PATHOPHYSIOLOGY of CVA (Stroke)

Diabetic Nephropathy

Accelerated atherosclerosis

Renal Disease

Production of glucose from protein

and fat stores

Wasting of lean body mass

Weight loss

Fatigue

Acidosis

Acetone breath

Inc. Ketones

Small vessel disease

Neuropathy

Impaired immune function

(decrease level of morphonuclear

leukocytes)

Infection Delayed wound healing

Diabetic Retinopathy

Inc. serum glucose level

Glycoprotein cell wall deposits

Inc. osmolarity due to glucose

Destruction of alpha and beta cells of the pancreas

Failure to produce insulin

Production of excess glucagon

Polydipsia Polyphagia Polyuria

Weight Loss

Modifiable Factors Non Modifiable Factors

Age, Family History of CVA, Family History of DM, Sex

(Men), Race

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

Hypertension

Increase LDL levels

Symmetrical loss of protective sensation

Numbness and tingling

in the extremities

Wasting of intrinsic muscle

Charcot changes in

joints

Autonomic neuropathy

Dry cracked skin

Gastro paresis

Impotence

Neurogenic bladder

Loss of vision Blindness

Cerebral ischemia

Long term Eschemia

(>10-15mins)

Short term Eschemia

(<10-15mins)

Temporary Deficit

Permanent Deficit

Decreased Tissue perfusion (brain)

Hemiparesis

Loss of speech

Hemisensory loss

Cerebral HypoxiaSyncope/ Vertigo

CEREBROVASCULAR ACCIDENT

Thrombus

Emboli

No permanent

damage

Irreversible damage

MID CEREBRAL ARTERY

ANTERIOR CEREBRAL A.

POSTERIOR CEREBRAL A.

VERTEBROBASILAR ARTERY

Hemiparesis/ Hemiplegia

Aphasia

DysarthiaDysphagia

Apraxia

Visual Changes

Ataxia

Agnosia Hemisensory loss

Horner’s Syndrome

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 tissue or the subarachnoid space causes a

hemorrhagic stroke. Ischemic strokes account for about 83%

of all strokes. The remaining 17% of strokes are

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

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

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.

f. Excessive alcohol consumption –heavy alcohol

consumption increases one’s 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

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

one’s 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

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

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.

GLYCOSURIA

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

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

Clinical Manifestations

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

1. Hemiparesis/Hemiplegia – the former means weakness of one side

of the body while the latter means paralysis of one side of the body.

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.

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. Horner’s 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