COLLEGE OF NURSING

BERHAMPUR

SUBJECT- MEDICAL SURGICAL NURSING

TOPIC- CVA
SUBMITTED TO- SUBMITTED BY-
Mrs Shantilata Das Miss Anwesha
Tutor MSc Nursing 2nd yr
MSc in Medical Surgical Nursing

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SL NO PAGE NO
CONTENT
1 DEFINITION 3

2 INCIDENCE 3

3 TYPES 3

4 ETIOLOGY AND RISK FACTOR 3

5 PATHOPHYSIOLOGY 4

6 CLINICAL MANIFESTATION 5

7 DIAGNOSTIC EVALUATION 6

8 MANAGEMENT
 MEDICAL MANAGEMENT
 PHARMACOLOGICAL MANAGEMENT
 NON PHARMACOLOGICAL MANAGMENT 6-9
 SURGICAL MANAGEMENT
 NURSING MANAGEMENT

9 COMPLICATION 10

10 CONCLUSION 10

11 BIBLIOGRAPHY 10

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INTRODUCTION
The brain is the body’s center of thinking, feeling physical function. A continuous blood supply is
essential to maintain function in the brain. Any disruption of blood flow causes the brain area to be
deprived of oxygen and cell death begins to occur in as little as 4 minutes. The effects of oxygenation
deprivation vary depending upon the area of brain involved and the length of time the brain is deprived
of oxygen. If the blood flow is not restored to the deprived area in time, fatal conditions may arise.

DEFINITION-
 CVA is an interruption of the blood supply to any part of the brain resulting in a sudden loss of
brain function due to lack of oxygen. A stroke is sometimes called as “brain attack”.
 According to WHO “CVA is a focal neurological defect due to local disruption in blood supply
to brain. Its onset is usually abrupt but may extend over a few hours or longer.”

If the neurologic deficit exists for >24 hours, only then it is termed as Stroke or CVA.
If neurologic deficits exists < 24 hours, it is called as Transient Ischemic Stroke (TIA)

INCIDENCE
 It is the 3rd biggest killer in India after heart attacks and cancers.
 A stroke happens every 40 sec and every 4 minutes, someone dies of stroke.
 The incidence of CVA increases with age. Mainly people between 40- 60 years of age are
affected.
 Brain strokes occurs 30% more in man than women. Man are more likely to have a thrombic
stroke and have better chance to survive from this & embolic stroke where as more likely to have
hemorrhagic stroke.

TYPES OF CVA
1) Ischemic stroke-It accounts for 83% of all types of strokes. It is of 2 types.
a) Embolic
b) Thrombotic
2) Hemorrhagic stroke-It accounts 17% of all types of strokes. It is of 2 types-
a) Intra cerebral
b) Sub arachnoid

ETIOLOGY AND RISK FACTORS-

Modifiable factors-
Pathologic disorders-Hypertension, cardiac disease, diabetes Mellitus

Lifestyle factors-
 Excessive alcohol consumption and cigarette smoking
 Obesity
 Drug abuse
 Sedentary lifestyle
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Non modifiable Factors-
 Age
 Gender
 Race
 Hereditary

CAUSES-
A. Cerebral Thrombosis- An athermanous plaque of hard fatty degenerative material may form in
the artery of brain, resulting in clot formation. It may increase in size and finally blocking the
blood vessels completely. The clot prevents blood flowing to brain and cells are starved of
oxygen.
B. Cerebral embolism-Cerebral embolism is a clot that forms elsewhere in the body before
travelling through the blood vessels and lodging in the brain. Piece of clot may break and moved
by blood until it lodged in a vessel which is too small to allow them pass further.
C. Cerebral hemorrhage-It is when the blood vessels bursts inside the brain and bleeds & rushes
into and through the brain destroying the brain tissue by its sheer force. It occurs due to-
 Weakness in vessels wall
 High BP
 Age above 55 years
 Cerebral aneurysm
 Arteria venous malformation

PATHOPHYSIOLOGY-
Due to etiological factors

Vasoconstriction

Bloackage of blood vessels

Lack of oxygen and nutrient supply

Hypoxia

Altered cerebral metaboliusm

Decreased cerebral perfusion

Local acidosis

Cytotoxic edema

Brain tissue necrosis

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CLINICAL MANIFESTATION
A stroke may produce different sign and symptoms depending upon the type, location and extend or
brain injury.

Hemorrhagic stroke-

 Severe headache that the patient describes as the “worst headache of my life.”
 stiff neck
 loss of consciousness
 vomiting
 Seizure
Embolic stroke-Symptoms appear without warning. One sided weakness
 Numbness
 Visual problems
 Confusion
 Memory lapse
 Dysphagia
 Language problem

Thrombotic Stroke-

 Confusion and memory loss

 Vision loss
 Slurred speech
Many signs and symptoms are related to the location of the damage.

RIGHT BRAIN DAMAGE LEFT BRAIN DAMAGE

 Paralyzed left side: Hemiplegia  Paralyzed right side: Hemiplegia
 Spatial- Perceptual deficits  Impaired speech, language
 Tends to deny or minimize problems  Impaired right/left discrimination
 Rapid performance, short attention span  Aware of deficits: depression and anxiety
 Impaired judgment  Impaired comprehension related to
 Impaired time concepts language, math.

Long term effects are-

 Aphasia-.Receptive Aphasia- Wernicke area, Expressing Aphasia- Broca’s area,

Dysarthria- Damage of upper motor neurons
 Dysphasia
 Dyspraxia
 Hemiplegia
 Sensory impairment
 Unilateral neglect- more common in right hemisphere damage

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  Homonymous Hemianopsia- It is a perceptual problem that involves the loss of one
side of field vision on same side of both eyes.
Eg- At meal time the patient may leave half of the plate untouched
The patient may shave his face completely on one side leave untouched other side.
 Elimination Disturbances

DIAGNOSTIC EVALUATION
 Complete physical and neurological examination
 CT Scan, MRI
 CT with Angiography
 Conventional Angiogram- A long catheter tube is inserted into an artery in the groin/ arm and
threaded into the arteries of brain. Dye is injected while X rays are taken and information can be
obtained about blood flow in the brain.
 Carotid doppler ultrasound- A noninvasive test that uses spend wave to look for narrowing or
stenosis
 Heart test- to know the source of embolism.
 Laboratory test- CBC, lipid levels (HDL & LDL), cardiac enzymes, blood glucose level to rule
out the simultaneous heart attack.

MANAGMENT-
 Medical Management
 Surgical Management
 Nursing Management

Medical Management-
A stroke is a medical emergency. Immediate treatment can survive lives and reduce disability.
Prompt restoration of blood flow to the area of blockage can prevent further damage.

 THROMBOLYTIC- Thrombolytic breaks the part of the blood clot and restore blood flow in
ischemic stroke by dissolving clots.
According to protocol tPA may be given.
tPA -
 Tissue plasminogen activatoris a protein involved in the breakdown of blood clots. It is
a serine protease found on endothelial cells, the cells that line the blood vessels. As
an enzyme, it catalyses the conversion of plasminogen to plasmin by binding to fibrin.

Intravenous-

 Rapid diagnosis of stroke and initiation thrombolytic therapy (with in 3 hour) in patient
with ischemic stroke leads to decrease the size. Delay makes the patient ineligible for
therapies because the re vascularization of necrotic tissue develops after 3 hours. Overall
improvement is seen after 3 months.
 The goal for intravenous t-PA to be given within 60 min of patient arriving to ED.

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  Generally, 2 IV sites are preferable prior administration to t-PA.
 Dosage- 0.9mg/kg with a maximum dose of 9omg. 10% of calculated dose is given bolus
for 1 min. The remaining 90% is given IV over 1 hour via an infusion pump.

Intra- arterial-

 This allows higher concentration of drug to be given directly to the clot. Treatment using
intra-arterial delivery must occur in specialized center with access to emergent cerebral
angiogram & interventional operating rooms.
 The patient who doesn’t not meet criteria for intravenous may not eligible for intra-
arterial.

Before receiving t-PA the patient is assessed using the National Institute of Health Stroke Scale
( NIHSS), a standardized assessment tool helps to evaluate the stroke severity. Score range is 0-42. (0-
normal and 42- severe).

Side effects-

 Once it is determined that the patient is a candidate for t-PA therapy, no anticoagulant
agents are given for the next 24 hours.
 Bleeding is the most common side effect of t-PA.

 ANTICOAGULANT-This is also called as blood thinners. The individual who does not meet
the criteria for t-PA may be given antiplatelet medicine (e.g-asipirin) or anticoagulant (IV
heparin or low molecular weight Heparin).

Managing other medical problem-

 Providing oxygen if the saturation is below 95%
 Blood pressure should be tightly controlled
 Elevation of bed up to 30 degrees (handling oral care and for decrease ICP)
 Intubation with an endotracheal tube
 Frequent neurological assessment if the stroke is evolving and the determining the acute
complications

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Surgical Management-
Ischemic stroke-
Carotid end arteriotomy-
Bypass graft-
Thrombectomy

Hemorrhagic stroke–

 In case of aneurysm-
Surgical clipping- Clip is placed in neck of aneurysm to stop bleeding.
Surgical Coiling- A long thin tube is inserted through the tube into the aneurysm “balloon” to fill
the space and seal off the bleeding.
 In case of hematoma-Craniotomy may be required.

Nursing Management-
Ischemic stroke- The acute phase of ischemic data last for 1-3 days, but ongoing monitoring of all body
system is essential as long as the patient requires care.

Assessment-
Subjective data-
 Numbness
 Visual problems
 Confusion
 Memory lapse
Objective data-
 Health history-present illness
 Vital sign
 Face symmetry
 Voluntary movement
 Sensation

Nursing diagnosis-1Acute pain related to inflammation and increased disease activity, or lowered
tolerance level.
Goal- To Improve comfort level; incorporate pain managementtechniques into daily life.
Intervention- Asses pain quality, intensity, frequencyand duration of pain.
- Provide comfortable position to thepatient.
- Restrict activitythat causes pain.
- Application ofheating pad to the lower abdomen.
- Administer anti- inflammatory, analgesic, medications as prescribed.
Evaluation- Pain reduced to some extend asevidence by pain score measurement 1/10 and patient’s
verbalization ofdecreased pain intensity

Nursing diagnosis-2- Inadequate nutrition less than body requirement related to decrease oral
intake as evidence byweight loss.
Goal- To improve nutritional status of the patient.

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 Intervention- Asses dietary pattern, preference.
- Assess factor contributing alterednutritional intake for anorexia and vomiting.
- Close monitoring ofintake and abnormal losses.
- Promote highcaloric food.
- Asses abdomen frequently foe return of softness, bowel sound, passage of flatus.
- Administer supplementation and medication as prescribed.
Evaluation- Nutritional status is enhanced as evidence by increase intakeof food by patient and weight
measurement

Nursing diagnosis-3- Deficit fluid volume related to vomiting and third space shift as evidence by
dry mucus membrane, poor skin turgor.
Goal- To improve fluid volumestatus.
Intervention- Monitor vitalsigns.
- Assess skin turgor, colour, condition, status of oral mucus membrane.
- Monitor intake output chart.
- Administer IV infusion, antiemetic, RL as prescribed.
- Provide adequate bed rest and bland diet.
Evaluation- Maintain adequate hydration, as evidenced by stable vital signs, good skin turgor, and
capillary refill time.

Nursing diagnosis-4- Activity intolerance related to generalized body weakness secondary to

progressive disease asevidence by inability to perform ADL.
Goal- To improve activity level of the patient
Intervention- Assess degree ofactivity tolerance and degree of fatigue.
- Teach energyconservation technique.
- Assist in scheduling a gradual increase indaily activity and exercise.
- Asses the nutritional status.
- Encourage rest inbetween works.
- Administer medication as prescribed.
Evaluation- Activity levelincreased as evidence by patient able toperform ADLwith minimal assistance.

Nursing diagnosis-5- Risk for injury related to paralysis as evidence by complete bed rest
Goal- The patient will have no fall or injury.
Interventions-.Keep the bed in low position and side rails raised.
- Put the call bell within the reach on unparalyzed side.
- Monitor the position of affected extremities to prevent trauma that might not be detected because
of poor sensation.
- Use sling or brace in order to support the affected brace.

Nursing diagnosis-6- Inadequate knowledge regarding therapeutic regimen as evidence by inability to

answer properly.
Goal: Patient will verbalize knowledge of disease and its management.
Interventions: Asses clients’ knowledge of care, review the disease process
- Encourage verbalization of fear, feeling.
- Clarify doubts if any.
- Reinforce importance of follow up.
Evaluation: patient will verbalize understanding of disease and its management.
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Rehabilitation-
 Rehabilitation begins once when the patient is stabilized.
 Encourage the patient to do as much as her work as possible to increase independence.
 Teach activities of daily living. ADL includes bathing, dressing, toileting, gait training.
 Encourage family participation
 Teach the patient transfer technique (bed to chair)

COMPLICATION-
 Deep vein thrombosis
 Pulmonary embolism
 Aspiration Pneumonia
 Post stroke depression
 Bed sore
 Hospital acquired sepsis

CONCLUSION
CVA is medical emergency which can be prevented if the risk factors are reduced. In case of
stroke the patient must instantly brought to the hospital and be given immediate intervention. Some
complications may be avoided if the patient is closely monitored and given due attention and care. The
manifestation and recovery depend upon the area affected, severity of brain damage and bleeding in the
patient’s brain.

BIBLIOGRAPHY

1. Ansari J, Kaur D.,(2018),A Text book of Medical Surgical Nursing, S Vikas and company Pee
Vee Publication, India, Page no-335-342
2. Basavanthappa B T. Essential of Medical Surgical Nursing, 17st edition, JAYPEE publishers,
page no-96-113.
3. Cheever K.H ,Hinkle J.L,(2018),South Asia edition Brunner and Suddarth’s Text Book of
Medical Surgical Nursing, Wolter Kluwer Publishers, India, Page no-1712-1735,Volume I.
4. Ignatavicius, Workman. Medical Surgical Nursing-patient centred collaborative care.8th edition.
Elsevier publishers, page no-566-577.
5. Lewis L.S, Linda B., (2014). Lewis’s Medical-Surgical Nursing: Assessment and Management
of Clinical Problems, 2nd edition, Elsevier Publishers, Canada,-page no-610-627, Volume I.
6. Williams S.L., Hopper, P.D, Understanding Medical Surgical Nursing, 3rd edition, 2007, F. A.
Davis Company publishers, Philadelphia, page no-532-545.

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