CVA (Cerebro Vascular Accident)&

TIA (Trans Ischemic Attack)BY:

BCoN faculty

CVAo Definition.• Cerebral vascular accident (CVA) (stroke) is the

disruption of the blood supply to the brain, resulting in neurological dysfunction.

• Results from ischemia to a part of the brain or Results from ischemia to a part of the brain or hemorrhage into the brain that results in death of hemorrhage into the brain that results in death of brain cellsbrain cells

Cerebrovascular AccidentCerebrovascular AccidentPathophysiologyPathophysiology

AtherosclerosisAtherosclerosis: major cause of CVA: major cause of CVAThrombus formation & emboli developmentThrombus formation & emboli development

Abnormal filtration of lipids in the intimal layer of the arterial wallAbnormal filtration of lipids in the intimal layer of the arterial wallPlaque develops & locations of increased insecurity of blood - Plaque develops & locations of increased insecurity of blood -

divisiondivisionIncreased turbulence of blood or a indirect areaIncreased turbulence of blood or a indirect areaCalcified plaques rupture or fissureCalcified plaques rupture or fissurePlatelets & fibrin stick to the plaquePlatelets & fibrin stick to the plaqueNarrowing or blockage of an artery by thrombus or emboliNarrowing or blockage of an artery by thrombus or emboliCerebral Infarction: blocked artery with blood supply cut off Cerebral Infarction: blocked artery with blood supply cut off

beyond the blockagebeyond the blockage

Cerebrovascular AccidentCerebrovascular AccidentClassificationsClassifications

Ischemic StrokeIschemic StrokeThromboticThromboticEmbolicEmbolic

Hemorrhagic StrokeHemorrhagic StrokeIntracerebral HemorrhageIntracerebral HemorrhageSubarachnoid HemorrhageSubarachnoid Hemorrhage

Ischemic StrokeIschemic Stroke—inadequate blood flow to the brain from partial or —inadequate blood flow to the brain from partial or complete occlusions of an artery--85% of all strokescomplete occlusions of an artery--85% of all strokes

– Extent of a stroke depends on:Extent of a stroke depends on:• Rapidity of onsetRapidity of onset• Size of the lesionSize of the lesion• Presence of collateral circulationPresence of collateral circulation

– Symptoms may progress in the first 72 hours as infarction & cerebral Symptoms may progress in the first 72 hours as infarction & cerebral edema increaseedema increase

Types of Ischemic StrokeTypes of Ischemic Stroke: :

Thrombotic StrokeThrombotic Stroke Embolic StrokeEmbolic Stroke

CVA RecognitionCVA Recognition

Ischemic – Thrombotic StrokeIschemic – Thrombotic Stroke

Lumen of the blood vessels narrow – then Lumen of the blood vessels narrow – then becomes occluded – infarctionbecomes occluded – infarction

Associated with HTN and Diabetes MellitusAssociated with HTN and Diabetes Mellitus>60% of strokes>60% of strokes50% are preceded by TIA50% are preceded by TIA

Common Sites of AtherosclerosisCommon Sites of Atherosclerosis

Ischemic – Embolic StrokeIschemic – Embolic StrokeEmbolus lodges in and occludes a cerebral arteryEmbolus lodges in and occludes a cerebral arteryResults in infarction & cerebral edema of the area supplied Results in infarction & cerebral edema of the area supplied

by the vesselby the vesselSecond most common cause of stroke – 24%Second most common cause of stroke – 24%Emboli originate in endocardial layer of the heart – at, MI, Emboli originate in endocardial layer of the heart – at, MI,

infective endocarditis, rheumatic heart diseaseinfective endocarditis, rheumatic heart diseaseRapid occurrence with severe symptoms – body does not Rapid occurrence with severe symptoms – body does not

have time to develop guarantee circulationhave time to develop guarantee circulationAny age groupAny age groupRecurrence common if underlying cause not treated Recurrence common if underlying cause not treated

Embolic StrokeEmbolic Stroke

Causes of Cerebral Vascular Accidents

(1) Thrombosis--blood clot within a blood vessel in the brain or neck.

(2) Cerebral embolism. (3) Stenosis of an artery supplying the brain. (4) Cerebral hemorrhage--rupture of a cerebral blood

vessel with bleeding/pressure into brain tissue.

. Risk Factors Associated with Cerebral Vascular Accidents.

(1) Hypertension. (2) Previous transient ischemic attacks. (3) Cardiac disease (atherosclerosis, arrhythmias,

valvular heart disease). (4) Advanced age. (5) Diabetes.

Signs and Symptoms (1) Highly dependent upon size and site of lesion. (2) Motor loss--hemiplegia (paralysis on one side of the

side) or hemiparesis (motor weakness on one side of the body).

(3) Communication loss. (a) Receptive aphasia (inability to understand the

spoken word). (b) Expressive aphasia (inability to speak). (4) Vision loss. (5) Sensory loss. (6) Bladder impairment.

Cont.. (7) Impairment of mental activity. (8) In most instances onset of symptoms is very sudden. (a) Level of consciousness may vary from lethargy, to

mental confusion, to deep coma. (b) Blood pressure may be severely elevated due to

increased intracranial pressure. (c) Patient may experience sudden, severe, headache

with nausea and vomiting. (d) Patient may remain comatose for hours, days, or even

weeks, and then recover. (e) Generally, the longer the coma, the poorer the

prognosis. (9) ICP is a frequent complication resulting from

hemorrhage or ischemia and subsequent cerebral edema.

Cerebrovascular AccidentCerebrovascular AccidentClinical ManifestationsClinical Manifestations

Right Brain – Left Brain DamageRight Brain – Left Brain Damage

Rehabilitation of the patient with CVA• Process of setting goals for rehabilitation must include

the patient. This increases the likelihood of the goals being met.

• General rehabilitative tasks faced by the patient include:

• Learning to use strength and abilities that are intact to compensate for impaired functions.

• Learning to become independent in activities of daily living (bathing, dressing, eating).

• Developing behavior patterns that are likely to prevent the recurrence of symptoms.

• Taking prescribed medications. • Stopping smoking. • Reducing day-to-day stress. • Modifying diet.

Cont…..

• 4) Specific teaching, encouragement, and support are needed. • (5) Individualized exercise program involving both affected and unaffected

extremities is required. • (6) Speech therapy, as indicated by patient's condition, may be necessary. • (7) Continuous revaluation of goals and patient's ability to meet the goals

is required to maintain a realistic plan of care. • (8) Counseling and support to family is an integral part of the

rehabilitation process. • (a) Both family and patient need direction and support in coping with

intellectual and personality impairment. • (b) Instruct family to expect some emotional lability such as inappropriate

crying, laughing, or outbursts of temper.

TIA (Transient ischemic attack)

• A transient ischemic attack (TIA) is when blood flow to a part of the brain stops for a brief period of time. A person will have stroke-like symptoms for up to 1-2 hours.

• A TIA is felt to be a warning sign that a true stroke may happen in the future if something is not done to prevent it.

• A signal for major stroke in future• Clinical features may be hemiparesis, aphasia, sensory disturbances etc.• Brain imaging is strongly recommended to rule out small hemorrhage.• distinguish time for implementation of secondary preventive measures

Pathophysiology

• A blood clot in an artery of the brain• A blood clot that travels to the brain from

somewhere else in the body (for example, from the heart)

• An injury to blood vessels• Narrowing of a blood vessel in the brain or

leading to the brain

Causes, incidence, and risk factors

• A TIA is different than a stroke. After a TIA, the blockage breaks up quickly and dissolves. Unlike a stroke, a TIA does not cause brain tissue to die.

• The loss of blood flow to an area of the brain• High blood pressure is the number one risk for TIAs and stroke. The

other major risk factors are:• Diabetes• Family history of stroke• High cholesterol• Increasing age, especially after age 55• People who have heart disease or poor blood flow in their legs

caused by narrowed arteries are also more likely to have a TIA or stroke.

Symptoms

• Symptoms begin suddenly, last only a short time (from a few minutes to 1 - 2 hours), and go away completely. They may occur again at a later time.

• The symptoms of TIA are the same as the symptoms of a stroke and include sudden:

• Abnormal feeling of movement (vertigo) or dizziness• Change in alertness (sleepiness, less responsive,

unconscious, or in a coma)• Changes in feeling, including touch, pain, temperature,

pressure, hearing, and taste• Confusion or loss of memory• Difficulty swallowing

Cont….• Almost always, the symptoms and signs of a TIA will have

gone away by the time you get to the hospital. A TIA diagnosis may be made based on your medical history alone.

• The health care provider will do a complete physical exam to check for heart and blood vessel problems, as well as for problems with nerves and muscles.

• Your blood pressure may be high. The doctor will use a stethoscope to listen to your heart and arteries. An abnormal sound called a bruit may be heard when listening to the carotid artery in the neck or other artery. A bruit is caused by irregular blood flow

Cont…

• Your doctor may do other tests to check high blood pressure, heart disease, diabetes, high cholesterol, and other causes of and risk factors for TIAs or stroke.

Treatment

• The goal is to prevent a stroke.• If you have had a TIA within the last 48 hours, you will

likely be admitted to the hospital so that doctors can search for the cause and observe you.

• High blood pressure, heart disease, diabetes, and blood disorders should be treated as needed.

• You may receive blood thinners, such as aspirin, to reduce blood clotting. Other options include dipyridamole, clopidogrel, Aggrenox or heparin, Coumadin, or similar medications. You may be treated for a long period of time.

Nursing DiagnosesNursing Diagnoses Ineffective tissue perfusion r/t decreased Ineffective tissue perfusion r/t decreased

cerebrovascular blood flowcerebrovascular blood flow Ineffective airway clearanceIneffective airway clearance Impaired physical mobilityImpaired physical mobility Impaired verbal communicationImpaired verbal communication Impaired swallowingImpaired swallowingUnilateral neglect r/t visual field cut & sensory lossUnilateral neglect r/t visual field cut & sensory loss Impaired urinary eliminationImpaired urinary eliminationSituational low self-esteem r/t actual or perceived Situational low self-esteem r/t actual or perceived

loss of functionloss of function

Nursing GoalsNursing Goals

Maintain stable or improved LOCMaintain stable or improved LOCAttain maximum physical functioningAttain maximum physical functioningAttain maximum self-care activities & skillsAttain maximum self-care activities & skillsMaintain stable body functionsMaintain stable body functionsMaximize communication abilitiesMaximize communication abilitiesMaintain adequate nutritionMaintain adequate nutritionAvoid complications of strokeAvoid complications of strokeMaintain effective personal & family copingMaintain effective personal & family coping

Medical and Nursing Management during the Acute Phase of CVA

• (1) Objectives of care during the acute phase:• (a) Keep the patient alive. • (b) Minimize cerebral damage by providing adequately

oxygenated blood to the brain. • (2) Support airway, breathing, and circulation. • (3) Maintain neurological flow sheet with frequent

observations of the following: • (a) Level of consciousness. • (b) Pupil size and reaction to light. • (c) Patient's response to commands. • (d) Movement and strength.

Cont….

• (e) Patient's vital signs--BP, pulse, respirations, and temperature.

• (f) Be aware of changes in any of the above. Deterioration could indicate progression of the CVA.

• 4) Continually reorient patient to person, place, and time (day, month) even if patient remains in a coma. Confusion may be a result of simply regaining consciousness, or may be due to a neurological deficit.

Cont…• (5) Maintain proper positioning/body alignment. • (a) Prevent complications of bed rest. • (b) Apply foot board, sand bags, trochanter rolls, and

splints as necessary. • (c) Keep head of bed elevated 30º, or as ordered, to

reduce increased intracranial pressure. • (d) Place air mattress or alternating pressure

mattress on bed and turn patient every two hours to maintain skin integrity.

Cont….• 6) Ensure adequate fluid and electrocyte balance.• (a) Fluids may be restricted in an attempt to reduce

intracranial pressure (ICP). • (b) Intravenous fluids are maintained until patient's condition

stabilizes, then nasogastric tube feedings or oral feedings are begun depending upon patient's abilities.

• (7) Administer medications, as ordered.• (a) Anti hypertensives. • (b) Antibiotics, if necessary. • (c) Seizure control medications. • (d) Anticoagulants. • (e) Sedatives and tranquilizers are not given because they

depress the respiratory center and obscure neurological observations.

Cont….

• (8) Maintain adequate elimination.• (a) A Foley catheter is usually inserted during the acute

phase; bladder retraining is begun during rehabilitation. • (b) Provide stool softeners to prevent constipation. Straining

at stool will increase intracranial pressure. • (9) Include patient's family and significant others in plan of

care to the maximum extent possible.• (a) Allow them to assist with care when feasible. • (b) Keep them informed and help them to understand the

patient's condition.

Epilepsy and SeizuresEpilepsy and Seizures

Epilepsy - Scientific Background

• When the brain functions normally, millions of fluctuating, simultaneous, tiny electrical charges go from the nerve cells to all parts of the body.

• People who have seizures / epilepsy have these normal electrical “patterns” interrupted by sudden and relatively intense bursts of electrical energy that may affect consciousness, body movements, and sensation.

• Nerve cells normally transmit electrochemical signals and maintain a balance of excitatory and inhibitory neurotransmitters as well as sodium, potassium, and other factors critical to energy stability.

• When this balance is changed, a seizure may result

Epilepsy vs. Seizures

• Do you know the difference between seizures and epilepsy?

• A seizure is defined by release of excessive and uncontrolled electrical activity in the brain. Seizures themselves are not a disease, they are an event.

• Epilepsy (seizure disorder) is a neurological condition, that in different times produce brief disturbances in the electrical functions of the brain. Seizures are a symptom of epilepsy.

Seizures• Seizures can cause different symptoms based on

the location of the source of and where the abnormal electrical activity spreads.

• Seizures can range from tingling in a finger to grand mal (generalized) seizures, during which people lose consciousness, become stiff, and jerk.

• Not everything that looks like a seizure is a seizure. And not every seizure is an epileptic seizure. Fainting, collapsing, and confusion can also result from other disorders or even from emotional stress. Withdrawal from alcohol or addicting drugs can also cause seizures.

• Epilepsy is an abnormal electrical disturbance in one or more areas of the brain. An estimated 2 to 4 million persons in the United States are afflicted with epilepsy and more that half of those are under 20 years of age.

• (1) The basic problem is thought to be an electrical disturbance in the nerve cells in one section of the brain, causing them to give off abnormal, recurrent, uncontrolled electrical discharges that produce a seizure or convulsion.

• (2) The underlying disorder may be structural, chemical, physiological, or a combination of all three.

Facts About Epilepsy• There are over 2.5 million people diagnosed with

epilepsy in the United States.• Epilepsy affects more people than other serious

conditions such as cerebral palsy, cancer, tuberculosis, muscular dystrophy, and multiple sclerosis combined.

• The leading cause of epilepsy in adults is automobile accidents

• All other things even, people who have epilepsy have the same abilities and intelligence as everyone else

• The leading cause in children is birth trauma• The leading cause for the elderly (people over 65) is

strokes

Factors that may predispose a patient to epilepsy/seizures

• (a) Trauma to the head/brain. • (b) Brain tumor. • (c) Circulatory disorder, stroke. • (d) Metabolic disorder (such as hypoglycemia,

hypocalcemia, or cerebral anoxia). • (e) Drug/alcohol toxicity. • (f) Infection (meningitis/brain abscess).

Classification of Seizures

• Seizures are classified into partial and generalized

• Partial seizures are divided into– Simple partial - Consciousness is not

impaired– Complex partial - Consciousness is

impaired– About 2/3 of people with epilepsy have

complex partial seizures

Different Types of Seizures

• Generalized seizures - Can be convulsive or non-convulsive

• Absence seizures - Typical vs. Atypical– Typical absence seizures - Non-convulsive

with muscle tone preserved. The seizure usually lasts less than 10 seconds.

– Atypical absence seizures - Convulsive, longer in duration, loss in muscle tone, and tonic/clonic movements are observed.

• Tonic-clonic seizures (grand mal) - Generalized convulsion occurring in the tonic phase and the clonic phase. Often this is preceded by an aura.

• Tonic phase - Muscles stiffen up, person loses consciousness, body grows rigid.

• Clonic phase- Body extremities jerk and twitch.

• Secondary generalized tonic-clonic seizures begins locally with partial seizures

Tonic and Clonic(Most often, these alternate)

Cont…

• Photosensitive seizures - These are very rare, even for people with epilepsy (<5%). A light related stimulus may trigger this seizure, hence the warning labels on electronic devices, theme park rides, and even video games.

• Atonic seizures - Sudden lack of muscle tone, causing the inability to sit and stand. They are also called akinetic seizures. These are very rare in adults.

Status Epilepticus

• Status Epilepticus - A state of recurring seizures when consciousness does not return between seizure events.– Can be very serious and at times fatal.

This is a seizure that lasts for about 20 minutes, and can cause serious brain damage, if not aborted.

– Benzodiazepines like diazepam or lorazepam may be given to patients in the hospital for treatment.

How do Seizures/Epilepsy How do Seizures/Epilepsy Affect You?Affect You?

• Seizures may restrict driving, working, and social opportunities and also affect self-esteem. But remember, you can influence how epilepsy will affect you.

• Most people’s epileptic seizures can be controlled. Some people end their seizures with the first medication they try. Others will need to partner with their Neuro-Oncologist or epileptologist to find the right dosage and combination of medications, especially as brain tumors can change geometry and location.

Take Control of Managing Seizures

• Understand your epilepsy, including your seizure type

• Make sure to talk to your Neuro-Oncologist or epileptologist about all available treatment options

• Fill out a medical history and seizure calendar, so you can become involved in your medical care

• Learn how to communicate well with your neurologist and his or her staff

Cont…

• Bring your epilepsy medications or a detailed printed list to each Neuro-Oncology visit Take your medication regularly.

• Linking this to a routine may be helpful (when you brush your teeth, prepare for bed, etc.).

• There are also devices that can help like a watch that beeps when your dose is due or special blister packaging that is pre-dosed Get enough sleep- lack of it can bring on epileptic seizures

Nursing Management Epilepsy• (1) Objectives of care:• (a) Determine and treat underlying cause of seizures if

possible. • (b) Prevent recurrence of seizures and therefore allow patient

to live a normal life. • (2) Institute and reinforce the importance of anticonvulsant

drug therapy:• (a) Drug therapy is a means of controlling the condition; it is

not a cure. • (b) Initially, dosage will have to be monitored and altered to

provide maximum control with minimum side effects. • 3) Instruct patient to keep record of events surrounding

his/her seizures (number, duration, time, sleep/eating patterns).

• (4) Use of multidisciplinary approach to cope with social, emotional, and vocational pressures of the person with epilepsy.

• (5) Place a padded tongue blade and oral airway at the patient's bedside. Tape them to the headboard or wall above the bed. This provides easy emergency access.

• (6) Take the seizure prone patient's temperature with a rectal thermometer; prevents possibility of patient biting an oral thermometer if a seizure should occur.

• 7) Set up suction equipment at the patient's bedside. • (a) Check the equipment daily to be sure it is working properly. • (b) Use during or after a seizure to clear the patient's airway. • (8) Essential steps necessary to protect the patient during a seizure.• (a) Turn patient on his side to provide for drainage of oral

secretions. • (b) Do not forcibly restrain patient during seizure. • (c) Remove objects that may obstruct breathing or cause injury to

patient. • (d) Protect patient's head from injury with pillow, blanket, etc.

Cont…• (9) Essential steps necessary to ensure safety of the

patient following a seizure.• (a) Keep bed flat and patient turned on his side until he

is alert. • (b) Room lighting should be dim and noise kept to a

minimum. • (c) Loosen restrictive clothing (if not done during

seizure). • (d) Check vital signs immediately following seizure and

every 30 minutes (or as ordered) until patient is alert. • (e) Check lips, tongue, and inside of mouth for injuries. • (f) If patient is incontinent, change clothing and

bedding with as little disturbance as possible.