1. Cerebrovascular Accident

2. Cerebrovascular Accident

3. Key words
It is an acute disruption (reduction/ absence) of blood supply to a territory of the brain, resulting in neurologic signs & symptoms.
This interruption of blood supply may be related to: ischemia, hemorrhage, or embolism.
Strokes are considered a medical emergency.
The 2nd leading cause of death in Gaza Strip, and a leading cause adult disability
Up to 80 percent of all strokes are preventable through risk factor management

4. Women and Stroke
Stroke kills more than twice as many American women every year as breast cancer
More women than men die from stroke and risk is higher for women due to higher life expectancy
Women suffer greater disability after stroke then men
Women ages 45 to 54 are experiencing a stroke surge, mainly due to increased risk factors and lack of prevention knowledge

5. Types of CVA Ischemic: 85% Thrombotic: Hemorrhagic 15%: TIA Embolic
SAH

6. (makes up approximately
Ischemic = Clot
(makes up approximately
87 percent of all strokes)
Hemorrhagic = Bleed
- Bleeding around brain
- Bleeding into brain
Thrombotic 87

7. The term “Brain Attack” is the most descriptive and realistic description of a stroke. It also provides a powerful call to action.
A brain attack should warrant the same degree of emergency care as a heart attack. After all, your brain is your mind and your body’s most vital and delicate organ.
Immediate response is crucial because every minute matters – from the time symptoms first become noticeable to the time treatment is received, more brain cells die. In other words TIME IS BRAIN. The best thing to do is to call for immediate assistance.
Treatment is available and some options are most effective if administered within the first three hours after experiencing symptoms.
Your chances of walking out of the hospital with little to no disability are greatly improved if you receive appropriate treatments early.
Unfortunately, it takes the average person in the U.S. 12 to 24 hours to get to the hospital after experiencing the first stroke symptom. This is why it’s important that everyone learns how to RECOGNIZE stroke symptoms and how to RESPOND.
References:
National Stroke Association. The Complete Guide to Stroke At:
Lichtman JH, Watanbe E, et al. Hospital Arrival Time and Intravenous t-PA Use in US
Academic Medical Centers, 2001–2004. Stroke. 2009;40:00-00.

8. Risk Factors Non modifiable: age and sex Modifiable: HTN
Atherosclerosis
Hyperlipidemia DM
Cocaine use
Atrial fibrillation
Smoking
Use of oral contraceptives
Obesity
Hypercoagulability
Cerebral aneurysm
Arteriovenous malformation (AV)
Risk Factors

9. Diagnostic Procedures and Nursing Interventions
History and complete physical and neurologic examination
Noncontrast CT scan
12-lead ECG and carotid ultrasound
CT angiography or MRI and angiography
Transcranial Doppler flow studies
Transthoracic or transesophageal echocardiography
(MRA) or cerebral angiography is used to identify
the presence of cerebral hemorrhage, abnormal
vessel structures, vessel ruptures,………..
LP is used to assess for presence of blood in the CSF.

10. Therapeutic Procedures and Nursing Interventions
Carotid endarterectomy is performed to open the artery by removing atherosclerotic plaque.
Interventional radiology is performed to treat cerebral aneurysms.

11. Monitor for signs and symptoms
Symptoms will vary based on the area of the brain that is not adequately supplied with oxygenated blood.
The left cerebral hemisphere is responsible for:
language,
mathematic skills, and
analytic thinking.
Aphasia (language use or comprehension difficulty)
Alexia (reading difficulty)
Agraphia (writing difficulty)
Right hemiplegia or hemiparesis
Slow, cautious behavior
Depression and quick frustration
Visual changes, such as hemianopsia

12. Clinical picture
Rt cerebral hemisphere is responsible for visual and spatial awareness and proprioception.
Unawareness of deficits (neglect syndrome, overestimation of abilities)
Loss of depth perception
Disorientation
Impulse-control difficulty
Poor judgment
Left hemiplegia or hemiparesis
Visual changes, such as hemianopsia

13. Stroke symptoms Sudden and severe headache Sudden confusion
Trouble speaking
Trouble seeing
in one or both eyes
Sudden numbness
or weakness of
face, arm or leg
Sudden dizziness,
Trouble walking

14. Assess/Monitor Airway patency Swallowing ability/aspiration risk
Level of consciousness
Neurological status
Motor function
Sensory function
Cognitive function
Glasgow Coma Scale score

17. NANDA Nursing Diagnoses
Ineffective tissue perfusion (cerebral)
Disturbed sensory perception
Impaired physical mobility
Acute pain
Unilateral neglect
Risk for injury
Self-care deficit
Impaired verbal communication

18. NANDA Nursing Diagnoses
Impaired swallowing
Impaired urinary elimination
Disturbed thought processes
Risk for impaired skin integrity
Interrupted family processes
Sexual dysfunction

19. Nursing Interventions
Maintain a patent airway.
Monitor for changes in the client’s LOC ( ICP).
Elevate the client’s head to ICP and to promote venous drainage.
Avoid extreme flexion/ extension (maintain the head in the midline neutral position, and elevate the head of the bed to 30°).
Keep seizure precautions.
Maintain a calm environment.
Assist with communication skills if the client’s speech is impaired.

20. Nursing Interventions
Assist with safe feeding.
Assess swallowing reflexes: swallowing, gag, and cough before feeding.
The client’s liquids may need to be thickened to avoid aspiration.
Have the client eat in an upright position and swallow with the head and neck flexed slightly forward.
Place food in the back of the mouth on the unaffected side.
Suction on standby.
Maintain a distraction-free environment during meals.

21. Nursing Interventions
Maintain skin integrity.
Reposition the client frequently and use padding.
Monitor bony prominences, paying particular attention to the affected extremities.
Encourage passive ROM every 2 hr to the affected extremities and active ROM every 2 hr to the unaffected extremities.
Elevate the affected extremities to promote venous return and to reduce swelling.
Maintain a safe environment to reduce the risk of falls.
Instruct the client to use a scanning technique (turning head from side to side) when eating and ambulating to compensate for hemianopsia.
Provide care to prevent DVT

22. Nursing Interventions
Administer medications as prescribed.
Thrombolytic therapy restores cerebral blood flow. It must be administered within hours of the onset of symptoms.
It is contraindicated for treatment of hemorrhagic stroke and for clients with an increased risk of bleeding.
Rule out hemorrhagic stroke with an MRI prior to initiation of thrombolytic therapy.
Anticoagulants: heparin, Coumadin
Antiplatelets

23. Nursing Interventions
Antiepileptic medications: Phenytoin (Dilantin)
Provide assistance with activities of daily living (ADLs) as needed.
Initiate referrals to social services (rehabilitation services) and Physical/ Occupational Therapy (adaptive equipment needs in the home).

24. Complications and Nursing Implications
Dysphagia and aspiration – Suction as needed. Preassess the client’s swallowing abilities.
Unilateral neglect – loss of awareness of the side affected by the CVA. This poses great risk for injury and inadequate self care.
Instruct the client to dress the affected side first. Teach the client to care for both sides.

25. Be stroke smart Reduce—Stroke risk Recognize—Stroke symptoms
Respond—At the first sign of stroke,
Call 101 immediately

26. Stroke Strikes FAST You Should, Too. Call 9-1-1
F = FACE: Ask the person to smile.
A = ARM: Ask the person to raise both arms.
S = SPEECH: Ask the person to speak a simple sentence.
T = TIME: If you observe any of these signs, call immediately
One way to help remember the symptoms of stroke and what to do, is to learn the Face, Arms, Speech Test, otherwise knows as FAST:
F = FACE: ask the person to smile – do both sides of the face move equally? (Normal) Or does one side of the face not move at all? (Abnormal)
A = ARM: ask the person to raise both arms – do both arms move equally? (Normal) Or does one arm drift downward compared to the other? (Abnormal)
S = SPEECH: ask the person to speak a simple sentence – Does the person use correct words with no slurring? (Normal) Or do they slur their speech, use inappropriate words or is unable to speak at all? (Abnormal)
T = TIME: to call 911 – if you observe any of these symptoms, call 911 immediately. Every minute matters!
References: National Stroke Association. The Complete Guide to Stroke At:
© 2011 National Stroke Association

27. Head Injury

28. Key Points Head injuries can be classified as:
open (penetrating trauma) or
closed (blunt trauma).
Head injuries are also classified as:
mild,
moderate, or
severe, depending upon Glasgow coma scale (GCS) ratings and length of loss of consciousness.
Open head injuries pose a high risk for infection (????).
Skull fractures are often associated with brain injury.
Any interruption in blood (O2 and/or glucose) supply to the brain may lead to permanent brain damage.

29. Key Points
Head injuries may or may not be associated with hemorrhage (epidural, subdural, and intracerebral).
CSF leakage is also possible, as a result: cerebral edema, cerebral hypoxia, and brain herniation may occur.
Cervical spine injury should always be suspected when head injury occurs.

30. Risk Factors Young males Motor vehicle or motorcycle crashes
Drug and alcohol use
Sports injuries
Assault
Gunshot wounds
Falls

32. Diagnostic and Therapeutic Procedures and Nursing Interventions
ABGs are used to assess oxygen status.
CT scan are used to assess the location (epidural, subdural) and extent of the head injury.
Intracranial pressure monitoring (ICP) –Elevated ICP poses a risk of infection. Normal ICP level is 10 to 15 mm Hg.
Craniotomy – removal of nonvital brain tissue to allow for expansion and/or removal of epidural or subdural hematomas.
Intracranial hemorrhages require surgical evacuation.

33. Assessments Assess/Monitor
Respiratory status – the PRIORITY assessment
Changes in level of consciousness – the EARLIEST indication of neurological deterioration
Alcohol or drug use at time of injury (can mask increased ICP)
Amnesia (loss of memory) before or after injury
Loss of consciousness and length
Cushing reflex (severe hypertension with a widened pulse pressure and bradycardia) – late sign of increased ICP

34. Assessments Posturing (decorticate, decerebrate, flaccid)
Cranial nerve function
Pupillary changes (PERRLA, pinpoint, fixed/nonresponsive, dilated)
Signs of infection (nuchal rigidity with meningitis)
CSF leakage from nose and ears (“halo” sign – yellow stain surrounded by blood; test positive for glucose)
GCS rating (15 normal; 3 = deep coma)

36. NANDA Nursing Diagnoses
Ineffective tissue perfusion (cerebral)
Decreased intracranial adaptive capacity
Ineffective breathing pattern
Ineffective airway clearance

37. Nursing Interventions
Maintain a patent airway, (MV)
Maintain c-spine stability until cleared by x-ray.
Elevate head to reduce ICP and to promote venous drainage.
Avoid extreme flexion or extension, maintain head in midline neutral position, keep the head of the bed elevated 30°.
Instruct the client to avoid coughing and blowing nose (increases ICP).
Report presence of CSF from nose or ears

38. Nursing Interventions
Provide a calm, restful environment
Use energy conservation measures
Implement seizure precautions.
Implement measures to prevent complications of immobility (change position, footboard and splints).
Monitor the client’s :
VS,
LOC,
pupils,
motor activity,
sensory perception, and verbal responses

39. Nursing Interventions
Provide adequate fluids to maintain cerebral perfusion.
Maintain client safety
Monitor F & E
Provide adequate fluids to maintain cerebral per.
Administer medications as prescribed:
Pain medications as prescribed in the absence of increased ICP (avoid opioids because they produce respiratory depression, pupillary changes, nausea, and CNS clouding).
Dexamethasone (Decadron), methylprednisolone (Solu-Medrol) to reduce cerebral edema.

40. Nursing Interventions
Mannitol – osmotic diuresis to treat cerebral edema.
Neuromuscular blocking agents, sedatives, and opioids to manage agitation (be cautious as they can mask changes in LOC).
Pentobarbital (Nembutal), sodium thiopental to induce a barbiturate coma in order to decrease cerebral metabolic demands.
Phenytoin (Dilantin) to prevent/treat seizures.
Provide nutritional support (for example, enteral nutrition)
Health Promotion/Prevention
Wear helmets.
Wear seat belts when driving.
Avoid dangerous activities (speeding, Mobile and driving).

41. Complications and Nursing Implications
Brain herniation – downward shift of brain tissue. Signs include fixed dilated pupils, deteriorating LOC, Cheyne Stoke respirations, hemodynamic instability, and abnormal posturing.