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Define Cerebral Vascular Accident (CVA)

Sudden loss of brain function resulting from a disruption of the normal blood supply to a part of the brain.

Define TIA

where there is mild ischemia & actual improvement between episodes & later progress to full-blown CVA. Vessels are narrowed or sometimes spasm & pt. has transient symptoms

Leading cause for adult long term disability

*Cause of death rank: 4th
*Stroke is the leading cause for adult long term disability.

FAST stands for?

Our job as nurses -- educate people about S&S: Call "911;" Get help fast! (Face, Arm, Speech, Time)

Brain Attack

term from American Stroke Association (ASA) to get lay public to recognize that, like a heart attack, best outcome will be achieved if person gets help quickly!

Treatment for hemorrhagic CVA

Management of hypertension with oral and IV agents to maintain systolic BP less than 160 mm Hg and seizure prophylaxis in acuter preiod

What causes an ischemic CVA

Caused by occlusion of a cerebral artery from either a thrombus (stationary clot) or embolus (moving clot)

Diagnosis of a TIA.


Give signs & symptoms of a TIA

depends upon which blood vessels are involved.
carotid system - affects vision, sensation, speaking
vertebrobasilar - ears, eyes, ptosis,diploia, vertigo, tinnitus

Transient Ischemic attack

Sometimes referred to as a mini-stroke, temporary interruption in the blood supply to the brain.


difficulty in speaking - general term

Aphasia receptive

inability to use or comprehend language either partially or completely (Wernicke's Aphasia) inability to understand spoken or written word, thus , can't follow commands, May use "jargon" or meaningless words not in context and they don't realize they're not making sense

Aphasia expressive

(Broca's Aphasia) incorrect words are spoken pt. becomes very frustrated, becuae they hear the wrong words come out


difficulty in articulation & pronunciation (cause is loss of motor function of tongue & muscles of speech), A speech disorder characterized by difficulty speaking properly, due to paralysis of the muscles of speech.


repetition of word, phrase, action inappropriately


inability to name objects even through usage is understood


difficulty writing


Oral motor muscles loose function, unable to speak with meaningfull utterances. DISORDER OF MOTOR PLANNING. LOSS OF LEARNED PURPOSEFUL MOVEMENTS.


-The inability to understand and interpret the significance of sensory input

homonymous hemianopsia

loss of half of the visual field from damage to optic tract or occipital lobe most often occurs as a homonymous---blindness in same side of both eyes (eg Nasal field of Rt. eye & temporal field of left = LEFT HH). Client has to turn head toscan visual field
these fibers cross at the optic chiasm---
*LEFT HH means that the injury is to the right optic tract
*RIGHT HH means that injury is to left optic tract

bi-temporal hemianopsia

loss of vision in the temporal half of both fields:"Tunnerl Vision"--due to an injury at the optic chiasm---involves only fibers that are crossing over to the opposite side


double vision

Resources utilized in transitioning a CVA client from hospital or rehab unit to home.

critical factor in discharge planning is pt's level of independance in performing ADLs

Concepts of stroke prevention

Modifiable concepts:
htn, a-fib, DM, poor diet, cholesterol
PVD, smoking, obesity

Discuss the importance of monitoring the Prothrombin Time (PT), Partial Thromboplastin Time (PTT), and International Normalized Ratio (INR) as a part of the treatment plan for a CVA client.

CVA patients are on anticoagulants to prevent future strokes by preventing the formation of a thrombus in the first place. These valuses need to be checked to have a balance between clot prevention and bleeding due to lack of clotting factors

Partial Thromboplastin Time (PTT)

Measures intrinsic clotting time, used to monitor heparin terapy; APTT range for heparin therapy is 1.5 - 2.5 times the normal value

Prothrombin Time (PT)

A test used to evaluate the extrinisic pathway; also used to monitor coumadin (warfin) therapy.

International Normalized Ratio (INR)

INR; a more consistant measure of coagulation for coagulation studies regardless of thromboplastin reagent used. Accepted from World Health Organization; makes results not dependent upon reagent used.

Determine when to notify the physician of a CVA patient's elevated blood pressure.

When BP is 220/120 or greater

Nursing interventions for CVA client with visual/perceptual deficits

approach patient from non-affected side, break tasks into small steps, develop structure, amy use eye patch for diplopia (alternate eye patch q4hr)

Nursing interventions for CVA client with self-care deficits

good skin care, promote elimination by offereing bedpan or urinal every 2 hours

Describe signs of increasing intracranial pressure.

causes brain compression and reduced cerebral blood flow.
*LOC - partial consciousness or unconsciousness
*Change in VS - pressure on thalamus, hypothalamus, pons, medulla causing cushing's triad
*ocular signs - compression of cranail nerve III, dialation of pupil on same side of injury, sluggish, ptosis of eyelid
*decrease motor function - contralateral hemiparesis or hemiplegia
*headache - continuous but gets orse
*vomiting -

Define & discuss neglect/extinction and identify appropriate nursing interventions.

put brightly colored object on affected limb to help re-integrate affected side into body image
*encourage pt. to touch affected side
*teach pt. to visually check position of limb

right-sided problems

caused by stroke on left side of brain, right hemiplegia, aphasis, impaired right/left discrimination, slow performance, cautious, aware of deficits, depression, anxiety, impaired comprehension related to language,math

left-sided problems

caused by stroke on right side of brain, left hemiplegia, left side neglect, spatial-perceptual deficits, deny or minimize problems, rapid performance, short attention span, impulsive, impaired judgement, impaired time concepts, safety problem

Expected outcome for CVA

1. maintenance of life
2. prevention of further neurological damage
3. promotion of recovery
4. restoration of prior performance
5.adaptation to visual, spatial, language, momory problems
6. prevention of injury & complications from CVA

Contributing factors for CVA

*advance age above 65
*latino or african american
*history of stroke
*poor diet
*peripheral vasuclar disease (PVD)

Treatment for ischemic CVA

The use of tPA within the first 4.5 hours of onset of symptoms

What does frontal lobe control?

*motivation, emotions, social behavior
*attention, judgement, problem solving, desicion-making
*expressive language (Broca's area), motor function of speech
*motor integration; voluntary movement

Broca's aphasia

An aphasia associated with damage to the Broca's area of the brain, demonstrated by the impairment in producing understandable speech.

What does parietal lobe control?

*awareness of spatial relations (body consciousness, 3-dimensional perception
*singing, playing musical instruments, processin non-verbal cues (singing is primarily a right brain function & speech a left)
*taste sensation
*academic skills

What does temporal lobe control?

*language comprehension
*receptive language (Wernicke's Center)
*interpretation of complex sounds, allows for processing of words into coherent thought &
*recognition of printed words into ideas
*learning, memory, understanding speech
*musical awareness
*sequencing skills

Wernicke's Center

Speech Comprehension Center

What does the occipital lobe control?

Primary visual center receiving stimuli from retina, where fibers from other lobes all synapse allows for processing complex thoughts.
An area at the back of each cerebral hemisphere that is the primary receiving area for visual information.


Difficult and defective speech due to a dysfunction of the muscles used for speech

ipsilateral control

situated on same side of stroke, example right cerebellum controls right side balance & motor coordination

circle of willis

A structure at the base of the brain that is formed by the joining of the carotid and basilar arteries.

Where do strokes typically originate?

middle cerebral arteries MCA

Name two types of aphasia.

Broca's aphasia - expressive
Wernicke's aphasia - receptive


loss of half of the visual field from damage to optic tract or occipital lobe

Name two types of hemianopsia.

homonymous - blindness in same side of both eyes
bitemporal-loss of vision in the temporal half of both fields

Name three surgical procedures to treat occlusive strokes or TIAs

carotid endarterectomy
superior temporal artery-middle cerebral artery (STA-MCA) anastomosis

carotid endarterectomy

the surgical removal of the inner lining of the carotid artery & re-establish blood flow leading to the brain.

What type of patient usually has a carotid endarterectomy?

Patients who have had warning signs of an impending CVA.

carotid angioplasty

a surgical option for treating cerebral stenosis by passing a balloon catheter and/or stent through blocked artery in the pt arm/leg to dialate and improve circulation.


Double vision., Inability to coordinate the muscles in the execution of voluntary movement


Ticlopidine Antiplatelet Used mainly for stroke related risk reductio


A surgical connection between two hollow or tubular structures

transient weakness


Superior temporal artery-middle cerebral artery anastomosis

bypass blocked artery by making a graft and anastomosing the two arteries, sets up a collateral circulation

Name 5 causes of hemorrhagic stroke.

1. HTN
2. ruptured aneurysm
3. Arteriovenous malformation (AVM)
4. Hypocoagulation of blood
5. ETOH consumption



Arteriovenous malformation

congenital tangle of vessels

Name 4 blood thinners that can cause hemorrhagic stroke.

Asprin (ASA)

Most common cause of hemorrhagic stroke.


Name the three parts that make up the limbic lobe.

thalamus, hypothalamus, hippocampus


A structure in the forebrain through which all sensory information (except smell) must pass to get to the cerebral cortex.


A neural structure lying below the thalamus; directs eating, drinking, body temperature; helps govern the endocrine system via the pituitary gland, and is linked to emotion


A curved forebrain structure that is part of the limbic system and is involved in learning and forming new memories

TIA is caused by?

a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia

Name three main caused for a thrombotic stroke.

elevated BP
narrowing of blood vessels

Most common vessels affected in thrombotic stroke

interanl carotids, middle cerebral, anterior cerebral

Name three types of ischemic strokes

thrombic, embolic, lacunar

lacunar stroke

Stroke caused by the occlusion of a small branch of a larger blood vessel w/development of a cavity in the place of the infarcted brain tissue, softened tissue sloughs away leaving a "small cavity"

thrmobic stroke

results of thrombosis or narrowing of the blood vessel

embolic stroke

occurs when an embolus lodges in and occuldes a cerebral artery resulting in infraction and edema of the area supplied by involved vessel

when are embolic strokes more common?

When awake or after activity

What type of stroke has onset during sleep and sfter arising? wy?



area affected


"clot-busting drug" used occasionally stroke, myocardial infarction, and pulmonary embolism

Why are embolic strokes increasing in young adults?

amphetamine use

What type of stroke has sudden onset?

embolic stroke

Embolic strokes are cardic in orgin due to damage caused by

heart vlalves damage by rheumatic heart disease
A fib
atherosclerotic plaque

rheumatic heart disease


atrial fibrulation

irregular and rapid atrial contraction, resulting in TOP of heart quivering, results in an irregularly irregular heart rhythm (atrium fire at irregular intervals)

Early treatment- intervention for TIA

antiplatelet aggregation drugs
lifestyle changes

Nursing managment pre-op tests for TIA

CT scan, chest x-ray, PTT, lab work

What diagnostic studies are done to determine cause of stroke?

CT w/o contrast
MRI --r/o hemorrhage or aneurysm
transcranial doppler

trancranial doppler

used to evaluate cerebral blood flow


(Partial Thromboplastin Time) evaluation of the intrinsic coagulation system. Patients on heparin therapy are monitored by a PTT

Name 6 clinical manifestations of strokes

1. motor function
2. communication
3. affect
4. intellectual function
5. spatial-perceptual alteration
6. eliminations


A contrast x-ray showing circulation. (CTA)

Motor impairments caused by stroke

1. mobility
2. respiratory function
3. swallowing and speech
4. gag reflex
5. self-care abilities

prevention of stroke in healthy people.

reduce salt intake
maintain normal body weight and blood pressure
increase exercise
limit alcohol
avoid smoking
diet lowin saturated fat, high in fruit and vegies

What is the most frequently drug used to prevent stroke in patients with TIA?

aspirin (antiplatelet) - dose of 81 to 325 mg/day

Name 4 other medications used to prevent stroke in TIA patients.

1. ticlopidine (Ticlid)
2. clogpidogrel (Plavix)
3. dipyridamole (Persantine)
4. dipryridamole/aspirin (Aggrenox)

Best drug for patients with A-fib and TIA?

oral anticoagulate - warfarin

Drug alert for Ticlopidine and clopidogrel

all healthcare providers and dentist must be informed that drug is being taken prior to surgery. Pt. must be off of medication 10 to 14 days prior to surgery

nonfluent aphasia

(Language disorders) slow and labored speech with short phrases

fluent aphasia

(Language disorders) pace of speech is normal but contains made-up words and sentences that do not make sense, ie stroke

Name characteristics of Broca's

nonfluent aphasia
damage to frontal lobe of brain
understands speech
speaks in short phrases

global aphasia

Loss of all language skills.

What causes intracrantial pressure to increase during stroke?

Blood supply to part of the brain is interrupted, ischemia occurs deprived of O2 (hypoxia and anoxia)& glucose; tissue dies (infarct), cerebral edema occurs due to tissue injury of brain-INFLAMMATION

Nursing interventions for stroke patients Monitor what?

monitor for decreased LOC and increased ICP

What time frame is the greatest risk for increased ICP after a CVA?

first 72 hours
early sign = confusion

Nursing intervention for stroke pt. to prevent/reduce cerebral edema.

position HOB at 30-45 degree fowlers, position to prevent hip & neck flexion & contractures, aspiration

Tissue Plasminogen activator

TPA- Alteplase (Activase) a (thrombolytic) must be used within first 4.5 of symptom onset, preferably within 1 hour but CT first to rule out hemorrhage

After a stroke what VS is elevated and why?

elevated BP is common, may be protective response to maintain cerebral perfusion.

When should drugs be used for BP after a stroke?

Only if BP arterial pressure >130 mm Hg or systolic pressure > 220 mm Hg, use antihypertensives: metoprolol, micardipine preferred

List normal lab ranges for PT, PTT, APTT

PT = 11- 12.5 seconds
PTT = 60 - 70 seconds
APTT = 30 -40 seconds

What type of stroke is more likely to increase ICP?


Management of increased ICP includes.

pratices that improve venous drainage:
*elevating HOB
*head & neck alignmeny
*avoiding hip flexion

hip flexion


Monitor Hyperthermia with stroke.

commonly following stroke during first 24 hours. increase temp = increase cerebral metabolism. 1 deg cel can increase metabolism by 10% = further damage

What medication is used to reduce cerebral edema in hemorrhagic CVA?

Steriods like Decadron

What medication is given t hemorrhagic CVA patients to prevent seizures?

Dilantin (anticonvulsant), must monitor peak & trough to prevent toxicity & maintain therapeutic level (10 - 20 for anticonvulsant levels; 10 -18 anti -arrhythmic level)

What is goal for anti-coag?

1 1/2 - 2x longer than normal for blood to clot

CVA norms 1.5x normal coagulation.

PT = 16.5 - 18.75
PTT = 90 - 105 sec
APTT = 45 - 60 sec

Patient teaching when on anticoagulants.

watch for blood in urine, bleeding gums, bruising, use soft toothbrush

Patient teaching what to avoid when on anticogulants.

foods high in Vitamin K (antidote for coumadin)
cranberry juice, grapefruit, kale, cabbage, broccoli, asparagus, lettuce, spinach, large doses of Vit C

When given coumadin what labs should be tested?

hold if

When given Heparin IV what labs should be tested?

hold if

What medication is given to SAH patients to prevent vasospasm?

Calcium channel blockers (nimodipine/Nimotop)
prevent spasm minimize cerebral damage.
hold for HR less than 60

When can a vasospasm occur?

after clipping/coiling treatment for aneurysm

What is a MERCI retriver?

mechanical embolus removal in cerebral ischemia retriever: under xray guidance catheter travels up carotid artery to clot in brain, tiny corkscrew dislodges it and captured and pulled out with balloon out of the body

What is the surgical treatment for an aneurysm to prevent rebleeding?

clipping or coiling

How does coiling work?

coil placed in aneurysm to occlude blood from circulating through the aneurysm reducing risk of rupture.

subarachnoid hemorrhage

Bleeding into the subarachnoid space into the cerebrospinal fluid- filled space between the arachoid and pia mater membrane on the surface of the brain, "Worst headache of my life"

Where do the majority of SAH occur?

in the circle of Willis, other causes trauma and cocaine abuse

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