CEREBROVASCULAR ACCIDENT (CVA)

DEFINITION

Cerebrovascular accident (CVA) is the medical term for what is commonly termed a
stroke. It refers to the injury to the brain that occurs when flow of blood to brain tissue is
interrupted by a clogged or ruptured artery, causing brain tissue to die because of lack of
nutrients and oxygen.

DESCRIPTION

The severity associated with cerebrovascular accident can best be demonstrated by the following
facts:

CVA is the leading cause of adult disability in the world.

Worldwide, one-quarter of all strokes are fatal.

Two-thirds of strokes occur in people over the age of 65.

Strokes affect men more often than women, although women are more likely to die from
a stroke.

The incidence of strokes among people ages 30 to 60 is less than 1%. This figure triples
by the age of 80.

Stroke Society of the Philippines (SSP) by Artemio A. Roxas Jr., MD (2016). Stroke is a
leading cause of disability and the second leading cause of death in the Philippines. With
an epidemic of unmanaged stroke risk factors and an aging population, we expect to see
more stroke patients.

RISK FACTORS

A Non-Modifiable

1 Age-elderly are more prone due to weaker blood vessels

2 Sex- Males are more prone.

3 Race- - Statistics show that African-Americans have a much higher risk of death from a
stroke than Caucasians do. This is partly because blacks have higher risks of high blood
pressure, diabetes and obesity

B Partially Modifiable
 1 Hypertension- during this case the blood vessel will narrow causing to decreased
blood circulation

2 Diabetes Mellitus-there is sluggish circulation leading to a slower movement of

blood resulting to the decreased supply of blood in the brain

3 Cardiac Impairments-there will be decreased cardiac output resulting to decreased

blood supply in the brain

4 Blood Lipid Abnormalities- Large amounts of cholesterol in the blood can build up and
cause blood clots, leading to a stroke

C Modifiable

1 Smoking- When you smoke, you inhale tobacco smoke, which contains over
7,000 toxic chemicals including carbon monoxide, formaldehyde and hydrogen
cyanide. These chemicals are transferred from your lungs into your bloodstream,
changing and damaging cells all around your body. The carbon monoxide you
inhale from cigarette smoke increases levels in your blood, making it more likely
for artery walls to become damaged. The chemicals you inhale also affect the
stickiness of your blood and production of a type of blood cell called a platelet.
This increases your bloods tendency to form clots. These factors increase
smokers risk of developing atherosclerosis whereby arteries become more narrow
and furred up. This reduces the blood flow through them so blood clots are more
likely to form. If a clot forms in an artery leading to the brain, it can then cause a
blockage, cutting off the blood supply and causing a stroke.

2 Obesity- individuals with higher degrees of obesity tended to have higher blood
pressure levels, diabetes prevalence, and higher cholesterol, which are all risk
factors for stroke

3 Stress- our bodies react by releasing stress hormones (adrenaline and cortisol) into
the blood. These hormones prepare the body for the fight or flight response by
making the heart beat faster and constricting blood vessels to get more blood to
the core of the body instead of the extremities.

4 Diet-increased fat intake, decreased fruit and vegetables

5 Use of oral contraceptives- it contains estrogen that increases the clotting factor
that can cause ischemic stroke.

CAUSES

1. Thrombosis
 - It is the formation of blood clot in the blood vessels and it is the most frequent
cause of CVA

- Most common cause: atherosclerosis

- It is common among patients with DM and HPN

- Onset of manifestation is gradual

2. Embolism

- It is the obstruction of blood vessel by a foreign substance or a blood clot

(embolus)

- Most frequently caused by RHD or MI

- Second most common cause of CVA

3. Intracranial Hemorrhage

- It involves interruption in the integrity of the blood vessels supplying the brain

- May be related to HPN, rupture of aneurysm, subarachnoid haemorrhage and A-V

malformation

TYPES

1. Ischemic Stroke

- refers to the loss of oxygen and nutrients for brain cells that occurs because the
blood supply to a portion of the brain has been cut off. It is caused by a blocked
blood vessel that supplies blood to the brain.

- account for approximately 80% of all strokes

a) Thrombotic strokes (Cerebral Thrombosis)

- can be seen in nearly all aging populations worldwide. . As people grow older,
atherosclerosis, or hardening of the arteries, occurs. This result in a build-up
of a waxy, cholesterol-laden substance in the arteries, which eventually
 narrows the interior space, or lumen, of the artery. This arterial narrowing
occurs in all parts of the body, including the brain. As the process continues,
the occlusion, or shutting off, of the artery eventually becomes complete so
that no blood supply can pass through. Usually the occurrence of the
symptoms of a thrombotic stroke are much more gradual and less dramatic
than other strokes due to the slow, ongoing process that produces it.

e.g Transient ischemic attacks (TIAs) is usually the least serious. TIAs represent the
occlusion of a very small artery, or arteriole. This blockage affects only a small
portion of brain tissue and does not leave noticeable permanent ill effects. These
transient ischemic attacks last only a matter of minutes, but are a forewarning that
part of the brain is not receiving its necessary supply of blood, and, consequently,
an insufficient amount of oxygen and nutrients.

b) Embolic strokes (Cerebral Embolus)

- are usually a more spectacular, emergency event.

- They take place when the heart's rhythm is changed for a number of reasons,
and blood clot formation takes place. Such a blood clot can move through the
circulatory system until it blocks a blood vessel and stops the blood supply to
cells in a specific portion of the body. If the blood clot occludes an artery that
nourishes heart muscle, it causes myocardial infarction, or heart attack. If it
blocks off a vessel that feeds brain tissue, it is termed an embolic stroke.
Normally, these blockages occur in the brain itself, as when arteries directly
feeding portions of brain tissue are blocked by a clot. But occasionally, the
obstruction is found in the arteries of the neck, especially the carotid artery.

2. Hemorrhagic strokes

- Occurs in 20% of all patient

- occur when an artery to the brain has a weakness and balloons outward, producing
an aneurysm. Such an aneurysm often ruptures due to this inflation and thinning
of the arterial wall, causing a hemorrhage in the affected portion of the brain.

Left Hemisphere Stroke Right Hemisphere Stroke

paralysis or weakness on the right side paralysis or weakness on the left side of
of the body the body
 right visual field deficit Left visual field deficit

aphasia Spatial perceptual deficit

altered intellectual ability Increased distractibility

slow, cautious behaviour Impulsive behaviour and poor

judgement

Lack of awareness of deficits

CLINICAL MANIFESTATIONS

CVA can cause a wide variety of neurologic deficits depending on the location of the
lesion/damage, the size of the area of inadequate perfusion and the amount of collateral blood
flow. The patient may present with any of the following signs and symptoms:

- Numbness or weakness of the face, arm, or leg especially on one side of the body

- Confusion or change in mental status

- Slurred speech. Sometimes weakness in the muscles of the face can cause drooling.

- Sudden trouble seeing in one or both eyes

- Visual disturbances

- Difficulty walking, dizziness, or loss of balance or coordination

- Sudden severe headache

Motor loss
Since the upper motor neurons decussate, a disturbance of the voluntary motor control on
one side of the body may reflect damage to the upper motor neurons on the opposite side of the
brain.

Perceptual disturbances
 Visual-perceptual dysfunctions are due to disturbances of the primary sensory pathways
between the eye and visual cortex.

Sensory loss
The sensory loss from stroke may take the form o f slight impairment of touch or maybe
more severe, with loss of proprioception as well as difficulty in interpreting visual, tactile, and
auditory stimuli.

Cognitive impairment & Psychological effects

If damage has occurred to the frontal lobe, learning capacity, memory, or other higher
cortical intellectual functions may be impaired. Such dysfunctions may be reflected in a limited
attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.

CVA SITE SIGNS AND SYMPTOMS

Posterior cerebral artery
Vertebral or basilar artery
Internal carotid artery
Middle cerebral artery
Visual field deficits, sensory impairments; reading difficulty
(dyslexia); coma;
cortical blindness resulting from ischemia in the occipital
area; paralysis
(rarely)
Numbness around the lips and mouth; dizziness; weakness on
the affected
side; vision deficits (color blindness; lack of depth perception;
double
vision [diplopia]); poor coordination; difficulty swallowing
(dysphagia);
slurred speech; amnesia; staggering gait (ataxia)
Headache; weakness; paralysis; numbness; sensory changes;
vision
disturbances (blurring on the affected side or blindness);
altered level
of consciousness; bruits over the carotid artery; defective
language
function (aphasia); speech impairment (dysphasia); eyelid
drooping
(ptosis)
Defective language function (aphasia); speech impairment
 (dysphasia);
reading difficulty (dyslexia); visual field deficits; hemiparesis
on the
affected side (more severe in the face and arm than in the leg)

Face-arm-speech test (FAST)

The Stroke Association says three simple checks that can help recognize whether someone has
had a stroke or mini-stroke.

Facial weakness: can the person smile? Has the mouth or eye drooped?

Arm weakness: can the person raise both arms?

Speech problems: can the person speak clearly and understand you?

Test these symptoms.

DIAGNOSIS

1. Complete neurological examination.

2. Computed tomography (CT) scan or magnetic resonance imaging (MRI) scan is

performed to distinguish a stroke caused by blood clot from one caused by hemorrhage, a
critical distinction that guides therapy. Blood and urine tests are done routinely to look
for possible abnormalities associated with ischemic activity within the body.

3. Electrocardiogram (EKG), angiography, and lumbar puncture are all used to rule out
any other possible causes of the symptoms.

MANAGEMENT

Immediate Treatment

- If a blood clot is the cause, 'clot busting' medication may be used to dissolve the
clot, but this must be given within three hours of the stroke. Anti-clotting
medication such as aspirin may also be given to stop the stroke from getting
worse.

- Anti-clotting medication is not given in strokes caused by haemorrhaging because

it will make the bleeding worse.
 - Emergency treatment of hemorrhagic stroke is aimed at controlling intracranial
pressure. Intravenous urea, or mannitol, plus hyperventilation are the most
common treatment. Corticosteroids may also be used. Patients with bleeding
disorders such as those due to anti- coagulant treatment should have these
disorders reversed, if possible.

1. Medical

Preventive Medications:

a. Anticoagulants- used for acute monitoring/ progressing ischemic/embolic stroke;

prevent progression of TIA

b. Anti-platelet drugs- main-stay drug for CVA

c. Vasodilators/ Anti-hypertensive drugs

d. Clot-busting drugs (thrombolytic therapy) - This medicine breaks up blood clots and
helps bring back blood flow to the damaged area.

2. Surgical

For ischemic stroke:

a. Angioplasty- may be accomplished through carotid stenting; used for patients who are
not good candidates of open surgey
b. Catheter Embolectomy- emergency removal of the emboli which are blocking the
circulation
c. Carotid Endarterectomy-careful removal of a plaque after the artery has been clamped
both and above obstruction.

For hemorrhagic stroke:

a. Aneurysm Clipping- performed to treat a balloon-like bulge of an artery wall known as

an aneurysm.

b. Coiling (Aneurysm Embolization)

3. Nursing Interventions

a. ACUTE PHASE (1st 72 hours)

1. Maintain a patent airway by oxygen therapy, positioning, suctioning as indicated.

2. Monitor vital signs.

3. Monitor for increasing ICP because the client is at most risk during this phase.

4. Position client on bed with head of the bed elevated at 15-30 degrees or as prescribed.

5. Monitor LOC, papillary response, motor and sensory response, cranial nerves and reflexes.

6. Maintain a quiet environment and provide minimal handling of client.

7. Monitor I and O.

8. Establish a form of communication.

b. POST-ACUTE PHASE (after 72 hours)

1. Continue interventions during the acute phase.

2. Position the client on the unaffected side for 2 hours and on the affected side for 20 mins. As
indicated.

3. Position patient in prone position 30 minutes 3x a day to prevent hip contractures.

4. Provide skin and mouth care.

5. Perform passive ROM exercises to prevent contractures.

6. Measure thighs and calves for increase in size and assess for (+) Homans sign.

7. Monitor or check for gag reflex.

8. Provide sips of fluid and slowly advance to soft diet as ordered.

c. CHRONIC PHASE

1. Neglect Syndrome

-teach the client to touch the affected side every now and then

-when positioning or transferring, place wheelchair on the unaffected side

2. Homonymous Hemianopsia
-encourage client to turn head to scan the complete range of visual field.

3. Contractures

-use footboard during the flaccid period following a stroke to keep the feet dorsiflexed, thus
preventing footdrop and plantar flexion

-to prevent external rotation of the hip joint, apply a trochanter roll from the iliac crest to the
midthighs.

-to prevent abnormal adduction of the affected shoulder, place a pillow under the axilla to keep
the arm away from the chest

-to prevent knee and hip flexion contractures, position the client in prone position 15-30 minutes,
2-3x a day.

MANAGEMENT:

1 Maintain Cerebral Oxygenation and Restore Cerebral Blood Flow

a Maintain patent airway and turn patient to side if unconscious to promote
drainage of saliva. The collar of the shirt should be loosened to facilitate venous
return.
b Elevate head and neck should not be flexed.
c Hypertension may be reduced with vasodilators and calcium channel blockers.
Caution is exercised when treating blood pressure because lowering blood
pressure too far may lower cerebral perfusion and increase cerebral ischemia.
d If the client demonstrates poor ventilator effort, intubation and mechanical
ventilation may be required to prevent hypoxia and increased cerebral ischemia.
e Thrombolytic agents are given. The goal of the therapy is recanalization of the
occluded vessel and reperfusion of ischemic brain tissue. This agents are
exogenous plasminogen activators, which dissolves the thrombus or embolus
blocking the cerebral blood flow.
2 Prevent complications
a After administration of thrombolytic agents. The client is monitored for potential
complications such as systemic bleeding and increased intracranial haemorrhage.
 b To decrease the risk, administration of anticoagulant and antiplatelet medications
is not recommended until 24 hours after administration of thrombolytic agents.
Instead, thrombolytic therapy should be stopped and Fresh frozen plasma with
fibrinogen or cryoprecipitate is administered to prevent coagulopathies.
3 Cerebral Edema
a Increased ICP is also a complication of intracerebral haemorrhage. All patients
are placed on bed rest and with the head of the bed elevated to 30 degrees to
facilitate venous drainage.
b External ventriculostomy drainage is sometimes used to reduce pressure from
cerebrospinal fluid accumulation. A burr hole is placed through the skull, and a
catheter is passed into the lateral ventricle to allow for controlled drainage of CSF.
4 Anticoagulant and antiplatelet
a Heparin is indicated to prevent stroke recurrence in clients at risk for cardiogenic
emboli.
b Initially, unfractionated heparin, dose based on body weight, is administered
intravenously, and then warfarin is administered orally.
c After a therapeutic anticoagulant level has been achieved with heparin therapy,
warfarin administration is begun because warfarin has a long half-life, the
physician initiates the warfarin therapy while the client is still receiving
intravenous heparin.
d Antiplatelet agents inhibit platelet function to decrease the risk of thrombus
formation. The selection of the specific antiplatelet agent is individualized
according to the clients medical history.
5 Aspiration
a Aspiration is most common in the early period and is related to loss of pharyngeal
sensation, loss of oropharyngeal motor and decreased LOC.
b If the client cannot eat or drink, alternate feeding routes are used such as
tube0feeding or hyperalimentation.
c When swallowing mechanism has returned, the client can be fed orally.
6 Hyperthermia
 a Temperature elevations lead to increased cerebral metabolic needs
which in turn cause cerebral edema which can lead to further ischemia
b Causing the client to shiver should be avoided because shivering increases
oxygen consumption and increases ICP.
c If seizures, develop anticonvulsant may be used.
7 Occupational therapy
a Help client relearn ADLs and to use assistive devices that promote independence
such as using clothes with self-fastening tape (Velcro) fasteners rather than
buttons.
8 Physical therapy
a Teach client how to use the wheelchair and promote walking with assistance such
as quad cane.
9 Speech therapy
a Speak at a slower rate
b Give client time to respond
c Do not shout and always put client at ease
d Repeat simple directions until they are understood
e Give client practice in repeating words after you
f The family should not do all the talking for the client
g Provide emotional support and health education to the client and family.

GADGETS:

1. Mechanical-ventilator

- A mechanical ventilator is a machine that makes it easier for patients to breathe until they
are able to breathe completely on their own. Sometimes the machine is called just a
ventilator, respirator or breathing machine. Usually, a patient is connected to the
ventilator through a tube (called an endotracheal tube) that is placed in the windpipe.
Sometimes, patients can use a machine that assists breathing through a mask or
mouthpiece but this may not work with severe respiratory problems. Despite their life-
saving benefits, mechanical ventilators carry many risks. Therefore, the goal is to help
patients recover as quickly as possible to get them off the ventilator at the earliest
possible time.
2. Defibrillator

- Is the definitive treatment for the life-threatening cardiac arrhythmias, ventricular

fibrillation and pulseless ventricular tachycardia. It depolarizes a critical mass of the heart
muscle, terminates the arrhythmia, and allows normal sinus rhythm to be reestablished by
the body's natural pacemaker, in the sinoatrial node of the heart.

3. ECG machine

- Is a transthoracic (across the thorax or chest) interpretation of the electrical activity of

the heart over a period of time, as detected by electrodes attached to the outer surface of
the skin and recorded by a device external to the body. An ECG test records the electrical
activity of the heart. It is used to measure the rate and regularity of heartbeats, as well as
the size and position of the chambers, the presence of any damage to the heart, and the
effects of drugs or devices used to regulate the heart, such as a pacemaker.

4. pulse oximetry

- It monitors the level of oxygen in a patient's blood and alert the health-care worker if
oxygen levels drop below safe levels, allowing rapid intervention. These devices are
essential in any setting in which a patient's blood oxygen levels requires monitoring like
operations, emergency and intensive care, and treatment and recovery in hospital wards.

5. Suction machine

- A portable suction apparatus used in wards and theatres for aspirating fluids and vomit
from the mouth and airways, and from operation sites by sucking the material through a
catheter into a bottle. The term could also apply to devices which operate from piped
vacuum supplies or bottle gas cylinders but is more commonly used to mean electric
suction units which contain a vacuum pump (piston, diaphragm, or rotary vane),
bacterial filter, vacuum gauge, trap for moisture (or any debris accidentally drawn into
the mechanism), a reservoir for the aspirated material, and a suction catheter or nozzle

6. Oxygenation treatment

- Oxygenation treatment administered through a nasal cannula, mask, chamber or tent, is

aimed at supplying huge concentrations of oxygen to the body. This is done to thwart
hypoxemia, in which the body malfunctions due to insufficient oxygen supply in the
blood.

7. Endotracheal Tube (ET Tube)

- Often, people with head injuries are not as awake as usual. This can mean they may need help
to breathe. If your loved one needs this help, a tube will be placed into the mouth or nose and
then into the trachea (wind pipe). The tube attaches to the ventilator (see below for more on
ventilators). The ET tube passes through the vocal cords, so your loved one will not be able
to talk until the tube is removed.

8. Foley Catheter

- This is a flexible rubber tube (catheter) placed into the bladder to drain urine. This helps us to
measure the amount of urine coming out.

9. Intracranial Pressure Monitor (ICP monitor)

- This is a small pressure sensor that is placed surgically beneath the skull. It attaches to the
ICP monitor at the top of the bed. It allows staff to continuously watch the ICP.

10. Intravenous Line (IV)

- IV lines allow access to veins for fluids and medications. We will try to place the IVs in sites
that might be more comfortable for the patient. We will need to avoid tough or fragile veins
though.

11. Monitor

- The monitor is a machine at the side or head of the bed. It helps to watch the heart rate and
rhythm. It also gives readings of blood pressure, respirations, and heart and lung pressures
when needed.
 Mariano Marcos State University
COLLEGE OF HEALTH SCIENCES
Department of Nursing

____________________________________________________________________________
In Partial Fulfillment
Of the Requirements in the Subject
NSG 163

_____________________________________________________
CEREBROVASCULAR ACCIDENT
_____________________________________________________

Presented by:
 CID, JEROME CLARK C.
TUNGPALAN, JOSHUA S.
NALUNDASAN, ARNEEH MAE B.
SORIANO, JENNY ANNE LOREIN B.

Presented to:

DR. ELMER SANTOS

____________________________________________________
April 2017