Ischemic and vascular Stroke CVA Brain attack.ppt

Heamorrhagic and ischemic stroke

1. STROKESTROKE
Cerebrovascular Accident (CVA) Cerebrovascular Accident (CVA)
&&
Brain Attack ( Stroke) Brain Attack ( Stroke)

2. 
Definition:Definition:

Sudden brain damage.Sudden brain damage.

Lack of blood flow to the brain caused by a Lack of blood flow to the brain caused by a
clote or rupture of a blood vessele. clote or rupture of a blood vessele.

3. StrokeStroke

Movement, sensation, or emotions Movement, sensation, or emotions
controlled by affected area are lost or controlled by affected area are lost or
impairedimpaired

Loss of function varies with location Loss of function varies with location
and extent of damage and extent of damage

4. StrokeStroke

Brain attack Brain attack
–Term increasingly being used to Term increasingly being used to
describe stroke and communicate describe stroke and communicate
urgency of recognizing stroke urgency of recognizing stroke
symptoms and treating their onset as symptoms and treating their onset as
a medical emergencya medical emergency

5. Risk FactorsRisk Factors
NonmodifiableNonmodifiable

AgeAge

Gender (women more likely to die)Gender (women more likely to die)

Race (African Americans)Race (African Americans)

Heredity Heredity

6. Risk FactorsRisk Factors
ModifiableModifiable

Asymptomatic carotid stenosisAsymptomatic carotid stenosis

Diabetes mellitus Diabetes mellitus

Heart disease, atrial fibrillation Heart disease, atrial fibrillation

Heavy alcohol consumption Heavy alcohol consumption

Hypercoagulability Hypercoagulability

Hyperlipidemia Hyperlipidemia

T. I. AT. I. A

7. Risk FactorsRisk Factors
ModifiableModifiable

HypertensionHypertension

ObesityObesity

Oral contraceptive useOral contraceptive use

Physical inactivity Physical inactivity

Sickle cell diseaseSickle cell disease

SmokingSmoking

8. Etiology and PathophysiologyEtiology and Pathophysiology

Brain requires continuous supply of O2 Brain requires continuous supply of O2
and glucose for neurons to function and glucose for neurons to function

If blood flow is interruptedIf blood flow is interrupted
–Neurologic metabolism is altered in Neurologic metabolism is altered in
30 seconds30 seconds
–Metabolism stops in 2 minutesMetabolism stops in 2 minutes
–Cell death occurs in 5 minutesCell death occurs in 5 minutes

9. Etiology and PathophysiologyEtiology and Pathophysiology

Atherosclerosis is a major cause of Atherosclerosis is a major cause of
strokestroke
–Can lead to thrombus formation and Can lead to thrombus formation and
contribute to embolicontribute to emboli

10. Sites for AtherosclerosisSites for Atherosclerosis
Fig. 56-2

11. Etiology and PathophysiologyEtiology and Pathophysiology

Around the core area of ischemia is a Around the core area of ischemia is a
border zone of reduced blood flow border zone of reduced blood flow
where ischemia is potentially reversible where ischemia is potentially reversible

If adequate blood flow can be restored If adequate blood flow can be restored
early (<3 hours) and the ischemic early (<3 hours) and the ischemic
cascade can be interruptedcascade can be interrupted
–less brain damage and less neurologic less brain damage and less neurologic
function lostfunction lost

12. Transient Ischemic Attacks Transient Ischemic Attacks
(TIA)(TIA)

Temporary focal loss of neurologic Temporary focal loss of neurologic
function caused by ischemia (analogous function caused by ischemia (analogous
to angina in CAD)to angina in CAD)

Most resolve within 3 hoursMost resolve within 3 hours

May be due to micro-emboli that May be due to micro-emboli that
temporarily block blood flowtemporarily block blood flow

A warning sign of progressive A warning sign of progressive
cerebrovascular diseasecerebrovascular disease

13. Types of StrokeTypes of Stroke

Classification based on underlying Classification based on underlying
pathophysiologic findings pathophysiologic findings
–IschemicIschemic

ThromboticThrombotic

EmbolicEmbolic
–HemorrhagicHemorrhagic

14. Major Types of StrokeMajor Types of Stroke
Fig. 56-3

15. Ischemic StrokeIschemic Stroke

Result of inadequate blood flow to brain Result of inadequate blood flow to brain
due to partial or complete occlusion of due to partial or complete occlusion of
an arteryan artery

Constitute 85% of all strokesConstitute 85% of all strokes

Most patients with ischemic stroke do Most patients with ischemic stroke do
not have a decreased level of not have a decreased level of
consciousness in the first 24 hoursconsciousness in the first 24 hours

Symptoms often worsen during first 72 Symptoms often worsen during first 72
hours d/t cerebral edemahours d/t cerebral edema

16. Ischemic StrokeIschemic Stroke

Thrombotic strokeThrombotic stroke
–Thrombosis occurs in relation to Thrombosis occurs in relation to
injury to a blood vessel wall injury to a blood vessel wall →→ blood blood
clotclot
–Result of thrombosis or narrowing of Result of thrombosis or narrowing of
the blood vesselthe blood vessel
–Most common cause of strokeMost common cause of stroke

17. Ischemic StrokeIschemic Stroke

Thrombotic strokeThrombotic stroke
–Two-thirds are associated with HTN Two-thirds are associated with HTN
and diabetes and diabetes
–Often preceded by a TIAOften preceded by a TIA

18. Ischemic StrokeIschemic Stroke

Embolic strokeEmbolic stroke
–Embolus lodges in and occludes a Embolus lodges in and occludes a
cerebral arterycerebral artery
–Results in infarction and edema of the Results in infarction and edema of the
area supplied by the vesselarea supplied by the vessel
–Second most common cause of strokeSecond most common cause of stroke

19. Ischemic StrokeIschemic Stroke

Embolic strokeEmbolic stroke
–Majority of emboli originate in heart, Majority of emboli originate in heart,
with plaque breaking off from the with plaque breaking off from the
endocardium and entering circulation endocardium and entering circulation
–Associated with sudden, rapid Associated with sudden, rapid
occurrence of severe clinical occurrence of severe clinical
symptoms symptoms

20. Ischemic StrokeIschemic Stroke

Embolic strokeEmbolic stroke
–Patient usually remains conscious Patient usually remains conscious
although may have a headache although may have a headache
–Recurrence is common unless the Recurrence is common unless the
underlying cause is aggressively underlying cause is aggressively
treated treated

21. Hemorrhagic StrokeHemorrhagic Stroke

Account for approximately 15% of all Account for approximately 15% of all
strokesstrokes

Result from bleeding into the brain Result from bleeding into the brain
tissue itself or into the subarachnoid tissue itself or into the subarachnoid
space or ventriclesspace or ventricles

22. Hemorrhagic StrokeHemorrhagic Stroke

Intracerebral hemorrhageIntracerebral hemorrhage
–Bleeding within the brain caused by a Bleeding within the brain caused by a
rupture of a vesselrupture of a vessel
–Hypertension is the most important Hypertension is the most important
causecause
–Commonly occurs during activityCommonly occurs during activity

23. Hemorrhagic StrokeHemorrhagic Stroke

Intracerebral hemorrhageIntracerebral hemorrhage
–Often a sudden onset of symptoms Often a sudden onset of symptoms
that progress over minutes to that progress over minutes to
hours b/c of ongoing bleedinghours b/c of ongoing bleeding
–Manifestations include neurologic Manifestations include neurologic
deficits, headache, N & V, decreased deficits, headache, N & V, decreased
levels of consciousness, and HTNlevels of consciousness, and HTN

24. Hemorrhagic StrokeHemorrhagic Stroke

Subarachnoid hemorrhageSubarachnoid hemorrhage
–Bleeding into cerebrospinal space Bleeding into cerebrospinal space
between the arachnoid and pia materbetween the arachnoid and pia mater
–Commonly caused by rupture of a Commonly caused by rupture of a
cerebral aneurysm cerebral aneurysm

25. Clinical Manifestations of StrokeClinical Manifestations of Stroke

Affects many body functionsAffects many body functions

Motor activityMotor activity
EliminationElimination

Intellectual functionIntellectual function
Spatial-perceptual alterationsSpatial-perceptual alterations

PersonalityPersonality

Affect Affect
Sensation Sensation

Communication Communication

26. Clinical ManifestationsClinical Manifestations
Motor FunctionMotor Function

Most obvious effect of strokeMost obvious effect of stroke

Can include impairment of :Can include impairment of :
–Mobility Mobility
–Respiratory functionRespiratory function
–Swallowing and speechSwallowing and speech
–Gag reflexGag reflex
–Self-care abilities Self-care abilities

27. Clinical ManifestationsClinical Manifestations
Motor FunctionMotor Function

Characteristic motor deficits (contra-Characteristic motor deficits (contra-
lateral)lateral)
–Loss of skilled voluntary movementLoss of skilled voluntary movement
–Impairment of integration of movementsImpairment of integration of movements
–Alterations in muscle tone (flaccid Alterations in muscle tone (flaccid → →
spastic)spastic)
–Alterations in reflexes (hypo Alterations in reflexes (hypo → hyper)→ hyper)

28. Clinical ManifestationsClinical Manifestations
CommunicationCommunication

Patient may experience aphasia when Patient may experience aphasia when
stroke damages the dominant stroke damages the dominant
hemisphere of the brainhemisphere of the brain
–Aphasia: total loss of comprehension Aphasia: total loss of comprehension
and use of languageand use of language
–Dysphasia: difficulty with Dysphasia: difficulty with
comprehension and use of languagecomprehension and use of language

Classified as nonfluent or fluentClassified as nonfluent or fluent

29. Clinical ManifestationsClinical Manifestations
CommunicationCommunication

Dysarthria Dysarthria
–Disturbance in the muscular control Disturbance in the muscular control
of speechof speech
–Impairments in pronunciation, Impairments in pronunciation,
articulation, and phonation; NOT articulation, and phonation; NOT
meaning or comprehension meaning or comprehension

30. Clinical ManifestationsClinical Manifestations
AffectAffect

May have difficulty controlling their May have difficulty controlling their
emotionsemotions

Emotional responses may be Emotional responses may be
exaggerated or unpredictable exaggerated or unpredictable

Depression , impaired body image and Depression , impaired body image and
loss of function can make this worseloss of function can make this worse

May be frustrated by mobility and May be frustrated by mobility and
communication problemscommunication problems

31. Clinical ManifestationsClinical Manifestations
Intellectual FunctionIntellectual Function

Memory and judgment may be Memory and judgment may be
impairedimpaired

Left-brain stroke: more likely to result Left-brain stroke: more likely to result
in memory problems related to in memory problems related to
languagelanguage

32. Manifestations of Right-Brain and Left-Brain Manifestations of Right-Brain and Left-Brain
StrokeStroke
Fig. 56-6

33. Clinical ManifestationsClinical Manifestations
Spatial-Perceptual AlterationsSpatial-Perceptual Alterations

Stroke on the right side of the brain is Stroke on the right side of the brain is
more likely to cause problems in spatial-more likely to cause problems in spatial-
perceptual orientationperceptual orientation

However, this may occur with left-However, this may occur with left-
brain strokebrain stroke

34. Clinical ManifestationsClinical Manifestations
Spatial-Perceptual AlterationsSpatial-Perceptual Alterations

Spatial-perceptual problems may be Spatial-perceptual problems may be
divided into four categoriesdivided into four categories
1.1.Incorrect perception of self and Incorrect perception of self and
illness (may deny illness or body illness (may deny illness or body
parts)parts)
2.2.Erroneous perception of self in Erroneous perception of self in
space (e.g., neglect all input from space (e.g., neglect all input from
affected side; distance judgement)affected side; distance judgement)

35. Clinical ManifestationsClinical Manifestations
Spatial-Perceptual AlterationsSpatial-Perceptual Alterations
3.3.Inability to recognize an object by Inability to recognize an object by
sight, touch, or hearingsight, touch, or hearing
4.4.Inability to carry out learned Inability to carry out learned
sequential movements on sequential movements on
commandcommand

36. Clinical ManifestationsClinical Manifestations
EliminationElimination

Most problems with elimination occur Most problems with elimination occur
initially and are temporaryinitially and are temporary

Prognosis for normal bladder function Prognosis for normal bladder function
is excellent when only one hemisphere is excellent when only one hemisphere
of brain is affected. of brain is affected.

37. 
Common signs and symptoms of Common signs and symptoms of
TIA, and ischemic stroke:TIA, and ischemic stroke:
1- Carotid (Anterior) circulation:- 1- Carotid (Anterior) circulation:-
*unilateral paralysis: weakness or heaviness *unilateral paralysis: weakness or heaviness
involove hand, arm, face, or leg, alone or in involove hand, arm, face, or leg, alone or in
combination. The invloved body parts are combination. The invloved body parts are
opposite the side of the diseased artery.opposite the side of the diseased artery.
*Numbness:sensory loss, tingling, or abnormal *Numbness:sensory loss, tingling, or abnormal
sensation usually occures simultaneously and on sensation usually occures simultaneously and on
the same side as weakness.the same side as weakness.
*Visual disturbance:opposite the side of the *Visual disturbance:opposite the side of the
diseased artery. diseased artery.

38. * lunguage disturbance:- aphasia or * lunguage disturbance:- aphasia or
dysarthria.dysarthria.
* monocular blindeness: partially or * monocular blindeness: partially or
completely may occurs on the same side. completely may occurs on the same side.

39. 2- Vertebral( posterior) circulation:* *vertigo. 2- Vertebral( posterior) circulation:* *vertigo.
*- visual disturbance: involve both eyes *- visual disturbance: involve both eyes
simultaneously.simultaneously.
* Diplopia. * paralysis: can involve one half * Diplopia. * paralysis: can involve one half
or infrequently all four limbs, the face can or infrequently all four limbs, the face can
be involved on one side and the limbs on the be involved on one side and the limbs on the
other.other.
* numbeness: can involve one half of the body * numbeness: can involve one half of the body
or all four limbs. or all four limbs.

40. * dysarthria.* dysarthria.
* ataxia: poor balance, stumbling gait, * ataxia: poor balance, stumbling gait,
uncoordination of one side of the body. uncoordination of one side of the body.

41. 
Signs and symptoms of hemorrhagic stroke:Signs and symptoms of hemorrhagic stroke:
* generaly patient with hemorrhagic stroke * generaly patient with hemorrhagic stroke
appear seriously ill, and have a more rapid appear seriously ill, and have a more rapid
course of deterioration than those of course of deterioration than those of
ischemic stroke.ischemic stroke.
* headache, disturbances in consciousness, * headache, disturbances in consciousness,
nausea, and vomiting are more prominent nausea, and vomiting are more prominent
with hemorrhagic stroke. with hemorrhagic stroke.

42. 
1- Subarachnoid hemorrhage:-1- Subarachnoid hemorrhage:-
the most Common symptom is a sudden severe the most Common symptom is a sudden severe
headache, transient loss of consciousness, headache, transient loss of consciousness,
assiciated with headache, seizer, or assiciated with headache, seizer, or
arrhythmia, nausea, vomiting, neck pain, arrhythmia, nausea, vomiting, neck pain,
intolerance of noise and light, and altered intolerance of noise and light, and altered
mental status.mental status.
Rupture of an intracranial aneurysm is in Rupture of an intracranial aneurysm is in
cause in one fourth of the of patientscause in one fourth of the of patients

43. 
2- Intracerebral hemorrhage:- 2- Intracerebral hemorrhage:-
Like ischemic stroke, more ever, they have a Like ischemic stroke, more ever, they have a
decreased in level of consciousness, decreased in level of consciousness,
headache, and vomiting. headache, and vomiting.

44. Diagnostic StudiesDiagnostic Studies

When symptoms of a stroke occur, When symptoms of a stroke occur,
diagnostic studies are done todiagnostic studies are done to
–Confirm that it is a strokeConfirm that it is a stroke
–Identify the likely cause of the strokeIdentify the likely cause of the stroke

CT is the primary diagnostic test used CT is the primary diagnostic test used
after a stroke to detet the type of stroke, after a stroke to detet the type of stroke,
and guide the treatment. and guide the treatment.

45. 
Diagnosis of strokeDiagnosis of stroke

*Neurological examination:the diagmosis of *Neurological examination:the diagmosis of
stroke is clinical from acute facial paresis, arm stroke is clinical from acute facial paresis, arm
drift, or abnormal speech.drift, or abnormal speech.

*Imaging techniques: determine the type and *Imaging techniques: determine the type and
cause of stroke as:-cause of stroke as:-

-CTscans without contrast.-CTscans without contrast.

- MRI.- MRI.

-ultrasound /doppler study of the -ultrasound /doppler study of the
carotides.carotides.

-Angiography of the cerebral vasculature. -Angiography of the cerebral vasculature.

46. 
Contin.......Contin.......

-ECG and echocardiography.-ECG and echocardiography.

-Blood test for hyperlipidemia,blood -Blood test for hyperlipidemia,blood
suger, bleeding diathesis.suger, bleeding diathesis.

-Holter: to determine intermitent -Holter: to determine intermitent
arrythmias. arrythmias.

47. 
- Management:-- Management:-

1- lschemic stroke:-1- lschemic stroke:-
* emergency diagnosis:- clinically and CT scan * emergency diagnosis:- clinically and CT scan
without contrast to exclude hemorrhagic without contrast to exclude hemorrhagic
stroke and guide treatment.stroke and guide treatment.
* differential diagnosis:-* differential diagnosis:-
. Persistent focal defecit:-. Persistent focal defecit:-

◐

◐
ischemic stroke. hemorrhagic stroke.
◐
ischemic stroke. hemorrhagic stroke.
◐
partial seizer with postictal(todd, s)
◐
partial seizer with postictal(todd, s)
◐
paralysisparalysis

....

48. ◐◐hypoglysemia. hyperglysemia.
◐
hypoglysemia. hyperglysemia.
◐
◐◐subdural hematoma. brain tumor.
◐
subdural hematoma. brain tumor.
◐
◐◐metabolic dysorder. drugs
◐
metabolic dysorder. drugs
◐
overdose. brain abscess with seizere.
◐
overdose. brain abscess with seizere.
◐
◐◐meningitis and encephalitis.meningitis and encephalitis.
*transient focal deficit:-*transient focal deficit:-

◐

◐
TIA. migrain with aura.
◐
TIA. migrain with aura.
◐

◐

◐
partial seizere. partial seizere.

49. * stroke severity and prognosis:-* stroke severity and prognosis:-
- Glasgow coma scale( GCS) :-- Glasgow coma scale( GCS) :-
-Eye opening. Score-Eye opening. Score
. Spontaneous. 4. Spontaneous. 4
.in response to speech. 3.in response to speech. 3
. In response to pain. 2. In response to pain. 2
. None. 1 . None. 1

50. - Best verbal response:- Best verbal response:
.oriented conversation. 5.oriented conversation. 5
.confused conversation. 4.confused conversation. 4
.inappropriate words. 3.inappropriate words. 3
.incomprehensible sounds. 2.incomprehensible sounds. 2
.none. 1.none. 1

51. - Best motor response:- Best motor response:
. obeys. 6. obeys. 6
. localize. 5. localize. 5
.withdraws. 4.withdraws. 4
. abnormal flexion. 3. abnormal flexion. 3
. abonrmal extention. 2. abonrmal extention. 2
. None 1. None 1
GCS of (8) or less has a very poor prognosis. GCS of (8) or less has a very poor prognosis.

52. * thrombolytic therapy as (T-PA) :-* thrombolytic therapy as (T-PA) :-
can be given within (3) hours of stroke onset, can be given within (3) hours of stroke onset,
if cerebral hemorrhage is excluded, and if cerebral hemorrhage is excluded, and
there is no contraindications for their used.there is no contraindications for their used.
* intravenous heparin in patients who will * intravenous heparin in patients who will
require chronic warfarin for secondary require chronic warfarin for secondary
prevention.prevention.
* asprin (325 mg) within 48 hours of onset, * asprin (325 mg) within 48 hours of onset,
may decreased the risk of recurrent stroke may decreased the risk of recurrent stroke
and death. and death.

53. * if patient receives thrombolytic * if patient receives thrombolytic
theraby:asprin and heparin should be theraby:asprin and heparin should be
delayed for at least (24) hours.delayed for at least (24) hours.
* hypertension should not be treated unless * hypertension should not be treated unless
the patient has another condition that the patient has another condition that
requires lowering the pressure as acute requires lowering the pressure as acute
myocardial infarction, acute CHF, aortic myocardial infarction, acute CHF, aortic
dissection, or acute renal failure.dissection, or acute renal failure.
* hyperglycemia:- damages the ischemic* hyperglycemia:- damages the ischemic

54. Penumbra by increasing local lactic acidosis. Penumbra by increasing local lactic acidosis.
Glucose containing solutions and hypotonic Glucose containing solutions and hypotonic
solutions should be avoided since they solutions should be avoided since they
worsen cerebral edema, insulin is used to worsen cerebral edema, insulin is used to
maintion normoglysemia, glucose is only maintion normoglysemia, glucose is only
given if the hypoglysemia is the cause of the given if the hypoglysemia is the cause of the
focal neurological deficit. focal neurological deficit.

55. * prevension of aspiration pneumonia:-* prevension of aspiration pneumonia:-
. elevation of the patient head at 30 degree . elevation of the patient head at 30 degree
. Prohibiting oral intake.. Prohibiting oral intake.
. lateral decubitus position if emesis occurs.. lateral decubitus position if emesis occurs.
* intubation is needed in patient with * intubation is needed in patient with
compromised airway.compromised airway.
* prevention of DVT :-* prevention of DVT :-
. Pneumatic compressing stockes.. Pneumatic compressing stockes.

56. . early mobility and rehabilitation.. early mobility and rehabilitation.
low dose heparin(5000) U. sabcutaneous / low dose heparin(5000) U. sabcutaneous /
12 h.12 h.
* secondary prevention of ischemic stroke:* secondary prevention of ischemic stroke:
. risk factors control.. risk factors control.
. antiplatelets agents as:. antiplatelets agents as:
.asprin (75-325) mg/ d..asprin (75-325) mg/ d.
. Clopidogril (75) mg / d. . Clopidogril (75) mg / d.

57. * carotid endarterectomy for carotid artery * carotid endarterectomy for carotid artery
stenosis.stenosis.
* warfarin( INR 2-3):- in hypercoagulable * warfarin( INR 2-3):- in hypercoagulable
state and cardiac embolism. state and cardiac embolism.

58. 2- treatment of hemorrhagic stroke:-
2- treatment of hemorrhagic stroke:-
A- intracerebral hemorrhage:-
A- intracerebral hemorrhage:-
. The most important risk factors are
. The most important risk factors are
advanced age and hypertention.
advanced age and hypertention.
. Control of blood pressure to a moderate
. Control of blood pressure to a moderate
range. . Control of Intracranial pressure as
range. . Control of Intracranial pressure as
by manitol.by manitol.
. Intravenous normal salin and ringer.
. Intravenous normal salin and ringer.
. Surgical intervension in same cases.
. Surgical intervension in same cases.

59. B- subarachnoid hemorrhage:- B- subarachnoid hemorrhage:-
. Is a medical emergency requiring accurate . Is a medical emergency requiring accurate
and early diagnosis.and early diagnosis.
. General management include care and . General management include care and
monitoring in intensive care unit.monitoring in intensive care unit.
. Ruptured aneurysm treated either by . Ruptured aneurysm treated either by
surgical clipping or endovascular coiling.surgical clipping or endovascular coiling.
. Nimodipine drug reduce the vasospasm and . Nimodipine drug reduce the vasospasm and
inproves clinical outcome. inproves clinical outcome.

60. . The major complicstions are increased . The major complicstions are increased
intracranial pressure, obstructive intracranial pressure, obstructive
hydrocephalus, seizures, and vasospasm. hydrocephalus, seizures, and vasospasm.

61. Collaborative CareCollaborative Care
Prevention Prevention

Education and management of Education and management of
modifiable risk factors to prevent a modifiable risk factors to prevent a
stroke stroke

Close management of patients with Close management of patients with
known risk factorsknown risk factors

62. Collaborative CareCollaborative Care
PreventionPrevention

Antiplatelet drugs (usually Aspirin) to Antiplatelet drugs (usually Aspirin) to
prevent stroke in those with history of prevent stroke in those with history of
TIATIA

63. Collaborative CareCollaborative Care
PreventionPrevention

Surgical interventions for those with Surgical interventions for those with
TIAs from carotid disease:TIAs from carotid disease:
–Carotid endarterectomy Carotid endarterectomy
–Transluminal angioplasty Transluminal angioplasty
–StentingStenting
–Extracranial-intracranial bypassExtracranial-intracranial bypass

64. 
Add Figure 56-7, p. 1533Add Figure 56-7, p. 1533

65. Collaborative CareCollaborative Care
Acute CareAcute Care

Assessment findingsAssessment findings
–Altered level of consciousness (See GCS, p. Altered level of consciousness (See GCS, p.
1500)1500)
–Weakness, numbness, or paralysis Weakness, numbness, or paralysis
–Speech or visual disturbancesSpeech or visual disturbances
–Severe headacheSevere headache
–↑ ↑ or ↓ heart rate or ↓ heart rate
–Respiratory distressRespiratory distress
–Unequal pupils Unequal pupils

66. Collaborative CareCollaborative Care
Acute CareAcute Care

Assessment findingsAssessment findings
–HypertensionHypertension
–Facial drooping on affected sideFacial drooping on affected side
–Difficulty swallowingDifficulty swallowing
–SeizuresSeizures
–Bladder or bowel incontinence Bladder or bowel incontinence
–Nausea and vomiting Nausea and vomiting
–Vertigo Vertigo

67. Collaborative CareCollaborative Care
Acute CareAcute Care

Interventions – Initial: ABCInterventions – Initial: ABC
–Ensure patient airwayEnsure patient airway
–Remove denturesRemove dentures
–Perform pulse oximetry Perform pulse oximetry
–Maintain adequate oxygenation Maintain adequate oxygenation
–IV accessIV access
–Maintain BP according to guidelinesMaintain BP according to guidelines
(treat if SBP > 220 or MAP > 130)(treat if SBP > 220 or MAP > 130)

68. Collaborative CareCollaborative Care
Acute CareAcute Care

Interventions – Initial Interventions – Initial
–Immediate CT scan to determine cause Immediate CT scan to determine cause
(ischemic vs hemorrhagic)(ischemic vs hemorrhagic)
–Measures to control ICPMeasures to control ICP

Head & neck in alignment (avoid flexion)Head & neck in alignment (avoid flexion)
 Elevate HOB 30 Elevate HOB 30 °° if no symptoms of shock or if no symptoms of shock or
injury injury

Avoid hip, knee flexionAvoid hip, knee flexion

Pain management, euvolemia, diuretics if Pain management, euvolemia, diuretics if
neededneeded

69. Collaborative CareCollaborative Care
Acute CareAcute Care

Interventions – Initial Interventions – Initial
–Institute seizure precautionsInstitute seizure precautions
–Avoid hyperthermia ( Avoid hyperthermia ( ↑s↑s cerebral cerebral
metabolism)metabolism)
–Anticipate thrombolytic/fibrinolytic Anticipate thrombolytic/fibrinolytic
therapy for ischemic stroke therapy for ischemic stroke

70. Collaborative CareCollaborative Care
Acute CareAcute Care

Thrombolytic/fibrinolytic therapy with Thrombolytic/fibrinolytic therapy with
recombinant tissue plasminogen recombinant tissue plasminogen
activator (tPA) is used to activator (tPA) is used to
–Reestablish blood flow and prevent Reestablish blood flow and prevent
cell death in patients of cell death in patients of ischemicischemic
stroke stroke

71. Collaborative CareCollaborative Care
Acute CareAcute Care

Thrombolytic/fibrinolytic therapy given Thrombolytic/fibrinolytic therapy given
within 3 hours of the onset of symptoms within 3 hours of the onset of symptoms
–↓↓ disabilitydisability
–But at the expense of But at the expense of ↑ in deaths ↑ in deaths
within the first 7 to 10 days and ↑ in within the first 7 to 10 days and ↑ in
intracranial hemorrhage intracranial hemorrhage

72. Collaborative CareCollaborative Care
Acute CareAcute Care

For ischemic strokes (24 hr after tPA):For ischemic strokes (24 hr after tPA):
–AntiplateletsAntiplatelets
–Anticoagulants (Heparin, coumadin)Anticoagulants (Heparin, coumadin)

Must maintain therapeutic levelsMust maintain therapeutic levels
–PTT, INRPTT, INR

73. Collaborative CareCollaborative Care
Acute CareAcute Care

Interventions – Ongoing Interventions – Ongoing
–Monitor vital signs and neurologic Monitor vital signs and neurologic
statusstatus

Level of consciousnessLevel of consciousness

Motor and sensory functionMotor and sensory function

Pupil size and reactivity Pupil size and reactivity

O2 saturationO2 saturation

Cardiac rhythm Cardiac rhythm

74. Collaborative CareCollaborative Care
Acute CareAcute Care

Approximately 10-15% of patients who Approximately 10-15% of patients who
experience a stroke will have seizures, experience a stroke will have seizures,
usually within 24 hoursusually within 24 hours

75. Collaborative CareCollaborative Care
Acute CareAcute Care

Surgical interventions:Surgical interventions:
–Immediate evacuation of hematomas Immediate evacuation of hematomas
that result from hemorrhagic strokethat result from hemorrhagic stroke
–Clip, wrap or coli aneurysm to Clip, wrap or coli aneurysm to
prevent rebleedprevent rebleed

76. Collaborative CareCollaborative Care
Rehabilitation CareRehabilitation Care

After the stroke has stabilized for 12-24 After the stroke has stabilized for 12-24
hours, collaborative care shifts from hours, collaborative care shifts from
preserving life to lessening disability preserving life to lessening disability
and attaining optimal functioningand attaining optimal functioning

77. Nursing ManagementNursing Management
NursingNursing AssessmentAssessment

Assess for:Assess for:
–Clinical manifestationsClinical manifestations
–Risk factorsRisk factors
–ComplicationsComplications

78. Nursing ManagementNursing Management
Nursing DiagnosesNursing Diagnoses

Ineffective tissue perfusion (cerebral)Ineffective tissue perfusion (cerebral)

Ineffective airway clearanceIneffective airway clearance

Impaired physical mobilityImpaired physical mobility

Impaired verbal communicationImpaired verbal communication

Unilateral neglectUnilateral neglect

Impaired urinary eliminationImpaired urinary elimination

79. Nursing ManagementNursing Management
Nursing DiagnosesNursing Diagnoses

Impaired swallowingImpaired swallowing

Situational low self-esteemSituational low self-esteem

80. Nursing ManagementNursing Management
PlanningPlanning

Physiotherapy :Goals Physiotherapy :Goals
–Maintain a stable or improved level Maintain a stable or improved level
of consciousnessof consciousness
–Attain maximum physical functioningAttain maximum physical functioning
–Attain maximum self-care abilities Attain maximum self-care abilities
and skillsand skills
–Maximize communication abilities Maximize communication abilities

81. Nursing ManagementNursing Management
PlanningPlanning

Goals Goals
–Maintain adequate nutrition Maintain adequate nutrition
–Avoid complications of strokeAvoid complications of stroke
–Maintain effective personal and Maintain effective personal and
family coping family coping

82. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Health PromotionHealth Promotion
–Teaching patients and families about Teaching patients and families about
early symptoms associated with early symptoms associated with
stroke or TIA and when to seek stroke or TIA and when to seek
health care for symptomshealth care for symptoms

83. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Respiratory SystemRespiratory System
–Management of the respiratory system Management of the respiratory system
is a nursing priority is a nursing priority
–Risk for aspiration pneumonia (why?)Risk for aspiration pneumonia (why?)
–Risks for airway obstruction Risks for airway obstruction
–May require intubation and ventilation May require intubation and ventilation

84. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Neurologic SystemNeurologic System
–Monitor closely for deterioration or Monitor closely for deterioration or
improvementimprovement

85. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Cardiovascular SystemCardiovascular System
–Monitor closelyMonitor closely
–Risk for DVTRisk for DVT

86. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Musculoskeletal SystemMusculoskeletal System
–Prevent joint contractures and Prevent joint contractures and
muscular atrophy muscular atrophy
–In the acute phase, range-of-motion In the acute phase, range-of-motion
exercises and positioningexercises and positioning
–Trochanter roll at hip to prevent Trochanter roll at hip to prevent
external rotationexternal rotation

87. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Musculoskeletal SystemMusculoskeletal System
–Hand cones to prevent hand Hand cones to prevent hand
contractures contractures
–Arm supports with slings and lap Arm supports with slings and lap
boards to prevent shoulder boards to prevent shoulder
displacementdisplacement

88. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Musculoskeletal SystemMusculoskeletal System
–Avoid pulling patient by arm to avoid Avoid pulling patient by arm to avoid
shoulder displacementshoulder displacement
–Posterior leg splints, footboards or Posterior leg splints, footboards or
high-topped shoes to prevent foot high-topped shoes to prevent foot
dropdrop
–Hand splints to reduce spasticity Hand splints to reduce spasticity

89. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Integumentary SystemIntegumentary System
–Skin is susceptible to breakdown Skin is susceptible to breakdown
related to loss of sensation, ↓ related to loss of sensation, ↓
circulation, and immobility circulation, and immobility
–Compounded by age, poor nutrition, Compounded by age, poor nutrition,
dehydration, edema, and incontinence dehydration, edema, and incontinence

90. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Integumentary SystemIntegumentary System
–Pressure relief by position changes, Pressure relief by position changes,
special mattresses, wheelchair cushionsspecial mattresses, wheelchair cushions
–Good skin hygieneGood skin hygiene
–Emollients for dry skinEmollients for dry skin
–Early mobility Early mobility
–Position patient affected side for only 30 Position patient affected side for only 30
minutes minutes

91. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Gastrointestinal SystemGastrointestinal System
–May require nutrition support May require nutrition support
–Assess gag and swallowing before first Assess gag and swallowing before first
feeding feeding
–Scrupulous oral hygiene after meals (food Scrupulous oral hygiene after meals (food
collects)collects)
–Place food on unaffected sidePlace food on unaffected side
–Foods with texture are more easily Foods with texture are more easily
swallowedswallowed

92. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Gastrointestinal SystemGastrointestinal System
–Constipation is common Constipation is common
–Manage with Manage with

Physical activity Physical activity

Adequate fluid intakeAdequate fluid intake

Laxatives, suppositories, stool softenersLaxatives, suppositories, stool softeners

93. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Urinary SystemUrinary System
–In the acute stage poor bladder In the acute stage poor bladder
control is the primary urinary control is the primary urinary
problem, resulting in incontinence problem, resulting in incontinence
–Avoid indwelling catheters Avoid indwelling catheters

94. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Communication Communication
–Assess ability to speak and Assess ability to speak and
understandunderstand
–Speak slowly and calmly, using Speak slowly and calmly, using
simple words or sentencessimple words or sentences
–Provide time to express selfProvide time to express self

95. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Sensory-Perceptual Alterations Sensory-Perceptual Alterations
–Blindness in the same half of each visual Blindness in the same half of each visual
field is a common (homonymous field is a common (homonymous
hemianopsia)hemianopsia)

Difficult to distinguish from unilateral Difficult to distinguish from unilateral
neglectneglect

Initially approach from, and place needed Initially approach from, and place needed
objects on “good” side. Later, teach to scan objects on “good” side. Later, teach to scan
and pay attention to affected sideand pay attention to affected side

96. Homonymous Hemianopsia (food on left side Homonymous Hemianopsia (food on left side
is not seen) is not seen)
Fig. 56-8

97. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Coping Coping
–A stroke is often a family disease, A stroke is often a family disease,
affecting the family emotionally, affecting the family emotionally,
socially, and financiallysocially, and financially
–Changing roles and responsibilities Changing roles and responsibilities
occur occur

98. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Coping Coping
–Clear explanations about what has Clear explanations about what has
happened, diagnostic and therapeutic happened, diagnostic and therapeutic
proceduresprocedures

99. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Ambulatory and Home Care Ambulatory and Home Care
–The patient is usually discharged The patient is usually discharged
from the acute care setting to home, from the acute care setting to home,
an intermediate or long-term care an intermediate or long-term care
facility, or a rehabilitation facility facility, or a rehabilitation facility
–Discharge planning should begin Discharge planning should begin
earlyearly

100. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Ambulatory and Home Care Ambulatory and Home Care
–The nurse initially emphasizes the The nurse initially emphasizes the
musculoskeletal functions of musculoskeletal functions of

EatingEating

ToiletingToileting

WalkingWalking

101. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Ambulatory and Home Care Ambulatory and Home Care
–Most patients begin to show signs of Most patients begin to show signs of
spasticity with exaggerated reflexes spasticity with exaggerated reflexes
within 48 hours following the strokewithin 48 hours following the stroke
–Balance training, transferringBalance training, transferring
–Supportive/assistive devices for Supportive/assistive devices for
mobilizingmobilizing

102. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Ambulatory and Home Care Ambulatory and Home Care
–Interventions to promote self-feedingInterventions to promote self-feeding

Using the unaffected upper extremity Using the unaffected upper extremity

Employing assistive devices such as Employing assistive devices such as
rocker knives, plate guards, and nonslip rocker knives, plate guards, and nonslip
pads for dishespads for dishes

103. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Ambulatory and Home Care Ambulatory and Home Care
–A bowel management program is A bowel management program is
implemented for problems with bowel implemented for problems with bowel
control, constipation, incontinencecontrol, constipation, incontinence
–A high-fiber diet and adequate fluid A high-fiber diet and adequate fluid
intakeintake

104. Nursing ManagementNursing Management
Nursing ImplementationNursing Implementation

Ambulatory and Home Care Ambulatory and Home Care
–Family members must cope with 3 Family members must cope with 3
aspects of the patient's behavioraspects of the patient's behavior
1.1.Behavioral changes resulting from Behavioral changes resulting from
neurologic deficits neurologic deficits
2.2.Responses to multiple lossesResponses to multiple losses
3.3.Behaviors that may have been Behaviors that may have been
reinforced during the early stages of reinforced during the early stages of
stroke as continued dependency stroke as continued dependency