CVA

1. “cerebrovascular accident”
BY:BIJAYA DHAKAL

2. REVIEW ANATOMY

5. BLOOD SUPPLY TO THE BRAIN
 Blood is supplied to the brain by two major pairs of
arteries-Internal carotid &Vertebral arteries

7. INTRODUCTION
 CVA is a term used to described neurological changes
caused by interruption in the blood supply to a part of
the brain.
 A stroke, or brain attack or cerebrovascular accident,
is the rapid loss of brain function due to disturbance
in the blood supply to the brain. A stroke is a medical
emergency and can cause permanent neurological
damage and death.

8. DEFINITION
 Stroke or CVA as the rapid development of clinical
signs and symptoms of a focal neurological
disturbance lasting more than 24 hours or leading
to death with no apparent cause other than
vascular origin (WHO, 2005).

9. EPIDEMIOLOGY
Stroke is the:
Third most common cause of death
First leading cause of disability
25% with initial stroke die within 1 year
50-75% will be functionally independent
25% will live with permanent disability

10. CAUSES OF CVA
A stroke occurs when the blood supply to the brain are
interrupted or reduced, this deprives brain of oxygen
and nutrients which cause brain cell to die.
The major causes of CVA are:
Ischemia
 thrombosis
Embolism
Haemorrhage
Transient ischemic attack

11. RISK FACTORS (Modifiable)
(1)
Atherosclerosis
(narrowing of
the arteries)

12. (2) Uncontrolled hypertension
Affects
Heart
Brain
Kidneys

13. (4) Untreated Irregular Heart Beats

14. (5) Smoking (6) Diabetes

15.  Other risk factors are:
Obesity
Physical inactivity
Use of ilicit drugs,such as: coccaine
Drinking alcohal
Oral contraceptives use
High cholesterol
hypercoagulability

16. TYPES OF CVA
 Stroke can be divided into two major categories:
ischemic stroke (85%) in which vascular occlusion and
significant hypoperfusion occur and hemorrhagic
(15%), in which there is extravasations of blood into
the brain or subarachnoid space

17.  Ischemic stroke results from inadequate blood supply
to the part of the brain from a partial or complete
occlusion of an artery that supply blood to the brain.
This accounts for approximately 85% of all the stroke.
 Ischemic stroke are further classified into :
Thrombolytic stroke: a thrombolytic stroke occurs
from injury to the blood vessels walls and formation of
blood clots . A clots may be caused by fatty deposit
that builds up in artery (atherosclerosis), the lumen of
the blood vessels may become narrowed and occluded
and then infraction may occur

18. Embolic stroke: it occurs when a blood clots and other
debris forms away from the brain, commonly in the
heart and travels through the blood stem and lodges in
narrower brain artery resulting in occlusion and
infraction.

19. Ischemic stroke

20.  Both result in a lack of blood flow to the brain and
buildup of blood that puts too much pressure on the
brain.

21. Hemorrhagic stroke
A hemorrhagic stroke occurs when a blood vessel on the
brain's surface ruptures and fills the space between the
brain and skull with blood (subarachnoid hemorrhage) or
when a defective artery in the brain bursts and fills the
surrounding tissue with blood (cerebral hemorrhage).

22. Types of hemorrhagic stroke are:
Intracerebral hemorrhage: in this type of hemorrhagic
stroke, an artery on and near the surface of the brain
brust and spills into the surface of the surrounding
brain tissue and damaging brain cells.
Subarachnoid hemorrhage: in subarachnoid
hemorrhage an artery on and near the brain brust and
spills into the space between brain and skull.

25. PATHOPHYSIOLOGY
Normally the brain received a constant flow of blood for a
normal function as it is unable to store oxygen & glucose.
The blood flow is important for the removal of metabolic
waste like CO2. otherwise due to lack of blood flow, the
brain may be damaged within a short period.
 The brain is hypoxia/anoxia due to different causes
 Cerebral ischemia
 Alter cerebral metabolism
 Permanent damage of brain cell within 3-5ms
 Neurological deficit seen in the patient

26. CLINICAL FEATURES

27. CLINICAL FEATURES
 Stroke symptoms typically starts suddenly over a
second to a minute.
 The symptoms depends on the area of brain affected.
The most extensive the area of the brain affected more
functions are likely to be lost.
 Some forms of stroke can cause additional symptoms
for e.g, in an intracranial hemorrhage ,the affected
area may compress other structure.
 The symptoms associated with strokes are:

28.  sudden onset of a severe headache – “worst headache
of one’s life” (specially in hemorrhagic and embolic
stroke)
 Change or Loss Of Conscious
 nausea, vomiting, seizures, stiff neck
 Cushing triad: hypertension, bradycardia,respiratory
changes

29. Hemiparesis & hemiplesia
Aphasia & Dysphasia
 Visual changes
 Honer’s syndrome(paralysis of nerve of the one eye)
 Agnosia (disturbances in ability to recognize familiar
object)
 Sensory deficit & behaviour changes
 Incontinence & Unilateral neglate
• Homonymous hemianopsia – defective vision or blindness
right or left halves of visual fields of both eyes

30. o Unilateral weakness, Numbness, Tingling
 Swallowing difficulty
 Bladder/bowel incontinence
 Pupillary abnormalities, Nystagmus
 Hemiplegia, Hemi paresis
 Facial droop, Seizures
 Confusion, Coma
 Hypertonicity

32. Clinical Manifestations
Right Brain – Left Brain Damage

33. DIAGNOSIS WORK UP
Laboratory
 CBC-for infection
 Platelets-identify
haemorrhagic risk
 PT-identify
coagulopathy
 Electrolytes
Imaging
 CT scan-site of
haemorrhage and
ischemia
 MRI
 Angiography
 Carotid
ultrasonography
 Arteriography

34. MANAGEMENT OF CVA
 Goals of management:
 Identify stroke early
 Maintain cerebral oxygenation
 Restore cerebral blood flow
 Prevent complication
 Rehabilitation after stroke

35.  Identify the stroke early: identify the stroke using FAST
treatment technique. FAST stands for:
 F: means face: if one side of the face drops it is the possible
signs of CVA
 A: means Arms: If the person can not hold the both arms
out it is the another possible stroke sign
 S: means speech: slurring of speech and poor
understanding of simple language is another possible for
stroke.
 T: means time if any of FAS signs are positive seek an
attention. T in fast also means longer time the blockage of
blood to the brain the more damage can occur.

37. MEDICAL MANAGEMENT
 Acute care:
 Proper positioning strictly at 30 degree head elevated
 Perform endotracheal intubation if necessary
 Cautiously lower blood pressure
 Avoid excessive hypotension
 Hyperventilation
 Give mannitol to minimize cerebral edema
 Give isotonic fluid eg normal saline
 Avoid hyperthermia
 Anticonvulsant drug

38.  Specific pharmacological management :treatment of
CVA depends up on the types of Stroke:
Ischemic stroke:
Anticoagulant medicine (warfarin)
Antipletelet aggregating medicine (aspirin)
Thrombolytic medicine tPA: (tissue plasminogen
Activator) produce localized fibrinolysis by binding to the
fibrin in the thrombi
Embolic stroke: treat other underlying cause

39. SURGICAL MANAGEMENT
 A carotid endarterectomy
 Craniotomy
 coiling , binding and clipping of aneurysm

41. Carotid Endarterectomy

42.  Transluminal angioplasty: insertion of the balloon to
open the stenosed artery and improve blood flow. The
balloon is threaded up into the carotid artery via the
catheter inserted into the femoral artery.

43. NURSING MANAGEMENT
 Assessment:
 Change in the level of consciousness or responsiveness
by using Glasgow coma scale
 Presence or absence of voluntary or involuntary
movements of the extremities; muscle tone; body
posture; and position of the head
 assess for any alteration in vital signs
 Eye opening, comparative size of pupils and pupillary
reactions to light.

44.  Assess for cranial nerve dysfunction
 Assess for skin breakdown, contracture, and other
complications of immobility
 Assess for stiffness and flaccidity of neck
 Monitor for effectiveness of anticoagulant
 Assess for bowel and bladder function
 Assess for facial drop

45.  Nursing Diagnosis
 Impaired physical mobility related to hemi paresis
,loss of balance ,and coordination and brain injury
 Acute pain related to hemiplegia and disuse
 Self care deficit related to hemiplegia.
 Disturbed sensory perception related to altered
sensory reception transmission and integration.
 Impaired swallowing related to cranial nerve
dysfunction

46.  Incontinence of urine related to flaccid bladder
 Disturbed thought process related to brain damage
 Risk for develop contracture related to physical immobility
 Risk for impaired skin integrity related to hemi paresis and
decreased movements
 Interrupted family coping process related to catastrophic
illness and care giving burden
 Imbalance nutrition less than body requirements related to
impaired self feeding chewing and swallowing

47.  Nursing intervention:
 Preventing complication of immobility:
 Position to prevent contractures, use measures to relief
pressure.
 Place the affected extremities slightly flexed on pillow
with each joined positioned higher than the preceding
one to prevent edema.
 Prevent foot drop by using foot boards
 Change position every 2 hourly
 Range of motion exercises

48.  Use of stocking in legs to prevent deep vein
thrombosis.
 Chest physiotherapy and suctioning to prevent chest
infection
 Teach patient to use unaffected parts to move an
affected parts
 Frequently assess for contractures
 Assist patient in ambulation if required.

49.  Preventing shoulder pain:
 Never lift the patient by flaccid shoulder
 Use of sling when ambulating
 Range of motion exercise
 Elevate the arm and hand to prevent dependant edema
 Administer analgesic as prescribed

50.  Optimizing cognitive abilities
 Be aware of the patients cognitive alertness and adjust
environment accordingly
 Participation in cognitive retraining programs: reality
orientation, visual imagery
 Focus on patient strength and give positive feedback
 In patient with increased awareness interact patient
with is familiar objects and persons.

51.  Preventing risk of injury:
 Keep the side rails of bed
 Frequent skin inspection for manifestation of
complication
 Remind client to walk slowly, rest adequately between
the interval of walking.

52. Improving nutritional status:
 Carefully assess the client diet to ensure adequate
nutrition
 Encourage small frequent feeding and allow enough
time to chew
 Remind patient to chew in unaffected side
 Feed the patient in upright position
 Give supplemental food as needed
 Inspect mouth for food collection and pocketing
before entry of each bolus food

53.  Reduce environmental distraction to improve patient
concentration
 Provide frequent oral care
 If the patient can not swallow at all provide NG tube
feeding

54. Facilitating communication:
 Speak at slower rate and give time to patient to respond
 Speak by using verbal cues and gesture and be consistent
and repeat as necessary
 Listen and watch carefully when aphasic patient attempts
to communicate
 Give planty of time to response and reinforce attempts as
well as correct response
 Help the family to communicate with the patient and
minimize distraction.

55.  Fostering independence:
 Teach the patient to use unaffected side for activity of
daily living but not to neglect affected side.
 Make sure personal care items are nearby patients
obtain assistance with transfer and other activities as
needed
 Encourage patient in positive achievement.

56.  Attaining bladder control:
 Insert indwelling catheter during an acute phase for
accurate fluid management and remove catheter as
soon as status stabilization
 Establishing regular voiding schedule
 Strictly maintain urine intake and output recording
 Assist with standing or sitting to void

57.  Strengthening family coping:
 Encourage the family to maintain outside interest
 Teach stress management technique such as relaxation
technique, exercise
 Involves as many family and friends to participate in
patients care
 Provide information about stroke and prognosis
 Teach the family that stroke survivors may show
depression in the first 3 months of recovery

58.  Patient education and health maintainence:
 Teach the patient and family to adopt home
environment for safety and ease of use
 Instruct the patient of the need for rest provides
throughout the day
 Reassure the family that it is common for post stroke
patient to experience emotional liability and
depression; treatment can be given
 Encourage consistency in environment without
distraction

59.  Assist the family to obtain self help aid for patient
 Instruct family in management of aphasia: e,g using
alternate means of communication
 Educate those at risk of stroke about life style
modification therapy can lower the risk.

60. COMPLICATIONS
 Aspiration pneumonia
 Dysphagia
 Deep vein thrombosis
 Pulmonary embolism
 Post stroke depression
 Brain stem herniation

61. keys of prevention..
1. If you STOP…..
2. Reduce your intake of ….
3. Maintain your BP
4.

62. Remember..the key is prevention

63. PROGNOSIS
 Recovery rates vary depending on age and the part of the brain affected and the
extent of the stroke. Function will be restored in more than half of individuals
with moderate to severe paralysis on one side of the body
 Stroke (all types) has an overall mortality rate of 39.1 per 100,000 individuals.
 About 5% to 10% of stroke survivors have a second stroke within a year.
 But there's reason for hope: Although up to 30 percent of stroke survivors suffer
some permanent disability, more than half recover functional independence
after a stroke.
 Control of risk factors such as hypertension, atrial fibrillation, atherosclerosis,
obesity, and high lipid levels is important to prevent additional strokes.
Rehabilitation is a significant factor in stroke outcomes

64. Rehabilitation
 The sooner the better !
 Consists of medical & nursing
care
 Physical & occupational therapy
 Use of adaptive aids
 Begins in the hospital and
continue at an outpatient clinic
or at home.
One of the most import
factors in successful
recovery is the person’s
own motivation!

65. The goal of a stroke rehabilitation program is to help to
relearn skills that lost when stroke affected part of brain.
Stroke rehabilitation can help to regain independence and
improve the quality of life.
 The severity of stroke complications and each person's
ability to recover lost abilities varies widely. Researchers
have found that the central nervous system is adaptive and
can recover some functions. They also have found that it's
necessary to keep practicing regained skills.

66.  It's common for stroke rehabilitation to start as soon
24 to 48 hours after stroke, during acute hospital stay
 The duration of the stroke rehabilitation depends on
the severity of the stroke and related complications.
Although some stroke survivors recover quickly, most
need some form of stroke rehabilitation long term,
possibly months or years after their stroke.

73. Thank you !