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1. STROKESTROKE
Presenter:Presenter:
Abdul MajidAbdul Majid
Aga Khan University HospitalAga Khan University Hospital
Date:Date: 19 Jan 201519 Jan 2015

2. LEARNING OBJECTIVESLEARNING OBJECTIVES
• Define Stroke, And Its Types?Define Stroke, And Its Types?
• What Is TIA?What Is TIA?
• Discuss Causes & Risk Factor OfDiscuss Causes & Risk Factor Of
Stroke?Stroke?
• Assess Sign & Symptom Of Stroke?Assess Sign & Symptom Of Stroke?
• Discuss The Diagnosis & Management.Discuss The Diagnosis & Management.
• Nursing Diagnosis & Consideration.Nursing Diagnosis & Consideration.
• Complication Of Stroke.Complication Of Stroke.

3. 3
How Serious Is Stroke in theHow Serious Is Stroke in the
USUS??
• About 700,000 strokes occur eachAbout 700,000 strokes occur each
year.year.
• Over 167,000 deaths each year.Over 167,000 deaths each year.
• #3 killer.#3 killer.
• A leading cause of serious long-termA leading cause of serious long-term
disability in adults.disability in adults.
• 4.7 million stroke survivors.4.7 million stroke survivors.

4. Relative Incidence of AtherothromboticRelative Incidence of Atherothrombotic
Stroke and MI by Age and GenderStroke and MI by Age and Gender

5. STROKESTROKE
A stroke is caused by the interruption ofA stroke is caused by the interruption of
the blood supply to the brain, usuallythe blood supply to the brain, usually
because a blood vessel bursts or isbecause a blood vessel bursts or is
blocked by a clot. This cuts off theblocked by a clot. This cuts off the
supply of oxygen and nutrients, causingsupply of oxygen and nutrients, causing
damage to the brain tissue.damage to the brain tissue.
Also called “Also called “brain attackbrain attack”, cerebral”, cerebral
infarction, cerebral hemorrhage,infarction, cerebral hemorrhage,
ischemic stroke or strokeischemic stroke or stroke

6. TYPES:TYPES:
1) ISCHEMIC STROKE1) ISCHEMIC STROKE
Occurs when a clot or a mass clogs a bloodOccurs when a clot or a mass clogs a blood
vessel, cutting off the blood flow to brain cells.vessel, cutting off the blood flow to brain cells.
The underlying condition for this type ofThe underlying condition for this type of
obstruction is the development of fatty depositsobstruction is the development of fatty deposits
lining the vessel walls. This condition is calledlining the vessel walls. This condition is called
atherosclerosis.atherosclerosis.
Almost 85% of strokes are ischemicAlmost 85% of strokes are ischemic
ATHEROSCLEROSISATHEROSCLEROSIS
It’s the process in which deposits of fattyIt’s the process in which deposits of fatty
substances, cholesterol, cellular waste products,substances, cholesterol, cellular waste products,
calcium and other substances build up in the innercalcium and other substances build up in the inner
lining of an artery. This buildup is called plaque.lining of an artery. This buildup is called plaque.

7. 2) HEMORRHAGIC STROKE2) HEMORRHAGIC STROKE
• Results from a weakened vessel that ruptures andResults from a weakened vessel that ruptures and
bleeds into the surrounding brain. The bloodbleeds into the surrounding brain. The blood
accumulates and compresses the surrounding brainaccumulates and compresses the surrounding brain
tissue.tissue.
• About 15% of all strokes but responsible for 30% ofAbout 15% of all strokes but responsible for 30% of
stroke deathsstroke deaths
TWO (02) TYPESTWO (02) TYPES
 SUBARACHNOID HEMORRHAGE (SAH)SUBARACHNOID HEMORRHAGE (SAH)
occurs when a blood vessel on the surface of the brainoccurs when a blood vessel on the surface of the brain
ruptures and bleeds into the space between the brain and theruptures and bleeds into the space between the brain and the
skullskull
 INTRACEREBRAL HEMORRHAGE (ICH)INTRACEREBRAL HEMORRHAGE (ICH)
Occurs when a blood vessel bleeds into the tissue deep withinOccurs when a blood vessel bleeds into the tissue deep within
the brain.the brain.

8. Two Major Types of StrokeTwo Major Types of Stroke

9. Transient Ischemic StrokeTransient Ischemic Stroke
(TIA)(TIA)
• When blood flow to part of the brain stops forWhen blood flow to part of the brain stops for
a short period of time, also called transienta short period of time, also called transient
ischemic attack (TIA). These symptomsischemic attack (TIA). These symptoms
appear and last less than 24 hours beforeappear and last less than 24 hours before
disappearing. While TIAs generally do notdisappearing. While TIAs generally do not
cause permanent brain damage, they are acause permanent brain damage, they are a
serious warning sign that a stroke mayserious warning sign that a stroke may
happen in the future and should not behappen in the future and should not be
ignored.ignored.
• When people use the term "ministroke," whatWhen people use the term "ministroke," what
they're really often referring to is a transientthey're really often referring to is a transient
ischemic attack (TIA) — a temporaryischemic attack (TIA) — a temporary
interruption of blood flow to part of the brain.interruption of blood flow to part of the brain.

10. Up to approximately 30% of people who sufferUp to approximately 30% of people who suffer
transient attacks (TIAs) will develop a stroketransient attacks (TIAs) will develop a stroke
within 5 years.within 5 years.

11. DIRECT CAUSES:DIRECT CAUSES:
• CEREBRAL THROMBOSISCEREBRAL THROMBOSIS
• a blood clot or plaque blocks an artery thata blood clot or plaque blocks an artery that
supplies a vital brain centersupplies a vital brain center
• CEREBRAL HEMORRHAGE/ANEURYSMCEREBRAL HEMORRHAGE/ANEURYSM
• an artery in the brain bursts, weakens thean artery in the brain bursts, weakens the
aneurysm wall; severe rise in BP causinganeurysm wall; severe rise in BP causing
hemorrhage and ischemiahemorrhage and ischemia
• CEREBRAL EMBOLISMCEREBRAL EMBOLISM
• a blood clot breaks off from a thrombus elsewherea blood clot breaks off from a thrombus elsewhere
in the body, lodges in a blood vessel in the brainin the body, lodges in a blood vessel in the brain
and shuts off blood supply to that part of the brainand shuts off blood supply to that part of the brain

12. • RISK FACTORS:RISK FACTORS:
• Being over age 55Being over age 55
• Being an African-AmericanBeing an African-American
• Having diabetesHaving diabetes
• Having a family history of strokeHaving a family history of stroke
• MEDICAL STROKE RISKMEDICAL STROKE RISK
• Previous strokePrevious stroke
• Previous episode of transient ischemic attack (TIA)Previous episode of transient ischemic attack (TIA)
• High cholesterolHigh cholesterol
• High blood pressureHigh blood pressure
• Heart diseaseHeart disease

13. Risk Factors for Stroke ThatRisk Factors for Stroke That
Cannot Be ChangedCannot Be Changed
• Increased ageIncreased age
• Being maleBeing male
• Race (e.g., African-Americans)Race (e.g., African-Americans)
• Diabetes mellitusDiabetes mellitus
• Prior stroke/transient ischemic attacksPrior stroke/transient ischemic attacks
• Family history of strokeFamily history of stroke
• Asymptomatic carotid bruitAsymptomatic carotid bruit

14. Risk Factor For Stroke:Risk Factor For Stroke:
TreatableTreatable
MajorMajor
• HypertensionHypertension
• Heart disease, esp. atrial fibrillationHeart disease, esp. atrial fibrillation
• Cigarette smokingCigarette smoking
• Transient ischemic attacksTransient ischemic attacks
• DyslipidemiaDyslipidemia
• Physical inactivityPhysical inactivity
• ObesityObesity

15. Common STROKE symptomsCommon STROKE symptoms
Weakness or paralysisWeakness or paralysis
Numbness, tingling, decreased sensationNumbness, tingling, decreased sensation
Vision changesVision changes
Speech problemsSpeech problems
Swallowing difficulties or droolingSwallowing difficulties or drooling
Loss of memoryLoss of memory
Vertigo (spinning sensation)Vertigo (spinning sensation)
Loss of balance and coordinationLoss of balance and coordination
Personality changesPersonality changes
Mood changes (depression, apathy)Mood changes (depression, apathy)
Drowsiness, lethargy, or loss of consciousnessDrowsiness, lethargy, or loss of consciousness
Uncontrollable eye movements or eyelidUncontrollable eye movements or eyelid
droopingdrooping

16. ACT F.A.S.TACT F.A.S.T
F – FACEF – FACE
• Ask the person to smile. Does one side of the face droop?Ask the person to smile. Does one side of the face droop?
A – ARMSA – ARMS
• Ask the person to raise both arms. Does one arm driftAsk the person to raise both arms. Does one arm drift
downward?downward?
S – SPEECHS – SPEECH
• Ask the person to repeat a simple sentence. Does theAsk the person to repeat a simple sentence. Does the
speech sound slurred or strange?speech sound slurred or strange?
T – TIMET – TIME
• Call 911 ImmediatelyCall 911 Immediately

18. ASSESSMENTASSESSMENT
Monitor for signs and symptomsMonitor for signs and symptoms
• Symptoms will vary based on the area of the brain thatSymptoms will vary based on the area of the brain that
is not adequately supplied with oxygenated bloodis not adequately supplied with oxygenated blood
• Assess/Monitor Airway patencyAssess/Monitor Airway patency
• Swallowing ability/aspiration riskSwallowing ability/aspiration risk
• Level of consciousnessLevel of consciousness
• Neurological statusNeurological status
• Motor, sensory and cognitive functionsMotor, sensory and cognitive functions
• Glasgow Coma Scale scoreGlasgow Coma Scale score

19. Left and Right Hemisphere Stroke:Left and Right Hemisphere Stroke:
Left (Dominant)Left (Dominant)
Hemisphere Stroke:Hemisphere Stroke:
Right (Non-dominant)Right (Non-dominant)
Hemisphere Stroke:Hemisphere Stroke:
• AphasiaAphasia
• Right hemiparesisRight hemiparesis
• Right-sided sensory lossRight-sided sensory loss
• Right visual field defectRight visual field defect
• Poor right conjugate gazePoor right conjugate gaze
• DysarthriaDysarthria
• Difficulty reading, writing,Difficulty reading, writing,
or calculatingor calculating
• Neglect of left visual fieldNeglect of left visual field
• Extinction of left-sidedExtinction of left-sided
stimulistimuli
• Left hemiparesisLeft hemiparesis
• Left-sided sensory lossLeft-sided sensory loss
• Left visual field defectLeft visual field defect
• Poor left conjugate gazePoor left conjugate gaze
• DysarthriaDysarthria
• Spatial disorientationSpatial disorientation

20. STROKE PREVENTIONSTROKE PREVENTION
• Get screened for high BP.Get screened for high BP.
• Have your cholesterol level checked.Have your cholesterol level checked.
LDL should be lower than 70 mg/dL.LDL should be lower than 70 mg/dL.
• Follow a low-fat diet.Follow a low-fat diet.
• Quit smoking!Quit smoking!
• Exercise!Exercise!
• Limit alcohol intake!Limit alcohol intake!

21. DiagnosisDiagnosis
• HistoryHistory
• Examination.Examination.
• (whooshing sound over neck,(whooshing sound over neck,
which may indicate hardening orwhich may indicate hardening or
narrowing (atherosclerosis) of thenarrowing (atherosclerosis) of the
carotid arteries.)carotid arteries.)
• use an ophthalmoscope to checkuse an ophthalmoscope to check
for signs of tiny cholesterolfor signs of tiny cholesterol
crystalscrystals or clots in the bloodor clots in the blood
vessels at thevessels at the back of your eyes.back of your eyes.
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22. Cholestrol level:Cholestrol level:
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23. Continue. .Continue. .
• Computerized tomography (CT) scan.Computerized tomography (CT) scan.
• Magnetic resonance imaging (MRI).Magnetic resonance imaging (MRI).
• Carotid ultrasound.Carotid ultrasound.
• Cerebral angiogram.Cerebral angiogram.
• Echocardiogram.Echocardiogram.
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24. TreatmentTreatment
• Anticoagulants (Heparin, Warfarin)Anticoagulants (Heparin, Warfarin)
• Antiplatelets (aspirin, clopidogrelAntiplatelets (aspirin, clopidogrel
• StatinStatin
• ARB (-sartan), or ACE inhibitor + HCTZARB (-sartan), or ACE inhibitor + HCTZ
• Carotid endarterectomy if indicatedCarotid endarterectomy if indicated
• Carotid or intracranial stent.Carotid or intracranial stent.
• Risk factor control!!!Risk factor control!!!

25. NURSING DIAGNOSISNURSING DIAGNOSIS
• Ineffective tissue perfusion (cerebral)Ineffective tissue perfusion (cerebral)
• Disturbed sensory perceptionDisturbed sensory perception
• Impaired physical mobilityImpaired physical mobility
• Risk for injuryRisk for injury
• Self-care deficitSelf-care deficit
• Impaired verbal communicationImpaired verbal communication
• Impaired swallowingImpaired swallowing

26. NURSING CONSIDERATIONSNURSING CONSIDERATIONS
• Maintain patent airwayMaintain patent airway
• Monitor for changes in the client’s level ofMonitor for changes in the client’s level of
consciousnessconsciousness
• Assist with communication skills if the client’sAssist with communication skills if the client’s
speech is impaired.speech is impaired.
• Assist with safe feeding.Assist with safe feeding.
• Assess swallowing reflexes.Assess swallowing reflexes.
• Thicken liquid to avoid aspiration.Thicken liquid to avoid aspiration.
• Eat in an upright position and swallow with the head and neckEat in an upright position and swallow with the head and neck
flexed slightly forward.flexed slightly forward.
• Place food in the back of the mouth on the unaffected side.Place food in the back of the mouth on the unaffected side.
• Suction on standby.Suction on standby.

27. Continue. . .Continue. . .
• Maintain skin integrity.Maintain skin integrity.
• Encourage PROM every 2 hr to the affected extremitiesEncourage PROM every 2 hr to the affected extremities
and AROM every 2 hr to the unaffected extremities.and AROM every 2 hr to the unaffected extremities.
• Elevate the affected extremities to promote venousElevate the affected extremities to promote venous
return and to reduce swelling.return and to reduce swelling.
• Maintain a safe environment to reduce the risks of falls.Maintain a safe environment to reduce the risks of falls.
• Provide care to prevent deep-vein thrombosisProvide care to prevent deep-vein thrombosis
(sequential compression stockings, frequent position(sequential compression stockings, frequent position
changes, mobilization)changes, mobilization)

28. ComplicationsComplications
• Loss of Muscle Control/ParalysisLoss of Muscle Control/Paralysis
• Speech ProblemsSpeech Problems
• Swallowing DifficultiesSwallowing Difficulties
• Cognitive ImpairmentsCognitive Impairments
• NumbnessNumbness
• PainPain
• Loss of IndependenceLoss of Independence
• Personality and Mood ChangesPersonality and Mood Changes
• DepressionDepression
• Shortened Life SpanShortened Life Span
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29. THAT’S iT..!!THAT’S iT..!!
THANK YOU FORTHANK YOU FOR
LiSTENiNG!LiSTENiNG! 