Stroke

Cerebrovascular Accident (CVA) / Brain Attack

Objectives
By the end of this lecture the student will be able to:
 Define stroke and trans ischemic attack
 List Risk factors of stroke
 Mention etiology of stroke
 Enumerate types of stroke
 List Signs and symptoms of stroke
 Explain Stroke patient’s problems
 Apply the role of gerontological nurse for stroke patient
Outlines:
 Definition of stroke and trans ischemic attack
 Risk factors of stroke
 Etiology of stroke
 Types of stroke
 Signs and symptoms of stroke
 Stroke patient’s problems
 Role of gerontological nurse for stroke patient
Definition:
Stroke:
Acute brain disorder of vascular origin accompanied by neurological
dysfunction that persists for longer than 24 hours”

The neurological dysfunction is:

 usually localized/ focal (vascular occlusion) or

 Global dysfunction (when vascular rupture leads to hemorrhage and
mass effect).
Transient Ischemic Attack (TIA):
  Is an acute episode of ischemia with focal loss of brain function that
lasts less than 24 hours (usually 5–20 minutes) and followed by a
full recovery of function
 (TIA) often referred to as mini-strokes
Acute stroke: refers to the first 24-hour-period of a stroke event.
Epidemiology
Morbidity: In 2010, prevalence of stroke was estimated at 2.3 million
males and 3.4 million females; many of the approximately 5.7 million
U.S.
Mortality: stroke ranked fifth as the cause of death for those aged 45 to
64 years and third for those aged 65 years or older. Hemorrhagic strokes
are more severe, and mortality rates are higher than ischemic strokes,
with a 30-day mortality rate of 40% to 80%.

Risk Factors
A. Non-modifiable
 Age ≥ 55 years are at higher risk.
 Gender (women more likely to die) more common in men than in
women.
 Race (African Americans)
 Heredity
B. Modifiable
 Carotid stenosis
 Heart disease, atrial fibrillation
 Hypercholesterolemia.
 Diabetes mellitus
 Hypertension
 Increased blood viscosity caused by some blood diseases.
 Physical inactivity
  Obesity
 Heavy alcohol consumption
 Smoking
 Oral contraceptive use
Etiology
 The major cause of stroke is Atherosclerotic plaque (Fatty build
up in the wall of an artery or its branches that supplying the brain).
 Atherosclerotic plaque can lead to a thrombus formation that
block the artery or can be dislodged and travel to the brain to cause
the obstruction (emboli).

 Brain requires continuous supply of O2 and glucose for neurons to

function, if blood flow is interrupted;
– Neurologic metabolism is altered in 30 seconds
– Metabolism stops in 2 minutes
– Cellular death (infarction) occurs in 5 minutes, causing irreversible
damage even after blood flow is restored
– The brain tissues that surrounding the infarct area also affected by
the ischemia but may recover their function if adequate blood flow
is restored early (<3 hours), less brain damage and less neurologic
function lost.
 – Each minute of cerebral infarction →destruction of 1.9 million
neurons therefore →4.5 hrs after onset of stroke→ loss of benefit
of thrombolytic drugs
Major Types of Stroke:
Ischemic stroke →87% of all strokes

80% → thrombotic strokes

 artery to the brain is blocked by a thrombus)

 Most common cause of stroke.
 Associated with HTN and diabetes.
 Often preceded by a TIA.
20% → embolic strokes

 Dislodged blood clot (an embolus), originate from thrombi outside

the brain, usually in the left side of the heart (from AF/ MI), aorta,
and common carotid artery
 Second most common cause of stroke
 Associated with sudden, rapid and severe clinical symptoms
Hemorrhagic stroke →13% of all strokes:

Due to hypertension, aneurysm, AVM, and trauma.

97% →Intracerebral hemorrhage

Bleeding within the brain.

Hypertension is the most important cause

3% → subarachnoid hemorrhage

Bleeding into cerebrospinal space between the arachnoid and pia mater

(Epidural and subdural hematomas are not considered to be strokes)

Signs and Symptoms:
Warning signs of stroke:
 Face drooping (one side of the face droop or numb)
 Arm weakness (one arm weak or numb)
 Speech difficulty (slurred speech, unable to speak or hard to
understand
 Time to call emergency ( if the person shows any of these
symptoms, go to hospital immediately)

Other stroke symptoms

 Numbness or weakness of the leg on one side of the
 Sudden trouble seeing in one or both eyes.
 Sudden loss of balance or coordination.
 Sudden severe headache, Nausea and vomiting, Coma/
seizure

Investigation of a stroke
 Computerized tomography (CT) is fast and the most useful method in
identifying/differentiating cerebral hemorrhage from infarction.
However, CT does not show any abnormality within the first hour of
an ischemic stroke.
 Magnetic resonance imaging (MRI), may be more useful in identify an
ischemic stroke but it is more time consuming.
 Echocardiography: To identify a source of cerebral emboli when
ischemic stroke is associated with atrial fibrillation, acute MI,

Stroke patient problems:

 Stroke Affects many body functions include; Motor activity
((Mobility, Respiratory function, Swallowing and Gag reflex),
Elimination, Intellectual function (Memory and judgment),
Personality, Affect, Sensation, and Communication.
Actual problems Potential problems
Dysphagia Risk for fall
Impaired physical mobility Risk for aspiration
Self-care deficit Risk for DVT
Impaired communication Risk for pressure ulcer
Incontinence
Impaired thought process

Role of Gerontological nurse in stroke management:

Nurses have important roles in all aspects of stroke care
1- Acute care
1. Assess ABCs (Airway/ Breathing / Circulation)
2. Assess V.S at least every 15 minutes.
 Fever: it is typically attributed to tissue injury, so give antipyretic
Therapy:
 Hypertension: reported in over half of patients with acute stroke
from cerebral edema, body respond to vasospasm and decreased
circulation to brain by increasing blood pressure
 Blood pressures typically return to baseline levels in 2–3 days.
 Reduction only when the systolic pressure exceeds 220 /120mm
Hg
3. Provide oxygen if hypoxemic to maintain O2saturation > 94%
4. Check blood glucose; treat if indicated, keep between 140-180
mg/dL (hyperglycemia aggravate brain injury)
5. Perform neurologic assessment using GCS / hourly or as needed
 Mental Status: Most cerebral infarctions are unilateral, and do
not result in loss of consciousness. When coma occurs, the
most likely conditions are intracerebral hemorrhage,
brainstem infarction.
 Aphasia (disturbance in the comprehension and/or
formulation of language). Injury in the left cerebral
hemisphere (the dominant hemisphere for speech) produces
aphasia.
 Sensorimotor: Injury in one cerebral hemisphere results in
weakness on the opposite side of the body (i.e.,
hemiparesis).
6. Obtain I.V. access and blood samples
7. Obtain 12-lead ECG
8. Order emergency computed tomography (CT) scanning of brain
9. Order Echocardiography: to identify a source of cerebral emboli
when ischemic stroke is associated with atrial fibrillation, acute
MI.
10. Administer thrombolytic therapy
 Thrombolytic therapy can be used only within 4.5 hours of
symptom onset
Alteplase: A tissue plasminogen activator (tPA); the only FDA
approved drug to treat ischemic stroke.
 The administration of anticoagulant (heparin) or antiplatelet agents
(aspirin) is contraindicated for the first 24 hours after thrombolytic
therapy
2- Secondary prevention: Prevention the risk factors for a further stroke;
a) Lifestyle modification includes:
Stopping smoking
Improving diet: a diet low in fat (especially saturated fat) and sodium
but high in fruit and vegetables
Increasing regular exercise
Avoiding excessive alcohol (i.e. no more than two standard drinks per
day).
b) Other measures: management of Blood pressure and diabetes and
long term use of Anticoagulation and Antiplatelet therapy all people with
ischemic stroke.
3- Rehabilitation
Rehabilitation should be structured to provide as much practice as
possible.
Management of the different problems of stroke patients;
a) Nutrition and hydration:
Assessed for swallowing deficits
Observe patient for coughing, food dribbling out OR retained for long
periods in
the mouth
Food easier to swallow, smaller boluses of food, a tube feeding if
indicated.
Patient sit upright, when eating and drinking
Oral hygiene.
b) Improving Mobility and Preventing Deformities:
Use a pressure-relieving mattress
Change position every 2 hours
Provide full range of motion exercise to maintain joint mobility and to
prevent venous stasis, which lead to thrombosis.
Observe for signs distress during exercise (e.g., shortness of breath,
chest pain,
cyanosis, and increasing pulse rate).
Begin walking as soon as standing balance is achieved (use assistive
device).
Provide assistive devices as indicated.
Keep environment organized.
Provide emotional support and encouragement to prevent fatigue and
discouragement.
d) Attaining Bowel and Bladder Control
Catheterization during the period of urinary incontinence or retention.
Provide high-fiber diet and adequate fluid intake (2 to 3 L/day), unless
contraindicated.
Establish a regular time for toileting.
e) Improving Communication
Speak slowly, and give one instruction at a time; allow the patient time
to process and avoid completing patient’s sentences.
Use non-verbal communication
Talk to aphasic patients when providing care activities to provide social
contact.
Provide strong emotional support and understanding to relieve anxiety