UNIVERSITY: DEDAN KIMATHI UNIVERSITY OF TECHNOLOGY

COURSE : BACHELOR OF SCIENCE IN NURSING

NAME : BELLE KINYA NJAGI

REG NO :H151-01-2391/2022

CLASS : SEPTEMBER 2022 DIRECT ENTRY

UNIT : Medical Surgical Nursing 3

UNIT CODE: HNS 2304

ASSIGNMENT:1: Discuss Cerebrovascular Accident (CVA)

Discuss Glasgow Coma scale

LECTURER: MR. Nicholas Mbae

SUBMITTED DATE : 08.10.2024

SIGNATURE :B.K.N
Cerebrovascular Accident (CVA)
Definition
A cerebrovascular accident, commonly known as a stroke, is a medical emergency
that occurs when blood flow to a part of the brain is interrupted or reduced,
preventing brain tissue from getting the necessary oxygen and nutrients. This can
lead to the death of brain cells and can result in lasting neurological deficits.

 Types of CVA

i. Ischemic Stroke:
 Thrombotic Stroke: Caused by a blood clot that develops in the arteries
supplying blood to the brain. Often linked to atherosclerosis.
 Embolic Stroke: Occurs when a blood clot forms elsewhere in the body
(often the heart) and travels to the brain's blood vessels.

ii. Hemorrhagic Stroke:

 Intracerebral Hemorrhage: Bleeding occurs within the brain itself, usually

due to high blood pressure or vascular malformations.
 Subarachnoid Hemorrhage: Bleeding occurs in the area between the brain
and the tissues covering it, often due to the rupture of an aneurysm.

iii. Transient Ischemic Attack (TIA):

Often referred to as a "mini-stroke," TIAs are temporary episodes of neurological

dysfunction caused by a temporary decrease in blood supply to the brain.
Symptoms typically resolve within 24 hours.

 Pathophysiology
The pathophysiological mechanisms behind CVA vary depending on the type.

a)Ischemic Stroke:
Begins with the formation of a thrombus or an embolus. Reduced blood flow
leads to a cascade of cellular events:

Ischemia: Lack of blood flow results in cellular injury and death.

Metabolic Failure: Decreased ATP production leads to impaired ion transport and
cell swelling.

Excitotoxicity: Excess release of glutamate leads to increased calcium influx,

exacerbating cell injury.

Inflammation: Ischemic cells release cytokines, attracting inflammatory cells that

can worsen tissue damage.

b)Hemorrhagic Stroke:

Results from a rupture of a blood vessel, causing bleeding into the brain or
surrounding spaces.

o Increased Intracranial Pressure: Blood accumulation can compress brain

structures, leading to further ischemia.
o Toxic Effects of Blood: Extravasated blood can have toxic effects on
surrounding brain tissue, promoting apoptosis and further damage.

 Risk factors
  Hypertension: The leading modifiable risk factor, significantly increasing
stroke risk due to damage to blood vessels over time.

 Diabetes: Poorly controlled blood sugar levels can lead to vascular damage,
raising the likelihood of stroke.

 Smoking: Tobacco use damages blood vessels and increases blood

pressure, contributing to stroke risk.

 Obesity: Excess weight is associate with hypertension, diabetes, and other

cardiovascular issues, all of which elevate stroke risk.

 Atrial Fibrillation: This heart condition can lead to the formation of blood
clots that may travel to the brain, causing ischemic strokes

 Symptoms of CVA

 Muscular: difficulty walking, paralysis with weak muscles, problems with

coordination, stiff muscles, overactive reflexes, or paralysis of one side of
the body

 Visual: blurred vision, double vision, sudden visual loss, or temporary loss
of vision in one eye

 Whole body: fatigue, light-headedness, or vertigo

 Speech: difficulty speaking, slurred speech, or speech loss

 Sensory: pins and needles or reduced sensation of touch

 Facial: muscle weakness or numbness

 Limbs: numbness or weakness

Also common: balance disorder, difficulty swallowing, headache, inability to

understand, mental confusion, or nystagmus

 Medical Management
1.Acute Treatment:

Ischemic Stroke: Administer thrombolytics (e.g., tPA) within a specific time

window to dissolve clots.

Hemorrhagic Stroke: Control bleeding and manage intracranial pressure; surgical

intervention may be required.

2.Anticoagulation and Antiplatelet Therapy:

Post-stroke management may include medications like aspirin or clopidogrel to

prevent further clot formation.

3.Blood Pressure Management:(Antihypertensive drugs)

Maintain optimal blood pressure to prevent secondary strokes or complications.

4.Cholesterol Management:

Statins may be prescribed to manage cholesterol levels and reduce stroke risk.

5.Rehabilitation:

Multidisciplinary approach involving physical therapy, occupational therapy, and

speech therapy to help patients regain function.

6.Administration of ACE inhibitors

Relaxes blood vessels, lowers blood pressure and prevents diabetes-related

kidney damage.

 Nursing Management
1.Neurological Assessment:
Regular assessment using the Glasgow Coma Scale (GCS) and monitoring for
changes in neurological status.

2.Monitoring Vital Signs:

Frequent monitoring of blood pressure, heart rate, and oxygen saturation to

detect complications.

3.Patient Safety:

Implement fall precautions and ensure a safe environment, as stroke patients

may have impaired mobility or coordination.

4.Supportive Care:

Provide assistance with activities of daily living (ADLs), ensuring comfort and
safety. Assess and manage swallowing difficulties, if present.

5.Patient and Family Education:

Educate patients and families about stroke prevention, lifestyle modifications, and
the importance of adherence to prescribed therapies.

Conclusion

Cerebrovascular accidents represent a significant health concern, requiring

prompt medical intervention and comprehensive nursing care. Understanding the
types, pathophysiology, and management strategies is crucial for improving
patient outcomes and reducing the impact of strokes on individuals and their
families.

Discuss Glasgow Coma scale

The Glasgow Coma Scale (GCS) is a clinical tool used to assess a patient's level of
consciousness after a head injury or other trauma, developed by Teasdale and
Jennett in 1974. The GCS is an objective method for evaluating a patient’s
neurological status, particularly useful in assessing and monitoring patients with
brain injuries. The GCS evaluates three main aspects of a patient’s neurological
function:

 eye-opening response
 verbal response,
 motor response.

A)Eye-Opening Response (E)

The eye-opening response assesses the patient’s ability to open their eyes in
response to stimuli. It is scored from 1 to 4 points:

4 – Spontaneous: The patient’s eyes open spontaneously without any external

stimuli.

3 – To voice: Eyes open in response to verbal stimuli (such as calling their name).

2 – To pain: Eyes open only in response to painful stimuli (like a pinch or sternal
rub).

1 – None: No eye-opening, even with painful stimuli.

B)Verbal Response (V)

This category assesses the patient’s ability to speak and make coherent
responses, scored from 1 to 5 points:

5 – Oriented: The patient is oriented to time, place, and person, and can respond
appropriately to questions.

4 – Confused: The patient speaks but is disoriented or confused.

3 – Inappropriate words: Speech is recognizable but consists of inappropriate

words or phrases.
2 – Incomprehensible sounds: The patient vocalizes sounds but cannot form
recognizable words.

1 – None: There is no verbal response at all.

C). Motor Response (M)

Motor response assesses how the patient responds to commands or painful

stimuli by moving, with scores from 1 to 6 points:

6 – Obeys commands: The patient can follow simple commands (e.g., “lift your
hand”).

5 – Localizes pain: The patient attempts to remove or push away the source of
pain (e.g., moves hand toward a pinching stimulus).

4 – Withdraws from pain: The patient withdraws or pulls away from a painful
stimulus.

3 – Abnormal flexion (decorticate posturing): There is abnormal flexion of the

arms toward the body when painful stimuli are applied.

2 – Abnormal extension (decerebrate posturing): The arms and legs extend

abnormally in response to pain.

1 – None: No movement in response to any stimuli.

Total Score
The total GCS score is the sum of the three individual component scores and
ranges from 3 to 15:

3 :represents the lowest possible score, indicating deep coma or brain death.

15: represents the highest possible score, indicating a fully alert and oriented
person.

Interpretation of GCS Scores

13-15: Mild brain injury or minor head trauma.

9-12: Moderate brain injury.

3-8: Severe brain injury. A GCS score of 8 or less typically indicates that the
patient is in a coma and may require airway management.

Clinical Application in Nursing

The GCS is used to monitor changes in neurological status over time. It provides
an easily understandable, standardized method for documenting a patient’s
neurological condition. Nurses frequently use the GCS in patients with traumatic
brain injuries, strokes, and other conditions affecting brain function. Repeated
assessments can track improvements or deteriorations in the patient's
neurological status.

The GCS helps guide treatment decisions and interventions. For example:

 A decreasing GCS score could indicate the need for more aggressive
medical intervention, such as intracranial pressure monitoring or surgical
intervention.
 A low GCS score (less than 8) often leads to intubation to protect the
airway.
The GCS is a helpful tool, it should be used in conjunction with other clinical
assessments and diagnostic tests, such as imaging, to fully evaluate a patient’s
neurological condition. Furthermore, factors such as sedation, alcohol
intoxication, and language barriers can affect the GCS score and should be
considered during assessment.

Limitations
The GCS has limitations, particularly in certain populations:

 Intubated patients cannot provide verbal responses, which reduces the

maximum possible score.
 Children, especially those under the age of 2, may require modified scales
since their verbal and motor skills are not as developed.
It may not capture subtle neurological changes.
Overall, the GCS remains a widely used tool in medical and surgical settings to
provide a quick, consistent measure of a patient’s consciousness level, critical for
early detection of neurological deterioration.

References
1.Brunner Suddarths Textbook of Medical surgical Nursing
2.Emergency and Trauma Care for Nurses and Paramedics - Page 242

3.Stroke E-Book: Pathophysiology, Diagnosis, and Management