergency CT brain. Have it read promptly by a qualified physician
Obtain 12-leads ECG Obtain a 12 Lead ECG, which may identify a recent or ongoing AMI or arrhythmias (eg:
arterial fibrillation) as a cause of embolic stroke. A small % of people with acute stroke
have coexisting myocardial ischemia. Recommend cardiac monitoring for first 24 hours
of evaluation in patients with acute ischemic stroke to detect arterial fibrillation and
arrhythmias.
23 Life threatening can follow a stroke particularly intra-cerebral hemorrhage.
DO NOT delay the CT scan to obtain the ECG
Management- Ischemic stroke
⚫Management is aimed at minimizing the volume of brain
that is irreversibly damaged, preventing complications
Early Management Ongoing Management

• Thrombolytic Therapy ⚫Anticoagulation therapy
• Interventional Radiology ⚫Control of hypertension
⮚ Intra-arterial ⚫Control of ICP
thrombolysis
⚫Control of blood glucose
⮚ Mechanical clot removal
level
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Management of Acute hemorrhagic stroke
Management is aimed at minimizing the volume of brain that is irreversibly
damaged, preventing complications
⚫ Analgesics/Antianxiety agents-To
relieve headache. Analgesics having
sedative properties are beneficial for
patients having sustained trauma (e.g.
morphine sulphate)
⚫ Antihypertensives- (e.g. sodium
nitroprusside, labetolol)
⚫ Hyperosmotic agents(e.g. mannitol,
glycerol, furosemide): To reduce cerebral
edema, and raised intracranial pressure.
⚫ Adequate hydration
⚫ Surgical intervention-(Craniotomy,
25 Clipping and Coiling)
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Time for Case study analysis
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Complication Prevention Treatment
Chest infection semi-erect position Antibiotics
Avoid aspiration (nil by mouth, Physiotherapy
nasogastrictube, possible gastrostomy)
Epileptic seizures Maintain cerebral oxygenation Anticonvulsants
Avoid metabolic disturbance
Deep venous Maintain hydration Anticoagulation
thrombosis/ Early mobilisation (exclude haemorrhagic
pulmonary Anti-embolism stockings stroke first)
embolism Heparin (for high-risk patients only)
Pressure sores Frequent turning Monitor pressure areas Nursing care
Pressure-relieving mattress
Urinary infection Avoid catheterization if possible Antibiotics
Constipation Appropriate aperients and diet Appropriate aperients
Depression Maintain positive attitude and provide Antidepressants

and anxiety information
28

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Stroke

1 Prepared by: Agleema Ahmed

⚫Blood supply to the brain

⚫Blood supply to the brain

Functions of the lobes of the brain

of the brain due to a thrombus or embolus)

to rupture of cerebral vessels)

⚫Pathophysiologic changes begin seconds after a reduction in blood

⚫ Patient’s history, physical examination and

Early Management Ongoing Management

Constipation Appropriate aperients and diet Appropriate aperients

Depression Maintain positive attitude and provide Antidepressants

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