Nursing Care of Adult II

(NURS 316)

Cerebral Vascular Stroke

Spring 2024-2025
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Learning objectives
At the end of this lecture, each student will be able to:
Describe the incidence and impact of cerebrovascular disorders.

Describe the causes, clinical manifestations, and medical management

cerebrovascular disorder and preventive measures.
Apply the nursing process as a framework for care of the multiple needs of the
patient with cerebrovascular disorder.
Compare the various types of cerebrovascular disorders.

Discuss essential elements for family education and preparation for home care of
the patient who has had a stroke 2
Outlines
• Definition
• Causes
• Clinical manifestations,
• Medical management
• Preventive measures
• Types of cerebrovascular disorders
• Nursing process of cerebrovascular disorders
• Family education at home
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Medical Terminology
• Apraxia: inability to perform previously learned purposeful motor acts on
a voluntary basis
• Dysarthria: defects of articulation due to neurologic causes
• Dysphagia: difficulty swallowing
• Expressive aphasia: inability to express oneself; often associated with
damage to the left frontal lobe area
• Hemianopsia: blindness of half of the field of vision in one or both eyes
• Hemiparesis: weakness of one side of the body, or part of it, due to an
injury in the motor area of the brain
• Hemiplegia: paralysis of one side of the body, or part of it, due to an
injury in the motor area of the brain
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Cerebrovascular Disorders
• Cerebral vascular stroke is umbrella which refers to
functional abnormality of the CNS that occurs when the
blood supply is disrupted.

• The pooled annual incidence of stroke in Saudi Arabia

was 0.029% (95% CI: 0.015 to 0.047) equivalent of 29
strokes per 100,000 people annually (95% CI: 15 to
47). Conclusion: The findings indicate that there are 29
stroke cases for every 100,000 people annually for
individuals residing Saudi Arabia.
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Major types of stroke
• Stroke (Brain attack): Sudden loss of function resulting
from a disruption of the blood supply to a part of the brain.

• Ischemic stroke: it is a result of obstruction of blood flow by

thrombosis or embolism (Ischemic 80%–85%).

• Hemorrhage stroke: it results from extravasation of

blood into the brain tissue or subarachnoid space
(Hemorrhagic 15%–20%). 6
Comparison of types of stroke

Item Ischemic (Brain attack) Hemorrhagic

Causes Large artery thrombosis Intracerebral hemorrhage
Small penetrating artery Subarachnoid hemorrhage
thrombosis Cerebral aneurysm
Cardiogenic embolism Arteriovenous malformation
Cryptogenic (Unknown cause)
Other
Main presenting Numbness or weakness of the face, Exploding headache
symptoms arm or leg especially on one side Decreased LOC
Functional Usually plateaus at 6 months Usually plateaus at 18 months
recovery
Treatment thrombolytic therapy within 3 to
4.5 hours after the onset of a
stroke
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Ischemic Stroke

• Sub-Types
• Large artery thrombosis (20%): (atherosclerotic plaques in
the large vessels of the brain)
• Small penetrating artery thrombosis the most common
stroke (25%). It called lacunar stroke because cavity is
created after infraction.
• Cardiogenic embolism (20%): emboli originated from heart
as caused by cardiac dysrhythmias, atrial fibrillation. The
common site is left middle cerebral artery.
• Cryptogenic (30%)
Unknown cause but it may caused by migraine
• Other (5%) or coagulopathies 8
Pathophysiology
• Thrombosis obstruction of blood flow decrease blood
supply to the brain formation of ischemic cascade
cellular events occurs when less than 25mL/ 100g blood/ min.
• Alteration of aerobic respiration and switch to anaerobic
respiration caused to changes of pH and electrolytes imbalance.
• Aerobic respiration used oxygen to produce energy ATP
(adenosine triphosphate) and product CO2 & H2CO3.
• Penumbra region: area low of cerebral blood flow. It is
ischemic brain tissue that may be recovered with timely
intervention.
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Manifestations of Ischemic Stroke
• Symptoms depend on the location and size of the
affected area
• Numbness or weakness of face, arm, or leg,
especially on one side
• Confusion or change in mental status
• Trouble speaking or understanding speech
• Difficulty in walking, dizziness, or loss of balance
or coordination
• Sudden, severe headache
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Clinical Manifestations- Motor loss
• Loss of voluntary movement as result of damage the
opposite side.

• Hemiplegia, Hemiparesis

• Ataxia (unable to keep feet together, needs a broad base to

stand), (staggering unsteady gait)

• Dysphagia
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Clinical Manifestations- Communication Loss
• Dysarthria: Difficulty in forming words

• Dysphasia: impaired speech

• Aphasia: Loss of speech. Expressive or Receptive

• Global: mixed aphasia: it is combination of both receptive and

expressive.

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 Clinical Manifestations- Perceptual
disturbance
• Homonymous hemianopsia: loss of the half visual field (unaware
of person or object on the affected side, difficulty judging
distances)

• Diplopia: Double vision

• loss of peripheral vision: difficulty seeing at night, unaware of

object or the boarder of object.
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 Clinical Manifestations- Sensory Loss
• It takes the form of slight impairment of the touch.

• Paresthesia occurs on the side opposite site the lesion

(numbness and tingling of extremity)

• Agnosias: inability to recognize familiar objects

perceived by one or more the senses
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 Clinical Manifestations- Cognitive &
emotional deficits
• Short & long term memory loss (Amnesia)
• Decreased attention span
• Impaired ability to concentrate
• Altered judgment
• Loss of self control
• Depression, withdrawal, feeling of isolation
• Decreased tolerance to stressful situation.
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 Question
What is agnosia?
A. Failure to recognize familiar objects perceived by the senses
B. Inability to express oneself or to understand language
C. Inability to perform previously learned purposeful motor acts
on a voluntary basis
D. Impaired ability to coordinate movement, often seen as a
staggering gait or postural imbalance

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Left & Right hemispheric stroke

Left Right
Paralysis or weakness on right side Paralysis or weakness on left side of
of body. body.
Right visual field deficit Left visual field deficit
Aphasia (expressive, receptive or Spatial-perceptual deficits
global) Impulsive behavior and poor
Altered intellectual ability judgment
Slow, cautious Lack of awareness

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Transient Ischemic Attack (TIA)
• Temporary neurologic deficit resulting from a temporary
impairment of blood flow

• “Warning of an impending stroke”

• Diagnostic workup is required to treat and prevent

irreversible deficits
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Diagnostic finding
• Non-contrast computed tomography is the first and
accurate diagnostic is done to determine the crises
ischemic or hemorrhagic.

• ECG to determine the source of emboli

• MRI, MR angiography.

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Prevention
• Non-modifiable risk factors
• Age (older than 55 years), male gender, African Americans
• Modifiable risk factors
• Hypertension is the primary risk factor
• Cardiovascular disease
• Elevated cholesterol or elevated hematocrit
• Obesity & Diet (low fat diet, low in animals protein)
• Diabetes
• Oral contraceptive use
• Smoking and drug and alcohol abuse

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Treatment
• Health maintenance measures including a healthy diet, exercise,
and the prevention and treatment of periodontal disease
• Carotid endarterectomy: removal of thrombus to prevent
occlusion.
• Anticoagulant therapy
• Antiplatelet therapy: aspirin, dipyridamole plus aspirin
(Aggrenox), clopidogrel (Plavix)
• “Statins” (simvastatin (Zocor), to include 2nd stroke prevention
recommended by FDA)
• Antihypertensive medications
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 Medical Management: Acute Phase of Stroke
• Assessment of stroke: NIHSS assessment tool
• Thrombolytic therapy (intra-arterial t-PA: Tissue plasminogen
activator)
• IV dosage and administration
• Patient monitoring
• Side effects: potential bleeding
• Elevate head of bed (HOB) unless contraindicated
• Maintain airway and ventilation
• Continuous hemodynamic monitoring and neurologic assessment
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 NIHSS
assessme
nt tool

Elevate extremity to 90
degrees and score drift/
movement

Elevate extremity to 30
degrees and score drift/
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movement
NIHSS assessment tool

NIHSS
assessme
nt tool

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Criteria for t-PA Administration

• Age 18 years or older

• Time onset of stroke known and 3 hours or less
• Blood pressure ≤185/110 mmHg
• No seizure at onset of stroke
• Not taking of warfarin
• Prothrombin time (PT) ≤ 15 Sec or INR ≤ 1.7
• Not receiving heparin during the past 48 hours with elevated partial
thromboplastin time
• Platelate: ≥100,000/ mm3
• No major surgical procedure within 14 day.
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Dosage and Administration of t-PA
• Two or more IV sites are established prior to administration
• The dosage for t-PA is 0.9 mg/kg, with a maximum dose of 90 mg.
• Ten percent of the calculated dose is given as an IV bolus over 1 minute
• The remaining dose (90%) is given IV over 1 hour via an infusion pump
• Standard protocol would be to measure vital signs every 15 minutes
for the first 2 hours, every 30 minutes for the next 6 hours, then every
hour until 24 hours after treatment
• Blood pressure should be maintained with the systolic pressure less than
180 mm Hg and the diastolic pressure less than 105 mm Hg

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Nursing Process: Ischemic Stroke—Assessment
• Acute phase
• Ongoing, frequent monitoring of all systems, including vital signs
and neurologic assessment—LOC, motor symptoms, speech, eye
symptoms
• Monitor for potential complications, including musculoskeletal
problems, swallowing difficulties, respiratory problems, and signs
and symptoms of increased ICP and meningeal irritation
• After the stroke is complete
• Focus on patient function; self-care ability, coping, and education
regarding needs to facilitate rehabilitation

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Nursing Process: Ischemic Stroke—Diagnoses
• Impaired physical mobility • Disturbed thought processes
• Acute pain • Impaired verbal
• Self-care deficits communication
• Disturbed sensory • Risk for impaired skin
perception integrity
• Impaired swallowing • Interrupted family processes
• Urinary incontinence • Sexual dysfunction

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Nursing Process: Ischemic Stroke—Planning
• Major goals may include • Major goals may include
• Improved mobility • Achieving a form of
• Avoidance of shoulder pain communication
• Achievement of self-care • Maintaining skin integrity
• Relief of sensory and • Restored family
perceptual deprivation
functioning
• Prevention of aspiration
• Improved sexual function
• Continence of bowel and
bladder • Absence of complications
• Improved thought processes 29
 Nursing Process: Ischemic Stroke-
Interventions

• Focus on the whole person

• Provide interventions to prevent complications and

promote rehabilitation

• Provide support and encouragement

• Listen to the patient 30

Nursing Process: Ischemic Stroke- Interventions

Improving Mobility and Preventing Joint

Deformities
• Turn and position in correct alignment every 2 hours
• Use of splints
• Passive or active ROM four or five times day
• Positioning of hands and fingers
• Prevention of flexion contractures
• Do not lift by flaccid shoulder
Positioning to Prevent Shoulder Abduction
• Measures to prevent and treat shoulder problems
(shoulder abduction)
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Nursing Process: Ischemic Stroke- Interventions
Improving Mobility and Preventing Joint Deformities

• Encourage patient to exercise unaffected side

• Establish regular exercise routine
• Quadriceps setting and gluteal exercises
• Assist patient out of bed as soon as possible;
assess and help patient achieve balance; move Prone Positioning to Help
Prevent Hip Flexion
slowly
• Ambulation training
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Nursing Process: Ischemic Stroke- Interventions
• Enhancing self-care
• Set realistic goals with the patient
• Encourage personal hygiene
• Ensure that patient does not neglect the affected side
• Use of assistive devices and modification of clothing
• Support and encouragement
• Strategies to enhance communication
• Encourage patient to turn head, look to side with visual field
loss
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Nursing Process: Ischemic Stroke- Interventions
• Nutrition
• Consult with speech therapy or nutritional services
• Have patient sit upright, preferably out of bed, to eat
• Chin tuck or swallowing method
• Use of thickened liquids or pureed diet
• Bowel and bladder control
• Assessment of voiding and scheduled voiding
• Measures to prevent constipation: fiber, fluid, toileting schedule
• Bowel and bladder retraining
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 Question
What intervention would not be included in aspiration precautions for a
patient in the acute phase of a stroke?
A. Referral to speech therapy
B. Have patient tuck their chin toward the chest when swallowing
C. Thickened fluids or pureed diet
D. Raise HOB to 30 degrees when feeding

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Collaborative Problems- Potential Complications, Ischemic Stroke

• Decreased cerebral blood flow

• Inadequate oxygen delivery to brain

• Pneumonia

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Hemorrhagic Stroke
• Caused by bleeding into brain tissue, the ventricles, or subarachnoid space
• May be caused by spontaneous rupture of small vessels primarily related to
hypertension;
• Subarachnoid hemorrhage caused by a ruptured aneurysm;
• Intracerebral hemorrhage related to amyloid angiopathy, arterial venous
malformations (AVMs), intracranial aneurysms, or medications such as
anticoagulants
• Brain metabolism is disrupted by exposure to blood.
• ICP increases caused by blood in the subarachnoid space.
• Compression or secondary ischemia from reduced perfusion and
vasoconstriction causes injury to brain tissue 37
Pathophysiology- Hemorrhagic Stroke
It depends on the cause and type of cerebral disorders.
• Intracerebral hemorrhage: it result from certain type of arterial
pathology (brain tumor, medication). It occurs in cerebral lobes, thalamus,
brain stem, basal ganglia and cerebellum.
• Intracranial (cerebral) aneurysm is the dilation of the wall of a cerebral
artery which result weakness of the arterial wall. It occurs anywhere. The
cause is unknown.
• Arteriovenous malformations: it occurs in the embryonal development.
It is the common cause of hemorrhage in the young people.

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Manifestations- Hemorrhagic Stroke
• Similar to ischemic stroke

• Severe headache

• Early and sudden changes in LOC

• Vomiting

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Complication- Hemorrhagic Stroke

• Cerebral hypoxia and decreased blood flow: Adequate

hydration reduced viscosity and improved blood flow.
Administering oxygen assists in maintaining tissue oxygenation.
Hypertension and hypotension must be avoided to prevent
extent the area of injury.

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Complication- Hemorrhagic Stroke
• Vasospasm: it is the leading cause of morbidity and mortality from hemorrhagic stroke.
It is narrowing of the cranial vessels lumen. It is monitored through transcranial
Doppler ultrasonography or cerebral angiography.

• It is occurred 3 to 14 days after initial hemorrhage.

• The warning signs are worsening headache, decrease LOC (disorientation, lethargy and
confusion).

• Endovascular technique (administer medication by stent) may be used to occlude the

artery supplying the aneurysm with balloon. Calcium channel blocker may be used to
prevent caution action
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 Complication- Hemorrhagic Stroke

• Increased intracranial pressure: it is occurred after ischemic also.

Neurological assessment is performed frequently. It is treated by mannitol
so dehydration and electrolyte imbalance may happen.

• Hypertension: it is controlled to prevent further bleeding and cerebral

hematoma. It is controlled through antihypertensive (nicardipine,
hydralazine).

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Medical Management- Hemorrhagic Stroke
• Preventive measures: control of hypertension, prevent DVT through sequential
compression device.

• Diagnosis: CT scan, cerebral angiography, lumbar puncture if CT is negative

and ICP is not elevated to confirm subarachnoid hemorrhage

• Care is primarily supportive

• Bed rest with sedation (analgesic to control headache and neck pain)

• Oxygen

• Treatment of vasospasm, increased ICP, hypertension, potential seizures, and

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prevention of further bleeding
Surgical treatment- Hemorrhagic Stroke
• Craniotomy is recommended to
evacuate the cerebral hemorrhage
and relieve compromise pressure.
The goal of surgery is to prevent
bleeding from an un-ruptured
aneurysm or further bleeding from
a ruptured one. 44
 Nursing Process: Hemorrhagic Stroke—Assessment

• Complete and ongoing neurologic assessment; use neurologic flow chart

• Monitor respiratory status and oxygenation
• Monitoring of ICP
• Patients with intracerebral or subarachnoid hemorrhage should be
monitored in the ICU
• Monitor for potential complications
• Monitor fluid balance and laboratory data
• All changes must be reported immediately

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Nursing Process: Hemorrhagic Stroke: Diagnoses

• Ineffective tissue perfusion (cerebral)

• Disturbed sensory perception
• Anxiety

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 Nursing Process: Hemorrhagic Stroke:
Planning

• Goals may include:

• Improved cerebral tissue perfusion
• Relief of sensory and perceptual deprivation
• Relief of anxiety
• The absence of complications

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 Nursing Process: Hemorrhagic Stroke—
Intervention
Aneurysm Precautions

• Absolute bed rest

• Elevate HOB 30 degrees to promote venous drainage or flat to increase cerebral
perfusion
• Avoid all activity that may increase ICP or BP; Valsalva maneuver, acute flexion,
or rotation of neck or head
• Exhale through the mouth when voiding or defecating to decrease strain
• Nurse provides all personal care and hygiene
• Non-stimulating, non-stressful environment; dim lighting, no reading, no TV, no
radio
• Prevent constipation 48
 Nursing Process: Hemorrhagic Stroke—
Intervention
• Relieving sensory deprivation and anxiety
• Keep sensory stimulation to a minimum for aneurysm
precautions
• Realty orientation
• Patient and family education
• Support and reassurance
• Seizure precautions
• Strategies to regain and promote self-care and rehabilitation
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 Home Care and Education for the Patient
Recovering from a Stroke
• Prevention of and signs and symptoms of complications

• Medication education

• Safety measures

• Adaptive strategies and use of assistive devices for ADLs

• Nutrition: diet, swallowing techniques, tube feeding administration

• Elimination: bowel and bladder programs, catheter use

• Exercise and activities, recreation and diversion

• Socialization, support groups, and community resources 50

Collaborative Problems and Potential Complications

• Vasospasm

• Seizures

• Hydrocephalus

• Re-bleeding

• Hyponatremia
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 Question
What are expected patient outcomes for a patient recovering from a
hemorrhagic stroke?
A. Exhibits absence of vasospasm
B. Residual aphasia
C. One to four seizures
D. Complains of visual changes

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Summary

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