Introduction
Cerebrovascular accident
CVA occurs when there is ischemia to a part of the brain or hemorrhage into the brain that results in death of brain cells. Functions such as movement, sensation or emotions that were controlled by the affected area of the brain are lost or impaired.1
70% of CVA occur in low-middle income countries and the subsequent disease burden is greater than that of high income countries. According to the Indian Stroke Association (ISA) There has been more than 100 per cent increase in incidence of stroke in low- and middle-income countries including India from 1970-1979 to 2000-2008.2
Risk Factors 3
Types of Stroke
Ischemic stroke
Thrombotic stroke
It occurs from injury to a blood vessel wall and formation of a blood clot.
The lumen of the blood vessel narrowed and if it becomes occluded, infarction occurs.4
Lacunar stroke
Refers to a stroke from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue.This most commonly occurs in the basal ganglia, thalamus, internal capsule and pons. 4, 5
Embolic stroke
It occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved blood vessels (24%) 4
-
Haemorrhagic stroke
-
Intracranial haemorrhage 4
ICH is bleeding within the brain caused by a rupture of a vessel and accounts for about 10% of all stroke. HTN is the common cause.
Occurs in the putamen and internal capsule, central white matter, thalamus, cerebellar hemispheres and pons.
Putaminal and internal capsule bleeding include weakness of one side, slurred speech and deviation of the eyes.
Thalamic haemorrhage results in hemiplegia with more sensory motor loss.
Cerebellar haemorrhage are characterized by severe headache, vomiting, dysphagia, difficulty walking.
Haemorrhage in pons is the most serious because basic life function are rapidly affected. It can be characterized by hemiplegia leading to complete paralysis, coma, abnormal body posture, fixed pupils, hyperthermia and death.
-
Subarachnoid haemorrhage
-
Pathophysiology 6
Table 1
Clinical manifestations of right-brain and left-brain stroke 6
Warning Signs of Stroke 6
Diagnostic Evaluation 7
Management
Emergency management of stroke
Initial Management 6
Ensure patent airway.
Call a stroke code or the stroke team.
Remove dentures.
Perform pulse oximetry.
Maintain adequate oxygenation with supplemental oxygen, if necessary.
Establish IV access with normal saline.
Maintain BP according to guidelines.
Remove tight clothing.
Obtain CT scan immediately.
Perform baseline laboratory tests immediately, and treat if hypoglycaemic.
Position head midline.
Elevate head of bed 30 degree. If no symptoms of shock or injury, elevate the bed.
Initiate seizure precautions.
Anticipate thrombolytic therapy for ischemic stroke.
A Case Study
A case study of a X ,59 years male ,married, hailing from Kokrajhar came to BH admitted in Intensive Care Unit on 13/08/2023 with the complain of Syncope ,Not able to move right side of the body since 4 days,Face drooping at right side since 4 days, Loss of sensation in right side of the body since 4 days, Not able to eat food properly since 4 days, Difficulty speech since 4 days ,Patient was unconscious and was transferred to the ICU in stretcher and after various lab investigation, diagnostic procedures, patient was diagnosed as CVA and was treated with Tissue Plasminogen Activator and is under observation .
Past history of illness
Childhood illness- Patient has no history of childhood illness except seasonal common cold and cough, diarrhoea, fever.
Adulthood illness, any current medication- patient has a history of hypertension since 6 years and is under anti-hypertensive medications.
Psychiatric illness- No history
Injuries, hospitalization- No history
Diagnostic and surgical procedures- patient has not undergone any surgical procedures before but has undergone USG, ECG and other blood investigations.
History of blood transfusion- No history
Use of alcohol and other drugs- patient use to drink occasionally 8 years back.
Family history of illness
4 members, Family history of hypertension is present. Patient’s grandfather, father and mother were hypertensive, Patient’s both parents expired and siblings are healthy, wife and children’s health status is good,Patient’s parents were hypertensive but no history of CVA presen,vaccination and immunization- Patient has been immunized with polio, Hep B, DPT and TT, patient is well- nourished ,Non-vegetarian,Personal hygiene- well- maintained ,Bowel and bladder habit- Normal,no historyAllergy to any drug, patient is engaged in active assisted exercise. Previously, before hospitalization he use to go exercise everyday,patient has insight about the disease and believes that he will be healthy.
Socio-economic history
Source of income- patient himself is the source of income,Income per month- Approx 50,000/-, patient house is pucca house and well-furnished. patient’s house is well-ventilated with doors, windows and proper day light and electricity is available,Govt. supply as well as hand pump is present and drainage is closed drainage system.good and healthy relationship with family members, Govt medical college, private hospitals, nursing homes are available near patient’s residence patient beliefs in spirituality and have faith on god and visit temple occasionally. Family origin or ancestors- patient has origin in Assam.
Physical examination
Patient is well-nourished and nutritional status is well-maintained. Body type is mesomorphic.
Body movement- patient has hemiplegia at right side.
Mental status- patient is conscious but not well oriented to time, place and person
Drooping of right side of face is seen
Corneal reflex is absent in rt eye
Pupil constricts to the light reaction but rt pupil dilates.
Restricted ROM due to hemiparesis
Rt extremities are not functioning properly, loss of sensation is present.
Preventive Management (Medications) 8, 9
Tenecteplase
Activates conversion of plasminogen to plasmin. Plasmin breaks down clots (fibrin), fibrinogen, factors V, VII, occlusion of venous access lines.
Dose/Route- 50mg given over 5 sec, IV
Indication- Acute MI, Coronary artery thrombosis
Contraindication- Arteriovenous malformation, aneurysm, active bleeding, intracranial/intraspinal surgery, CNS neoplasm
Side-effects- Dysrhythmias, hypotension, pulmonary embolism, cardiogenic shock, HF, rash, urticaria, retroperitoneal bleeding.
Nursing responsibility- Assess for any allergic reaction, evaluate therapeutic response resolution of MI.
PT, PTT must be done before starting therapy
Teach proper dental care to avoid bleeding and notify prescriber of bleeding.
Amlodipine
inhibits calcium ion influx across cell membrane during cardiac depolarization; produces relaxation of coronary vascular smooth muscles, peripheral vascular smooth muscle, dilates coronary vascular arteries, increases myocardial oxygen delivery in patients with vasospastic angina.
Dose/Route- 10mg/day per oral
Indication- chronic stable angina pectoris, hypertension, variant angina
Contraindication- hypersensitivity, severe aortic stenosis, severe obstructive CAD
Side-effects- headache, anxiety, peripheral edema, bradycardia, syncope, nausea, vomiting, gingival hyperplasia, nocturia
Nursing responsibility- Assess cardiac status, jugular vein distension
Atrovastatin
inhibits HMG-COA reductase enzyme, which reduces cholesterol synthesis; high doses lead to plaque regression.
Dose/Route- 10mg HS per oral
Indication- hypercholesterolemia, dysbetalipoproteinemia, elevated triglyceride levels
Contraindication- pregnancy, breast feeding, active hepatic disease
S/E- lens opacities, asthenia, abdominal cramps, UTI, arthralgia, myalgia
Nursing responsibility- Assess hypercholesterolemia, renal studies in pt with compromised renal system
Blood test and eye examination be necessary during treatment.
Medical management
Recombinant tissue plasminogen activator (tPA)- it must be administered within 3 hours of the onset of clinical signs of ischemic stroke.
Acetylsalicylic acid (Aspirin)- it is used within 48 hours of the stroke complication. Aspirin administration should be done cautiously if the patient has a history of peptic ulcer disease.
Platelet inhibitors- Aspirin, ticlopidine, clopidogrel, dipyridamole
Anticoagulants and platelet inhibitors are contraindicated in patients with haemorrhagic strokes.
Calcium channel blockers (Nimodipine)- given in subarachnoid haemorrhage to decrease the effects of vasospasm and minimize cerebral damage.
Seizure occurs in 5% to 7% of stroke patients in the first 24 hours. Anti-seizure drug such a phenytoin is given.
Nursing Management 11, 12
Past health history
Addiction- use of oral contraceptives, compliance with anti-hypertensive and anticoagulant therapy.
Health perception-health management- positive family h/o stroke, alcohol abuse smoking.
Nutritional-metabolic- Anorexia, nausea, vomiting, dysphagia, altered sensation of taste and smell.
Activity- loss of movement, syncope, generalized weakness.
Cognitive-perceptual- numbness, tingling of one side of the body, loss of memory, alteration in speech and language, visual disturbance, denial of illness.
Ineffective cerebral tissue perfusion related to interruption of blood flow secondary to thrombosis as evidenced by GCS 8/15, SpO2 85%
Impaired verbal communication related to residual aphasia, loss of facial muscle tone as evidenced by refusal and inability to speak, inappropriate verbalization.
Disturbed sensory perception related to neuromuscular dysfunction as evidenced by patient not responding to external stimulus in the rt side of the body.
Self-care deficit related to neuromuscular impairment and decreased strength and endurance in the rt side of the body as evidenced by inability to perform ADLs without assistance.
Risk for impaired skin integrity related to hemiplegia and decreased mobility.
General Prevention 10
Controlling high blood pressure.
Lowering the amount of cholesterol and saturated fats.
Quitting tobacco use.
Managing diabetes.
Maintaining a healthy weight.
Eating a diet rich in fruits and vegetables.
Exercising regularly.
Treating obstructive sleep apnea.
Preventive medications (aspirin, clopidogrel, warfarin)