mister light stroke

Cerebrovascular Accident (CVA)
)stroke(
Prepared by:
Nour el-dien khalaf

Objectives:
By the end of the Lecture each Student should
be able:
Discus brain anatomy and its function.
 Identify the stroke.
List the risk factors of stroke.
Mention the causes of stroke.
Describe signs and symptoms of stroke

Cont.,
List types of stroke.
Differentiate between the types of stroke.
 Identify the Transient ischemic attack(TIAs).
List warning signs of stroke.
Discus complications of stroke.
Apply nursing care for stroke patients.

Outlines:
 Introduction.
 The definition of Stroke.
 Risk factors of stroke.
 Causes of stroke.
 Signs and Symptoms of Stroke.
 Types of Stroke.

Con.,
Transient ischemic attack(TIAs).
Stroke warning signs.
Complications of stroke.
Diagnosis of stroke.
management of stroke.

Introduction:
Stroke is a form of cardiovascular disease affecting the blood
supply to the brain.
Stroke is a major health problem in the country.
Stroke as a disease of elderly but also affects younger individuals.
 If 100 persons have stroke:
10% are able to return to previous level of activity.
50% return home and carry on with only limited assistance.
40% require significant assistance in caring for themselves.

Anatomy of the brain
Brain
Brain stem
Cerebrum Left hemispheres
Right hemispheres
Frontal
Temporal
Parietal
Occipital
Cerebellum

Stroke
 Stroke is the sudden death of a portion of the brain cells
due to a lack of oxygen.
 Stroke occurs when blood flow to the brain is damage
resulting in abnormal function of brain.
 It causes by blockage or rupture of an artery to the brain.

Risk factors
Controllable Medical Risk Factors:
1) High blood pressure(Hypertension).
2) Heart disease
3) Diabetes.
4) High cholesterol
5) Atherosclerosis
6) Carotid bruit.

Cont.,
Controllable Lifestyle Risk Factors:
1) Smoking.
2) Obesity and Physical Inactivity.
Uncontrollable Risk Factors:
1) Age
2) Heredity and family history
3) History of TIAs.

Controllable Medical Risk Factors:
1-High blood pressure(Hypertension) :
Making the arteries more vulnerable to thickening or
narrowing to rupture.
Controlling hypertension is the key to preventing stroke.

Cont.,
2-Heart disease:
 Damage to the heart more likely to form clots within heart and it
can travel to the brain.
 If the blood vessels feeding the heart are diseased, it is likely that
arteries to the brain are also affected.
 Patients with A.F, heart failure, and C.H.F, have increase in the
risk of stroke.

Cont.,
3-Diabetes:
 Major risk factor for ischemic stroke.
Increased susceptibility to atherosclerosis and hypertension,
obesity, and abnormal blood lipids.
Many people with diabetes also have high cholesterol,
increasing their risk for stroke.

Con.,
4-High cholesterol:
Increase cholesterol
Blockage of arteries
Risk of stroke increase

Cont.,
5-Atherosclerosis:
is the progressive buildup of plaque – fatty deposits and
other cells – in artery walls.

Cont.,
6-Carotid bruit:
A bruit is a noise made by turbulent flow in blood vessel that
usually can be heard only by stethoscope.
The most common cause is carotid stenosis due to atherosclerosis.
Carotid bruit increase to have a stroke by 5% .
May need surgical procedure called carotid endarterectomy.

Controllable Lifestyle Risk Factors:
1-Smoking:
The more you smoke, the more this risk increases.
Smoke 20 cigarettes a day, you are six times more likely
to have a stroke compared to a non-smoker.
If you have had a stroke, it is
strongly
recommended that you stop
smoking to
help prevent any further
strokes. Research
has shown that you are at
greatest risk
of another stroke shortly after
the first.

Cont.,
2-Obesity and in activity:
Obesity increase the risk of HTN,HD and DM and they also stroke
risk factor

Uncontrollable Risk Factors:
1-Age
Age is a significant risk factor for stroke.
About 75% of strokes occur in individuals ≥ 65 yrs.

Cont.,
2-Heredity and family history
 The chance of having a stroke is higher for people who have a
family history of this disease.
3-History of TIAs?
 Is localized neurological problem caused by ischemia(decreased
blood flow)resolves within24hours.

Causes of stroke:
1-Cerebral thrombosis
(blood clot within blood vessel of the brain or neck)
2-Cerebral embolism
(blood clot or other material carried to the brain
from another part of the body)

Cont.,
3-Cerebral ischemia
(insufficiency of the blood supply to the brain)
4-Cerebral hemorrhage
(rupture of a cerebral vessel with bleeding into the brain tissue or
spaces around the brain)

Types of stroke
Stroke
Ischemic stroke
70%
Thrombotic
stroke
15%
Embolic
stroke
25%
Lacunar
stroke
30%
Others
5%
Hemorrhagic
stroke
25%
Intracerebral
hemorrhag
e
15%
Subarachnoi
d
hemorrhage
10%

Types of stroke:
1-Ischemic stroke 70 %
 Insufficiency of the blood supply to the brain.

Subcategories of Ischemic stroke:
Thrombotic stroke 15%
Is caused by a clot that blocks blood flow in an artery.
B-Embolic stroke 25%
Is caused by a wandering clot that forms in one part of
the body, and travel in the bloodstream until lodges in
an artery.
C-Lacunar stroke 30%
Is caused by occlusion of arterioles, the very small ends
of the arteries that penetrate deep into the Bain .

2-Hemorrhagic stroke 25%
 Bleeding within the brain tissue either the brain
itself(intracerebral hemorrhage)or the space around
the brain(subarachnoid hemorrhage)

Intracerebral Hemorrhage and
Subarachnoid Hemorrhage
Intracerebral Hemorrhage:
Blood leaks from small vessels at the base of brain.
Subarachnoid Hemorrhage :
Blood leaks from small vessels at the space around the brain.

Causes of hemorrhagic stroke
1. High blood pressure(hypertension).
2. Aneurysm.
3. Trauma.
4. Tumors.
5. Abnormalities in blood vessels (arteriovenous malformations).

The classic signs and symptoms of
ICH and SAH
 Sudden severe headache with unknown cause.
 Seizures.
 Stiff neck.
 Sensitivity to light.
 Change in consciousness.
 Nausea and Vomiting.

Transient ischemic attack(TIAs)
 Is localized neurological problem caused by ischemia(decreased
blood flow)resolves within24 hours.
Most TIAs are due to either an embolus(blood clot)or restricted
blood flow often causes by narrowing in the carotid
artery(carotid stenosis).

Stroke warning signs
 Sudden weakness or numbness of the face, arm ,and leg on one
side of the body.
 Sudden onset of blurred or double vision.
 Sudden confusion, trouble speaking or understanding..
 Sudden trouble walking, dizziness, lack of balance or
coordination.
 Sudden severe headache with no known cause.

Signs and Symptoms of Stroke
Hemiplegia:
The total paralysis of the arm, leg, and trunk on one side of the
body.
Hemiparesis:
Is weakness on one side of the body. It is less severe than
hemiplegia.

Con.,
 Dysarthria:
Difficulty in forming words but not lose any speech
comprehension or writing skills.
 Aphasia:
Difficulty in producing or comprehending spoken or written
language.
 Apraxia:
Is the inability to execute learned purposeful movements spite
having the desire and the physical capacity to perform the
movements.

Con.,
 Dysphagia:
Difficulty in swallowing.
 Homonymous hemianopsia:
Loss of the half of the visual field (left or right side of the vertical
midline) It can affect one eye but usually affects both eyes.

Con.,
 Amorphosynthesi:
The patient’s head turns away from the affected side of the body
and he tend to neglect that side.
 Limited attention span.
 Depression , hostility, resentment and frustration.

Complications:
1)Systemic thrombotic complications:
 Deep venous thrombosis(DVT)
The risk of deep vein thrombosis (DVT) after stroke is increased in
patients with restricted mobility.
pulmonary embolism
Pulmonary embolism in patients with acute stroke can be a cause of
early mortality (during the first month after the ictus).

Con.,
2)Pulmonary complications
Aspiration Pneumonia .
3. Cardiac complications
Sinus tachycardia.
Sinus bradycardia.
 A.F

Con.,
4. genitourinary complications
urinary incontinence.
urinary tract infection.
most common organism : Escherichia coli
5.Gastrointestinal complication
 GI bleeding.

Con.,
6-Miscellaneous complications:
Falls.
skin breakdown.
Depression.

Diagnosis of stroke
1-History and Examination:
Vital signs.
Carotid Bruit.
Cardiac Exam .
 Signs of trauma.
Past history.
History oh TIAs.

Recognize the Symptoms of a Stroke
3 Simple Questions:
 Ask the person to smile.
 Ask the person to raise both arms.
 Ask the person to say a simple sentence “The sky is blue in
Assiout”.
The sky is
blue in
assiout

Con.,
Neurologic Exam
 Level of consciousness/GCS.
 Language/Speech.
 Orientation, vision, and hearing.
 memory, motor skills, and emotional control.
 Visual deficits.
 Weakness/Paralysis.

Con.,
2-Imaging studies:
Brain computed tomography(CT)
 Is a painless test that uses x rays to take clear, detailed pictures of
your brain.
Can show bleeding in the brain or damage to the brain cells from
a stroke.

Magnetic Resonance Imaging(MRI):
 Is a painless test that uses magnets and radio waves to create
pictures of the organs and structures in your body.
Computed Tomography Arteriogram and Magnetic
Resonance Arteriogram.(CTA &MRA)
Can show the large blood vessels in the brain.

Con.,
Carotid Ultrasound:
 is a painless and harmless test that uses sound waves to create
pictures of the insides of your carotid arteries.
Doppler ultrasound:
 is a special test that shows the speed and direction of blood
moving through your blood vessels.

Con.,
Carotid Angiography:
 is a test that uses dye and special x rays to show the insides of
your carotid arteries.
Contraindications?

Con.,
EKG (Electrocardiogram):
 Is a simple, painless test that records the heart's electrical activity.
Can help detect heart problems that may have led to a stroke. For
example, the test can help diagnose atrial fibrillation or a
previous heart attack.

Con.,
Echocardiography(Echo.):
 Is a painless test that uses sound waves to create pictures of your
heart.
Gives information about the size and shape of your heart and
how well your heart's chambers and valves are working.

Blood Tests:
PT and PTT tests These tests show whether your blood is clotting
normally.

Nutritionists
Social
Workers
Case
Managers
Occupational
Therapists
Nurses
Medical
Doctors
Physiotherapists
Neurologist
Pharmacologist
Patient
Neurosurgeon
Multidisciplinary in Stroke

management of stroke
A-Firstly
1-Prevention of Stroke:
 Public Awareness and health teaching
Through the mass media to raise awareness about the
health .
Public should be able to recognize signs and symptoms
of stroke, and sudden signs and symptoms.
Health teaching should emphasize stroke is a medical
emergency act as FAST.
Education should include that stroke can affect persons
of any age.

Easy way to remember the sudden signs
and symptoms of a stroke:

Con.,
Know your blood pressure, have it checked at least annually, if it
is elevated, work with your doctor to control it.
 If you smoke, stop.
Know your cholesterol number. If it is high, work with your
doctor to control it.
 If you are diabetic, follow your doctor’s recommendations
carefully to control your diabetes.

Con.,
Include exercise in your daily routine.
Enjoy a lower sodium (salt) and lower fat diet.
If you have circulation problems, work with your doctor
to improve your circulation.
If you experience any stroke symptoms please, go to
doctor rapidly Every minute matters.

Con.,
Giving basic information for all patients with stroke or at
risk of stroke and their families Includes:
About meaning of stroke.
Stroke is a medical emergency act as FAST.
About Transient ischemic attack(TIAs).
Sudden signs and symptoms of stroke.

Con.,
Who are the risk factors.
 Care of stroke.
Post-stroke complication.
Rehabilitation process.

management of stroke
B-Secondary:
A-Medical treatment:
Reduce blood clots formation by preventing the smallest blood
cells (platelets) from sticking together and forming blood
clots.
Anticoagulants drugs (warfarin, heparin).
Antiplatelet drugs(Aspirin, Plavix).
Antihypertensive drugs(Capoten, Norvasc, Cardura, etc..).

Anticoagulants drugs:
Warfarin.
Heparin.

Antiplatelet drugs:
 Aspirin.
 Plavix.

Con.,
Glucose control
 Hyperglycemia is an independent risk factor for hemorrhage.
 Drugs as insulin and Amaryl.
Antiepileptic Drugs
 Seizures are common after hemorrhagic .
 Drugs as phenytoin

Tissue plasminogen activator (TPA)
The magician
TPA to treat ischemic stroke in the first three hours after
the onset of symptoms.

Calculation and Documentation of tPA
0.9 mg/kg – Do not exceed the 90 mg max dose
Mix 100 mg in 100 ml of sterile water, subtract pt dose from 100
ml and discard the difference. Final concentration 1mg/1ml
Withdraw 10% and give IV bolus over 1 minute, followed by the
remainder over 60 min.
Double check for correct dose (MD, RN)
Document bolus dose and drip dose over 1 hr

Example of tPA Calculation
 Patient wt – 80 kg
 Chart:
 0800 tPA bolus 7.2 mg
 0801 tPA infusion 64.8
mg in 64.8 ml given over
60 minutes
 0.9mg/kg = 72
72mg in 72 ml (total
dose)
 - 10% = 7.2 mg or ml
(bolus dose)
 72 -7.2 = 64.8mg (infusion
dose)

Nursing interventions
During tPA Administration
Check BP every 15 min for 2 hours.
Treat hypertension/hypotension as ordered.
Monitor Neuro status every 30 min.
Watch for bleeding – puncture sites, urine, stool
etc.
Know signs/symptoms of Intracerebral
Hemorrhage.

Hemorrhage Suspected
Stop TPA infusion.
Call MD immediately.
Stat head CT without contrast.
Draw blood for PT, PTT, plt ct, fibrinogen, and
type and hold.
Prepare for administration of cryo and or
platelets .

Post tPA
Continue to monitor for signs/symptoms of
intracerebral hemorrhage.
No unnecessary blood draws or invasive procedures for
12 hours after tPA.
Repeat CT scan 24 hours after tPA to evaluate for
bleeding
No aspirin, heparin, warfarin, or other antithrombotic
or antiplatelet drugs 24 hours after tPA.

B-Surgical intervention
carotid endarterectomy for carotid stenosis

Bypass surgery for ischemic stroke:

Coil embolization
Surgical clipping for aneurysm

Evacuation for hemorrhage and hematoma

C-Nursing intervention:
1-Monitor vital signs for changes.
2-Asses neurological status, perform neurological checks at least
every 4hours by using GCS.
3-Monitor for signs of increased ICP.
4-Turning position every 2hours.
5-Assess the patient in the feeding process.
important for people to understand stroke warning signs and get to
a hospital FAST in case they are eligible to receive tPA

Con.,
6-keep skin clean and dry.
7-massage to maintain skin integrity.
8-Using footboard used during flaccid period to prevent sores.
9-Perform passive ROM 4 to 5 times.
10-Apply care to the patient to promote health.

C-Thirdly
Recovery and Rehabilitation
No program can succeed without a strong desire.
1-physica therapy:
 Help patient to learn to walk again
 (walking, range of motion)

Con.,
2-Occupational therapy:
 Help the patient to perform basic activity by muscular
coordination.
 (Taking care of one’s self ,bathing, dressing)

3-speech therapy:
Help the patient to regain to speech and communicate.

Summery:
myth
Not preventable
cannot be treated
only strikes the elderly
Stroke happens in the
heart
reality
80%are preventable
requires emergency
Anyone can have a
stroke
Stroke is a “Brain
Attack”
stroke

Check Up Quiz
At a family gathering, your cousin tells you that
your uncle has had a stroke. Your cousin says you
should not worry about it happening to either of
you because stroke is caused by old age. Is his
statement true or false?

Check Up Quiz
What is a stroke?
A. A blood clot stops the flow of blood in a limb.
B. The heart slows and nearly stops functioning.
C. Blood flow to the brain is interrupted, or a blood vessel in the
brain bursts
D. All of the Above.

Check Up Quiz
What are risk factors for stroke?
A. High blood pressure
B. Diabetes
C. Heart disease
D. All of the Above

Check Up Quiz
What are the symptoms of stroke?
A. Sudden weakness or numbness on one side of the body,
and/or sudden, severe headaches.
B. Sudden confusion, difficulty speaking, and/or blurred vision.
C. Sudden dizziness or problems moving or walking.
D. All of the Above.

Check Up Quiz
What therapy is used to prevent a second ischemic stroke?
A. Surgery to remove carotid artery plaque
B. Angioplasty in the carotid artery
C. Anticoagulant medication
D. All of the Above

References
Brunner and sudderth’s.(2011).text book of medical surgical
nursing,9th edition, Lippincott, page(1725-1735).
www.medicalnewstoday.com
www.stroke.org
www.strokeassociation.org
www.strokenetwork.org

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