CASE PRESENTATION ON CEREBRO VASCULAR ACCIDENT

1. CASE PRESENTATION ON CEREBRO VASCULAR ACCIDENT PREPARED BY: JINU STAFF NURSE, ICU DEPARTMENT

2. DEMOGRAPHIC DATA • CASE NO: 19039 • NAME: XYZ • AGE: 48YRS • SEX: MALE • COMPLAINT:RIGHTSIDE WEAKNESS,BREATHING DIFFICULTY • DIAGNOSIS: CEREBRO VASCULAR ACCIDENT • DOA: 21/03/2013

3. PHYSICAL ASSESSMENT • An assessment is conducted starting at the head and proceeding in a systemic and efficient downward (head to toe). The procedure varies according to age, belief, religion of the subject, the severity of illness of the patient, the location of the examination, the priorities and procedures.

4. General Assessment The patient is 48 years of age,, approximately weighs 75kg • He is conscious and oriented.GCS15 /15 with the following vital signs. • BP= 170/90 mmHg • PR=110 bpm • RR= 20 mts • Temp=36.4 ⁰C • SPO²= 98%

5. Skin: • Warm to touch • No palpable mass or lesions • Cyanosis absent. Head: • Maxillary, frontal sinuses are not tender. • No palpable masses and lesion. • No areas of deformity

6. Level of Consciousness and Orientation: • Patient conscious and oriented. • GCS: 15/15 Eyes: • Pink conjunctiva and no dryness • Pupils equally round and reactive to light Ears: • No unusual discharges noted.

7. Nose: • No unusual nasal discharges. Neck and Throat: • No palpable lymph nodes • No masses and lesions seen • Use assessory muscles for respiration Chest and Lungs: • Equal chest expansion • air entry is not good in right side. • wheezing sound present.

8. Heart: • Regular rhythm Abdomen: • Soft abdomen • Bowel movement present Genitals: • Folys catheter present • No hernia noted.

9. Extremities: • Pulse full and equal • No lesions noted • swelling present • right side weakness present MOUTH: • Pink and moist oral mucosa and free of swelling and lesions.

10. PATIENT HISTORY PAST MEDICAL HISTORY • With history of hypertension since 2 years and diabetes mellitus since 3 years and he is on medicine tab. Metformin

11. PRESENT MEDICAL HISTORY • Patient is came to ER with the complaints of right sided weakness and slight slurring of speech. Patient conscious and oriented,GCS 15/15. From ER patient treated with aspirin . After all investigation Patient shifted to ICU for further observation and management.

12. From ICU patient is treated with Inj. Clexane and Aspirin and also treated with Tab.COZAR to reduce hypertension. After all these management patient is able to ambulate with the help of a assistant. After two days patient was shifted to surgery ward. Then after two days of treatment patient was discharged from there.

13. MEDICATION

14. INVESTIGATION

15. Non Contrast CT Brain: Hypodensity is seen in periventricular white matter ( chronic ischemic changes ) in left parital area. Brain atrophy present. Opacification is seen in right maxillary sinuses. CAROTID DOPPLER: • Right side- Bilateral vertebral arteries have normal ante grade flow. • Left side - There is initial thickening measures 1.3 mm in thickness causing stenosis 22% in the left common carotid artery.

16. INTRODUCTION • The term cerebrovascular disease designates any abnormality of the brain resulting from a pathologic process of the blood vessels e.g. occlusion of the lumen by a thrombus or embolus, rupture of the vessel, any lesion or altered permeability of the vessel wall and increased viscosity or other change in quality of blood. Disorders of the cerebral circulation include any disease of the vascular system that causes ischemia or infarction of the brain or spontaneous hemorrhage into the brain or subarachnoid space. Although the classification of cerebrovascular diseases can be complex, four practical definitions are adequate for most clinical purpose.

17. DEFINITION • Cerebrovascular accident: The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a stroke

18. X. ANATOMY AND PHYSIOLOGY

23. VI. PATHOPHYSIOLOGY Thrombosis, embolism Uncontrolled bleeding between the innermost two of the three meninges, the pia matter and the arachnoid matter Hypertension Artery inside the brain fails Blood pools in the subarachnoid space SUBARACHNOID HEMMORAGE Loss of perfusion to an area of the brain ISCHEMIA Burst and bleed- INTRACEREBRAL HEMMORHAGE Head trauma or a ruptured aneurysm Inability to move, understand , formulate speech or see in one side of the visual field.

24. ETIOLOGY • Ischemic stroke. About 85 percent of strokes are ischemic strokes. The most common ischemic strokes include: • Thrombotic stroke. • Embolic stroke. • Hemorrhagic stroke. Hemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures.. • Transient ischemic attack (TIA). A transient ischemic attack (TIA) — also called a ministroke — is a brief episode of symptoms similar to those you'd have in a stroke. A transient ischemic attack is caused by a temporary decrease in blood supply to part of your brain. TIAs often last less than five minutes.

25. RISK FACTORS • Being Age over 55 • Having Diabetes • Having any family history • MEDICAL STROKE RISK FACTOERS • Hyper tension • previous Stroke • High cholesterol level • Any heart disease • LIFE STYLE RISK FACTORS • Smoking • Being over weight • Drinking too much alcohol.

26. SIGNS AND SYMPTOMS • In embolism • Usually occurs without warning • Client often with history of cerebro vascular accident • In thrombosis • Dizzy spells or sudden memory loss • No pain, and client may ignore signs and symptoms • In cerebral hemorrhage • May having warning like dizziness and ringing in the ear (tinnitus) • Violent headache with nausea and vomiting.

27. SUDDEN ONSET OF CVA • Usually most severe • Trouble with speaking and understand • Paralysis and numbess of the arms and legs • Trouble with walking • Trouble with seeing in one or both eyes • Loss of consciousness • Elevated BP • Pulse is slow but full and bounding • Breathing is noisy and strained • Swallowing difficulties or drooling • Loss of balance and co- ordination • Mood changes ( depression , apathy)

28. TREATMENT • THERAPUTIC TREATMENT • Support of vital function • Maintain airway, breathing oxygenation and circulation • Neurological assessment • To check the deterioration related to re bleed or devoplment of cerebral edema. • Neurological consultation for possible evacuation of intracranial hemorrhage may be explored. • Reversal of coagulopathies: • Anticoagulant therapy if thrombus or embolus is present, antiplatelet therapy. • If ischemic type, thrombolytic therapy with recombinant tissue plasminogen activator, (t-PA) with in 3 hours of onset.

29. Management for BP with in prescribed parameter. • Maintain BP less than 160 /90 to reduces vessel wall stressors. • Prophylactic treatment of seizure with phenytoin. • Anti-inflammatory or osmotic diuretics may be used to reduce cerebral edema and intracranial pressure. • Evaluate any signs of increased intracranial pressure. • IV fluid at maintaince until able to tolerate oral feed • SURGICAL MANAGEMENT • Hemicraniectomy • Carotid endraterectomy • Also called stent placement( may be done prophylactically) to improve cerebral flow when carotid arteries are narrowed by arteriosclerotic plaque.

30. COMPLICATIONS • Decubitus ulcers • Dementia • Disability • Osteoporosis • Chronic pain • Recurrent stroke • Tremor • Difficulty speaking • Difficulty swallowing • Arm weakness (unilateral) • Leg weakness (unilateral) • Aspiration pneumonia • Facial weakness • Inability to live independently • Urinary incontinence • Bowel incontinence • Memory loss • Muscle spasms

31. INTERVENTION Nursing intervention includes: • Monitor Vital Signs, especially the blood pressure. • Monitor the Neurovascular Status. • Refer any untoward change in sensorium. Give stat medications immediately as ordered. • Give due medications on time. • Institute safety and aspiration precaution. • Suction whenever needed

32. NURSING HEALTH TEACHING • Family health teaching is an important role of the nurse which includes the following: • Maintaining skin care • Adequate hydration. • Scheduled and strict positioning • Monitoring vital signs such as temperature, pulse, and blood pressure • Strict compliance to rehabilitation – physical therapy, occupational therapy and speech-language pathology

33. BED SORE MANAGEMENT • Strict turning every two hours, nursed in airbed. • Keeping prominent areas dry, clean and free from pressure. • Use wrinkle free bed sheet. • Applying creams/ointments as prescribed. • Dressing wound/bed sores .If any, give adequate nutrition. • Daily assessment of pressure areas.

34. GLASCO COMA SCALE

35. PRIORITIZATION OF NURSING PROBLEMS • Impaired physical mobility related to motor deficit • Ineffective airway clearance related to inflammation and increased sputum production. • Disturbed thought process related to brain injury. • Self care deficit: bathing ,dressing ,toileting related to paralysis. • Impaired verbal communication related to brain injury • Fear and anxiety related to disease condition and hospitalization

38. CONCLUSION CVA is a medical emergency which can be prevented if the risk factors are reduced. In case of stroke, the patient must be instantly brought to the hospital and be given immediate interventions. In this case patient admitted in ICU and treated with Tab. Aspirin and Inj. Clexane. Some complications can be avoided if the patient is closely monitored and given due attention and care. The manifestations and recovery depend on the location and severity of the damage or bleeding in the patient’s brain.

39. BIBLIOGRAPHY • Wikipedia. • Medical and surgical nursing book volume 1 and 2 of Brunner. • Luck man and Sorensen’s Medical-Surgical Nursing a Physiologic Approach 4th edition Lippincott Manual of Nursing Practice 9th edition.

40. QUESTIONS 1.COMPLICATIONS OF CVA? 2.WHICH ARE THE MEMBRRANES COVERING THE BRAIN? 3.BULGING OF AN ARTERY BECAUSE OF WEAKENING OF AN ARTERY IS CALLED-------? 4.WHAT ARE THE ETIOLOGY OF STROKE? 5.TIA IS OTHERWISE CALLED------------? 6.WHAT ARE THE LIFE STYLE RISK FACTORS OF STROKE? 7.WHAT ARE THE SIGNS AND SYMPTOMS OF STROKE?

41. 8.WHAT IS THE TIME PERIOD OF GIVING OF TPA STROKE? 9.WHAT IS THE PROPHYLACTIC TREATMENT OF SEIZURE ? 10.WHAT ARE THE SURGICAL MANAGEMENT OF STROKE?