GENERAL OBJECTIVE + At the end of the lecture/discussion + atthe end of the lecture/discussion students should be able to: |. 1 Define cerebrovascular accident * 2. explain the predisposing factors 3, Explain the couses 4, Describe the management CEREBRAL VASCULAR students should be able to acquire Towed on management of patents ACCIDENT(CVA) with cerebrovascular accident, ts sacans SPECIFIC OBJECTIVES DEFINITION + Cerebrovascular Accident is @ sudden loss of brain function resulting from a disruption of blood supply to a part of the brain characterized by hemiplegia. PREDISPOSING FACTORS + Hypertension as it can cause rupture of blood vessels supplying the brain due +o high blood pressure + Smoking as It causes arteriosclerosis (hardening of blood vessels) + Obesity cause narrowing of blood vessels dive to accumulation of fats + Alcohol causes accumulation of atin the blood vessels reducing the capacity carrying blood to the brain. 20/03/2018+ Heart diseases can cause someone to have low blood pressure reducing supply CAUSES * A stroke results from one of the three events; cerebral thrambasis cerebral tothe brain | haemormage and embolism. TRE Stand fer £ = Fereeret Neot}i sur CEREREALTinOMBOSE + Itrests fom arteriosclerosis where the * This is the most common cause of CVA. + Itis common in middle-aged and elderly people * Accounts for 61% of the cause of CVA, + Has gradual onset cerebral arteries become thickened and ‘oughened and blood flow may be obstructed and efotting occurs. + This clot blocks the arteries and deprives part ofthe brain of blood supply leading to stoke, ‘CEREBRAL HAEMORRHAGE + This is the third commonest cause of CVA (15%) + teoccurs suddenly occur at any age. + Haemorrhage results from chronic hypertension or aneurysms which cause sudden rapture ofa cerebral artery, + Haemorrhage can occur in the epidural, subdural or subarachnoid space, CEREBRAL EMBOLISM * This is the second commonest cause of CVA (244) * Can occur at any age especialy patients with history of RHD, Endocarditis, post- traumatic valvular disease, myocardial fibrilation, and other cardiac arrhythmias + tusvally develops rapidly and without warning oo TERE EE i20/03/2018 + Emboli may lodge in one of the cerebral arteries and produce a stroke SIGNS AND SYMPTOMS LA stroke affecting-the brain stem therefore can produce symptoms relating to deficits in these eranial nerves: ‘@ Altered smell, taste, hearing, or vision (total or partial) 4 Drooping of eyelid (ptosis) and weekness of cult muscles 4 Decreased reflexes: gag, swallow, pupil reactivity to light [Decrease sensation al mussle ‘weakness ofthe face ¢9 Balance problems and nystagmus ‘Altered breathing and heart rate + Wekness in stetnocleidomastoid muscle ‘with inability to turn head to one side Wealmess in tongue (inability to protrude and/or move from side to side) 2. Ifthe cerebral contes is involved, can produce the following symptoms: + aphasia (inability to speak or understand language from involvement of Broca’s or ‘Wericke's area) Apraxia (altered voluntary movements) Visual field defeet Memory deficits (involvement of temporal lobe}Disorganized thinking, confusion, hnypersexual gestures (with involvement of frontal lobe) 3. Ifthe cerebellum is involved, the patient may have the following: ~ “Troubled walking Altered movement coordination Vertigo and or disequilibrium 4.Coma INVESTIGATIONS + A plysial examination and a medical history of the symptoms and a urological status, helps eving an evaluation ofthe location and severity of a stroke + Computerised Tomography (CT scan) ~ detects structural abnormalities, oedema, and lesion’ aneurysms. + Magnetic Resonance Imaging (MRI) ~ allows evaluation of the lesions location and size without exposing the patient to radiation. + Ultrasound/dopoler study of the carotid arteries (to detect carotid stenosis) or lissection ofthe pre-cerebral arteries + Electrocardiogram (ECG) and echocardiogram (to identify arrhythmias ‘and resultant clots inthe heart which ‘may spread to the brain vessels through the bloodstream) * Angiogram of the cerebral vasculature (iF bleed is thought to have originated from fan aneurysm or arteriovenous ‘malformation) + Blood tests to determine hhypercholesterolemia * Lumber puncture done to chesk the infection of the brain and to measute the pressure |20/03/2018 * Ophthalmoscopy ~ may show signs of hypertension and atherosclerotic changes in retinal arteries, + Electroencephalogram (EEG) ~ may detect reduced electrical activity in an area of brain, * Coagulation studies, may show coagulation problems * Full Blood Count. May reveal increased haematocrit MEDICAL TREATMENT. + Medical management commonly Includes physical rehabilitation, dietary and drug regimes and care measures to help patient adapt to specific deficits such as speech impairment and paralysis, * Anticonvulsants such as phenytoin or henabarbitone to treat or prevent seizures phenobarbitone 80-180m¢ nocte or * phenytoin 3-amg/kg body weight daily + Oxygen therapy Siitres/minute * Corticosteroids such as Dexamethasone 0.5-20me W slowly to minimise associated cerebral oedema + Analgesics suchas panadol 1g tds 3/7 to relieve headache + Anticoagulants such as Heparin may be sed In cases of cerebral thrombosis 10000-20000 units be + Or warfarin 15-30mg intially then ‘maintenance dose according to prothrombin time, + Ant hypertensives e.g. Calum channel blockers Nifedipine 20mg bd for 5/7Nursing management AIMS + To maintain a clear airway. * To maintain patient's nutritional status * To prevent complications. + To rehabilitate the patient. * Prevent injury to the patient Environment * During acute phase the patient is nursed ina quiet place free of disturbances. + To protect the patient from injury | will provide bed with rails + The room should be clean, warm and well ventilated to promote comfort of the patient. + To ensure a patent air way | will ensure that oxygen apparatus and suction ‘machine are available for maintenance of a patent airway and oxygenation. Maintaining Patient Airway + Loosen tight clothes to prevent Interfering with normal breathing + Aspirate secretions from the mouth or rose to maintain a patBat airway. + Insert an artifical airway, and start ‘mechanical ventilation or supplemental oxygen if necessary. + Patient is nurse ina lateral recumbent postion, prone oF semi prone postion with head turned to onesie. + This facties drainage and minimises aspiration of nasopharyngeal and gastric secretions + Oxygen therapy is given in case of dyspnoee + Prepare for tracheostomy if coma is deepening and if there is evidence of inadequate respiratory exchange20/03/2018 + Endotracheal intubation may be done if patients comatose + Nurse patient ina raled bed to prevent falls ‘Observation + Level of consciousness using the Glasgow coma scale. Z V which assesses the eye opening, best verbal response and motor response as indicators of the level of consciousness. Vif itis increasing it means patient is responding and decreasing will indicate deterioration of consciousness. Observations cont + Lwill also observe for the signs of Increased ICP, e.g. persistent headache, nausea and vomiting in order to act promptly. +1 ll watch for signs of pulmonary “r emboli such as shortness of breath, cyanosis, tachycardia, fever anc changed sensory perception, + Observe vital signs thats, temperature, pulse and respirations n order to note ‘any further deviation from normal and ‘patient response to treatment Psychological care + Provide psychological support, and establish rapport withthe patient to alley anxiety. + Explain his deficits and strengths in order to promote cooperation. + Involve the loved ones inthe care of the patient to make him feel loved and improve his wil to live + Explain the tests, treatments and rehabilitation to promote cooperation Nutrition and fl + Maintain fluid and electrolyte balance to prevent dehydration and electrolyte imbalance, + Administer V fluids as advised and never tive too much as this can increase the ree + Initially patient willbe on IV fluids eg, Dextrose 8%, Normal saline to maintain nutritionNutrition and fluid cont + NG tube feeding may be used if patient is Unconscious fora long periad to maintain ruvitiona status * Ascondition improves, give light diet and progress to normal diet in order to provide the needed nutrients, * Lill cemind my patient to chew on the Unaffected side to ensure food is properly chewed before swallowing Nutrition and fluids cont + Provide oral care to promote appetite and thereby maintain nutritional status, * Don’t give solid foods to patient who has dysphagia or one-sided facial paralysis to Prevent discomfort Hygiene + Clean and irrigate the patient's mouth to remove food particles, + Provide meticulous eye care to prevent eve problems. + Ro baths to promote blood circulation and remove diet from the skin * Change soiled linen to promote patients comfort Elimination + Lil perform intermittent or in dweling bladder catheterization during the acute stage In order to ensure bladder emptying * I illalso establish Fegular schedules of voiding like every 2-3 hours once the bladder tone returns + For bowel motions | will provide the bed pan and also screen the bed during its Use to promote bowel motions and privacy respectively [EVE care arerpressure-sore-prevemtron— Remove secretions with a cotton ball from the eyes. * Instleye drops as ordered. * Patch the patient's eye if he can't close his evel. + 2 hourly turnings in acute phase to promote blood circulation hence prevent pressure sore formation, * Assist the patient with exercise to ‘maintain muscle tone and promate blood at ‘Communication + Establish and maintain communication with the patient to enable him ai his concerns and alley anxiety + fh is aphasic use simple method af communicating basic needs such assign language, pen and paper if patient is able to write and read. + Inthe acute phase provide a bell for the patient to use whenever he needs help20/03/2018 Information Education and ‘Communication + necessary, teach patient self care activities such as combing hair, dressing, washing etc 0 as to promote self care and improve self esteem + Lwill instruct the family in management of aphasia in order to avoid frustration of both the patient and loved one and also promote communication at home Information Education and Communication cont + Involve Speech Therapist if available to assist patient with speech problems: + Physiotherapist should also assist in the rehablitation ofthe patient this should continue at home to help the patient attain the use of the affected part as ‘much as possible. + Teach patient and family on drugs diet and importance of reducing weight if obese {, Emphasise the importance of review * dates in order to be monitored and hence ensure full ecovery. + Teach the patient on need to correct risk factors to prevent the recurrence of the condition. Prevention of complications + Lull use a foot board during the flaccid period after the stroke + Lull position my patient in the ‘anatomical position to prevent contractures and deformity ‘Iwill apply a splint and braces as needed to suppart the limbs in anatomical position to prevent contracture + Encourage early ambulation according to the patient’ ability to do soto prevent deep vein thrombosis, Complications * Infection such as Encephalitis, Brain ‘Abscess, Pneumonia, * « sensory impairment, + Visual impairment + Aspiration pneumonia. + contractures. + Post stroke depression