Disorder of Nervous System 1 : Stroke

& Traumatic Brain Injury

Medical & Surgical Nursing II

SN 3712
Intended learning outcome

 By the end of this session, students are expected to be able to…

 1) Recognize the pathophysiology of stroke
 2) Identify the types, risk factors and epidemiology of stroke.
 3) Recognize the early warning signs & sign/symptoms of stroke
 4) Understand the nursing assessment, intervention and evaluation of stroke
patient
Cerebral Vascular Disorder

 Cerebrovascular disorders is an umbrella term to describe a functional

abnormality of the central nervous system (CNS)
 Many people refer it as stroke
 It occurs when the normal blood supply to the brain is disrupted
Epidemiology

 Cerebrovascular disorder (or Cerebrovascular Disease) claimed about 27000

in-patient discharges and in-patient deaths in all hospitals with 3423
registered deaths in Hong Kong in 2010
 Fourth commonest cause of death in Hong Kong and accounted for 8% of all
deaths in 2012
 Age-standardized death rates:
 30.4 for male per 100000 population in 2010
 21.0 for female per 100000 population in 2010
Classification of Cerebrovascular disease
/ stroke
Two broad categories of stroke
 Haemorrhage
 Characterized by too much blood with the closed cranial cavity
 Ischemia
 Characterized by too little blood to supply an adequate amount of oxygen and
nutrients to a part of the brain
 Each categories can be divided into subtypes that differences in causes,
clinical courses, outcomes and treatment strategies
Stroke (Overview)

 Statistics (Black & Hawks, 2015)

 – 83% of all = ischaemic stroke
 – 17% of all = hameorrhagic stroke
 – Survivors: 31% needed self‐care assistance; 71% had some verbal
impairment; 16% institutionalized
 Only 16.8% pt could arrive AED within 150 min. (PMH, 2016)
 In psychiatric ward, particularly psychogeriatric ward, stroke patient is not
uncommon
Brain ischemia / ischemic stroke

3 main subtypes
 Thrombosis
 The obstruction may be due to disease of the arterial wall, such as arteriosclerosis
or dissection
 A local problem
 Embolism
 Particles of debris originating elsewhere that block arterial access to a particular
brain region
 Non-local problem
 Systemic hypoperfusion
 More general circulatory problem
Picture source: Catangui, E. J. & Slark, J. (2012). A thrombolysis pathway for
patients following acute ischaemic stroke. Nursing Standard, 26(31): 35-42.
Brain ischemia / ischemic shock -
Thrombosis
Thrombotic strokes can be further divided into:
 Large, or
 Small vessel disease
The causes, outcomes and treatment are different
Thrombotic strokes –
Large vessel diseases
 Severe stenosis ->promote formations of thrombi-> breaks off and embolize
 Vascular obstruction->reduced blood flow-> makes circulation less competent
at washing out and clearing these emboli
Thrombotic strokes –
Large vessel diseases
Pathologies affecting both large extracranial AND intracranial vessels includes:
DATEX
 Atherosclerosis (most common)
 Dissection (a tear in the inner wall of the vessel)
Thrombotic strokes –
Small vessel diseases
 Affects the intracerebral arterial system, specifically penetrating arteries
that arise from the distal vertebral artery, the basilar artery, the middle
cerebral artery stem and the arteries of the circle of Willis
Brain ischemia - Embolism

Embolic strokes are further divided into 4 categories

 Those with a known source that is cardiac origin (Most common)
 Those with a vascular sources (such as atheromatous plaques in wall of aorta,
carotid arteries or smaller cerebral vessels)
 Those with a paradoxical sources
 (1) congenital atrial septal defects that leads emboli cross from (Rt sided) venous
circulation to (Lt sided)arterial circulation -> Rare source
 (2) Deep venous thrombosis (DVT) -> Common source
 Those with a truly unknown source in which tests for embolic sources are all
negative
Symptoms

Symptoms depends on which region of the brain affected

 Since the embolus suddenly blocks the recipient site -> onset of the symptom
is abrupt and usually maximal at the start
 Unlike thrombosis, which usually affect a single site (remember it is a local
problem), embolic subtype may affect multiple site when the source is the
heart
Hemorrhagic stroke - Primary

 As a spontaneous intracerebral haemorrhage

 Caused by bleeding into the brain tissue, the ventricles or the subarachnoid
space
 Primarily caused by intracranial or subarachnoid hemorrhage
 Primary intracerebral hemorrhagic caused by spontaneous rupture of small
vessels (80%) – mainly caused by uncontrolled hypertension
 Patients who survive the acute phase usually have more severe deficits and a
longer recovery phase compared to those with ischemic stroke
Hemorrhagic stroke - Secondary

 As an identified vascular malformation

 Secondary intracerebral hemorrhage is associated with:
 Arteriovenous malformations (AVMs)
 Intracranial aneurysms
 Ruptured intracranial aneurysm (a weakening in the arterial wall) account 50% of the
subarachnoid hemorrhage

 Intracranial neoplasms
Risk Factor
Intrinsic Extrinsic
Advancing age Hypertension
Men DM
Ethnicity (Black>white) Carotid stenosis
Family history Smoking, alcohol, cocaine abuser
Stroke (Summary)
Ischemic Stroke Hemorrhagic Stroke

Sudden loss of function Sudden loss of function resulting

resulting from from intracranial or
disruption of the blood subarachnoid hemorrhage
to part of the brain
Causes Blocking of a cerebral Intracerebral hemorrhage
blood vessel by subarachnoid hemorrhage
thrombus, embolus,
hypotension
Largely artery Common vessels involved:
Types thrombosis 20% Anterior cerebral artery
Small penetrating Anterior communicating artery
artery thrombotic Internal carotid artery
strokes 25% Middle cerebral artery
Cardiogenic embolic Intracranial aneurysm
strokes 20%
Cryptogenic strokes
30% (no known causes)
Left vs. Right Hemispheric stroke

Left Right

Paralysis or weakness on right side of Paralysis or weakness on left side of

body body

Right side visual deficit Left side visual deficit

Aphasia (Expressive, receptive or Spatial-perceptual deficits

global)
 Left Vs Right

Left side of brain involved Right side of brain involved

Right hemiplegia Spatial perceptual deficit
Aphasia Tendency for distractibility
Intellectual Impairment Impulsive behavior
Slow movement Poor judgment
Deficit in right vision Deficit in left vision
Warning signs of stroke
Facial dumpress .

Arm weakness
difficulties.
speech
Time to call ambulance .

 Weakness, paralysis, in-coordination, +/-sensory loss of the arm or leg

 Asymmetric facial weakness, +/- sensory loss
 Dysarthria or aphasia
 Monocular or binocular visual loss
 Ataxia, poor balance or difficulty in walking
 Vertigo, diplopia, nausea or vomiting
 Stupor or coma, confusion, agitation or seizure
(Cheung, 2001)
Warning signs of strokes (cont’d)

 Severe headache
 Nausea, & vomiting
 Photophobia
 Phonophobia
 Neck stiffness
(Cheung, 2001)
Clinical Manifestation (Physical Aspects)

 Stroke can cause a wide range of neurological problem

 The extent, types, and severity of the problem depends on the location of the
lesion (vessels under affected), size of the area of inadequate blood supply,
and the amount of blood supply.

Communication
Motor Loss
loss

s/s

Perceptual
Sensory Loss
Disturbance
 Clinical manifestation (Physical Aspects)

 Motor loss
 Area of brain involved: upper motor neuron
 Loss of voluntary control over motor movement
A disturbance of voluntary motor control of one side of the
body may reflect damage to the upper motor neuron on the
opposite side of the brain
 Hemiplegia & Hemiparesis is the most common sign
 Clinical Manifestation (Physical Aspects)
 Communication Loss:
 Dysarthria (Difficulty in speaking)
 Speech impairment
 Caused by paralysis of the muscle responsible for producing speech
 Dysphasia (Impaired ability in expression by speech)
 Patientcan think clearly and know what they're feeling, and their intellect is
maintained
 Aphasia (more severe form of dysphasia. Loss of ability in expression by speech)
 Able to hear the sounds but unable to give meaning and comprehend the message
 Able to speak but makes many errors when using words
 Apraxia (inability to perform a previous learned action)
Clinical manifestation (Physical Aspects)
 Perceptual disturbance
 Caused by disturbance of the primary sensory pathway between
the eye and visual cortex
 Hemianopsia (Loss of half of the visual field)
 Loss of peripheral vision
 Unware the border of object
 Diplopia
 Double vision
 Clinical Manifestation

 Sensory loss
 Sensory problems can have different effects on
different people depending on the area of
damage. Some of the effects include:
 Unable to feel touch or pressure
 Unable to feel exactly where they are being
touched.
 Unable to feel where their arm or leg is.
 Unable to feel the difference between hot and cold.
Clinical Manifestation other than
physical signs
 Cognitive Impairments:
 Involved area of brain: Frontal lobe, then learning,
memory or other intellectual functions may be affected
 Limited attention span
 Difficulties in comprehension
 Forgetfulness

 Lack of motivation
 Emotional problems:
 Depression, labile mood, hostility, frustration,
resentment, lack of cooperation.
Decorticate & Decerebrate movement
 Decorticate movement
 Abnormal flexion characterized by flexion, adduction and internal rotation of
wrists and arms to the chest with rigidly extended legs
 indicates cortico‐spinal tract injury near the hemisphere
 Decerebrate movement
 abnormal extension characterized by extension, pronation of arm with rigidly
extended legs
 Indicates diencephalon or upper brain stem injury
Diagnostic test

 Computerized Tomography (CT) contrast

 Computerized Tomography (CT) without contrast
 Magnetic resonance imaging (MRI)
 Magnetic resonance angiogram (MRA)
Transient Ischemic Attack (TIA)
 A stroke condition with s/s resolve within 24 hours
 May caused by atheroma, variable blood flow across a stenotic area or to emboli
 Forewarning of stroke
 Prevention of stroke
 Modification of risk factors, e.g. HT, Obesity, hyperlipidemia
 Anti-platelet treatment e.g. aspirin, ticlid
 Treat underlying causes such as Hypertension
 Surgical intervention like carotid artery angioplasty and stenting
Management

 3-6 hours for neuro-protective agents (nimodipine) aid to

reduce cerebral vasospasm
 Thrombolytic agent (clots breaking, [Link] (rt-pa))
 Use ASAP (within 3 hours) to ischemic stroke due to thrombosis
/embolism lead to reduce the size of stroke
 Improves functional and neurological outcome (Reperfusion)
 Maintain airway, breathing & oxygen to avoid hypoxia
 Avoid hypo and hyper-glycaemia to reduce risk of cerebral edema
 Prevention of hospital acquired infection (URTI, UTI)
Nursing Management
 AOM
 Anti‐thrombotic therapy
 Asparin

 Ticlid (ticlopidine)
 Plavix (Clopidogrel)
 Heparin

 Warfarin (for embolic stroke only)

 ASSESSMENT TOOLS
 ACUTE
 NIH STROKE SCALE
 GLASCOW COMA SCALE (GCS) & Neurological Observation
 REHAB
 Barthel index (for ADL) & MoCA (for Cognitive impairment)
Nursing Management
 Assess the type and degree of impairment using various tools,
e.g. Barthel Index, neurological observation & NIH Stroke Scale
 Assess diminished or absence of response to sensation, visual acuity / visual field
 Provide slings, braces, support shoes, wheelchairs, sticks, and home modifications
(OT/PT)
 Teach patient alternative methods of mobility and restore Activities of Daily Living
 Provide for Passive ROM exercise
 Position of affected limbs and protect involved areas
 Promote self care
 Education on the prevention of injury
 Nursing Management
 For visual problem: Hemianopsia (Loss of half of the visual field)
 Position person, call light, bedside stand, TV / telephone and lockers on the unaffected side
 Position the bed with unaffected side is towards the door / entrance
 Approach and speak to person from unaffected side
 Alert the client when approaching from affected side to avoid startling the person
 ADL
 Assisted Bathing
 Assisted Clothing
 Walking aids
 Toileting
 Encourage patient to void Q3H
 Offer toilet reminder for patient with cognitive disability after meal / before bedtime
 Monitor patient I/O & incontinence
Nursing Management
 For eating
 Instruct to have small amounts; place food on unaffected side of the mouth; check
and sweep out ‘pockets’ of food from affected side after every bite; provide oral
care; put the food initially in the visual field, then train patient to scan the
environment
 Sitting a patient upright
 Ensuring that he or she is comfortable and relaxed
 Giving him or her plenty of time
 Checking the consistency of his or her food
 Ensuring that small amounts of food are taken
 Concentrate on each swallow
 Pause between mouthful
 Encourage lip closure
 Providing oral care after each meal
 Ensuring that the patient sits upright for 30 minutes after finishing food
 Identify the problems of dysphagia and the needs for referring to Speech therapist
for Swallowing assessment
 Nursing management

 For communication
 Consult speech therapist if needed
 Reduce environmental noise
 Encourage patient to speak
 Slow down speech and to speak louder
 Ask questions requiring short answers to avoid frustration and fatigue
 If speech is unintelligible, teach client to use gestures, writing messages and flash cards
 Do not alter the tone, speed and type of message and speak on adult level
 Explain and reassure the problem of frustration about inability to communicate
 Teach relatives and significant others techniques and repetitive approaches to improve
communication
 Provide alternative ways of communication
 E.g. flash cards with pictures or words for basic/frequent needs, pens and pads, number and letter
Traumatic Brain Injury
Medical & Surgical Nursing
Intended learning Outcomes

 By the end of this lecture student is expected to be able to

 1) Recognize the types of head injury
 2) Identify to major sign and symptoms of head injury and
increased ICP
 3) Understand the basic acute nursing assessment and
management of head injury
Traumatic Brain Injuries

 Head injuries are a major cause of morbidity and mortality in the

community
 In fact, it is not uncommon in psychiatric hospital setting
 Type
 Concussion:
 After the injury, patient with temporary loss of neurologic function
with no apparent structure change
 Contusion:
A moderate to severe head injury, the brain is bruised and damaged in
a specific area
• Motor vehicle accidents (MVA)
• Industrial/occupational accidents • Falls
• Physical assault
• Home accidents
 Traumatic Brain Injury
 Opened injury
 caused by an object penetrates the skull and enters the
brain.
 Open head injuries are usually focal
 affect a specific area of brain tissue
 Can be very serious and cause permanent disability and
even death
 Traumatic Brain Injury

 Closed Injury
 a trauma in which the brain is injured as a result of a blow
to the head, or a sudden, violent motion that causes the
brain to knock against the skull.
 Bleeding inside the skull
 Intracranial Haemorrhage
 Epidural: epidural / extradural haematoma
 Subdural: subdural haematoma
 Subarachnoid space: subarachnoid haematoma
 Brain parenchyma: laceration
 May develop delayed complications over the next few
hours or days.
Example of intracranial hemorrhage
Clinical Manifestation
Signs Symptoms
LOC/Increased drowsiness Scalp swelling
confusion Headache
Personality change (Become irresponsible) Visual difficulties
Increased ICP Slurred speech
Bounding pulse Stiff neck
Slow breathing Nausea
convulsion vomiting
Irritability, restless
Become very irritable, the bus man)
Abnormal skull x ray
Increased intracranial pressure (ICP)
 The pressure inside the cranium maintained by a dynamic equilibrium (blood, CSF,
brain matter)
 Normal ICP oxygen & nutrients perfuse to the brain effectively
 Normal intracranial pressure (ICP) = 0 ‐ 15 mmHg
 Focus on identifying the early warning sign of increased intracranial pressure (ICP) and
prevent the deterioration of the traumatic brain injury such as brain herniation
 Sustained high ICP brain herniation tonsillar herniation: may cause immediate death)
 Cushing’s Traid (signs of ICP):
 – Increased BP: attempt to compensate cerebral ischaemia due to increased ICP
 – Decreased HR: a parasympathetic vagal response
 – Abnormal respiratory patterns (suggests brainstem dysfunction & exhaustion of
compliance mechanism to maintain normal ICP –
 Increased ICP requires aggressive treatment. Patient may be cared in ICU
Nursing Management
 Assessment
 History taking
 When did the injury occur?
 What caused the injury
 What was the direction and force of blow
 Assess the level of consciousness
 Glasgow Coma Scale
 Neurological observation (Will cover in lab)
 Level of consciousness
 Pupil size
 Muscle power
 Vital Signs
 Glasgow Coma Scale
 Procedure
 Eye opening:
 Observe eye opening without speaking to patient to see whether patient looks around.
 If not, call his name.
 If no response again, use a mildly painful stimulus, given in the central part of the
body, such as rubbing sternum or squeeze trapezius muscle or pinch patients earlobe.
 Avoid supraorbital pressure
 Verbal response:
 Ask appropriate questions to assess patient’s orientation to “time”, “place” &
“person”.
 Motor response:
 Ask the client to follow specific commands such as “raise your right arm” to assess
motor response. Don’t ask patient to squeeze hand as it may be a reflex action after
head injury.
 If patient is unable to follow command observe his response to a painful stimulus.
Compare the right and left extremities.
 Lowest GCS score: 3
 Highest GCS score: 15
 8 or below indicates coma
Nursing Management
 Assessment on vital signs
 Vital signs / neurological functions are inextricably linked through
haemodynamics of the homeostatic mechanisms (e.g. brainstem:
control centres for respiration & cardiovascular functions)
 Blood pressure (increased)
 Cushing Triad (irregular respiration; bradycardia; raised SBP & declined
DBP)
 Temperature (hyperthermia)
 Observe the trend over time to determine if the patient is stable,
Nursing management
 Nursing intervention aims at
• Prevent secondary injury to the brain • Achieve normal CP(0–15mmHg)
• Promote comfort, Prevent complications, Planning for recovery
 Principles of care
 Maintain effective airway (consider cervical spine precaution)
 Maintain effective respirations and oxygenation
 Maintain effective circulation and cerebral perfusion
 Maintain ICP (monitor ICP, BP, MAP, CPP, ventilation)
 Maintain optimal position for CSF drainage (positioning)
 Maintain Body Temperature (hypothermia?)
 Maintain comfort / hygiene
 Maintain nutrition / hydration
 Maintain normal elimination
 Maintain advocacy for patient and relatives support
Reference:
1. Centre for Health Protection. (2012). Cerebrovascular Disease. <
[Link] > (Accessed on 21 Jan
2013).
2. Caplan, L. R. (1989). Intracranial branch atheromatous disease: a
neglected, understudied, and underused concept. Neurology, 39(9):1246.
3. Catangui, E. J. & Slark, J. (2012). A thrombolysis pathway for patients
following acute ischaemic stroke. Nursing Standard, 26(31): 35-42.
4. Cross, S. (2008). Stroke care: a nursing perspective. Nursing Standard,
22(23): 47-56.
5. Collins, C. (2007). Pathophysiology and classification of stroke. Nursing
Standard, 21(28): 35-39.