1. The Pathophysiology of ischemic strokes is widely known.

Ischemic strokes are the most common type of stroke contributing to over 80 percent of stroke cases. Ischemic strokes are caused by blood clots that subsequently deprive parts of the brain from blood flow and oxygen resulting in the death of brain cells and tissue and a stroke. There are many factors that can affect the buildup of a blood clot resulting in a stroke. The chance of an ischemic stroke is largely affected by several main factors including: age, family history, systolic blood pressure, smoking, alcohol, myocardial disease, diabetes and atrial fibrillation. In terms of the Pathophysiology of ischemic stroke age and systolic blood pressure are the most influential factors in ischemic strokes. +Hemorrhagic strokes are the second most common type of stroke and are caused due to a burst blood vessel either within the brain itself or just outside of it. There are two main types of hemorrhagic strokes each with different Pathophysiology. One type of hemorrhagic stroke is an intracranial hemorrhage. This type occurs within the brain or in the area surrounding the brain. The bleeding in an intracranial hemorrhage occurs directly into the brain and subsequently the surrounding brain can be damaged by the increase pressure imposed by the mass effect of the burst blood vessel. The main causes of hemorrhagic strokes include: systolic blood pressure, age and anticoagulation. High blood pressure is the main cause of both hemorrhagic and ischemic strokes. Some of the less common causes of hemorrhagic strokes include: cranial trauma, tumors, hypertensive hemorrhages and vasculitides all of which can lead to a buildup of blood around the brain causing a hemorrhagic stroke. 2. Risk factors for ischemic attack are smoking, high blood pressure, high cholesterol, and diabetes as well as family history Also, any condition that results in stagnant blood flow and or clotting may result in a TIA due to embolization of a blood clot. Such conditions may include atrial fibrillation, large heart attacks, and severe weakness of the heart muscle. Risk factors for hemorrhage attack Age ,Gender, Ethnicity, Presence of Other Vascular Disease, Abnormal Blood Pressure, Heart Abnormalities Causing Traveling Blood Clots (Embolisms), Smoking, Diabetes and Insulin Resistance, Obesity and Metabolic Syndrome, Cholesterol and Other Lipids, Genetic and Inborn Factors, Inherited Disorders that Contribute to Stroke, Stress, Depression, Infections and Inflammation, Peripheral Artery Disease, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

3. Signs and symptoms for ischemic attack

Facial weakness Arm weakness Leg weakness Confusion Speech problems

Slurred speech Difficulty talking Difficulty understanding speech

Vision disturbances Trouble seeing in one eye Trouble seeing in both eyes

Difficulty walking Dizziness Loss of balance Loss of coordination Blurred consciousness No loss of consciousness Loss of consciousness

Signs and symptoms for hemorrhagic attack

Weakness or inability to move a body part Numbness or loss of sensation Decreased or lost vision (may be partial) Speech difficulties Inability to recognize or identify familiar things Sudden headache Vertigo (sensation of the world spinning around) Dizziness Loss of coordination Swallowing difficulties Sleepy, stuporous, lethargic, comatose, or unconscious

4. Treatment of a CVA A stroke is a medical emergency. Immediate treatment can save lives and reduce disability. Call 911 or your local emergency number or seek immediate medical care at

the first signs of a stroke. It is important to get the person to the emergency room immediately to determine if the stroke is due to bleeding or a blood clot so appropriate treatment can be started within 3 hours of when the stroke began . Treatment depends on the severity and cause of the stroke. A hospital stay is required for most strokes. Treatment in Hospital Clot-busting drugs (thrombolytic therapy) may be used if the stroke is caused by a blood clot. Such medicine breaks up blood clots and helps restore blood flow to the damaged area. However, not everyone can receive this type of medicine.

For these drugs to work, a person must be seen and treatment must begin within 3 hours of when the symptoms first started. A CT scan must be done to see whether the stroke is from a clot or from bleeding. If the stroke is caused by bleeding rather than clotting, clot-busting drugs (thrombolytics) can cause more bleeding. Blood thinners such as heparin or warfarin (Coumadin) are used to treat strokes due to blood clots. Aspirin of clopidogrel (Plavix) may also be used. Other medications may be needed to control other symptoms, including high blood pressure. Painkillers may be given to control severe headache. In some situations, a special stroke team and skilled radiologists may be able to use angiography to highlight the clogged blood vessel and open it up. For hemorrhagic stroke, surgery is often required to remove blood from around the brain and to repair damaged blood vessels. Surgery on the carotid artery may be needed. See also Carotid artery disease and Carotid artery surgery.

Other treatments depend on the cause of the stroke:

Nutrients and fluids may be necessary, especially if the person has swallowing difficulties. These may be given through a vein (intravenously) or a feeding tube in the stomach (gastrostomy tube). Swallowing difficulties may be temporary or permanent. Physical therapy, occupational therapy, speech therapy, and swallowing therapy will all begin in the hospital. Long-Term Treatment The goal of long-term treatment is to help the patient recover as much function as possible and prevent future strokes. The recovery time and need for long-term treatment differs from person to person. Depending on the symptoms, rehabilitation may include:

Occupational therapy Physical therapy Speech therapy

Therapies such as repositioning and range-of-motion exercises can help prevent

complications related to stroke, such as infection and bed sores. Those who have had a stroke should try to remain as active as physically possible. Alternative forms of communication such as pictures, verbal cues, and other techniques may be needed in some cases. Sometimes, urinary catheterization or bladder and bowel control programs may be needed to control incontinence. A safe environment must be considered. Some people with stroke appear to have no awareness of their surroundings on the affected side. Others show indifference or lack of judgment, which increases the need for safety precautions. Caregivers may need to show the person pictures, repeatedly demonstrate how to perform tasks, or use other communication strategies, depending on the type and extent of the language problems. In-home care, boarding homes, adult day care, or convalescent homes may be required to provide a safe environment, control aggressive or agitated behavior, and meet medical needs. Family counseling may help in coping with the changes required for home care. Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful. Legal advice may be appropriate. Advance directives, power of attorney, and other legal actions may make it easier to make ethical decisions regarding the care of a person who has had a stroke.

5. Describe the components of a full neurological assessment. Health history, mental status, cranial nerve function, motor function, loc, sensory function, cerebellar function, reflex function, gait and stance 6. How are the results of a head CT used to determine therapy in the patient with CVA? Ct scan determines type of stroke, size and location of hematoma, presence or absence of ventricular blood and hydrocephalus. 7. Discuss the use of rtPA (Alteplase). Treats acute ischemic strokes to help breakdown clots. (clot buster) In order to consider tPA administration:1. Ischemic stroke onset within 3 hours of drug administration. 2. Measurable deficit on NIH Stroke Scale examination. 3. Patient's computed tomography (CT) does not show hemorrhage or nonstroke cause of deficit.

4.

Patient's age is >18 years.

Do NOT administer tPA if any of these statements are true:1. Patient's symptoms are minor or rapidly improving. 2. Patient had seizure at onset of stroke. 3. Patient has had another stroke or serious head trauma within the past 3 months. 4. Patient had major surgery within the last 14 days. 5. Patient has known history of intracranial hemorrhage. 6. Patient has sustained systolic blood pressure >185 mmHg. 7. Patient has sustained diastolic blood pressure >110 mmHg. 8. Aggressive treatment is necessary to lower the patient's blood pressure. 9. Patient has symptoms suggestive of subarachnoid hemorrhage. 10. Patient has had gastrointestinal or urinary tract hemorrhage within the last 21 days. 11. Patient has had arterial puncture at noncompressible site within the last 7 days. 12. Patient has received heparin with the last 48 hours and has elevated PTT. 13. Patient's prothrombin time (PT) is >15 seconds. 14. Patient's platelet count is <100,000 uL. 15. Patient's serum glucose is <50 mg/dL or >400 mg/dL. If either of the following statements is true, use tPA with caution:1. Patient has a large stroke with NIH Stroke Scale score >22. 2. Patient's CT shows evidence of large middle cerebral artery (MCA) territory infarction 8. Discuss the management of the patient who deteriorates neurologically due to a CVA. goal is to stabilize the patient and to complete initial evaluation and assessment, including imaging and laboratory studies, within 60 minutes of patient arrival. Critical decisions focus on the need for intubation, blood pressure control, and determination of risk/benefit for thrombolytic intervention. Time IntervalTime Target Door to doctor10 min Access to neurologic expertise15 min Door to CT scan completion25 min Door to CT scan interpretation45 min Door to treatment60 min Admission to stroke unit or ICU3 h Blood glucoseTreat hypoglycemia with D50

Treat hyperglycemia with insulin if serum glucose >200 mg/dL

Blood pressureSee recommendations for thrombolysis candidates and noncandidates (Table 3) Cardiac monitorContinuous monitoring for ischemic changes or atrial fibrillation Intravenous fluidsAvoid D5W and excessive fluid administration

IV isotonic sodium chloride solution at 50 mL/h unless otherwise indicated

Oral intakeNPO initially; aspiration risk is great, avoid oral intake until swallowing assessed OxygenSupplement if indicated (Sa02 < 94%) TemperatureAvoid hyperthermia; use oral or rectal acetaminophen and cooling blankets as needed Patients presenting with Glasgow Coma Scale scores of 8 or less, rapidly decreasing Glasgow Coma Scale scores, or inadequate airway protection or ventilation require emergent airway control via rapid sequence intubation. 9. Potential complications for IschemicCVA: decreased cerebral blood flow due to increased ICP, inadequate oxygen delivery to the brain, pneumonia, cardiac dysrhythmias, immobility (hemiplegia, hemiparesis). These are managed by continuous cardiac monitor, Vital signs every 15 min. for 2 hrs, then every 30 min. for 6 hrs., then every hour for 24 hrs, administration of supplemental oxygen, maintain airway, administration of t-PA (clot buster) within 3 hours of ischemic stroke, correct positioning for weakened or paralyzed side of body Immediate and potential complications for HemorrhagicCVA: cerebral hypoxia, decreased cerebral blood flow, extension of the area of injury, rebleeding or hematoma expansion, cerebral vasospasm resulting in cerebral ischemia, increased ICP, acute hydroencephalus which results when free blood obstrocts the reabsorption of CSF by arachnoid villi, and seizures. These are managed by supplemental oxygen, IV fluids to improve blood flow, prevent hypotension or hypertension to decrease extension and rebleeding, calcium channel blockers for vasospasm, administer mannitol for ICP, maintain airway and prevent injury for seizure 10. Nursing interventions: Ischemic stroke: Elevate head of the bed to decrease ICP, maintain adequate blood flow, maintain adequate airway (endotracheal tube if necessary), maintain adequate gas exchange, correctly position patient's weakened or paralyzed extremities, change position of patient every 2 hours, ambulate as soon as possible to prevent pneumonia

Nursing interventions: Hemorrhagic stroke: monitor neuro status (glasgow coma scale), maintain airway, HOB is 15-30 degrees to promote drainage and decrease ICP, avoid vasalva maneuver or any straining to prevent high BP, prevent acute flexion or rotation of head and neck, do not administer enemas, use compression stockings, prepare to manage seizure. 11. A serum glucose test is important when ruling out a CVA because symptoms of hypolgycemia could mimic a stroke such as headache, lightheadedness, confusion, slurred speech impaired coordination, if hypoglycemia is severe enough they could lose conciousness, have seizures, or display disoriented behavior 12. Test the patients pharyngeal reflexes before offering food or fluids. Assist patient with meals. Place food on the unaffected side of the mouth. Allow ample time to eat. 13. Encourage use of eyeglasses if available. Encourage the use of a cane or other object to identify objects in the periphery of the visual field. Place objects in center of patients intact visual field. Driving ability will need to be evaluated. Explain to the patient the location of an object when placing it near the patient. Consistently place patient care items in the same location. 14. Perform Neurologic assessments including, level of orientation, level of consciousness, Glasgow coma scale, assessment of cranial nerves, and motor exam and vital signs assessment.