2. Cerebrovascular accidentd for nursing .pdf

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1. Cerebrovascular accident (TIA
& Stroke)
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

2. Educational learning outcomes
At the end of the lecture students will:
•Define transient ischemic attack (TIA)
•List etiology of TIA
•Mention risk factors of TIA
•Outline symptoms and warning signs.
•Discuss Diagnosis of TIA
•Outline treatment of TIA
•Discuss Nursing intervention of TIA
•Define the cerebrovascular accident ( Stroke).
•List the causes and types of stroke.
•Discuss the risk factors of stroke.
•Describe the clinical manifestations of stroke.
•Identify diagnostic evaluation of Stroke.
•Discuss common nursing diagnosis of stroke
•Discuss nursing intervention during acute phase of stroke
•Discuss nursing intervention during chronic phase of stroke
•Describe patient education and health maintenance




Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

3. Outlines
•Introduction
•Definition of transient ischemic attack (TIA)
•Etiology of TIA
•Risk factors of TIA
•Symptoms and warning signs.
•Diagnosis of TIA
•Treatment of TIA
• Nursing intervention of TIA
•Definition of cerebrovascular accident ( Stroke).
•Causes and types of stroke.
•Risk factors of stroke.
•Clinical manifestations of stroke.
•Diagnostic evaluation of Stroke.
•Common nursing diagnosis of stroke
•Nursing intervention during acute phase of stroke
•Nursing intervention during chronic phase of stroke
•Patient education and health Maintenance

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

4. Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

5. Introduction
A transient ischemic attack (TIA) or "mini stroke" is caused by a
temporary disruption in the blood supply to part of the brain.
The disruption in blood supply results in a lack of oxygen to the
brain.
This can cause sudden symptoms similar to a stroke, such as speech
and visual disturbance, and numbness or weakness in the face, arms
and legs.
But a TIA does not last as long as a stroke. The effects last a few
minutes to a few hours and fully resolve within 24 hours.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

6. Definition
•TIA refers to temporary, focal cerebral ischemia that results in
reversible neurological deficits without acute infarction (i.e., imaging
findings show no signs of infarction)

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

7. Etiology
•Cardioembolic (e.g., due to atrial fibrillation)
•Lacunar/small vessel disease (e.g., due to chronic hypertension)
•Large vessel disease/low-flow state (e.g., atherosclerosis of MCA,
severe carotid artery stenosis)
•Blood disorders/hypercoagulable states
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

8. Risk factors
•Smoking
•High blood pressure (hypertension)
•Obesity
•High cholesterol levels
•Regularly drinking an excessive amount of alcohol
•Having a type of irregular heartbeat called atrial fibrillation
•Having diabetes
•People over 55 years of age.
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

9. Pathophysiology
•One of the blood vessels that supply the brain with oxygen-rich blood
becomes blocked.
•This blockage is usually caused by a blood clot that's formed
elsewhere in the body and travelled to the blood vessels supplying the
brain, although it can also be caused by pieces of fatty material or air
bubbles.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

10. Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

11. Symptoms of a transient ischemic attack (TIA)
•The main symptoms of a TIA can be remembered with the word FAST:
Face – the face may have dropped on one side, the person may not be able to smile, or their mouth or eye
may have dropped.
Arms – the person may not be able to lift both arms and keep them raised because of weakness or
numbness in one arm.
Speech – their speech may be slurred or garbled, or the person may not be able to talk at all, despite
appearing to be awake; they may also have problems understanding what you're saying to them.
Time –immediately ask for medical intervention if you see any of these signs or symptoms.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

12. Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

13. The following are common warning signs of a TIA:

•Unilateral weakness, numbness, or paralysis
•Altered balance and coordination
•Slurred speech
•Difficulty swallowing (dysphagia)
•Double vision or vision loss
•Dizziness or vertigo

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

14. Diagnosis
• Physical exam include auscultation of the heart and checking the blood pressure.
• A neurological exam to see how a potential stroke is affecting nervous system.
•Blood tests
•Computerized tomography (CT) scan.
•Magnetic resonance imaging (MRI).
•Cerebral angiogram. This procedure gives a detailed view of arteries in the brain and neck.
•Echocardiogram can find a source of clots in the heart that may have traveled from the heart to
the brain and caused a stroke.
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

15. Treating a transient ischaemic attack (TIA)

•Although the symptoms of a transient ischemic attack (TIA) resolve in a
few minutes or hours, patient need treatment to help prevent another TIA
or a full stroke happening in the future.
•Lifestyle changes is essential to reduce stroke risk.
•Treatment of the cause
•In some cases, a surgery called a carotid endarterectomy may be needed
to unblock the carotid arteries, which are the main blood vessels that
supply your brain with blood.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

16. Medical management
•An IV injection of recombinant tissue plasminogen activator (TPA) — also called alteplase
(Activase): is the gold standard treatment for ischemic stroke.
• An injection of TPA is usually given through a vein in the arm within the first three hours
(Thrombolysis)
•Thrombectomy (surgical removal of blood clot)
•Aspirin and other antiplatelet
•Anticoagulants
•Anti hypertensive drugs
•Statins (lowering blood cholesterol)
•Carotid endarterectomy (surgical removal of plaques from carotid artery)
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

17. Preventing a transient ischaemic attack (TIA)

•A transient ischaemic attack (TIA) is often a sign that another one may follow
and patient at a high risk of having a full, life-threatening stroke in the near
future.
To prevent recurrent stroke patient should:
•Maintain regular healthy weight
•Eat healthy balanced diet
•Maintain regular exercise
•Control of hypertension
•Stop alcohol and smoking


Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

18. Nursing intervention
Assessment:
•1. Rapidly assess F.A.S.T.
F.A.S.T. stands for “face, arm, speech, and time.”
•2. Determine neurovascular status.
Lack of blood flow to the brain affect vision, speech and language, and
motor and sensory function.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

19. Assessment:
•3. Monitor vital signs.
Vital signs should be evaluated, including blood pressure in both arms,
to rule out subclavian artery stenosis. This will show a significant
difference in the readings of both arms.
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

20. Assessment
4. Auscultate the heart and neck.
Auscultation of the heart and neck should be performed.
Carotid artery stenosis in TIA may present as positive carotid bruits.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

21. Assessment
5. Perform ECG.
Atrial fibrillation (AFib), an abnormal ECG rhythm, may develop after a TIA. This
can cause a blood clot that originates in the heart and travels to the brain.
6. Obtain neuroimaging scans.
Within 24 hours of the initiation of the symptoms, neuroimaging scans (MRI and
diffusion-weighted MR imaging are indicated).
A head CT with CT angiography is performed as a backup if an MRI is not possible.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

22. Nursing intervention
Keep the blood pressure manageable.
Activate the Rapid Response Team (RRT)
Administer antiplatelet medications as prescribed
Provide anticoagulants as ordered
Control cholesterol levels
Advise the patient about following the recommended diet
Prepare for possible surgery
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

23. Stroke
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

24. Definition
•A stroke is a syndrome in which the cerebral circulation is
interrupted, causing neurological deficits.
•Cerebral anoxia lasting longer than 10 minutes causes cerebral
infarction with irreversible changes.
•Cerebral edema and congestion cause further dysfunction.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

25. Causes
•Ischemic Strokes:
•Thrombotic – plaque build up causing narrowing
•Embolic – dislodged thrombi of plaque, blot clot and occludes cerebral arteries
•Lacunar Stroke:
•Ischemic type stroke from occlusions of small arteries deep in brain. These are less
severe strokes and usually have no or less-pronounced neurological changes.
•Hemorrhagic:
•stroke Occurs suddenly; may include severe headache described as “the worst
headache of my life”

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

26. Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

27. Risk factors
Non-Modifiable Factors (that cannot be changed)
•Age
•Race
•Gender
•Heredity

Modifiable Factors
(that can be eliminated or controlled)
•Atherosclerosis
•Hypertension
•Anticoagulation therapy
•Diabetes mellitus
•Stress
•Obesity
•Oral contraceptives
•Sedentary lifestyle
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

28. Assessment Findings, cont.
•A critical factor in the early intervention and treatment of stroke is the
accurate identification of stroke manifestations and establishing the
onset of the manifestations.
•Stroke screening scales may be used to quickly identify stroke
manifestations.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

29. Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

30. CARDINAL SIGNS OF STROKE:

•Numbness or weakness of the face, arm or leg, especially on one
side of the body. visual problems,
•Sudden confusion, trouble speaking or understanding
•Sudden trouble seeing in one or both eyes
•Sudden trouble walking, dizziness, loss of balance or coordination.
•Sudden severe headache with no known cause.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

31. Manifestation of right brain and left brain
stroke


Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

32. Clinical manifestations
•Motor loss (loss of voluntary control over motor movements).
•The most common motor dysfunction is Hemiplegia (paralysis of one side of
the body) and Hemiparesis (weakness of one side of the body)
•Communication loss (dysfunction of language)
•Perceptual disturbances (sensory loss)
•Impairment of mental activity and psychological effects
•Bladder dysfunction (urinary incontinence)


Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

33. Diagnostic Evaluation:
•CT Scan or MRI may reveal the site of infarction, hematoma, and shift of brain structures.
•Cerebral angiography is used to identify collateral blood circulation and may reveal the
site of rupture or occlusion.
•PET Scanning may reveal information on cerebral metabolism and blood flow
characteristics.
•EEG may reveal abnormal electrical activity of the brain.
•Electrocardiogram (ECG) may reveal atrial fibrillation as the source of emboli.
•Echocardiography may reveal thrombus on valvular heart structures as a source of emboli.
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

34. Diagnostic Evaluation, cont.
•Trans-cranial Doppler Ultrasound may reveal decreased cerebral metabolism and
characteristics of blood flow.
•Blood chemistry studies may reveal decreased hemoglobin level, hematocrit, and RBC
count; increased PT, PTT, and liver function test results, and elevated cholesterol,
triglycerides, and glucose levels; and positive sickle cell trait.
•CSF analysis, which isn’t routinely done, may reveal CSF with hemorrhagic CVA.
•Lumbar puncture, which isn’t routinely done, may reveal increased CSF pressure.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

35. Medical Treatment in the Acute Phase
Drug therapy Options:
•Thrombolytic Enzyme: Tissue plasminogen activator (TPA) for embolic or thrombotic stroke, given to dissolve clots in acute
ischemic strokes
•Antipyretic analgesics: Acetaminophen (Tylenol)
•Analgesics: Codeine phosphate, codeine sulfate
•Anticoagulants: heparin, warfarin
•Glucocorticoid: Dexamethasone (Decadron)
•Diuretic: Furosemide (Lasix), Mannitol
•Anti-convulsant: Phenytoin (Dilantin) and phenobarbital
•Antiplatelet aggregation drugs: Acetylsalicylic acid (aspirin), Clopidogrel (Plavix)
•Calcium Channel Blocker: Nimodipine (Nimotop), Nifedipine (Procardia)
•H2-Receptor antagonists: cimetidine (Tagamet), famotidine (Pepcid), Ranitidine (Zantac)
•Insulin to maintain tight glycemic control

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

36. Nursing Diagnosis
•Ineffective Airway Clearance and Ineffective Breathing Patterns
•Risk for Injury
•Deficient Fluid Volume or Excess Fluid Volume
•Imbalanced Nutrition
•Disturbed Sensory Perception
•Ineffective Thermoregulation
•Disturbed Thought Processes
•Impaired Verbal Communication
•Impaired Physical Mobility
•Total or Functional Urinary Incontinence
•Constipation and/or Bowel Incontinence
•Ineffective Coping
•Interrupted Family Processes

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

37. Nursing Planning and Goals:
•The patient will regain his normal LOC, cognition and motor-sensory function
•The patient will develop maximal self-care abilities and physical mobility and an
effective means of communication within the limitations imposed by the stroke.
•The patient will experience no preventable complications associated with a stroke.
•The patient will develop strategies to effectively cope with health problems and
body image disturbances associated with a stroke.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

38. Nursing Interventions during the acute
phase of stroke (Lasts 48 To 72 Hours).
•Maintain a patent airway and administer oxygen as prescribed.
•Monitor vital signs.
•Usually a blood pressure of 150/100 mm Hg is maintained to ensure cerebral perfusion.
•Suction secretions as prescribed, but never suction nasally or for longer than 10 seconds to prevent
increased ICP.
•Monitor for increased ICP because the patient is most at risk during the first 72 hours following the
stroke.
•Position the patient on the side, with the head of the bed elevated 15 to 30 degrees as prescribed.
•Monitor level of consciousness, pupillary response, motor and sensory response, cranial nerve
function, and reflexes.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

39. Nursing interventions during the acute
phase of stroke, cont.:
•Maintain a quiet environment.
•Insert a Foley catheter as prescribed.
• Administer intravenous fluids as prescribed.
• Maintain fluid and electrolyte balance.
• Prepare to administer anticoagulants, anti-platelets, diuretics, anti-
hypertensives, and anticonvulsants as prescribed.
• Establish a form of communication.
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

40. Nursing interventions in the post-acute phase
of a stroke:
•Continue with interventions from the acute phase.
•Position the patient 2 hours on the unaffected side and 20 minutes on
the affected side.
•Position the patient in the prone position if prescribed, for 30
minutes three times daily.
•Provide skin, mouth, and eye care.
•Perform passive range-of-motion exercises to prevent contractures.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

41. Nursing interventions in the post-acute phase
of a stroke, cont.:
•Place antiembolism stockings on the patient; remove daily to check skin.
•Measure thighs and calves daily for an increase in size.
•Monitor the gag reflex and ability to swallow.
•Provide sips of fluids and slowly advance diet to foods that are easy to chew and
swallow.
•Provide soft and semisoft foods and flavored, cool or warm, thickened fluids rather
than thin liquids, speech therapists may do swallow studies to recommend consistency
of food and fluids.
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

42. Nursing interventions in the chronic phase of
stroke
Neglect syndrome
patient is unaware of the existence of his or her paralyzed side (unilateral
neglect), which places the patient at risk for injury.
Teach the patient to touch and use both sides of the body.
Hemianopsia
•Patient has blindness in half the visual field.
•Encourage the patient to turn the head to scan the complete range of vision;
•Approach the patient from the unaffected side.
•Place the patient’s personal objects within the visual field.
•Provide eye care for visual deficits.
•Place a patch over the affected eye if the patient has diplopia.
•Increase mobility as tolerated
Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

43. Nursing interventions in the chronic phase of
stroke, cont.
•Encourage fluid intake and a high-fiber diet.
•Administer stool softeners as prescribed.
•Encourage the patient to express her or his feelings.
•Encourage independence in activities of daily living.
•Assess the need for assistive devices such as a cane, walker, splint, or braces.
•Teach transfer technique from bed to chair and from chair to bed.
•Provide gait training.
•Initiate physical and occupational therapy for assessment and the need for adaptive equipment or
other supports for self-care and mobility.
•Refer patient to a speech and language pathologist as prescribed.
•Encourage the patient and family to contact available community resources.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

44. Patient Education and Health Maintenance
•Patients may be discharged to home or go to specialized rehabilitation centers for
continued therapy
•Outpatient therapy is an option for some patients
•When able, patients are transitioned back into the home setting and it is essential to
include family, friends, and significant others in this process
•During and after the rehabilitation phase, patients and families need to be made aware of
resources to help them deal with continuing disabilities
•In rehabilitation, the patient is respectfully challenged to return to the highest level of
function possible

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

45. Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed

46. Evaluation
•The patient regains his normal LOC, cognition and motor-sensory function
•The patient develops maximal self-care abilities and physical mobility and
an effective means of communication within the limitations imposed by
the stroke.
•The patient avoids preventable complications associated with a stroke.
•The patient develops strategies to effectively cope with health problems
and body image disturbances associated with a stroke.

Med-Surg Nursing-2 theory (NUR 346), Dr/ Soad Mohammed