Introduction to Medical-Surgical Nursing, 6th ed.
28
Lesson Plans for
Cerebrovascular Accident
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 28.1:
2. Identify the two major types of CVA.
4. Describe the neurologic deficits that may result from CVA.
6. Discuss criteria used to identify patients eligible for treatment with recombinant tissue plasminogen
7. List data to be included in the nursing assessment of the CVA patient.
9. Specify criteria used to evaluate the outcomes of nursing care for the CVA patient.
10. Identify resources for the CVA patient and family.
CHAPTER TEACHING FOCUS
• In this chapter, students will have the opportunity to learn about the various types of CVA.
• The chapter includes information on diagnosis, treatment, and risk factors for transient ischemic attack
and stroke as well as medical therapy.
• Furthermore, students will be introduced to the nursing assessment and interventions for both the
acute phase and the rehabilitation phase.
• Finally, students will be introduced to possible long-term neurologic deficits along with therapeutic
options.
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
Concepts for nursing practice. St. Louis: Elsevier. The specific exemplars chosen and listed below for
each concept have been tailored specifically to correspond to the Linton textbook.
THEME: Attributes and Resources
• Concept: Functional Ability
• Exemplar: Cerebrovascular Accident, p. 482
• Pharmacology Capsule, p. 485
• Cultural Considerations: What does Culture have to Do with Stroke, p. 485
• Put on Your Thinking Cap! p. 488
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CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) Which of the following people has the most nonmodifiable risk factors for having a stroke?
a) 78-year-old Caucasian male
b) 70-year-old Asian female
c) 65-year-old African-American male
d) 38-year-old Caucasian female
2) It would be correct to say that CVAs __________.
a) are the third leading cause of disability in the United States
b) are only a problem in the elderly
c) cannot recur in the same area of the brain
d) can be caused by drug abuse or binge drinking
3) A transient ischemic attack (TIA) __________.
a) typically lasts 24 to 48 hours
b) is a result of a previous stroke
c) can be a precursor to a stroke
d) can result in permanent deficits
4) The most common type of CVA is __________.
a) hemorrhagic stroke
b) ischemic stroke
c) subarachnoid hemorrhage
d) subdural bleed
5) The signs and symptoms of a stroke or “brain attack” can vary and depend on __________.
a) whether or not the person has an underlying heart condition
b) the region of the brain affected by the alteration in blood flow and oxygen supply
c) the presence or absence of bruits in the carotid arteries
d) the number of modifiable stroke risk factors for the individual
6) One possible devastating effect of stroke is dysarthria. This will affect the patient’s ability to
__________.
a) understand spoken or written words
b) walk without assistance
c) speak clearly and be understood
d) perform simple, common tasks
7) There are many chronic diseases that can contribute to the development of a stroke. A good example
is __________.
a) postherpetic neuralgia
b) diabetes mellitus
c) osteoarthritis
d) ulcerative colitis
8) The brainstem includes the midbrain, pons, and __________.
a) circle of Willis
b) anterior communicating artery
c) frontal lobe
d) medulla
9) Ineffective coping is a common nursing diagnosis for a patient with a CVA. Evidence of this problem
would be the patient’s __________.
a) refusal to go to physical therapy
b) difficulty in understanding speech
c) inability to chew and swallow a general diet
d) use of assistive devices to eat independently
10) Immediately after an acute stroke, blood pressure is usually elevated. It is important to remember that
__________.
a) sudden reductions in blood pressure may worsen the brain tissue damage
b) to minimize brain damage, blood pressure should be quickly returned to a normal range
c) antihypertensive medications are contraindicated in these patients
d) fluids should be restricted until blood pressure decreases
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Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: A nurse works in a rehabilitation setting. The nurse’s new patient had an ischemic stroke in
the right cerebrum. His elderly siblings came to visit him from out of town. They want to know why their
brother is incontinent of urine. What should the nurse tell them?
Answer: The nurse should explain that after a stroke, the bladder can become flaccid and not be able to
Question: In the medical record of a newly admitted patient with a CVA, a nurse notes a nursing
diagnosis Risk for injury. What are the possible reasons this diagnosis might be on the medical record?
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LESSON 28.1
Instructor Preparation
Textbook Objectives Covered
2. Identify the two major types of CVA.
4. Describe the neurologic deficits that may result from CVA.
6. Discuss criteria used to identify patients eligible for treatment with recombinant tissue
plasminogen activator (rt-PA).
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying cerebrovascular accident including:
• The types of CVA
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• aphasia (p. 489)
• diplopia (p. 498)
• ptosis (p. 498)
• receptive aphasia (p. 489)
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 28.1
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 483-484)
REVIEW
ANSWER – Text
• Review Questions for the NCLEX Examination: 8 (p. 508)
2
READ – Textbook (pp. 484-488)
REVIEW
• Figure 28-2: Cerebral circulation (p. 483)
• Figure 28-4: Types of stroke (p. 489)
• Figure 28-5: Comparison of right-sided and left-sided stroke (p. 489)
ANSWER – Text
• Review Questions for the NCLEX Examination: 6 (p. 508)
ANSWER – Study Guide
• Part ID: 1-3 (p. 166)
3
READ – Textbook (pp. 484-493)
REVIEW
• Figure 28-3: Carotid endarterectomy (p. 488)
• Table 28-2: Medications for Cerebrovascular Accident (p. 486)
• Box 28-1: Signs of a Stroke (p. 483)
• Box 28-3: Assessment of the Cerebrovascular Accident Patient (p. 494)
ANSWER – Text
• Review Questions for the NCLEX Examination: 2, 3, 4, 5 (p. 507)
ANSWER – Study Guide
• Part IA: 1-17 (pp. 165-166)
4
READ – Textbook (pp. 485-491)
REVIEW
ANSWER – Text
• Review Questions for the NCLEX Examination: 7 (p. 508)
ANSWER – Study Guide
• Part IIE: 4 (p. 167)
5
READ – Textbook (p. 491)
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LESSON 28.1
6
READ – Textbook (p. 492)
ANSWER – Text
• Review Questions for the NCLEX Examination: 9 (p. 508)
ANSWER – Study Guide
• Part IIE: 12 (p. 167)
Lecture Outline 20 minutes
Slide 1
Chapter 28
Cerebrovascular Accident
1
Cerebrum
• Complex functions: initiation of movements, recognition of sensory input, higher-order
TALKING POINTS:
• Which hemisphere is dominant for most people?
• The left hemisphere controls the more analytic mental processes such as language
Slide 3
Cerebrum (cont.)
• Brainstem
• Includes midbrain, pons, medulla, and part of the reticular activating system
• Controls vital, basic functions, including respiration, heart rate, and consciousness
TALKING POINTS:
• The brainstem controls some of the most primitive functions of the body. When death
occurs, the brain stem continues to functions until near the time of death.
Slide 4
Cerebellum
• Uses information received from the cerebrum, muscles, joints, and inner ear to coordinate
movement, balance, and posture
• Unlike the cerebrum, the right side of the cerebellum controls the right side of the body,
and the left side of the cerebellum controls the left side of the body
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 28.1
Slide 5
Circulation
• Carotid system
• Begins as one common artery; later divides into the external and internal carotid
TALKING POINTS:
• The brain is rich with arterial circulation to satisfy its high need for oxygen.
• How much of the oxygen supply and cardiac circulation does the brain consume each
minute?
Slide 6
Circulation (cont.)
• Vertebral arteries
• Originate from the subclavian artery, travel up the anterior neck to merge and form the
basilar artery at the brainstem
TALKING POINTS:
• What increases some people’s likelihood of sustaining a CVA?
Slide 7
Risk Factors for Stroke
• Nonmodifiable factors
• Risk factors that cannot be changed
• Age, race, gender, and heredity
• Modifiable factors
• Those that can be eliminated or controlled
TALKING POINTS:
• Discuss why each is modifiable or not modifiable and how you would modify those that
can be modified.
2
Transient Ischemic Attack (TIA)
• Temporary neurologic deficit caused by impairment of cerebral blood flow
TALKING POINTS:
• How much cerebral blood flow must be blocked for symptoms to appear?
• Current recommendations suggest that the transient events can cause permanent brain
injury and should be evaluated to determine the cause and treated aggressively to
prevent a stroke.
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LESSON 28.1
Slide 9
Transient Ischemic Attack (cont.)
• Signs and symptoms
• Dizziness, momentary confusion, loss of speech, loss of balance, tinnitus, visual
disturbances, ptosis, dysarthria, dysphagia, drooping mouth, weakness, and tingling
TALKING POINTS:
• Neurologic signs and symptoms last from a few minutes to 24 hours, often with no
permanent effects.
• What determines the nature and severity of the symptoms of a TIA?
• A bruit reveals that the artery is partially obstructed as with an atherosclerotic plaque.
Slide 10
Transient Ischemic Attack (cont.)
• Medical treatment
• Depends on the location of the narrowed vessel and the degree of narrowing
• Acetylsalicylic acid (aspirin), ticlopidine hydrochloride (Ticlid), extended-release
TALKING POINTS:
• In atrial fibrillation, microscopic emboli are believed to form which later are released from
the heart and travel to the arteries of the brain to cause a TIA or stroke.
• What is the dosage for warfarin therapy based on? Heparin therapy?
Slide 11
Stroke
• An abrupt impairment of brain function resulting in a set of neurologic signs and
symptoms that are caused by impaired blood flow to the brain and last more than 24
hours
TALKING POINTS:
• Stroke is the third leading cause of death and the leading cause of adult disability in the
United States.
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 28.1
Slide 12
Stroke: Pathophysiology
• Hemorrhagic stroke
• Blood vessel in brain ruptures; bleeding into the brain occurs
• Ischemic stroke
TALKING POINTS:
• Hemorrhagic stroke accounts for only about 20% of all strokes.
• What are two classifications of hemorrhagic strokes?
• Ischemic strokes account for 80% of all strokes including embolic and thrombotic strokes.
Stroke: Signs and Symptoms
• Different signs and symptoms, depending on the type, location, and extent of brain injury
• Hemorrhagic stroke
TALKING POINTS:
• Point out the differences between a right-sided stroke and a left-sided stroke. Ask
students to identify variations in symptoms that may occur with each.
Stroke: Signs and Symptoms (cont.)
• Embolic stroke
• Appear without warning
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LESSON 28.1
Slide 15
Stroke: Signs and Symptoms (cont.)
• Aphasia
• A defect in the use of language; speech, reading, writing, or word comprehension
• Dysarthria
• The inability to speak clearly
• Dysphagia
• Swallowing difficulty
• Dyspraxia
TALKING POINTS:
• What is the difference between receptive and expressive aphasia?
• Dysarthric patients are difficult to understand, but they understand what is said and have
no difficulty putting together their thoughts.
• Dysphagia is a very serious problem because of the risk of aspiration and because it can
Slide 16
Stroke: Signs and Symptoms (cont.)
• Sensory impairment
• Unable to feel touch, pain, or temperature in affected body parts
• Unilateral neglect
• Do not recognize one side of the body as belonging to them
• Homonymous hemianopsia
TALKING POINTS:
• Altered sensations put the patient at risk for injury from pressure and excess heat or cold.
Injuries may be ignored because the patient is not aware of them.
• Is a person with left-sided CVA or right-sided CVA more likely to experience unilateral
neglect?
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 28.1
Medical Diagnosis
• Blood studies, electrocardiogram (ECG), computed tomography, magnetic resonance
TALKING POINTS:
• Blood studies and the ECG are done to identify the presence of risk factors for stroke
such as hyperlipidemia and atrial fibrillation.
Complications
• Constipation, dehydration, contractures, urinary tract infections, thrombophlebitis,
decubitus ulcers, and pneumonia
TALKING POINTS:
• What are complications in a patient who has suffered a stroke related to?
Prognosis
• Prognosis for TIA or stroke increasingly hopeful
• Critical variables for recovery: patient’s condition before the stroke, time between stroke
Medical Treatment in the Acute Phase
• Begins with the onset of signs and symptoms and continues until vital signs, particularly
blood pressure and neurologic condition, stabilize
TALKING POINTS:
• A challenge for the physician is to provide immediate care for acute problems while
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LESSON 28.1
6
Slide 21
Medical Treatment in the Acute Phase (cont.)
• Major focus areas
• Hypertension
• Oxygenation
• Hyperthermia
• Hyperglycemia
TALKING POINTS:
• Tissue plasminogen activator must be initiated within 3 hours from the onset of stroke
symptoms.
• What are the eligibility criteria for rt-PA?
2
&
3
Slide 22
Medical Treatment in the Acute Phase (cont.)
• Other medications
• Mannitol
• Nimodipine (Nimotop)
• Phenytoin (Dilantin) and phenobarbital
• Acetylsalicylic acid (aspirin), ticlopidine hydrochloride (Ticlid), Aggrenox, and
clopidogrel (Plavix)
TALKING POINTS:
• The trauma of a CVA causes edema in the affected tissues and surrounding tissues; the
edema is sometimes treated with osmotic diuretics such as mannitol.
Slide 23
Medical Treatment in the Acute Phase (cont.)
• Surgical intervention
• An option for some patients with hemorrhagic strokes
• Decisions about surgery are based on patient’s age, intracranial pressure, and
location of the hemorrhage
Medical Treatment in the Acute Phase (cont.)
• Fluids and nutrition
• Intravenous fluids
TALKING POINTS:
• Vitamins and electrolyte supplementation may also be ordered.
• When is total parenteral nutrition used?
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 28.1
Medical Treatment in the Acute Phase (cont.)
• Urine elimination
TALKING POINTS:
• How often is intermittent catheterization done?
Slide 26
Question 1
• Which of the following is NOT a function of the cerebrum?
A. Higher-order thinking
B. Control of basic functions—respiration, heart rate, consciousness
C. Initiation of movements
D. Recognition of sensory input
Slide 27
Question 2
• The brain comprises 2% of the body’s weight and it consumes _____ of the oxygen
supply and cardiac circulation each minute.
A. 5%
B. 10%
C. 15%
D. 20%
TALKING POINTS: