PATHOPHYSIOLOGY of CVA (Stroke)

Modifiable Factors

Non Modifiable Factors

Smoking, Obesity, Hypertension, High Cholesterol Level, Excessive Alcohol Consumption, Drug Addiction, High Dose of estrogen OC, Diabetes Mellitus, Atrial Fibrillation, Type A personality, Sedentary Life Style

Age, Family History of CVA, Family History of DM, Sex (Men), Race

Weight Loss

Destruction of alpha and beta cells of the pancreas

Polydipsia

Polyuria

Polyphagia

Failure to produce insulin Production of excess glucagon Inc. Ketones

Inc. osmolarity due to glucose

Inc. serum glucose level

Production of glucose from protein and fat stores

Acidosis

Acetone breath Wasting of lean body mass

Glycoprotein cell wall deposits

Fatigue Weight loss

Impaired immune function (decrease level of morphonuclear leukocytes)

Small vessel disease

Diabetic Nephropathy Neuropath y

Accelerated atherosclerosis

Infection

Delayed wound healing

Diabetic Retinopathy

Renal Disease

Symmetri cal loss of protective sensation

Hypertension Loss of vision Blindness Increase LDL levels

Numbness and tingling in the extremities

Autonomic neuropathy

Dry cracked skin

Wasting of intrinsic muscle

Gastro paresis

Impotence Charcot changes in joints

Neurogenic bladder

Thrombus Emboli

CEREBROVASCULAR ACCIDENT Hemiparesis Decreased Tissue perfusion (brain) Loss of speech Hemisensory loss Cerebral Hypoxia Syncope/ Vertigo Cerebral ischemia Long term Eschemia (>1015mins)

Short term Eschemia (<1015mins)

Temporary Deficit

Permanent Deficit

No permanent damage

Irreversible damage

MID CEREBRAL ARTERY

ANTERIOR CEREBRAL A.

POSTERIOR CEREBRAL A.

VERTEBROBASILAR ARTERY

Hemiparesis/ Hemiplegia

Visual Changes

Dysphagia

Dysarthia

Horners Syndrome

Aphasia

Apraxia

Agnosia

Hemisensory loss

Ataxia

Unilarteral Neglect

Incontinence

DEFINITION OF DISEASE] Cerebrovascular accident (CVA) is the medical term for what is commonly termed as stroke. It refers to the injury to the brai n that occurs when flow of blood to brain tissue is interrupted by a clogged or ruptured artery, causing brain tissue to die because of lack of nutrients and oxygen. A stroke (sometimes called a cerebrovascular accident (CVA)) is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain, caused by a blocked or burst blood vessel. This can be due to ischemia (lack of glucose and oxygen supply) caused by thrombosis or embolism or due to a hemorrhage. As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or inability to see one side of the visual field. A stroke is a medical emergency and can cause permanent neurological damage, complications, and death. Stroke is a term used to describe neurologic changes caused by an interruption in the blood supply to part of the brain. Two major types of stroke are ischemic and hemorrhagic. Ischemic stroke is caused by thrombotic or embolic blockage of blood flow to the brain. Bleeding into the brain of all tissue or the The subarachnoid remaining space causes a are hemorrhagic stroke. Ischemic strokes account for about 83% strokes. 17% of strokes hemorrhagic. Cerebrovascular disorders are the third leading cause of death in United States and account for about 164, 000 mortalities annually. An estimated 550,000 strokes people experience a stroke each year. When second strokes are considered in the estimates, the incidence increases to 700, 000 per year in the united States alone. Stroke is a leading cause of adult disability and leading primary diagnosis for long term care. More than four million stroke survivors are living with varying degrees of disability in the United States. Along with a high mortality rate, strokes produce significant morbidity in people who survive them. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

Vascular Disease which includes C.V.A. is the second leading cause of death in the Philippines with a total of 51,680 according to DOH 2004. Along with this are 37,092 who survived with it. (http://www.doh.gov.ph/kp/statistics/morbidity) New therapies can now prevent or limit the extent can now prevent or limit the extent of damage to brain tissue caused by acute ischemic stroke. Thrombolytic therapy must be administered as soon as possible after onset of the stroke; a treatment window 3 hours from the onset of manifestations has been established. To convey this sense of urgency regarding the evaluation and treatment of stroke, health care professionals now refer to stroke as brain attack. Public education is focused on prevention, recognition of manifestation, and early treatment of brain attack. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005) Diabetes Mellitus is a chronic systemic disease characterized by either a deficiency of insulin or a decreased ability of the body to use insulin Diabetes mellitus is sometimes referred to as high sugars by both clients and health care providers. The notion of associating sugar with diabetes is appropriate because the passage of large amounts of sugar-laden urine is characteristic of poorly controlled diabetes. However high levels of blood glucose are only one component of the pathologic process and clinical manifestation associated with DM. DM can be associated serious complications, but people with diabetes can take preventive measures to reduce the likelihood of such occurrences. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005) Modifiable and Non Modifiable Factors 1. Modifiable

a.

Smoking

nicotine

content

of

cigarettes

causes

a. Age Intracranial hemorrhage is most often secondary to hypertension and is most common after age 50 years. b. Family history of CVA Family history of stroke increase

vasoconstriction there by resulting hypertension which may lead to CVA. b. Hypertension this is due to plaque deposits on the wall of the arteries which causes narrowing of the blood vessel thereby causing hypertension which may lead to

ones risk c. Family history of DM Family which has history of DM especially type 2 is high risk of having stroke due to accelerated atherosclerosis. d. Sex (Male) Incidence of stroke in men is slightly higher

hemorrhagic stroke. c. Obesity This is due to increase cholesterol in the body which may contribute plaque formation that will narrow the blood vessel or may cause thrombus formation. d. Hyperlipidemia too much lipid in the blood may cause increase plaque formation which may cause thrombus formation. e. Drug addiction This may cause vasopasm, hypertension, hypercoagulability and cerebral eschemia which may cause CVA.

than that of women. e. Race (more prevalent among African Americans than whites or Hispanics) SIGNS AND SYMPTOMS DIABETES MELLITUS HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) Diabetes Mellitus type II may be due to lack of

physiologically active insulin that stimulates glucose uptake in the muscles and tissues. Therefore, it leads to an accumulation of glucose in the intravascular space. The glucose is not utilized by the body and it remains in the blood stream. POLYURIA Polyuria is an increased frequency of urination. This may be

f.

Excessive

alcohol

consumption

heavy

alcohol

consumption increases ones risk of a stroke, light or moderate alcohol may protect against ischemic stroke. g. High dose Estrogen Oral Contraceptives increases the risk of stroke in women. h. Diabetes Mellitus The mechanism is related to macrovascular changes in people with diabetes mellitus. There is an increase viscousity of blood which may cause formation of thrombus formation. i. Atrial fibrillation pulling of blood from poorly emptying atrial which leads to formation of tiny clots in Left atrium which can move on the cerebral circulation. j. Type A personality stress causes hypertension thereby increasing chance of having hemorrhagic stroke. k. Sedentary lifestyle increase of having DM and Obesity which one of the factors of having CVA Non-Modifiable

due to the osmotic diuretic effect of the glucose, wherein it attracts water during urination. When you have diabetes, excess sugar (glucose) builds up in your blood. Your kidneys are forced to work overtime to filter and absorb the excess sugar. If your kidneys can't keep up, the excess sugar is excreted into your urine along with fluids drawn from your tissues. This triggers more frequent urination, which may leave you dehydrated. POLYDIPSIA Polydipsia is an increased thirst and fluid intake. This may be due to the activation of the thirst center in the hypothalamus resulting from the intracellular dehydration or volume depletion caused by excessive urine production. POLYPHAGIA

Increased hunger and food intake. Because glucose cannot enter cells of the satiety center of the brain without insulin, the satiety center in the hypothalamus is stimulated resulting in a hunger sensation as if there were very little blood glucose, resulting in an exaggerated appetite. BODY MALAISE This is due to the decreased glucose uptake by the tissues leading to decreased energy production.

Testing

the

urine

for

microalbuminuria

shows

early

nephropathy, long before it would be on routine urinalysis, ANEMIA If there are renal affectations, this might bring to decrease production of erythropoietin which brings to decrease production of RBC from the bone marrow that may result to anemia. CEREBROVASCULAR ACCIDENT

GLYCOSURIA Clinical Manifestations The kidney filters the blood, making it to its normal state. Glucose was filtered out and excreted in the urine. Due to the excess glucose ad compared to the kidney threshold, which results to the excretion of glucose in the urine. BLURRED VISION Diabetes can affect the lens, vitreous, and retina, causing visual symptoms. Visual blurring may develop acutely as the lens changes shape with marked changes in blood glucose concentrations. This effect, which is caused by osmotic fluxes of water into and out of the lens, usually occurs as hyperglycemia increases. WEIGHT LOSS Despite eating more than usual to relieve constant hunger by the stimulation of satiety center, weight loss may still exist. Without the glucose supplies, muscle tissues and fat stores may deplete. SLOW-HEALING SORE AND FREQUENT INFECTION High levels of blood sugar impair your body's natural healing process and your ability to fight infections. For women, bladder and vaginal infections are especially common. TINGLING SENSATION/ NUMBNESS IN THE HAND AND FEET Excess sugar in your blood can lead to nerve damage. You may notice tingling and loss of sensation in your hands and feet, as well as burning pain in your arms, hands, legs and feet. PROTEINURIA
2. Aphasia defects on using and interpreting symbols of language 3. Apraxia - a condition in which a client can move the affected part but cannot use it for purposeful actions. 4. Homonymous Hemianopsia a defective vision or vision loss in the same half of the visual field. 5. Agnosia a problem in interpreting visual, tactile or other sensory information. 1. Hemiparesis/Hemiplegia the former means weakness of one side of the body while the latter means paralysis of one side of the body.

1. headache and vomiting due to an increase ICP which causes cerebral edema, and compressing the medulla oblongata 2. seizures due to hyper-excitability of neurons because of irritation. 3. changes in mental status affectation in the RAS 4. fever affectation in the hypothalamus 5. ECG changes problem with the medulla oblongata Warning Signs 1. transient hemiparesis 2. loss of speech 3. hemisensory loss 4. vertigo/syncope
Specific Deficits

6. Dysarthia imperfect articulation condition. 7. Kinesthesia alteration in sensation. 8. Incontinence due to inattention, memory lapses, emotional factors, and inability to communicate. 9. Shoulder pain severe pain in the affected shoulder after CVA 10. Horners syndrome paralysis of sympathetic nerves to the eye causing sinking of the eyeball, ptosis of the upper eyelid, constriction of pupil, and lack of tearing in the eye. 11. Unilateral neglect inability to respond to stimulus on the contralateral side. 12. Dysphagia (01/29/09 -01/31/09) difficulty of swallowing 13. Ataxia (01/29/09 -01/31/09) Problem with motor coordination