COLLEGE OF NURSING

Silliman University Dumaguete City Resource Unit On

CEREBROVASCULAR ACCIDENT

Submitted to: Mr. Dominique Ablir Submitted by: Charles Kevin Ramos Rogelli Anne Real

August 23, 2011 COLLEGE OF NURSING

Silliman University Dumaguete City

Vision:
A leading Christian institution committed to total human development for the well-being of society and environment.

Mission:
1. Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where Christian fellowship and relationship can be nurtured and promoted. 2. Provide opportunities for growth and excellence in every dimension of the University life in order to strengthen character, competence and faith. 3. Instill in all members of the University community an enlightened social consciousness and a deep sense of justice and compassion 4. Promote unity among peoples and contribute to national development.

Specific Objectives At the end of the discussion, the students shall: Be able to define stroke

Content I. Definition of terms: Stroke is a term used to describe neurologic changes caused by an interruption in the blood supply to a part of the brain. The two major types of stroke are ischemic and hemorrhagic. II. Introduction A. Anatomy and Physiology Brain Cerebrum The cerebrum, also known as the telencephalon, is the largest and most highly developed part of the human brain. It encompasses about two-thirds of the brain mass and lies over and around most of the structures of the brain. The outer portion (1.5mm to 5mm) of the cerebrum is covered by a thin layer of gray tissue called the cerebral cortex. The cerebrum is divided into right and left hemispheres that are connected by the corpus callosum. Each hemisphere is in turn divided into fourlobes. The cerebrum or telencephalon, along with thediencephalon comprise the two major divisions of prosencephalon(forebrain). Function: The cerebrum is involved in several functions of the body including: Determining Intelligence Determining Personality Thinking Perceiving Producing and Understanding Language Interpretation of Sensory Impulses Motor Function Planning and Organization Touch Sensation

T.A. 1 min

T-L Activities Lecture discussion

Evaluation Oral evaluation Written evaluation Quiz-75% mastery level

Comprehensivel y review the anatomy of the involve body system

3 mins

Socialized discussion

The cerebral cortex can be divided into four sections, which are known as. The frontal lobe, parietal lobe, occipital lobe and temporal lobe have been associated with different functions ranging from reasoning to auditory perception. The frontal lobe is located at the front of the brain and is associated with reasoning, motor skills, higher level cognition, and expressive language. At the back of the frontal lobe, near the central sulcus, lies the motor cortex. This area of the brain receives information from various lobes of the brain and utilizes this information to carry out body movements. The parietal lobe is located in the middle section of the brain and is associated with processing tactile sensory information such as pressure, touch, and pain. A portion of the brain known as the somatosensory cortex is located in this lobe and is essential to the processing of the body's senses. The temporal lobe is located on the bottom section of the brain. This lobe is also the location of the primary auditory cortex, which is important for interpreting sounds and the language we hear. The hippocampus is also located in the temporal lobe, which is why this portion of the brain is also heavily associated with the formation of memories. The occipital lobe is located at the back portion of the brain and is associated with interpreting visual stimuli and information. The primary visual cortex, which receives and interprets information from the retinas of the eyes, is located in the occipital lobe. The cerebellum is involved in the coordination of voluntary motor movement, balance and equilibrium and muscle tone. It is located just above the brain stem and toward the back of the brain. It is relatively well protected from trauma compared to the frontal and temporal lobes and brain stem.

Identify the risk factors of stroke

5 mins

Lecture discussion

III. Cerebrovascular Accident

Explain the types of stroke

a. Etiology and Risk Factors Risk factors can be divided into modifiable and nonmodifiable. Stroke risk increases with multiple risk factors. a. Nonmodifiable risk factors include age, gender, race and family history/heredity. Stroke risk increases with age, doubling each decade after 55 years of age. It is also more common in men, but more women die from stroke than men. Because women tend to live longer than men, they have more opportunity to suffer a stroke. A family history of stroke, a prior transient ischemic attack, or prior stroke also increases the risk of stroke. b. Modifiable risk factors include hypertension, heart disease, smoking, excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, and drug abuse. The early forms of birth control pills that contained levels of progestin and estrogen increased a womans chance of experiencing a stroke, especially if they also smoked heavily. Other conditions that may increase stroke risk include headaches, inflammatory conditions, hyperhomocytinemia and sickle cell disease. b. Types of Stroke Ischemic stroke An ischemic stroke, is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. Ischemic strokes are subdivided into five different types according to their cause: large artery thrombosis (20%), small penetrating artery thrombosis (25%), cardiogenic embolic stroke (20%), cryptogenic (30%) and other (5%). Large artery thrombotic strokes are due to atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction. Small penetrating artery thrombotic strokes affect one or more vessels and are the most common type of ischemic stroke.

10 mins

Small artery thrombotic strokes are also called lacunar strokes because of the cavity that is created once the infarcted brain tissue disintegrates. In Lacunar strokes, the endothelium of smaller vessels is affected primarily by hypertension, which causes a thickening of the vessel wall and stenosis. Lacunar infarctions are also common in people with diabetes mellitus. Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting in a stroke. Embolic strokes may be prevented by the use of anticoagulation therapy in patients with atrial fibrillation. The last two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and other strokes, from causes such as cocaine use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. Hemorrhagic strokes Hemorrhagic strokes are caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space. Primary intracerebral hemorrhage from a spontaneous rupture of small vessels accounts for approximately 80% of hemorrhagic strokes and is primarily caused by uncontrolled hypertension. Secondary intracerebral hemorrhage is associated with arteriovenous malformations (AVMs), intracranial aneurysms, or certain medications. Transient Ischemia Attack Transient ischemic attack (TIA) is a temporary impairment of the cerebral circulation causing neurological impairment. It is characterized by focal neurological deficits, typically minutes to hours in duration. Symptoms resolve completely within 24 hours. Symptoms that last longer than 24 hours but do not cause permanent neurological changes are called reversible ischemic neurological deficits (RIND).

Socialized discussion

Discuss the pathophysiology of stroke

5 mins

c. Pathophysiology Cerebral infarction Ischemia quickly alters cerebral metabolism. Cell death and permanent changes can occur within 3 to 10 minutes. The clients baseline oxygen level and ability to compensate determine how quickly irreversible changes occur. Blood flow can be altered by localized perfusion problems, such as stroke, or by generalized perfusion problems, such as hypotension or cardiac arrest. Cerebral perfusion pressure must fall to two thirds of normal ( a mean arterial pressure of 50 mmHg or below) before the brain does not receive adequate blood flow. A client who has lost compensatory autoregulation experiences manifestations of neurologic deficit sooner. Occlusion of a cerebral artery produces ischemia in the brain tissue supplied by the affected artery and edema in the surrounding tissue. Cells in the center of the stroke area, or the core, die almost immediately after stroke onset; this is referred to as primary neuronal injury. A zone of hypoperfusion also exists around the infracted core; this zone is called the penumbra. The size of this zone depends on the amount of collateral circulation present. Collateral circulation describes the vessels that augment the major circulatory vessels of the brain. Differences in the size and number of collateral vessels help to explain variations in the severity of manifestations experienced by clients with strokes in the same anatomic area. Enumerate the different clinical manifestations of fracture. A series of biochemical processes occurs within minutes of cerebral ischemia. Neurotoxins, including oxygen free radicals, nitric oxide, and glutamate, are released. Local acidosis develops. Membrane depolarization occurs. This results in an influx of calcium and sodium. Cytotoxic edema and cell death are a result; this is secondary neuronal injury. Penumbral neurons are highly susceptible to the effects of the ischemic cascade. The area of edema after ischemia may lead to temporary neurologic deficits. Edema may subside in afew hours or sometimes in several days, and the client may regain function. 3 mins

Cerebral hemorrhage Most intracerebral haemorrhages are caused by the rupture of arteriosclerotic and hypertensive vessels. Most intracerebral haemorrhages are very large. Therefore it is not surprising that hemorrhage into the brain causes the most fatalities of all strokes. Aneurysms are weakened outpouchings in a vessel wall. Although cerebral aneurysms are usually small (2 to 6 mm in diameter), they can rupture. A stroke secondary to bleeding often produces spasm of cerebral vessels and cerebral ischemia because the blood outside of the vessels act as an irritant to the tissues. d. Clinical Manifestations Neuromotor Function Problems associated with neuromotor function deficit include impairment of (1) Mobility (2) Respiratory function (3) Swallowing and speech (4) Gag reflex (5) Self-care abilities The symptoms are cause by the destruction of the motor neurons in the pyramidal pathway (nerve fibers from the brain and passing through the spinal cord to the motor cells). The characteristics motor deficits include loss of skilled voluntary movement (akinesia), impairment of integration of movements, alterations in muscle tone, and alteration in reflexes. Communication The left hemisphere is dominant for language skills in all righthanded persons and in the majority of left-handed persons. Language disorders involve the expression and comprehension written and spoken words. The patients may experience aphasia (total loss of comprehension and use of language) when a stroke damages the dominant hemisphere of the brain. Dysphasia refers to dysfunction related to the comprehension or use of language and is

due to partial disruption or loss. Dysphasia can be classified as nonfluent (minimal speech activity with slow speech that requires obvious effort) or fluent (speech is present, but contains little meaningful communication). Most dysphasia are mixed with minimal impairment in expression and understanding. A massive stroke may result in global aphasia, in which all communication and receptive function is lost. Affect Patient who have had a stroke may be unable to control their emotions. Their emotional response may be exaggerated or unpredictable. This situation is compounded by the depression associated with the changes is body image and loss of function. They also frustrated related to mobility and communication problems. Intellectual Function Both memory and judgement may be impaired as a result of stroke. A left-brain stroke is more likely to result in memory problems related to language and are very cautious in matters of judgement. The patient with a right-brain stroke tends to be impulsive and to move quickly. Patients with either type of stroke may experience difficulty in making generalizations, which interferes with their ability to learn. Spatial-Perceptual Alterations A stroke in the right side of the brain is more likely to cause deficits in spatial-perceptual orientation. These spatial-perceptual deficits may be divided into four categories: (1) Related to patients erroneous perception of self and illness. Patients may deny their illnesses or their own body parts. (2) Concerns the patients erroneous perception in space. The patient may neglect all input from the affected side. The patient may also have a difficulty with spatial orientation, such as judgement of distances. (3) Agnosia, the inability to recognize an object by sight, touch, or hearing.

Enumerate the complications related to stroke

5 mins

(4) Apraxia, the inability to carry out learned sequential movements on command. Elimination Function Most problems with urinary and bowel elimination occur initially and are transient. When a stroke affects one hemisphere of the brain, the prognosis of normal bladder function is excellent. The pathway between the bladder and the spinal cord remains intact and partial sensation for bladder filling remains, as well as partial voluntary urination. Initially, the patient may experience frequency, urgency, and incontinence. Constipation is associated with immobility, weak abdominal muscle, dehydration, and diminished response to the defecation reflex. Both urinary and bowel elimination problems may also be related to the function inabilities to express need and inability to manage clothing. Manifestations of right-sided and left-sided stroke. Right side damage Left side damage (stroke on right of the brain) (stroke on left side of the brain) Paralyzed left side: Paralyzed right side: hemiplegia hemiplegia Left-side neglect Impaired speech/language aphasias Spatial-perceptual deficits Impaired right/left Tents to deny or minimize discrimination problems Slow performance, cautious Rapid performance, short attention span Impaired speech /language Impulsive, safety problems Aware of deficit: depression, anxiety Impaired judgement Impaired comprehension Impaired time concepts related to language, math

Know the different diagnostic evaluation for stroke and their nursing considerations

Complications Bleeding In the initial studies of rt-PA in acute in acute ischemic stroke, symptomatic intracranial hemorrhage occurred in 6.4% of clients within the first 36 hours after treatment. Intracranial hemorrhage carries a mortality rate greater than 50%. All fatal intracranial haemorrhages occurred within the first 24 hours of treatment. The expanding clot of an intracranial hemorrhage destroys brain tissue. The pressure of the clot also disrupts blood flow and causes additional ischemia. Increased intracranial pressure results from the space-occupying clot and surrounding edema of ischemic tissue and can lead to midline shift of intracranial contents, possible brain stem herniation, and death. Cerebral edema Increased ICP is a potential complication of large ischemic strokes. Increased ICP is also a potential complication of intracerebral hemorrhage, either primary or secondary to thrombolytic therapy. Manifestations of increased ICP include change in LOC, reflex hypertension, and worsening neurologic status. Stroke recurrence The incidence of stroke recurrence in the first 4 weeks after acute ischemic stroke ranges from 0.6% to 2.2% per week. The risks of anticoagulation include intracranial hemorrhage, systemic bleeding, and death. Aspiration Clients with stroke are at high risk for aspiration pneumonia, which is the direct cause of death in 6% of clients following stroke. Aspiration is most common in the early period and is related to loss of pharyngeal sensation, loss of oropharyngeal moto control, and decreased LOC.

2 mins

Appreciate the various surgical management to

patients with stroke

Discuss the different drugs used for a stroke patient

Other potential complications Other complications of stroke depend primarily on the location of the lesion or infracted tissue. If the brain is affected, blood pressure fluctuations, altered respiratory patterns, and cardiac dysrhytmias are all possible. Physical injury related to the clients inability to realize his or her limitations can occur. Complications of immobility can also occur. Coma can follow strokes of various causes. The blood supply to the brain stem or reticular activating system, which controls consciousness, may have been directly occluded. Similarly, the deep structures of the thalamus that relay information to the cerebral cortex may be involved. Vascular occlusion of the internal carotid artery or one of its major branches may also decrease LOC. Sometimes the cerebral edema that follows stroke may produce midline shifts, resulting in coma. Temperature elevations lead to increased cerebral metabolic needs, which in turn cause cerebral edema and increased risk for cerebral ischemia. Strokes caused by occlusive disease rarely cause sudden death. When stroke is fatal, death may occur within 3 to 12 hours, but it occurs more often between 1 and 14 days after the original episode. Typically, with any type of fatal stroke, a rise in temperature, heart rate, and respiratory rate occurs along with deepening coma several hours or days before death. These result from damage to the vasomotor and heat-regulating centers. e. Diagnostic Findings Acute brain imaging plays an important role in the diagnosis and treatment of stroke. A noncontrast head computed tomography (CT) scan is performed to rule out hemorrhagic stroke as a cause of acute neurologic deficits. Cellular changes that are diagnostic of stroke do not appear on the head CT scan accurately. Standard magnetic resonance imaging has limited value in diagnosing acute ischemic stroke because the infarct is usually not apparent until 8 to 12 hours after the onset of symptoms. New MRI techniques-diffusion weighted imaging and perfusion imaging-may improve the diagnosis and

3 mins

3 mins

treatment of acute stroke. These techniques have greater sensitivity and anatomic resolution and the potential to allow earlier detection and characterization of acute ischemic stroke. Nursing Implications: CT scan Assess for possible reaction to iodine dye (by asking about allergy to seafood). Document any allergy and inform the physician and radiology department. MRI Instruct the patient to remove all metallic objects, including jewelry, hairpins, or watches. Ask whether the patient has any surgically implanted joints, pins, clips, valves, pumps, or pacemakers containing metal that could be attracted to strong MRI magnet. If he does, he wont be able to have the test. f. Medical management Surgical therapy Carotid endarterectomy (CEA) - The atheromatous lesions is removed from the carotid artery to improve blood flow. This surgery is reserved for patients with occlusions of 70%-90% of blood flow. Transluminal angioplasty - The insertion of a balloon to open a stenosed artery to permit increased blood flow. This procedure has been used to treat patients with clinical manifestation related to stenosis in the vertebrobasilar or carotid arteries and their major branches. Extracranial-in-tracranial (EC-IC) bybass - Extracranial to intracranial (EC-IC) bypass is a surgical procedure to increase cerebral blood flow. This procedure entails connecting a branch of the external carotid artery (usually the superficial temporal artery) to a branch of the internal carotid artery (usually the middle cerebral artery), either directly or via a vein graft. This procedure is similar to

Discuss the nursing management for stroke

cardiac bypass surgery where blocked heart arteries are bypassed. g. Pharmacological management Thrombolytic therapy
Most strokes are caused when blood clots move to a blood vessel in the brain and block blood flow to that area. For such strokes (ischemic strokes), thrombolytics can be used to help dissolve the clot quickly. Giving thrombolytics within 3 hours of the first stroke symptoms can help limit stroke damage and disability. The decision to give the drug is based upon: A brain CT scan to make sure there is no bleeding A physical exam that shows a significant stroke Your medical history As in heart attacks, a clot-dissolving drug isn't usually given if you have one of the other medical problems listed above. Thrombolytics are not given to someone who is having a hemorrhagic stroke. They could worsen the stroke by causing increased bleeding. RISKS There are various drugs used for thrombolytic therapy, but thrombolytics are used most often. Others drugs include: Lanoteplase Reteplase Staphylokinase Streptokinase (SK) Tenecteplase Urokinase Hemorrhage or bleeding is the most common risk. It can be life-threatening. Minor bleeding from the gums or nose can occur in approximately 25% of people who receive the drug. Bleeding into the brain occurs approximately 1% of the time. This risk

10 min

is the same for both stroke and heart attack patients

Recombinant tissue plasminogen activator (tPA) - administered IV is used to re-established blood flow through a blocked artery to prevent cell death in patients with the acute onset of ischemic stroke symptoms. tPA must be administered within 4 hours of the onset of clinical signs of ischemic stroke. Anticoagulants and platelet inhibitors are contraindicated in patients with hemorrhagic strokes. The calcium channel blocker nimopidine (Nimotop) is given to patients with subarachnoid hemorrhage to decrease the effect of vasospasm and minimize cerebral damage.

Other drugs Drugs therapies to treat hyperthermia include aspirin or acetaminophen (Tylenol). A temperature elevation of even 1 degree Celsius can increase brain metabolism by 10% and contribute to further brain damage. Seizures occur in 5% to 7% of stroke patients in the first 24 hours. An antiseizures drug, such as phenytoin (Dilantin) is given of a seizures occur.

h. Nursing Management Patients are at risk for increased intracranial pressure following a CVA. The patient in intensive care may have an intracranial pressure monitor. Any activities or interventions that increase ICP should be avoided, such as repeated suctioning, coughing, and vigorous turning. If the patient has had a seizure, anticonvulsant medications may be ordered. Patients who have had a CVA are also at risk for a repeat

CVA. Changes in neurological status should be reported immediately to the physician. Patients are also at risk for falls because of motor and sensory deficits and impaired judgment. Patients should be assisted with transfers and ambulation. If the patient has difficulty swallowing or is unable to self-feed, altered nutrition is a concern. The physician may order a swallowing study to determine the extent of the problem. A speech-language pathologist assesses the patient and makes recommendations for safe swallowing techniques. Measures to prevent aspiration generally include staying with the patient during meals, having the patient in a chair or high Fowlers position for meals, avoiding straws, using a thickening agent for thin liquids, and having the patient swallow twice after each bite. Check the patients mouth after each bite, because patients may pocket food on the affected side of the mouth. The patient with hemiplegia has difficulty turning or repositioning. If the patient has sensory deficits, pain or pressure are not noticed and injury may occur. Careful and frequent repositioning is essential to prevent skin, respiratory, and musculoskeletal complications. Pillows can be used to maintain the body in good alignment and promote comfort. Skin should be inspected each time the patient is repositioned. Range-of-motion exercises should be begun within 24 hours of admission to help prevent contractures. Splints may be used for some patients to maintain a functional position of extremities. Some patients experience injury to the shoulder of an affected arm. Care should be taken to support the arm on pillows when it is in a dependent position. Use a lift sheet to reposition the patient in bed, rather than pulling on the arms. A physical therapist can be consulted to assess the patient and make specific recommendations related to mobility. Aphasia can cause great frustration to the patient, family, and caregivers. Care depends on whether the aphasia is receptive or expressive. If you have determined that the patients responses are valid, asking yes/no questions may be helpful. Gestures and visual aids may be tried. Some patients can relearn language skills with the help of a speech therapist. It is important that staff and family

continue to speak to the patient, because he or she may understand what is being said but may be unable to respond. The patient and significant other are likely to be very frightened of what is happening. Correct information about what a CVA is, tests and procedures, and rationale for care activities help reduce anxiety. Information should be presented in small amounts and as simply as possible. Cerebrovascular accidents, even those that leave relatively mild residual effects, have a significant impact on psychosocial functioning. Patients and their significant others may experience changes in roles, responsibilities, finances, and intimacy. Significant others should be encouraged to assess how the patients functional level will affect their lives. Encourage them to identify support systems and make use of community resources. Assumption of roles or responsibilities previously fulfilled by the patient may be very stressful to significant others. The nurse and social worker can help them identify priorities and plan ways of adapting to change.

SOURCES: Black, J. M., & Hawks, J. H.(2004). Medical-Surgical Nursing Clinical Management for Positive Outcomes 7th edition. St. Louis Missouri: Elsevier Inc. Chipps, E., et.al. (1992). Neurological Disorders: Mosbys Clinical Series. Mosby Inc. USA Lewis, S.M., Heitkemper, M.M., & Dirksen, S.R. (2004).Medical Surgical Nursing: treatment and management of clinical problem. 6th edition. Mosby Inc. USA Petit, J.M. (2001). Primary Neurologic Care. USA Smeltzer, S. & Bare, B. (2004). Medical-Surgical Nursing. USA