CEREBROV ASCULAR ACCI DENT (CV A): STROKE
Cerebrovascular Accident (CVA) aka: stroke











Occurs when there is ischemia to a part of the brain that results in death of brain cells
Functions are lost or impaired
o Such as movement, sensation, or emotions that were controlled by the affected
area of the brain
Etiology
o The brain requires a continuous supply of blood to provide the oxygen and
glucose that neurons need to function
20% of glucose needs to be in the brain at all times/ 20% of oxygen needs to be in the
brain at all times
o If blood flow to brain is totally interrupted, then flow of glucose/oxygen
interrupted
Neurological metabolism is altered in 30 seconds
Metabolism stops in 2 minutes
Cellular death occurs in 5 minutes
o Factors affecting blood flow to brain
Systemic BP—good BP to push blood into the brain
Cardiac Output
Blood viscosity—Thick blood is more likely to clot and cause stroke
o #1 risk factor is HTNputs vessels under pressurethey tear over timecholesterol
gets in the tearsleads to atherosclerosisimpedes blood flow
Major Types of Strokes
o Thrombotic stroke
o Embolic Stroke
o Hemorrhagic Stroke






CVA Warning Signs
o
Who’s at risk?
o Black Americans
o Hypertensive
o Diabetes
o Sickle Cell Anemia
o Smoker
o Obese
Modifiable Risk Factors
o HTN (#1 risk factor)
o Cigarette smoking
o Heart disease
A-fibclots form easily because ventricles are not pumping blood through/ A-fib patients
need to be on anticoagulants to prevent formation of clots which could eventually
cause stroke
Valvular disease
o High cholesterol
o Obesity
o Hx of TIA
o Physical inactivity
o Drug abuse
o Oral contraceptives
o Hypercoagulation
o DM
o Alcohol uses
Nonmodifiable risk factors
o Advanced Age
o Gender—men and women occurrence are equal, women die from it more often
o Race— Black Americans have greatest risk due to highest incidence of HTN,
Obesity, Diabetes. For American Indian, Hispanic and Asian Descent, risk is
greater than Caucasians
o Family Hx
CLINICAL MANIFESTATIONS OF CVA



Manifestations of Right Brain and Left-Brain Stroke
o
Motor function (contralateral side to damage)
o Include impairment of
 Mobility
 Respiratory fxn
 Swallowing and speech
 Gag reflex
 Self-care abilities
 Loss of skilled voluntary movement
o An initial period of flaccidity
 May last days to weeks. Spasticity follows flaccid stage
GCS Scale—GSC less than 15 requires RN care because need to constantly assess


o Eye opening response
o Best verbal response
o Best motor response
Cranial nerves (Same side as damage)
o Dysfunction in cranial nerves IX and X (control ability to swallow) could lead to
aspiration pneumonia
o If a person can’t swallow anymore after a stroke, they will have to get a J or G
tube
Communication
o Aphasia
 Receptive—Loss of comprehension, cannot understand what is being said
 Expressive—Loss of production of language; Understands what is being
said but cannot respond coherently
 Global—total inability to communicate
o Dysphagia refers to impaired ability to communicate (used interchangeably with
aphasia)
 Non-fluent—minimal speech activity with slow speech
 Fluent—speech is present but contains little meaningful communication
o




Dysarthria—disturbance in the muscular control of speech; impairments may
involve
 Pronunciation
 Articulation
 phonation
Affect
o Difficulty controlling their emotions
o exaggerated or unpredictable emotional responses
o Depression associated with changes in body image and loss of function (more
left sided)
o Frustration caused by mobility and communication problems
Intellectual Function
o Both memory and judgement can be impaired (SAFETY ISSUE)
o Left brain stroke more likely to result in memory loss r/t language
Spatial-Perceptual Alterations
o More likely to be caused by right sided brain damage, but can be caused by left
sided damage too
o Four categories:
 Incorrect perception of self and illness (does not recognize self)
 Erroneous perception of self in space (neglect affected side)
 Inability to recognize an object by sight, touch, or hearing-agnosia
 Inability to carry out learned sequential steps like putting food in the
mouth
Elimination
o Most problems with urinary and bowel elimination occur initially and are
temporary
o When a stroke affects one hemisphere of the brain, the prognosis for normal
bladder function eventually is excellent
DIAGNOSTIC STUDIES: CVA
 Non-contrast CT scan to determine what kind of stroke is happening
o Should be obtained within 25 mins of arrival
o Should be read within 25 mins of arrival
o Indicate size and location of the lesion
o Differentiate between ischemic and hemorrhagic stroke
 RX depends on the kind of stroke
 MRI
o MRI more effective; CT scan quicker
o Can use for TIA because it is not an acute situation
o Contraindicated if client has internal metal devices like a pacemaker/artificial
valve
 Angiography
o Inject dye and visualize blood vessels in the neck and Circle of Willis
 Know if patient is allergic to shellfish
 Carotid Artery studies
o Ultrasound to look for atherosclerosis
 Serum studies
o assess for contraindications for thrombolytic therapy
 If INR is high, then thrombolytic therapy is contraindicated

Swallowing studies
o precaution to prevent aspiration
ISCHEMIC STROKE
o What is an Ischemic Stroke?
 Ischemic stroke occurs when a vessel supplying blood to the brain is
obstructed.
O THROMBOTIC STROKE
 Occurs from injury to a blood vessel wall and formation of a blood clot
(atherosclerosis)
 It is the result of thrombosis (clot blocks veins or arteries) or narrowing of a
blood vessel
 2/3 associated with HTN and DM
 30-50% have been preceded by TIA
o TRANSIENT ISCHEMIC ATTACKS (TIA) AKA MINI STROKE—Warning sign of Major
stroke (can occur in ea. Type of stroke)
 Temporary loss of neurological function caused by ischemia
 Usually lasts < 1 hour
 S&S: blurred vision, unable to move arms/legs, unable to speak, double
vision, vertigo, aphasia, dysarthria
 Treatment: ASA, Ticlid, Plavix, dipyridamole, anticoagulants
 Make blood less viscous so it can flow through clogged up
arteries
 Collab Care: TIA
 Surgical interventions for the patient with TIAs from carotid
disease include—Carotid arteries may be fille with fatty tissue
(atherosclerosis) stopping blood from going up to the brain
 Carotid endarterectomy—cut open the carotid and pull the
fatty deposits (atherosclerosis) out
 Keep BP low in after care to prevent surgical site
from tearing open
 Stenting
 Transluminal angioplasty
O EMBOLIC STROKE
 Occurs when an embolus lodges in and occludes a cerebral artery
blood can’t get pastResults in infarction and edema of the area
(cerebral edema) supplied by the involved vessel
 Nurses should remember to always use a filter when drawing up
medications from an ampule to prevent injecting a piece of glass into the
patient
 2nd most common cause of stroke (24%)
HEMORRHAGIC STROKE (15%)
 Occurs when a vessel suddenly rupture; most common cause is HTN
 Poor prognosis; high mortality
 Bleeding in the brain tissue blood can accumulate and shift the cranium/brain results
in death or vegetative state
o Cause: Weakening in the arterial wall (Like an aneurysm) + really high BP = Can
Rupture





Cerebral aneurysm
o Majority of aneurysms are in the Circle of Willis
o Silent Killer
 Loss of consciousness may or may not occur
 Survivor often have significant complications and deficits
o FamilialFamily hx puts you at risk
o HTN and atherosclerosis are most common
Arterial Venous Malformation
o Person has arteries and Veins but no capillaries. AVM is an abnormal tangle of
blood vessels connecting arteries and veins, which disrupts normal blood flow
and oxygen circulation. This creates huge clumps that can weaken and rupture.
Berry aneurysm—A lump that sticks off the artery
o Rx: clipping of the aneurysm
 Keep blood pressure low before to prevent rupture and after to prevent
opening up
Fusiform aneurysm— bulges or balloons out on all sides of the blood vessel
o Cannot be cut out, wrap in biosynthetic material to strengthen the wall
Treatment
o Cannot do anything, just try to keep patient alive. Thrombolytics contraindicated
due to BLEEDING
COLLAB CARE: ISCHEMIC STROKE
 ACUTE CARE: GOALS
o Preserve life
o Preventing further brain damage
o Reducing disability
o (Time of onset of symptoms is critical info/ RX differs according to the type of
stroke and as the patient changes)
o Managing ABCs***
 Airway
 Breathingintubate if they cannot breathe
 Circulation
Baseline neurologic assessment***
 Monitor closely for
 Signs of increasing neurologic deficit
 Increased ICP
o Change in LOC
o Risk for aspiration
 Elevate HOB
 Side-lying position
o Elevated BP is common immediately after stroke
 (May reflect body’s attempt to maintain cerebral perfusion)
 Need BP to stay high to perfuse brain
o Fluid and Electrolyte balance
 Adequate hydration promotes perfusion
ACUTE CARE: ASSESSMENT
o Altered LOC—Aox3
o Weakness, numbness, or paralysis
o Speech or visual disturbances
o Severe H/A
o

or HR
HTN
Respiratory distresssign of deterioration
Unequal pupilsIf pupils don’t constrict there’s an injury to brain (usually same
side); should be brisk
o Facial drooping on affected side
o Difficulty swallowing
o Seizures
o Bladder or bowel incontinence
o N/V
o Vertigo
NIH STROKE SCALE BASELINE
o The higher the number, the worse the stroke is—should decrease with
interventions
ACUTE CARE: INTERVENTIONS—INITIAL STABILIZING ACTIONS
o Ensure patent airway; maintain adequate oxygenation
o Call stroke code or stroke team
o Pulse oximetry
o IV access with normal saline
o Maintain safe BP-may be higher than normal BP
o Obtain CT scan immediately
o Perform baseline laboratory tests
o Position head midline
o Elevate head of bed 30 degrees
o Institute seizure precautions
 Keeping oxygen and suction available at the bedside
 Side lying position to prevent aspiration
 Siderails up and padded
 Pillow under their head
 Bed in lowest position
o
o
o
o




DRUG THERAPY
o Recombinant tissue plasminogen activator (tPA)
 Used to reestablish blood flow through a blocked artery to prevent cell
death—breaks up the clot
 Must be administered within 3 to 4.5 hours from onset of clinical signs of
ischemic stroke (IV pushed by nurse)
 Intraarterial tPA procedure can be done within 6 hours (IA pushed by
doctor)
o Anticoagulants and platelet inhibitors to prevent further clot formation after
patient is stabilized
COLLAB CARE: HEMORRHAGIC STROKE
 DRUG THERAPY
o Anticoagulants and platelet inhibitors are contraindicated-BLEEDING
o Management of hypertension is the main focus.
 Oral and IV agents are used to maintain BP within a normal to high-normal
range. 130-140
o Seizure prophylaxis is situation-specific
 Surgical Therapy (based on cause of stroke)
o Resection of AVMsRepair of arterial venous malformation
 Done if there is not a lot of cranial pressure
Clipping of an aneurysm
Evacuation of hematoma if possible
 Drill a hole and drain slowly to avoid shifting of the brain which would
cause a vegetative state
Acute Care: Ongoing Interventions
o Neuro status q 1hour/ GCS
 LOC
 Monitor and sensory fxn (can they move? Can they feel?)
 Pupil size and reactivity
 Telemonitor
 O2 Sat.
 Cardiac rhythm
o
o

COLLAB CARE: ALL STROKES
 Acute Care
o ASA used in first 48 hrs.
o TPA follow up with Plavix or ASA
 Contraindicated in hem/ recent surgery
o Platelet inhibitors and anticoagulants may be used in thrombus and embolus
stroke patients after stabilization
 Contraindicated for patients with hemorrhagic stroke—BLEEDING
 Nursing Management---Nursing Implementation: Preventing Complications
o Risk for atelectasis: collapse of alveoli that inhibits oxygen
 Prevent with movement
o Risk for aspiration pneumonia
 Prevent with side-lying, HOB 45 degrees, suction
o Risk for airway obstruction
o May req. endotracheal intubation and mechanical ventilation
 Cardiovascular
o Frequent vitals
o Monitor cardiac rhythms
o I&Os, note imbalances
o Regulating IV infusions
o Monitor lung sounds for crackles and rhonchi (pulmonary congestion)
o Monitor heart sounds for murmurs or S3 or S4
o Prevent VTE-consider hemiplegic side
 Lovenox or Heparin
 Compression boots
 Ted stockings
 Ambulate/ dorsiflexion if unable to ambulate
COLLAB CARE: REHABILITATION
 Stabilize first 12-24 hrs. then shift from preserving life to lessening disability and attaining
optimal functioning
o Once stabilized, transfer to rehab unit, outpatient therapy, or home care-based
rehab
 Rehab goals
o Learn techniques to self-monitor and maintain
o
o
o
o
o
o
o
o
physical wellness
Demonstrate self-care skills
Exhibit problem-solving skills with self-care
Avoid complications associated with stroke
Establish and maintain a useful communication
system
Maintain nutritional and hydration status
If muscles are still flaccid several weeks after the stroke, prognosis for regaining
function is poor
 Exaggerated reflexes within 48 hours following stroke
NURSING MANAGEMENT: IMPLEMENTATION (NURSES’ ROLE: ASSESS, COMMUNICATE,
OBSERVE, EVALUATE)
o Musculoskeletal
 Maintain optimal fxn
 Accomplished by prevention of joint contractures and muscular atrophy
 Trochanter roll at hips to prevent external rotation-maintain posture
 Paralyzed side needs special attention when positioned
 Hand cones to prevent hand contractures
 Out of bed (OOB) using unaffected side for strength moving
 Footboards to prevent foot dropping
o Integumentary
 Susceptible to breakdown r/t to loss of sensation, decreased circulation,
immobility
 Pressure relief by position changes, special mattress, or wheelchair
cushions
 No longer than 30 minutes on paralyzed side
o GI/GU
 Implement a bowel management program for problems with bowel
control, constipation, incontinence
 High fiber diet and adequate fluid intake
 In the acute state, poor bladder control results in incontinence
 Efforts should be made to promote normal GU fxn –offer
commode/bedpan
 Avoid use of indwelling catheters
o Nutrition
 Test swallow, chewing gag reflex and pocketing before beginning oral
feeding
 Tongue must be able to move
 Oral hygiene after feedings
o Managing Medications
 Difficulty swallowing
 Risk for polypharmacy; medication interactions/Side effects
o Communication
 Patient assessment for: ability to speak/ability to understand
 Speak slowly and calmly, use simple words and phrases
 Use gestures to support verbal cues
o Sensory-perceptual alterations
Blindless in same half of each visual field (Homonymous Hemianopsia) is a
common problem after stroke
 Stand/place objects in patient’s visual field
 If left side stroke, will lose sight in right side of each eye
 Other visual problems may include diplopia (double vision), loss of the
corneal reflex, ptosis (drooping eyelid)
Survivorship and coping
 Patients with a stroke may be coping with many losses
 Often go through process of grief
 May experience long term depression
 Coping
 Family should be given a detailed explanation of what has
happened to patient
 Family members usually have not had time to prepare for the
illness—social services referral is often helpful
Interventions for atypical emotional response
 Distract the patient.
 Explain to patient and family that emotional outbursts may occur. They
should:
 Maintain a calm environment.
 Avoid shaming or scolding patient.

o
o
TEACHINGS: HEALTH PROMOTION FOR THOSE AT RISK FOR STROKE (43:00)
 Manage HTN
 Smoking cessation
 Limit alcohol
 Lipid and cholesterol-lowering meds
 Antithrombotic/antiplatelet agents for TIAs
 Weight management
 Regular exercise program
 Diet mgt: cholesterol, fat, salt
 Manage A-fib with anticoagulation
 Optimal glucose control with DM-keep HgbA1C (3-6)
RESOURCES
https://www.registerednursern.com/stroke-cva-nclex-questions/
https://rnspeak.com/stroke-nclex-questions/
SUMMARY







Risk factors
o Comorbidities: HTN!!, high cholesterol, obesity, A-fib/ African American/ Family Hx;
Women & Men have equal chances— women die more from stroke/ Older age
Diagnostics
o CT scan to r/o brain hemorrhage
o MRI
o Angiography
S/S of stroke
o Facial drooping
o Arm weakness/numbness
o Speech difficulty
o Time
Ischemic Stroke—clot blocking the flow of blood to the brain or narrowing of blood
vessel (Includes TIA, Thrombotic, Embolic)
 Cause:
 S/S: blurred vision, unable to move arms/legs, unable to speak, double
vision, vertigo, aphasia, dysarthria
 TX: TPA (3-4.5 hrs. from start of s/s)—follow up with Plavix or ASA
 Monitor bleeding/neuro checks
 Monitor labs for TX TPA therapy contraindicated if INR is high
Hemorrhagic Stroke
o Cause: Rupture of blood vessel [arterial venous malformation (AVM), aneurysm +
high BP, berry aneurysm—a lump hanging off the artery, fusiform aneurysm—
bulges out on all sides of the blood vessel]
o S/S: headache
o TX: management of HTN, surgical therapy: clipping of aneurysm, wrapping
fusiform aneurysm in biosynthetic material to strengthen wall
Left Side stroke
o S/S:
 Right side paralysis/issues seeing on the right
 Impaired speech/language aphasia
 Slow performance/cautious
 Aware of deficits; impaired comprehension of language, math
Right Side Stroke
o S/S
 Left side paralysis/ left side neglect/issues seeing on the left
 Spatial-perceptual deficits
 Rapid performance/short attention span/unaware of limits
 Impaired judgement/time concepts

Complications
o Receptive aphasia—Loss of comprehension, cannot understand what is being
said
 Keep it short & simple/ gestures/ repeat
o Expressive aphasia—Loss of production of language; Understands what is being
said but cannot respond coherently
 Ask one question at a time/ simple questions
o Global aphasia—total inability to communicate
o Dysarthria—disturbance in the muscular control of speech; impairments may
involve: Pronunciation; Articulation; Phonation
o Dysphagia—impaired ability to communicate/swallow
 Non-fluent—minimal speech activity w/ slow speech
 Fluent—speech present but contains little meaningful communication
 Issues swallowingRisk for aspirationRisk for pneumonia
 Thick liquids
o Homonymous Hemianopia—vision loss in same half of each visual field
 Right side strokelose sight in left side of both eyes
 Left side strokelose sight in right side of both eyes
o Seizure
 Seizure precautions—keep o2/suction at bedside, pt. side lying, rails up