Brain Attack

NR-75D
Diana Diaz RN, MS
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.
History of Stroke
Hippocrates-2,400 yrs ago
Names for Stroke
Most commonly known today
Brain Attack

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

Incidence
3
rd
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
Risk Factors
Non Modifiable
Age
Gender
Race
Heredity
Risk Factors
Modifiable
Obesity
HTN
Smoking
Heavy alcohol
consumption
Hypercoagulability
Hyperlipidemia


Asymptomatic
carotid stenosis
Diabetes mellitus
Heart disease, atrial
fibrillation
Oral contraceptives
Physical inactivity
Sickle cell disease

Review of Cerebral Circulation
Blood supply by arteries
Blood is supplied to the brain by two
major pairs of arteries
Internal carotid arteries
Vertebral arteries

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

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

Brain Attack means:

Blood flow to the brain is
totally interrupted



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.

Common sites for the
development of Atherosclerosis
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




Types of Stroke
Strokes are classified based on the
underlying pathophysiologic findings

Ischemic
Hemorrhagic

Ischemic vs. Hemorrhagic
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

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


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

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
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

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


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

Hemorrhagic Stroke
Intracerebral hemorrhage
Manifestations include neurologic deficits,
headache, nausea, vomiting, decreased
levels of consciousness, and hypertension
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
Clinical Manifestations
Affects many body functions
Motor activity
Elimination
Intellectual function
Spatial-perceptual alterations
Personality
Affect
Sensation
Communication
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
Clinical Manifestations
Motor Function
Most obvious effect of stroke
Include impairment of
Mobility
Respiratory function
Swallowing and speech
Gag reflex
Self-care abilities
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
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
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
Clinical Manifestations
Communication
Dysarthria does not affect the
meaning of communication or the
comprehension of language
It does affect the mechanics of speech
Clinical Manifestations
Affect
Patients who suffer a stroke may have
difficulty controlling their emotions
Emotional responses may be
exaggerated or unpredictable
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
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
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
Clinical Manifestations
Spatial-Perceptual Alterations
3. Inability to recognize an object
by sight, touch, or hearing
4. Inability to carry out learned
sequential movements on
command
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
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
Diagnostic Studies
Additional studies
Complete blood count
Platelets, prothrombin time, activated
partial thromboplastin time
Electrolytes, blood glucose
Renal and hepatic studies
Lipid profile
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
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
Collaborative Care
Prevention
Surgical interventions for the patient
with TIAs from carotid disease include
Carotid endarterectomy
Transluminal angioplasty
Stenting
Extracranial-intracranial bypass
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
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
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
Collaborative Care
Acute Care
Interventions Ongoing
Monitor vital signs and neurologic status
Level of consciousness
Motor and sensory function
Pupil size and reactivity
O
2
saturation
Cardiac rhythm
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
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
Collaborative Care
Acute Care

Surgical interventions for stroke
include immediate evacuation of
Aneurysm-induced hematomas
Cerebellar hematomas (>3 cm)
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
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

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

Nursing Management
Nursing Implementation
Cardiovascular System
Monitoring vital signs frequently
Monitoring cardiac rhythms
Calculating intake and output, noting
imbalances
Regulating IV infusions
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 S
3
or S
4
heart sounds
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
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

Nursing Management
Nursing Implementation
Integumentary System
Pressure relief by position changes,
special mattresses, or wheelchair
cushions
Good skin hygiene
Emollients applied to dry skin
Nursing Management
Nursing Implementation
Integumentary System
Early mobility
Position patient on the weak or paralyzed
side for only 30 minutes
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
Nursing Management
Nursing Implementation
Communication
Nurses 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
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)
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
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

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