CEREBROVASCULAR DISEASE; Infarct, Left Mid-Cerebral Artery

IMPRESSION

What is CEREBROVASCULAR DISEASE?

Other names are BRAIN ATTACK, ISCHEMIC STROKE & CEREBROVASCULAR ACCIDENT (CVA) It is a sudden loss of brain function resulting from disruption of the blood supply to a part of the brain. COMMON SITE Middle Cerebral Artery Half of the survivors sustain permanent neurologic defects.

CONTRIBUTORY FACTORS
High Blood Pressure Smoking Diabetes High Cholesterol Too much alcohol intake Diet and Lifestyle Cardiogenic shock Embolus and Thrombosis Age Gender Family History

PATHOPHYSIOLOGY
Embolus/ Thrombus Obstruction to the cerebral vessels Decreased cerebral blood flow

Neurons switched to anaerobic respi

Neurons (-) aerobic circulation

Ischemic Cascade begins

Increase lactic acid and changes pH

Insufficient ATP for depolarization

Cells cease to function

Presence of Penumbra region

Cells are threaten in this region

Influx of Ca & Release of Glutamate

If it continues.. VASOCONSTRICTION and generation of free radicals

Destroys neurons cell membrane

Area of infarction will enlarge

STROKE

SIGNS AND SYMPTOMS

HEMIANOPSIA- unaware of person on side of visual loss LOSS OF PERIPHERAL VISION-difficulty seeing in the night DIPLOPIA- double vision

VISUAL FIELD DEFICITS

MOTOR DEFICITS
HEMIPARESIS-weakness of face, arm and leg on the same side HEMIPLEGIA-Paralysis of the face, arm and leg on the same side ATAXIA-staggering, unsteady gait DYSARTHRIA- difficulty in forming words DYSPHAGIA-difficulty in swallowing

SENSORY DEFICIT
PARESTHESIA (opposite of the lesion) numbness & tingling of the extremity

VERBAL DEFICIT
APHASIA- impairment in speaking, listening, writing and understanding; most cases are mixed)

COGNITIVE DEFICITS
Short & Long Term Memory Loss Decrease attention span Impaired ability to concentrate Poor abstract reasoning Altered judgement

EMOTIONAL DEFICIT
Loss of self control Decrease tolerance to stress Depression Withdrawal Fear Fealing of isolation

OTHERS
BLADDER IMPAIRMENT POSSIBLE RESPIRATORY IMPAIRMENT IMPAIRED MENTAL ACTIVITY LOSS OF CONSCIOUSNESS AND DIZZINESS

MANAGEMENT

NURSING MANAGEMENT
Prevent Joint deformities by correct positioning Change positions every 2 hrs Prepare for ambulation Establish exercise programs Enhance self-care Assist with Nutrition Attain Bowel and Bladder Control Improve Communication, thought processes

MEDICAL MANAGEMENT
MEDICATIONS
Use of Anti-coagulants (ASPIRIN, Coumadin) Use of Thrombolytic Therapy

COMPLICATIONS
TISSUE ISCHEMIA ASPIRATION PNEUMONIA UTI CARDIAC DYSRHYTHMIAS COMPLICATIONS OF IMMOBILITY

DRUG STUDY
CLINDAMYCIN INDICATION-infxn caused by anaerobic & GR (+) bacteria. Skin soft tissues DOSAGE: 150-300mg CONTRAINDICATIONS:Hyper sensitivity PRECAUTION: hx of GI dse SIDE EFFECT:diarrhea, abdominal pain CO- AMOXICLAV I- short term tx of upper and lower respi tract, skin & soft tissue infxn D- 375mg 1 tab / TID C/I: cross sensitivity P: liver/ renal dysfxn S/E: GI disturbances Interaction: oral conbtraceptives

DRUG STUDY
CAPTOPRIL INDICATION-HPN DOSAGE: 25 mg BID/ TID CONTRAINDICATIONS:Hyper sensitivity/ Pregnancy PRECAUTION:Impaired renal fxn, hypokalemia SIDE EFFECT: rash, taste alteration, cough INTERACTION: diuretics, nitrates, NSAID OMEPRAZOLE I-Inhibit gastric acid secretion D- gastric ulcer: 20 mg OD 4-8 wks C/I: hypersensitivity P: liver disorder S/E: diarrhea, constipation, abdominal pain

DRUG STUDY
LACTULOSE
INDICATION- constipation & portal systemic encephalopathy DOSAGE: 15-45 ml initial; 1530 maintenance CONTRAINDICATIONS: Low galactose diet PRECAUTION:lactose intolerance SIDE EFFECT:diarrhea, flatulence

SIMVASTATIN I- Coronary heart dse, tx for hypercholestereolemia, reduce cardiac events D- 10 mg OD/ HS C/I: Hypersensitivity

DRUG STUDY
CITICOLINE
INDICATION- CVA acute & recovery phase, s/sx of cerebral insufficiency, dizziness, headache, memory loss, disorientation DOSAGE: 1-2 cap OD/ BIOD; 250 mg/ml 1 injection daily CONTRAINDICATIONS: hypertonia of the parasympoathetic PRECAUTION:Persistent intracranial hemorrhage SIDE EFFECT: stimulates parasympathetic action

MANNITOL I- Prophylaxis of acute renal failure,post op oliguria, eliminate toxic, forced diuresis, decreased ICPreduce cardiac events D- 250-500ml/day C/I: dhn, cardiac insufficiency P-observe electrolyte states

NURSING CARE PLAN

ASSESSMENT
OBJECTIVE DATA: -Unresponsive -Absence of Motor, emotional, sensory reaction -Right Sided body weakness -Increased V/S particularly in BP150/90 T-37.6 PR-59 RR-24 -(-) stool and urine - Hiccup observed every 10-15 min -Asleep all the timeSkin is dry -With an IVF of PNSS 1 liter at 500 cc level regulated @ 21 gtts/min -NGT anchored properly

NSG. DIAGNOSIS
Ineffective cerebral tissue perfusion r/t interruption of blood flow evidenced by being unresponsive, absence of motor, sensory, emotional response, right sided body weakness and asleep all the time

PLANNING
After 10 hrs of duty during the 2days ward exposure, the client will be observed with the ff: -to have an improved LOC, emotional, motor/sensory function -to demonstrate stable V/S -to display no further deterioration in his health condition

INTERVENTION EVALUATION S
INDEPENDENT: -Assess and Monitor Neurolgic status frequently.. Document changes -Monitor for increased ICP-watch out for s/sx -Check V/S particularly BP, heart rhythm and respi -Evaluate Pupils -Ensure Correct position-turn patients side to side q 2hrs; prone position -Position head slightly elevated -Maintain bed rest & quite environment - Assess nuchal rigidity PLANS ARE PARTIALLY MET After 10 hrs of duty during the 2days ward exposure, the patient: -Responds to minor stimulations -V/S still increased BP- 150/90 T- 36.7 PR-64 RR-22 -has no observed deterioration of health condition

ASSESSMENT
SUBJECTIVE: Unresponsive & always asleep cant interview

NSG. DIAGNOSIS

PLANNING

INTERVENTION EVALUATION S
-Enhance communication -Maximize pts social interaction -Assist in personal hygiene -Provide Health teaching -- effective communication, new ways to interact, safety precautions, hygiene, clothing, plan for home adaptations COLLABORATIVE -Administer meds -Monitor & Follow up lab results -Seek and plan of care with Therapist (if available)

COMPARISON B/N THE CONCEPT and THE PATIENTS ASSESSMENT

S/SX

VISUAL FIELD DEFICITS

HEMIANOPSIAunaware of person on side of visual loss LOSS OF PERIPHERAL VISION-difficulty seeing in the night DIPLOPIA- double vision NOT OBSERVED

NOT OBSERVED NOT OBSERVED

MOTOR DEFICITS
HEMIPARESIS-weakness of face, arm and leg on the same side HEMIPLEGIA-Paralysis of the face, arm and leg on the same side ATAXIA-staggering, unsteady gait DYSARTHRIA- difficulty in forming words DYSPHAGIA-difficulty in swallowing OBSERVED

OBSERVED

NOT OBSERVED NOT OBSERVED NOT OBSERVED

SENSORY DEFICIT
PARESTHESIA (opposite of the lesion) numbness & tingling of the extremity NOT OBSERVED

VERBAL DEFICIT
APHASIA- impairment in NOT OBSERVED speaking, listening, writing and understanding; most cases are mixed)

COGNITIVE DEFICITS
Short & Long Term Memory Loss Decrease attention span Impaired ability to concentrate Poor abstract reasoning Altered judgement NOT OBSERVED NOT OBSERVED NOT OBSERVED NOT OBSERVED NOT OBSERVED

EMOTIONAL DEFICIT
Loss of self control Decrease tolerance to stress Depression Withdrawal Fear Fealing of isolation NOT OBSERVED NOT OBSERVED NOT OBSERVED NOT OBSERVED NOT OBSERVED NOT OBSERVED

OTHERS
BLADDER IMPAIRMENT POSSIBLE RESPIRATORY IMPAIRMENT IMPAIRED MENTAL ACTIVITY LOSS OF CONSCIOUSNESS AND DIZZINESS OBSERVED OBSERVED OBSERVED OBSERVED