Cerebrovascular Accident (CVA)

A. General Information

• Destruction (infarction) of brain cells caused by a

reduction in cerebral blood flow and oxygen.
• Affects men more than women; incidence increases
with age.
• Caused by thrombosis, embolism, hemorrhage
B. Risk factors:

• Hypertension, diabetis mellitus, arteriosclerosis or

atherosclerosis, cardiac disease (valvular disease/
replacement, chronic atrial fibrillation, myocardial
infarction)
• Life-style: obesity, smoking, inactivity, stress, and use
of oral contraceptives

C. Pathophysiology:

o Interruption of cerebral blood flow for 5 minutes or more

causes death of neurons in affected area with irreversible
loss of function

o Modifying factors:

• Cerebral edema: develops around affected area

causing further impairment

• Vasospasm: constriction of cerebral blood vessel may

occur, causing further decrease in blood flow.

• Collateral circulation: may help to maintain cerebral

blood flow when there is compromise of main blood
supply.

D. Stages of development

a. Transient ischemic attack (TIA)

• Warning sign of impending CVA

• Brief period of neurologic deficit: visual loss,
hemiparesis, slurred speech, aphasia, and vertigo
• May last less than 30 seconds but no more than 24
hours with complete resolution of symptoms

b. Stroke in evolution: progressive development of stroke

symptoms over a period of hours to days.

c. Completed stroke: neurologic deficit remains unchanged

for a 2 to 3-day.

E. Assessment findings

• Headache
• Generalized signs: Vomiting, seizures, confusion,
disorientation, decreased LOC, nuchal rigidity, fever,
hypertension, slow bounding pulse, Cheyne – Strokes
respirations
• Focal signs (related to site of infection): hemiplegia,
sensory loss, aphasia, and homonymous hemianopsia
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(Neurologic Exam)

F. Diagnostic tests

o CT and brain scan: reveal lesion

o EEG: abnormal changes

o Cerebral arteriography: may show occlusion or
malformation of blood vessels.

G. Nursing intervention: Acute stage

1. Maintain patent airway and adequate ventilation.

2. Monitor vital signs and neuro checks and observe for
signs of increased ICP, shock,hyperthermia, and seizures.
3. Provide complete bed rest as ordered.
4. Maintain fluid and electrolyte balance and ensure
adequate nutrition.
a. IV therapy for the first few days
b. Nasograstic tube feedings if client unable to swallow
c. Fluid restriction as ordered to decrease cerebral edema

5. Maintain proper positioning and body alignment.

a. Head of bed may be elevated 30-45 degrees to

decrease ICP
b. Turn and reposition every 2 hours (only 20 minutes on
the affected side)

6. Promote optimum skin integrity: turn client and apply

lotion every 2 hours
7. Maintain adequate elimination.

a. Offer bedpan or urinal every 2 hours, catheterize only

if absolutely necessary.
b. Administer stool softeners and suppositories as
ordered to prevent constipation and fecal impaction.

8. Provide a quiet, restful environment.

9. Establish a means of communicating with the client.
10. Administer medications as ordered:

a. Hyperosmotic agents, corticosteroids to decrease

cerebral edema
b. Anticonvulsants to prevent or treat seizures
c. Thrombolytics given to dissolve clot (hemorrhage must
be ruled out)

1) Tissue plasminogen activator (tPA, Altepalse)

2) Streptokinase, urokinase
3) Must be given within 2 hours of episode

d. Anticoagulants for stroke in evolution or embolic

stroke (hemorrhage must be ruled out)

1) Heparin
2) Warfarin (Coumadin) for long-term therapy
3) Aspirin and dipyridamole (Persantine) to
inhibit platelet aggregation in treating TIAs

e. Antihypertensives if indicated for elevated blood

pressure

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H. Nursing interventions: Rehabilitation
1. Hemiplegia: results from injury to cells in the cerebral motor
cortex or to corticospinal tracts (causes contralateral
hemiplegia since tracts cross in medulla)
a. Turn every 2 hours (20 minutes only on
affected side).
b. Use roper positioning to prevent deformities
(foot drop, external rotation of hip, flexion of fingers,
wrist drop, abduction of shoulder and arm).
c. Support paralyzed arm on pillow or use sling
while out of bed to prevent subluxation of shoulder.
d. Elevate extremities to prevent dependent
edema.
e. Provide active and passive ROM exercises
every 4 hours.
2. Susceptibility to hazards
a. Keep side rails up at all times.
b. Institute safety measures.
c. Inspect body parts frequently for signs of injury.
7. Sensory/perceptual deficits: more common in left
hemiplegics; characterized by impulsiveness, unawareness of
disabilities, visual neglect (neglect of affected side and visual
space on affected side)
a. Assist with self-care.
b. Provide safety measures.
c. Initially arrange objects in environment on unaffected
side.
d. Gradually teach client to take care of the affected side
and turn frequently and look at affected side.
8. Apraxia: loss of ability to perform purposeful, skilled acts.
a. Guide client through intended movement (e.g., take
object such as washcloth and guide client
through movement of washing).
b. Keep repeating the movement.
9. Generalizations about clients with left hemiplegia versus
right hemiplegia and nursing care.
a. Left hemiplegia
1) Perceptual, sensory deflects; quick and impulsive
behavior
2) Use safety measures, verbal cues, and simplicity in
all areas of care

3. Dysphagia (difficulty swallowing) b. Right hemiplegia

a. Check gag reflex before feeding client. 1) Speech-language deficits; slow and cautious
b. Maintain a calm, unhurried approach behavior
c. Place a client in upright position 2) Use pantomime and demonstration
d. Place food inn unaffected side of mouth.
e. Offer soft foods.
f. Give mouth care before and after meals.

4. Homonymous hemianopsia: loss of half of each visual

field.

a. Approach client on unaffected side.

b. Place personal belongings, food, etc. on unaffected
side.
c. Gradually teach client to compensate by scanning, i.e.,
turning the head to see things on affected side.

5. Emotional liability: mood swings, frustration

a. Create a quite, restful environment with a reduction in

excessive sensory stimuli.
b. Maintain a calm, nonthreatening manner.
c. Explain to family that the client’s behavior is not
purposeful.

6. Aphasia: most common in right hemiplegics; may be

receptive/expressive

a. Receptive aphasia
1) Give simple, slow directions.
2) Give one command at a time; gradually shift topics.
3) Use nonverbal techniques of communication (e.g.,
pantomime, demonstration).

b. Expressive aphasia
1) Listen and watch very carefully when the client attempts
to speak.
2) Anticipate client’s needs to decrease frustration and
feelings of helplessness.
3) Allow sufficient time for client to answer.
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 CARDIOVASCULAR DISORDER 2. Left- sided heart failure
- Signs of pulmonary system
HEART FAILURE - Cough: can become frothy and productive
- Inability of the heart to maintain adequate circulation - Dyspnea upon exertion
- Diminished cardiac output and inadequate perfusion of - Orthopnea
peripheral tissue - Paroxysmal nocturnal dyspnea
- Congestion of lungs may occur - (+) rales and crackles
- Classification: acute or chronic - Tachycardia
- Pulsus alterans
- Types - Fatigue
1. Right side heart failure/left sided heart failure - Pallor
- Represents 2 different pumping system - Cyanosis
- Heart failure begins with left ventricular failure then - Confusion and disorientation
both - Signs of cerebral anoxia
- Acute pulmonary edema occurs: medical emergency

2. Forward failure/backward failure 3. Acute pulmonary edema

- Inadequate output in affected ventricles - Severe dyspnea and orthopnea
- Decrease perfusion of vital organs - Pallor
- Blood backs up behind the affected ventricle= - Tachycardia
increase pressure in the atria - Expectoration of blood tinged, frothy sputum
- Wheezing and rales
3. Low output/ high output heart failure - Bubbling respiration
- Low output: low cardiac output - Profuse sweating and cold clammy perspiration
- Cyanosis
- High output: heart increase in activity to meet - Nasal flaring and use of accessory muscle of respiration
demands of the body - Tachypnea

4. Systolic failure/ diastolic failure Immediate management

- Diastolic failure: problem in relaxing and filling of 1. High fowlers position
blood 2. O2 administration: high concentration
- Systolic failure: problem of contraction and ejection of 3. Prepare for intubation and ventilator support
blood 4. Suction as needed
5. Assess LOC
- Compensatory mechanism 6. Monitor VS
7. Monitor for hypotension
1. Restore cardiac output
8. Assess edema on dependent areas
2. Increase myocardial oxygen consumption
9. Insert Foley catheter after diuretic administration
3. Increased heart rate, improve stroke volume,
10. Monitor I and O
arterial vasoconstriction, sodium and water
11. Avoid unnecessary IV
retention and myocardial hypertrophy
12. Administer morphine sulfate
13. Administer diuretics
- Assessment
14. Administer digitalis
15. Administer bronchodilators for bronchospasm
1. Right-sided heart failure
16. Administer additional inotropic meds (dopamine
- Signs in systemic circulation
or dobutamine
- Pitting, dependent edema
17. Administer vasodilators
- Ascitis due to portal hypertension
18. Monitor weight
- Tenderness of right upper quadrant
19. Assess for hepatomegaly and ascitis
- Distended neck veins 20. Analyze ABG result
- Pulsus alterans 21. Monitor potassium level
- Abdominal pain, bloating
- Anorexia, nausea Management after acute episode
- Fatigue 1. Let patient verbalize regarding lifestyle changes
- Weight gain 2. Instruct patient regarding medication and to
- Nocturnal diuresis report adverse effect of the drugs
3. Instruct patient to avoid caffeine
4. Diet: low sodium, low fat and low cholesterol diet
5. Increase intake of potassium
6. Instruct patient to report signs of fluid retention

HYPERTENSION

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 - Persistent elevation of the systolic blood pressure at the HYPERTENSIVE CRISIS
level of 140mmHg or higher and diastolic blood pressure • Hypertensive emergency
at the level of 909mmHg or higher – Blood pressure >180/120 and must be lowered
- Common in African Americans immediately to prevent damage to target organs.
- End result: heart attack • Hypertensive urgency
- Primary (essential) hypertension: 90% of all cases – Blood pressure is very high but no evidence of
- Secondary Hypertension: due to renal failure immediate or progressive target organ damage.
- Malignant hypertension: resistant or persistent severe
HYPERTENSIVE EMERGENCY
hypertension
• Reduce BP 25% in first hour
- Non modifiable factors • Reduce to 160/100 over 6 hours
Family history • Then gradual reduction to normal over a period of days
Age • Exceptions are ischemic stroke and aortic dissection
Gender • Medications
Ethnicity
– IV vasodilators: sodium nitroprusside, nicardipine,
fenoldopam mesylate, enalaprilat, nitroglycerin
Modifiable risk factors
Stress • Need very frequent monitoring of BP and cardiovascular
status
Obesity
Nutrients HYPERTENSIVE URGENCY
Substance abuse • Patient requires close monitoring of blood pressure and
cardiovascular status.
Pathophysiology • Assess for potential evidence of target organ damage.
• Medications
*Primary hypertension
Four control system play a role in maintaining blood pressure – Fast-acting oral agents: beta-adrenergic blocker-
labetalol; angiotensin-converting enzyme inhibitors:
1. Arterial baroreceptor and
captopril or alpha2-agonists-clonidine
chemoreceptor
2. Regulation of body fluid
volume
3. Renin angiotensin system
4. Vascular auto regulation

*Secondary hypertension
o Chronic renal disease (Chronic GN and renal artery
stenosis)
Primary aldosteronism
Pheochromocytoma
Cushing’s syndrome
*Vessel changes
o Sclerosis of large arteries

Management
Lifestyle modification
Weight reduction
Sodium restriction
Dietary fat modification
Exercise
Alcohol restriction
Caffeine restriction
Relaxation techniques
Smoking cessation
Potassium supplementation
Antihypertensive medications
Diuretics
Alpha and beta adrenergic antagonist
Vasodilators
Calcium antagonist
ACE inhibitors
Angiotensin receptor blockers

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