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StrokeStrokeby
Ann Van EerdenApril, 2011
byAnn Van Eerden
April, 2011
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Learning OutcomesLearning Outcomes Learner will define CVA Learner will distinguish the causes of CVA Learner will state risk factors for CVA Learner will recognize clinical manifestations of
a stroke Learner will identify the nursing diagnosis “at
risk for falls.” Learner will discern conditions related to risk for
falls Learner will develop nursing outcomes and
interventions
Learner will define CVA Learner will distinguish the causes of CVA Learner will state risk factors for CVA Learner will recognize clinical manifestations of
a stroke Learner will identify the nursing diagnosis “at
risk for falls.” Learner will discern conditions related to risk for
falls Learner will develop nursing outcomes and
interventions
Table of ContentsTable of Contents Welcome to Your Clinical What is a Stroke? Causes of Stroke Risk Factors Clinical Manifestations “At Risk for Falls” Conditions Related to “At Risk for Fa
lls” References
Welcome to Your Clinical What is a Stroke? Causes of Stroke Risk Factors Clinical Manifestations “At Risk for Falls” Conditions Related to “At Risk for Fa
lls” References
Welcome to the first day at your new clinical site!
You learn that the patient you have been assigned for the day has a medical diagnosis
of stroke, more specifically, a left sided cerebrovascular accident. Would you like to
continue?
Welcome to the first day at your new clinical site!
You learn that the patient you have been assigned for the day has a medical diagnosis
of stroke, more specifically, a left sided cerebrovascular accident. Would you like to
continue?
Yes! No, I think I am going to drop this class.
Before you make that decision, please stay for awhile; you’ll feel
much better after this tutorial!
Before you make that decision, please stay for awhile; you’ll feel
much better after this tutorial!
Your instructor greets you and introduces you to the night nurse who immediately
begins giving you report. This is your first time on a medical unit. Your mind is
racing; you are trying to recall everything that you remember about stroke, and
nothing comes to mind. Would you like a review?
Your instructor greets you and introduces you to the night nurse who immediately
begins giving you report. This is your first time on a medical unit. Your mind is
racing; you are trying to recall everything that you remember about stroke, and
nothing comes to mind. Would you like a review?
Yes, please! No thanks, I’ve decided to change my major.
Ha! Ha! But, before you make that official, you might feel better if you take a few minutes to review stroke
with this tutorial.
Ha! Ha! But, before you make that official, you might feel better if you take a few minutes to review stroke
with this tutorial.
A stroke is a BRAIN ATTACK! It means that there is an interrupted flow of blood to the brain.
What do you think might cause this interruption?
A stroke is a BRAIN ATTACK! It means that there is an interrupted flow of blood to the brain.
What do you think might cause this interruption?
A ThrombusYou are correct! Is
there anything else?
An EmbolismYou are correct! Is
there anything else?
A HemorrhageYou are correct! Is
there anything else?
A thrombus is the most common cause of stroke. It accounts for 60% of all strokes.
It occurs more often in men.The onset is usually during or after sleep.The signs and symptoms develop slowly.
(Lewis, 2004, p. 1528)
A thrombus is the most common cause of stroke. It accounts for 60% of all strokes.
It occurs more often in men.The onset is usually during or after sleep.The signs and symptoms develop slowly.
(Lewis, 2004, p. 1528)
An embolic stroke occurs when an embolus occludes a cerebral artery.
It occurs more often in men.
The onset is rapid.
It is a single event.(Lewis, 2004, p. 1529)
(Used with permission of Emily Gillis)
An embolic stroke occurs when an embolus occludes a cerebral artery.
It occurs more often in men.
The onset is rapid.
It is a single event.(Lewis, 2004, p. 1529)
(Used with permission of Emily Gillis)
Hemorrhagic strokes are either an intracerebral hemorrhage or a subarachnoid hemorrhage.
An intracerebral hemorrhage has a sudden onset and a very poor prognosis.
A subarachnoid hemorrhage is caused by an aneurysm and often follows
strenuous activity.(Lewis, 2004, p. 1529)
(Used with permission of Emily Gillis)
Hemorrhagic strokes are either an intracerebral hemorrhage or a subarachnoid hemorrhage.
An intracerebral hemorrhage has a sudden onset and a very poor prognosis.
A subarachnoid hemorrhage is caused by an aneurysm and often follows
strenuous activity.(Lewis, 2004, p. 1529)
(Used with permission of Emily Gillis)
Okay! The night nurse has left and its time for you to take over. Mr. C. V. Accident is still sleeping and a nursing assistant offers
to get his breakfast tray, so you have time to get organized. Let’s use the nursing
process.
Okay! The night nurse has left and its time for you to take over. Mr. C. V. Accident is still sleeping and a nursing assistant offers
to get his breakfast tray, so you have time to get organized. Let’s use the nursing
process.
Do you remember the process?Do you remember the process?
Click on each box below for a review.Click on each box below for a review.ASSESS
DIAGNOSE
PLAN
IMPLEMENT
EVALUATE
Mr. C.V. Accident’s ChartMr. C.V. Accident’s Chart Mr. C.V. Accident is a 72 year old
African- American with a history of hypertension. He is overweight, does not
exercise, and smokes one pack of cigarettes per day. His wife died last year
and since her death his diet consists primarily of fast food.
Mr. C.V. Accident is a 72 year old African- American with a history of
hypertension. He is overweight, does not exercise, and smokes one pack of
cigarettes per day. His wife died last year and since her death his diet consists
primarily of fast food.
There are a number of risk factors that contribute to stroke. Some are
modifiable, others are not.
Click here to review the modifiable risk factors.
Click here to review the non-modifiable risk factors.
There are a number of risk factors that contribute to stroke. Some are
modifiable, others are not.
Click here to review the modifiable risk factors.
Click here to review the non-modifiable risk factors.
Modifiable Risk FactorsModifiable Risk Factors Atrial fibrillation Carotid stenosis Cigarette smoking Diabetes Heavy alcohol consumption Hypercoagulability Hyperlipidemia Hypertension Obesity Oral contraceptive use Physical inactivity Sickle cell disease (Lewis, 2004, p. 1526)
Atrial fibrillation Carotid stenosis Cigarette smoking Diabetes Heavy alcohol consumption Hypercoagulability Hyperlipidemia Hypertension Obesity Oral contraceptive use Physical inactivity Sickle cell disease (Lewis, 2004, p. 1526)
Non-Modifiable Risk Factors
Non-Modifiable Risk Factors
Age Gender Race Family history Prior stroke, TIA, or heart
attack
(Lewis, 2004, p. 1525)
Age Gender Race Family history Prior stroke, TIA, or heart
attack
(Lewis, 2004, p. 1525)
Hypertension is the most important modifiable risk factor. Hypertension is a
sustained elevation in blood pressure.It is defined as a systolic blood pressure equal
to or greater than 140 mm Hg OR a diastolic blood pressure equal to or greater than 90 mm
Hg for extended periods of time.Would you like to review what happens with
hypertension? (Lewis, 2004, p.779)
Hypertension is the most important modifiable risk factor. Hypertension is a
sustained elevation in blood pressure.It is defined as a systolic blood pressure equal
to or greater than 140 mm Hg OR a diastolic blood pressure equal to or greater than 90 mm
Hg for extended periods of time.Would you like to review what happens with
hypertension? (Lewis, 2004, p.779)
Yes No thanks.
Hypertension Flow ChartHypertension Flow ChartIncreased Blood
Pressure
Injury to vessels
Inflammation
Plaque develops and leads to atherosclerosis
Risk of thrombus and emboli and INCREASED RISK FOR
STROKE
What does high blood pressure do
to the blood vessels?
What happens to injured vessels?
Do you remember what happens to the inflamed vessels?
And what does atherosclerosis
lead to?
Atherosclerosis is often described as hardening and thickening of the arteries.
How does this lead to stroke?
Atherosclerosis is often described as hardening and thickening of the arteries.
How does this lead to stroke?
Lipids in the arteries develop into
Plaque leads to narrowing and thickening of the arteries
PLAQUE
PLAQUEnarrows arteries and
can lead to hypertension and
ultimately STROKE!
PLAQUEmay break off and
occlude the artery and ultimately cause
STROKE!
Other factors affect these processes.They are:
AgingGenetics
InflammationStress
Other factors affect these processes.They are:
AgingGenetics
InflammationStress
Contribution of Aging
Contribution of Aging
Aging
Aorta and arteries decrease in elasticity
Increase in systolic blood pressure
Increased risk for stroke
What does aging do to the aorta and arteries?
What does this do to blood pressure?
Contribution of GeneticsContribution of GeneticsSickle cell disease
Increased risk of thrombus
Increased coagulation
Vessel lining becomes inflamed
Sickles adhere to endothelium
Increased risk for stroke
What do the sickle cells adhere to?
What happens to the vessel lining?
What else do these sickle cells promote?
What is the risk associated with
increased coagulation?
Contribution of InflammationContribution of InflammationInjury to Endothelial
Cell
Inflammatory cells migrate to injury
Contribute to development of atherosclerotic plaques
Atherosclerosis
Increased risk for stroke
Hypertension
Do you remember what happens to an injured
cell?
What do these cells do?
What is this plaque build up called in the
vessels?
What modifiable risk factor does this contribute to?
Contribution of the Stress ResponseContribution of the Stress ResponseStress
Sympathetic Nervous System releases epinephrine and
norepinephrine
Increased blood pressure and increased mechanical
stress
Endothelial Cell Injury
Atherosclerosis
Increased risk for stroke
Hypertension
What does stress do to the sympathetic nervous system?
What happens to your blood pressure?
Do you remember what this does to the
cells?
And this leads to hardening of the
arteries, also known as?
Do you remember which risk factor
develops because of this?
What Are Modifiable Risk Factors that Contributed to Mr. C.V. Accident’s Stroke?
What Are Modifiable Risk Factors that Contributed to Mr. C.V. Accident’s Stroke?
AgeNo, this is not
modifiable.
HypertensionYes, this is
correct.
RaceNo, race is not
modifiable.
WeightYes, this is modifiable.
Activity LevelYes, this is modifiable.
Family HistoryNo, this is not
modifiable.
DietYes, this is modifiable.
SexNo, this is not
modifiable.
HeightThis is not a risk factor.
ProfessionThis is not a risk factor.
SmokingYes, this is modifiable.
Hair ColorThis is not a risk factor.
Mr. C. V. Accident’s history indicates that while he was at church with his daughter, the
right side of his face started drooping. Suddenly, he was unable to lift his right arm,
and his speech became slurred.
Mr. C. V. Accident’s history indicates that while he was at church with his daughter, the
right side of his face started drooping. Suddenly, he was unable to lift his right arm,
and his speech became slurred.
His daughter acted quickly and immediately called 9-1-1.
His daughter acted quickly and immediately called 9-1-1.
Mr. C.V. Accident had an ischemic stroke. Because he got to the hospital in LESS THAN
THREE HOURS from the onset of his symptoms and a CT scan excluded the
diagnosis of hemorrhagic stroke, Mr. C. V. Accident received recombinant tissue-type plasminogen activator (tPA), a
thrombolytic agent.
How does tPA work?
Mr. C.V. Accident had an ischemic stroke. Because he got to the hospital in LESS THAN
THREE HOURS from the onset of his symptoms and a CT scan excluded the
diagnosis of hemorrhagic stroke, Mr. C. V. Accident received recombinant tissue-type plasminogen activator (tPA), a
thrombolytic agent.
How does tPA work?
Here is how tPA works:Here is how tPA works:
Tissue plasminogen activator (tPA) targets the
thrombus and catalyzes the conversion of
plasminogen to plasmin resulting in thrombolysis.
Tissue plasminogen activator (tPA) targets the
thrombus and catalyzes the conversion of
plasminogen to plasmin resulting in thrombolysis.
Mr. C.V. Accident is diagnosed with a left sided cerebral accident. This means that the left side of his brain has been damaged and that the right side of his body
will be impaired. Damage to the right side of his brain would result in impairment to the left side of his body.
(Used with permission of Emily Gillis)
Mr. C.V. Accident is diagnosed with a left sided cerebral accident. This means that the left side of his brain has been damaged and that the right side of his body
will be impaired. Damage to the right side of his brain would result in impairment to the left side of his body.
(Used with permission of Emily Gillis)
In your assessment, what are some of the clinical manifestations you might see with Mr. C.V.
Accident? (Remember he has a left sided CVA.)
In your assessment, what are some of the clinical manifestations you might see with Mr. C.V.
Accident? (Remember he has a left sided CVA.)
Right sided hemiplegia
Yes, you are correct!
Homonymous hemianopsia
Yes, this is the loss of the visual field at the
vertical midline of both eyes and is true of all
strokes!
Left sided weakness
No, not with a left sided CVA.
Impaired speech and language
Yes, this is true!
ImpulsivityNo, this is true for right sided
strokes.
Right sided neglect
Yes, this is true for left sided
brain damage.
Difficulty in learning new information
Yes, this is true for any stroke!
Impaired concept of timeNo, this is true for right sided
strokes.
Your assessment is complete, now, its time for a nursing
diagnoses for Mr. C.V. Accident.
Do you think Mr. C.V. Accident is at risk for falls?
Your assessment is complete, now, its time for a nursing
diagnoses for Mr. C.V. Accident.
Do you think Mr. C.V. Accident is at risk for falls?
YES MAYBE NO
Falls are one of the most common medical complications after stroke.
7% incidence first week after stroke
25%-37% incidence between one and six months post-stroke
40%-50% incidence six to twelve months after stroke
55%-73% incidence one year after stroke(Verheyden, 2010)
(Microsoft Clip Art)
Falls are one of the most common medical complications after stroke.
7% incidence first week after stroke
25%-37% incidence between one and six months post-stroke
40%-50% incidence six to twelve months after stroke
55%-73% incidence one year after stroke(Verheyden, 2010)
(Microsoft Clip Art)
So, Mr. C.V. Accident isAT RISK FOR FALLS related to
So, Mr. C.V. Accident isAT RISK FOR FALLS related to
Balance Impairment
Hemi-neglect
Self-care deficit
Cognitive impairment
Hemiparesis
Hemianopsia
Balance Impairment
Hemi-neglect
Self-care deficit
Cognitive impairment
Hemiparesis
Hemianopsia
At risk for falls related to balance impairment
At risk for falls related to balance impairment
Outcome: Mr. C.V. Accident will remain free from falls
Which nursing intervention would you use?
(Microsoft Clip Art)
Outcome: Mr. C.V. Accident will remain free from falls
Which nursing intervention would you use?
(Microsoft Clip Art)
Encourage Mr. C.V. Accident to use walking aids when ambulating.
Yes! You are correct!
Monitor Mr. C.V. Accident’s fluid intake.This may be valuable for other reasons, but it will not
decrease the risk of falls related to balance impairment.
At risk for falls related to hemi-neglectAt risk for falls related to hemi-neglect
Outcome: Mr. C.V. Accident will remain free
from falls
Which nursing intervention would you use?
Outcome: Mr. C.V. Accident will remain free
from falls
Which nursing intervention would you use?
Offer Mr. C.V. Accident frequent reminders to be aware of his left side.
You are correct!
Assess Mr. C.V. Accident’s pain level.While this may be a great intervention if Mr. C.V. Accident
exhibits signs of pain, this will not help him address his hemi-neglect.
At risk for falls related to self care deficit
At risk for falls related to self care deficit
Outcome: Mr. C.V. Accident will remain free
from falls
Which nursing intervention would you use?
(Microsoft Clip Art)
Outcome: Mr. C.V. Accident will remain free
from falls
Which nursing intervention would you use?
(Microsoft Clip Art)
Monitor Mr. C.V. Accident’s vital signs every four hours.While vital signs are important, this will not keep Mr. C.V.
Accident from falling while dressing himself.
Assist Mr. C.V. Accident with dressing.Hooray! You are correct!
At risk for falls related to cognitive impairment
At risk for falls related to cognitive impairment
Outcome: Mr. C.V. Accident will remain free from falls
Which nursing intervention would you use?
(Microsoft Clip Art)
Outcome: Mr. C.V. Accident will remain free from falls
Which nursing intervention would you use?
(Microsoft Clip Art)
Orient Mr. C.V. Accident to his environment. Include the location and way to use his call button.
Correct!
Assess neurological status with the Glasgow coma scale.This is appropriate if Mr. C.V. Accident exhibits an altered level of
consciousness, but it will not keep him free from falls.
At risk for falls related to hemiparesisAt risk for falls related to hemiparesisOutcome: Mr. C.V. Accident will remain free
from falls
Which nursing intervention would you use?
(Microsoft Clip Art)
Outcome: Mr. C.V. Accident will remain free
from falls
Which nursing intervention would you use?
(Microsoft Clip Art)
Perform neurological assessment every four hours.Sorry! This will not prevent Mr. C.V. Accident from falling.
Encourage Mr. C.V. Accident to use assistive devices for walking.Hooray! You are correct! If he uses his assistive devices, the risk for
falls will be decreased.
At risk for falls related to hemianopsiaAt risk for falls related to hemianopsiaOutcome: Mr. C.V. Accident will remain free
from falls
Which nursing intervention would you use?
(Microsoft Clip Art)
Outcome: Mr. C.V. Accident will remain free
from falls
Which nursing intervention would you use?
(Microsoft Clip Art)
Place items in Mr. C.V. Accident’s field of vision.Correct! You are doing a great job!
Encourage Mr. C.V. Accident to increase his fluid intake.While fluids are important, this will not prevent falls.
Click here to help Mr. C.V. Accident find
the knife.
Wow! Mr. C.V. Accident’s care plan is done! Its time to implement the nursing interventions, and evaluate them as the day goes on. This first
clinical is almost over and it is going very well!
Wow! Mr. C.V. Accident’s care plan is done! Its time to implement the nursing interventions, and evaluate them as the day goes on. This first
clinical is almost over and it is going very well!
ReferencesReferences
Centers for Disease Control and Prevention (n.d.). Stroke Facts. Retrieved from http://www.cdc.gov/stroke/facts.htmm.
Lewis, S.M., Heitkemper, M. M., & Dirksen, S. Medical surgical nursing: assessment and management of clinical problems, ed 6, St. Louis, 2004, Mosby.
Microsoft Clip Art
Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott. Verheyden, G., Weerdesteyn, V., Pickering, R., Hyndman, D., Lennon, S., Geurts, A., & Ashburn, A. (2010). Interventions for preventing falls in people after stroke.
Centers for Disease Control and Prevention (n.d.). Stroke Facts. Retrieved from http://www.cdc.gov/stroke/facts.htmm.
Lewis, S.M., Heitkemper, M. M., & Dirksen, S. Medical surgical nursing: assessment and management of clinical problems, ed 6, St. Louis, 2004, Mosby.
Microsoft Clip Art
Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott. Verheyden, G., Weerdesteyn, V., Pickering, R., Hyndman, D., Lennon, S., Geurts, A., & Ashburn, A. (2010). Interventions for preventing falls in people after stroke.
