1. Brain Attack
NR-75D
Diana Diaz RN, MS

2. Objectives
 Define “stroke”
 Discuss incidence & risk factors
 Review Cerebral flow and factors that
affect it
 Discuss pathophysiology of CVA
 Correlate clinical manifestations of
stroke with the pathophysiology.

3. History of Stroke
 Hippocrates-2,400 yrs ago
 Names for Stroke
 Most commonly known today
 Brain Attack

4. Definition
 Ischemia is inadequate blood flow
 Brain attack (Stroke) occurs when there
is ischemia to a part of the brain that
results in death of brain cells

5. Incidence
 3rd Cause of death in US and Canada
 Statistics
 2/3 in people >65
 = in men and women
 Higher incidence and death rates
among African-Americans, Hispanics,
Native-American, Asian Americans

6. Risk Factors
Non Modifiable
 Age
 Gender
 Race
 Heredity

7. Risk Factors
Modifiable  Asymptomatic
 Obesity carotid stenosis
 HTN  Diabetes mellitus
 Smoking  Heart disease, atrial
 Heavy alcohol
fibrillation
consumption  Oral contraceptives
 Hypercoagulability  Physical inactivity
 Hyperlipidemia  Sickle cell disease

8. Review of Cerebral Circulation

9. Blood supply by arteries
 Blood is supplied to the brain by two
major pairs of arteries
 Internal carotid arteries
 Vertebral arteries

10. Blood supply by arteries
 Carotid arteries branch to supply most
of the
 Frontal, parietal, and temporal lobes
 Basal ganglia
 Part of the diencephalon
 Thalamus
 Hypothalamus

11. Blood supply by arteries
 Vertebral arteries join to form the
basilar artery, which supply the
 Middle and lower temporal lobes
 Occipital lobes
 Cerebellum
 Brainstem
 Part of the diencephalon

12. “Brain Attack” means:
Blood flow to the brain is
totally interrupted

13. Etiology
 Atherosclerosis – Disease of the
arteries; hardening and thickening of
the arterial wall because of soft
deposits of intraarterial fat and fibrin
that harden over time.

14. Common sites for the
development of Atherosclerosis

15. Transient Ischemic Attack
(TIA)
 Transient ischemic attack (TIA) is a
temporary focal loss of neurologic
function caused by ischemia
 Most TIAs resolve within 3 hours
 TIAs are a warning sign of progressive
cerebrovascular disease

16. Types of Stroke
 Strokes are classified based on the
underlying pathophysiologic findings
 Ischemic
 Hemorrhagic

17. Ischemic vs. Hemorrhagic

18. Ischemic Stroke
 Ischemic strokes result from inadequate
blood flow to the brain from partial or
complete occlusion of an artery
 85% of all strokes are ischemic strokes

19. Ischemic Stroke
 Thrombotic or Embolic
Most patients with ischemic
stroke do not have a decreased
level of consciousness in the
first 24 hours
May progress in the first 72
hours

20. Thrombotic stroke
 Thrombosis occurs in relation to injury to a
blood vessel wall and formation of a blood
clot
 Result of thrombosis or narrowing of the
blood vessel
 Most common cause of stroke

21. Embolic stroke
 Occur when an embolus lodges in and
occludes a cerebral artery
 Results in infarction and edema of the area
supplied by the involved vessel
 Second most common cause of stroke

22. Embolic stroke
 Majority of emboli originate in the inside
layer of the heart, with plaque breaking off
from the endocardium and entering the
circulation
 Patient with an embolic stroke commonly
has a rapid occurrence of severe clinical
symptoms

23. Hemorrhagic Stroke
 Account for approximately 15% of all
strokes
 Result from bleeding into the brain
tissue itself or into the subarachnoid
space or ventricles

24. Hemorrhagic Stroke
 Intracerebral hemorrhage
 Bleeding within the brain caused by a
rupture of a vessel
 Hypertension is the most important cause
 Hemorrhage commonly occurs during
periods of activity

25. Hemorrhagic Stroke
 Intracerebral hemorrhage
 Manifestations include neurologic deficits,
headache, nausea, vomiting, decreased
levels of consciousness, and hypertension

26. Hemorrhagic Stroke
 Subarachnoid hemorrhage
 Occurs when there is intracranial bleeding
into cerebrospinal fluid-filled space
between the arachnoid and pia mater
 Commonly caused by rupture of a
cerebral aneurysm

27. Clinical Manifestations
 Affects many body functions
 Motor activity
 Elimination
 Intellectual function
 Spatial-perceptual alterations
 Personality
 Affect
 Sensation
 Communication

28. Clinical Manifestations
 Brain attack
 Term increasingly being used to describe
stroke and communicate urgency of
recognizing stroke symptoms and treating
their onset as a medical emergency

29. Clinical Manifestations
Motor Function
 Most obvious effect of stroke
 Include impairment of
 Mobility
 Respiratory function
 Swallowing and speech
 Gag reflex
 Self-care abilities

30. Clinical Manifestations
Motor Function
 An initial period of flaccidity may last
from days to several weeks and is
related to nerve damage
 Spasticity of the muscles follows the
flaccid stage and is related to
interruption of upper motor neuron
influence

31. Clinical Manifestations
Communication
 Patient may experience aphasia when
a stroke damages the dominant
hemisphere of the brain
 Aphasia is a total loss of
comprehension and use of language

32. Clinical Manifestations
Communication
 Dysphasia refers to difficulty related to
the comprehension or use of language
and is due to partial disruption or loss
 Dysphasia can be classified as
nonfluent or fluent

33. Clinical Manifestations
Communication
 Dysarthria does not affect the
meaning of communication or the
comprehension of language
 It does affect the mechanics of speech

34. Clinical Manifestations
Affect
 Patients who suffer a stroke may have
difficulty controlling their emotions
 Emotional responses may be
exaggerated or unpredictable

35. Clinical Manifestations
Intellectual Function
 Both memory and judgment may be
impaired as a result of stroke
 A left-brain stroke is more likely to
result in memory problems related to
language

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

37. Clinical Manifestations
Spatial-Perceptual Alterations
 Spatial-perceptual problems may be
divided into four categories
1. Incorrect perception of self and
illness
2. Erroneous perception of self in space

38. Clinical Manifestations
Spatial-Perceptual Alterations
1. Inability to recognize an object
by sight, touch, or hearing
2. Inability to carry out learned
sequential movements on
command

39. Clinical Manifestations
Elimination
 Most problems with urinary and bowel
elimination occur initially and are
temporary
 When a stroke affects one hemisphere
of the brain, the prognosis for normal
bladder function is excellent

40. Diagnostic Studies
 When symptoms of a stroke occur,
diagnostic studies are done to
 Confirm that it is a stroke
 Identify the likely cause of the stroke
 CT is the primary diagnostic test used
after a stroke

41. Diagnostic Studies
 Additional studies
 Complete blood count
 Platelets, prothrombin time, activated
partial thromboplastin time
 Electrolytes, blood glucose
 Renal and hepatic studies
 Lipid profile

42. Collaborative Care
Prevention
 Goals of stroke prevention include
 Health management for the well individual
 Education and management of modifiable
risk factors to prevent a stroke

43. Collaborative Care
Prevention
 Antiplatelet drugs are usually the
chosen treatment to prevent further
stroke in patients who have had a TIA
 Aspirin is the most frequently used
antiplatelet drug

44. Collaborative Care
Prevention
 Surgical interventions for the patient
with TIAs from carotid disease include
 Carotid endarterectomy
 Transluminal angioplasty
 Stenting
 Extracranial-intracranial bypass

45. Collaborative Care
Acute Care
 Assessment findings
 Altered level of consciousness
 Weakness, numbness, or paralysis
 Speech or visual disturbances
 Severe headache
 ↑ or ↓ heart rate
 Respiratory distress
 Unequal pupils

46. Collaborative Care
Acute Care
 Interventions – Initial
 Ensure patient airway
 Remove dentures
 Perform pulse oximetry
 Maintain adequate oxygenation
 IV access with normal saline
 Maintain BP according to guidelines

47. Collaborative Care
Acute Care
 Interventions – Initial
 Remove clothing
 Obtain CT scan immediately
 Perform baseline laboratory tests
 Position head midline
 Elevate head of bed 30 degrees if no
symptoms of shock or injury

48. Collaborative Care
Acute Care
 Interventions – Ongoing
 Monitor vital signs and neurologic status
 Level of consciousness
 Motor and sensory function
 Pupil size and reactivity
 O2 saturation
 Cardiac rhythm

49. Collaborative Care
Acute Care
 Recombinant tissue plasminogen
activator (tPA) is used to
 Reestablish blood flow through a blocked
artery to prevent cell death in patients
with acute onset of ischemic stroke
symptoms

50. Collaborative Care
Acute Care
 Thrombolytic therapy given within 3
hours of the onset of symptoms
 ↓ disability
 But at the expense of ↑ in deaths within
the first 7 to 10 days and ↑ in intracranial
hemorrhage

51. Collaborative Care
Acute Care
 Surgical interventions for stroke
include immediate evacuation of
 Aneurysm-induced hematomas
 Cerebellar hematomas (>3 cm)

52. Collaborative Care
Rehabilitation Care
 After the stroke has stabilized for
12-24 hours, collaborative care shifts
from preserving life to lessening
disability and attaining optimal
functioning
 Patient may be transferred to a
rehabilitation unit

53. Nursing Management
Nursing Implementation
 Respiratory System
 Management of the respiratory system is a
nursing priority
 Risk for aspiration pneumonia
 Risks for airway obstruction
 May require endotracheal intubation and
mechanical ventilation

54. Nursing Management
Nursing Implementation
 Neurologic System
 Monitor closely to detect changes
suggesting
 Extension of the stroke
 ↑ ICP
 Vasospasm
 Recovery from stroke symptoms

55. Nursing Management
Nursing Implementation
 Cardiovascular System
 Monitoring vital signs frequently
 Monitoring cardiac rhythms
 Calculating intake and output, noting
imbalances
 Regulating IV infusions

56. Nursing Management
Nursing Implementation
 Cardiovascular System
 Adjusting fluid intake to the individual
needs of the patient
 Monitoring lung sounds for crackles and
rhonchi (pulmonary congestion)
 Monitoring heart sounds for murmurs or
for S3 or S4 heart sounds

57. Nursing Management
Nursing Implementation
 Musculoskeletal System
 Trochanter roll at hip to prevent external
rotation
 Hand cones to prevent hand contractures
 Arm supports with slings and lap boards
to prevent shoulder displacement

58. Nursing Management
Nursing Implementation
 Integumentary System
 Skin of the patient is susceptible to
breakdown related to loss of sensation, ↓
circulation, and immobility
 Compounded by patient age, poor
nutrition, dehydration, edema, and
incontinence

59. Nursing Management
Nursing Implementation
 Integumentary System
 Pressure relief by position changes,
special mattresses, or wheelchair
cushions
 Good skin hygiene
 Emollients applied to dry skin

60. Nursing Management
Nursing Implementation
 Integumentary System
 Early mobility
 Position patient on the weak or paralyzed
side for only 30 minutes

61. Nursing Management
Nursing Implementation
 Gastrointestinal System
 After careful assessment of swallowing,
chewing, gag reflex, and pocketing, oral
feedings can be initiated
 Feedings must be followed by scrupulous
oral hygiene

62. Nursing Management
Nursing Implementation
 Communication
 Nurse’s role in meeting psychologic needs
of the patient is primarily supportive
 Patient is assessed both for the ability to
speak and the ability to understand
 Speak slowly and calmly, using simple
words or sentences

63. Nursing Management
Nursing Implementation
 Sensory-Perceptual Alterations
 Blindness in the same half of each visual
field is a common problem after stroke
 Other visual problems may include diplopia
(double vision), loss of the corneal reflex,
and ptosis (drooping eyelid)

64. Nursing Management
Nursing Implementation
 Ambulatory and Home Care
 The rehabilitation nurse assesses the
patient and family with
 Rehabilitation potential of the patient
 Physical status of all body systems
 Presence of complications caused by the stroke
or other chronic conditions
 Cognitive status of the patient

65. Nursing Management
Nursing Implementation
 Ambulatory and Home Care
 The patient is usually discharged from the
acute care setting to home, an
intermediate or long-term care facility, or a
rehabilitation facility

66. Nursing Management
Nursing Implementation
 Ambulatory and Home Care
 Nurses have an excellent opportunity to
prepare the patient and family for
discharge through
 Education
 Demonstration
 Practice
 Evaluation of self-care skills