1. cva or stroke

CVA/Stroke/ Brain Attack

Dr. RS Mehta, BPKIHS

• 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 disabilityDr. RS Mehta, BPKIHS

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

Dr. RS Mehta, BPKIHS

Dr. RS Mehta, BPKIHS

Circle of wills

Dr. RS Mehta, BPKIHS

Dr. RS Mehta, BPKIHS

• 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

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

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

CVA• Thromboetic infraction: 80%• Cerebral Haemorrhage: 10%• Sub-arrhochonoid hemorrhage: 5%• Others

Dr. RS Mehta, BPKIHS

Dr. RS Mehta, BPKIHS

Cerebral edema

Dr. RS Mehta, BPKIHS

Local infarction:

Dr. RS Mehta, BPKIHS

Dr. RS Mehta, BPKIHS

Cerebral Infarct - 1 Week

Dr. RS Mehta, BPKIHS

Cerebral Infarct - 2 Weeks

Dr. RS Mehta, BPKIHS

Cerebral Infarction - Late

Dr. RS Mehta, BPKIHS

Dr. RS Mehta, BPKIHS

Causes: • Thrombosis. • Embolus. • Hemorrhage (HTN. Rupture).

Dr. RS Mehta, BPKIHS

Risk factors• Modifiable risk factors

– High BP– Cigarette smoking– Alcohol intake– Uncontrolled Heart disease– Atrial fibrillation– Uncontrolled Diabetes– Carotid congestion

Dr. RS Mehta, BPKIHS

• High blood cholesterol• Sedentary lifestyle• Obesity• Seasons• Stress

Dr. RS Mehta, BPKIHS

Risk Factors Unable to Control

• Age• Gender• Race• Prior strokes• Heredity• Sickle Cell Disease

Dr. RS Mehta, BPKIHS

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

THREE STROKE TYPES

IschemicStroke

Clot occludingartery

Intracerebral Hemorrhage

Bleedinginto brain

Subarachnoid Hemorrhage

Bleeding around brain

Focal Brain Dysfunction

Diffuse Brain Dysfunction

Intracerebral Hemorrhage

Bleedinginto brain

IschemicStroke

Clot occludingartery

85% 10% 5%

Dr. RS Mehta, BPKIHS

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 Permanent infraction of Temporary or TIAS cerebral cells.

(Permanent changes occur within 3-10 minutes).

Dr. RS Mehta, BPKIHS

Early warning signs: • Headache• Vomiting• Seizures• fever etc.

Silent Stroke: do not cause SymptomsDr. RS Mehta, BPKIHS

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

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

Left Brain Damage• Right side paralysis• Speech and language disturbance• Behavioral changes• Swallowing problems

Dr. RS Mehta, BPKIHS

Right Brain Damage• Left side paralysis• Coordination• Perception

Dr. RS Mehta, BPKIHS

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

Clinical Manifestations • Affects many body functions

• Motor activity• Elimination• Intellectual function• Perceptual alterations• Personality• Sensation • Communication

Dr. RS Mehta, BPKIHS

Use a “FAST” STROKE Assessment

• Face• Arm• Speech• Time of onset

Dr. RS Mehta, BPKIHS

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

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

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

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

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

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

Medical management: Aim:

–Preserving life. –Minimizing residual deficits. –Reducing ICP. –Preventing extension or

recurrence.

Dr. RS Mehta, BPKIHS

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

RxA. CVA: Ischemic1. Tab. Asprin 150 mg, Po/NGT OD (Asprin allergy: Clopidogel 300mg

stat,75mg/day)2. Ranitidine/Ocid/Pantop: decrease gastric ulcer3. Antihypertensive4. O2 support: based on ABG, ABC5. NGT feeding/IV infusion6. Chest physiotherapy and passive exercise7. DVT prophylaxis and Seizure control8. Laxative9. Catheter: Foleys early10. Steroid: if Meningitis/ Inflammation / SwellingB. Clot:11. anti-hypertensive12. Mannitol-20%13. Tissue Plasminogen Activator: t-PA (clot buster): previously STK was

used Dr. RS Mehta, BPKIHS

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

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

Dr. RS Mehta, BPKIHS

Dr. RS Mehta, BPKIHS

Internal Carotid Endarterectomy(if Stenosis > 70%)Dr. RS Mehta, BPKIHS

Nursing Management

Dr. RS Mehta, BPKIHS

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

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

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

• 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

• 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

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

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

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

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

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

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

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 pageDr. RS Mehta, BPKIHS

• 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%)

Effects

Dr. RS Mehta, BPKIHS

Rehabilitation: (Nurses role)

• Exercise. • Diet.• Regular follow up. • Family support.• Psychological support. • Occupational therapy.

Dr. RS Mehta, BPKIHS

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

Primary Prevention: Decrease Risk Factors

1. Treatment of HTN2. Avoid Smoking3. Active Life Style4. Avoid Alcohol5. Decrease LDL Cholesterol6. Anticoagulant in Atrial Fibrillation

Dr. RS Mehta, BPKIHS

Dr. RS Mehta, BPKIHS

Dr. RS Mehta, BPKIHS

Thank you

Dr. RS Mehta, BPKIHS