CEREBRAL VASCULAR ACCIDENT

February 22, 2023

CEREBRAL VASCULAR ACCIDENT

Cerebral-Vascular accident (CVA) is the sudden disruption of O₂ supply to the nerve cells, generally caused by obstruction or rupture in one or more of the blood vessels that supply the brain characterised by loss of consciousness, paralysis and impaired speech

CAUSES OF CEREBRAL VASCULAR ACCIDENT

1. CEREBRAL THROMBOSIS: In elderly people, the cerebral arteries are affected by arteriosclerosis in which the lining of the arteries becomes thickened and roughened. The flow of blood is obstructed and clotting occurs. This clot (thrombus) blocks the artery and deprives part of the brain of its blood supply

2. CEREBRAL HAEMORRHAGE: Rupture of a blood vessel produces hemorrhage into the brain. This event is more common in case of hypertensio

3. CEREBRAL EMBOLISM: An embolus, or detached clot, may lodge in one of the cerebral arteries and produce a stroke. This variety of stroke is seen in diseases where a clot forms on the left side of the heart and is carried up in the blood stream to lodge in one of the cerebral vessels. The diseases which most frequently cause a clot in the left side of the heart ar

a. Mitral stenosis with atrial fibrillatio

b. Myocardial infarctio

c. Subacute bacterial endocarditi

PATHOPHYSIOLOGY OF CEREBRAL VASCULAR ACCIDEN

The brain must receive a steady supply of nutrients from the blood because it has no capacity to store either O₂ or glucose. It is supplied with blood from two major pairs of vessels, the internal carotids and vertebrals

The complex processes of cerebral auto regulation maintain blood flow to the brain at a fairly constant rate of 750mls per minute. The cerebral vessels dilate and constrict in response to changes in blood pressure and carbon dioxide tension. Ischemia will cause primary death of cerebral cells or cerebral infarction, which creates a core of necrotic tissues. There is secondary area of tissue damage in which cells are temporarily unable to function but may remain viable. Ischemia will cause the following

• Impaired movement of calcium and potassium. High levels of calcium are believed to trigger the activation of enzymes that attack neuron cell membranes

• The accumulation of O₂ free radicals, which further disrupt calcium metabolism

• The presence of glucose is low: perfusion area enhances lactate production, which worsens cellular damage and acidosis

• An influx of fluid-activated white cells and coagulation factors further clog the microcirculation

Stroke associated with hemorrhage is primarily related to an abrupt rise in intracranial pressure and ischemia followed by cerebral edema. With intracerebral bleeding blood is forced into the adjacent brain tissue, where a hematoma forms. This will result in compression of tissue and even result in brain tissue displacement or herniation

THE CLINICAL FEATURES OF C

Specific symptoms will reflect the site and severity of ischemic damage

MOTOR EFFECT

• Hemiparesis or hemiplegia of the side of the body opposite the site of ischemia

• Initially flaccid, progressing to spactic

• Dysphagia : swallowing reflex may also be impaire

• Dysarthri

BOWEL AND BLADDE

• Frequency, urgency and urinary incontinenc

• Constipatio

• Bowel incontinenc

LANGUAG

• Aphasia: difficulty or inability to express self verbally or difficulty or inability to comprehend speech

• Alexia: inability to understand written wor

• Agraphia: inability to express self in writing

SENSORY-PERCEPTUA

• Diminished response to superficial sensation i.e. touch, pain, pressure, heat and cold

• Diminished proprioception: loss of awareness of where various body parts are in relationship to each other and the environment

COGNITIVE-EMOTIONA

• Emotional lability and unpredictabilit

• Depressio

• Memory los

• Short attention spa

• Loss of reasoning,( judgment and abstract thinking ability

AS the cerebral edema increases; there will be changes in mentation including apathy, irritability, disorientation, memory loss, withdrawal, drowsiness, stupor or coma

Other clinical features are

• Numbness or loss of sensatio

• Weakness or paralysis on part or one side of the body

• Headache, neck stiffness and rigidit

• Vomitin

• Seizure

• Dizziness or syncop

MANAGEMENT OF C

1. MEDICAL MANAGEME

A. INVESTIGATION

a. CT scan: To reveal site of infarction, hematoma and shift of brain structure

b. MRI: Magnetic Resonance Imaging to reveal site of infarctio

c. EEG: Shows abnormal nerve impulse transmissio

d. Lumbar Puncture for CSF analysis: Not done routinely especially if there is IICP

e. Cerebral Angiography: To pin point site of rupture or occlusion and identify collateral blood circulation

2. MEDICAL TREATMEN

• RESPIRATORY SUPPORT: Maintenance of air-way and delivery of O₂ as needed. Intermittent positive pressure breathing (IPPB) and chest physiotherapy are important

• IV fluids: To maintain fluid and electrolyte balance. Fluids may be limited while IICP is a risk

• Positioning: Bed rest during acute stage. Activity level is increased as patient’s condition improves. Elevate HOB at 30° as prescribed. HOB may be kept up with hemorrhagic stroke or patients with IICP to decrease cerebral perfusion and improve venous outflow

• Diet: NPO status and possible gastric tube if swallow and gag reflexes are diminished or if patient has decreased LOC. A low-Na⁺ and low- fat diet may be prescribed to minimize other risk factors

PHARMACOTHERAP

• Anticoagulants: In patients with CVS or transient Ischemic attacks Heparin sodium and Warfarin Sodium to help prevent further thrombosis

• Antihypertensive agents e.g. Nifedipine to control very high Blood pressure, which may cause cerebral edema and IICP

• Antiplatelet medications e.g. Aspirin in conjuction with dipyridamole or Sulfinpyrazone; to prevent platelet aggregation that may lead to thrombus formation

• Glucocorticosteroids: e.g. Dexamethasone and Osmotic diuretics (Mannitol) to prevent or reduce cerebral edema

• Antacids and histamine H₂-Receptor blockers (e.g. ranitidine) to reduce the risk of GI hemorrhage from gastric ulcer caused by stress

• Ant epilepsy drug e.g. phenytoin or Phenobarbital; to control and prevent seizures

• Sedatives/Tranquilizers e.g. diphenhydramine; to promote rest. These are used cautiously to avoid further impairment of neurologic function

• Analgesics e.g. Acetaminophen; to control headach

• Stool softeners e.g. Acetaminophen to control headach

• Stool softeners e.g. Docusate or Bisocondayle to prevent straining which can result in IIC

• Hemodilution: e.g. albumin, Crystalloid fluids. Hydration is promoted via fluids and volume expanders to decrease blood viscosity in order to improve cerebral blood flow

NURSING CA

AIM

1. TO PREVENT COMPLICATIONS ASSOCIATED WITH STROK

2. TO MAINTAIN A PATENT AIRWA

3. TO PROVIDE A NUTRITIOUS DIE

4. TO BRING BACK THE PATIENT TI HIS/HER NORMAL OR NEAR NORMAL FUNCTIONAL STATE

The nursing care of a patient with stroke calls for total nursing care in which all activities of daily living are done on behalf of the patient

ENVIRONMENT/POSITIO

• The patient is best nursed in the intensive care unit where he/she will be closely monitored during the acute/critical stage

• The patient is placed on bed rest with the head of the bed elevated at 30° and positioned well, to prevent the tongue from falling back

• Supplemental O₂ may be administered preferably 100% O₂ from the cylinder

• The environment is kept as quiet and restful as possible and all activities that are known to increase intracranial pressure, such as coughing, straining, lying prone, muscle contraction, emotional upset and abrupt head or neck flexion are avoided or minimized

• The patient is assisted to change positions every 2 hours and encouraged to move independently in bed as soon as possible. The affected arm is positioned with the hand elevated above the wrist and the wrist above the elbow to support venous return and minimize edema

• Shoulders are placed in neutral position with support as needed. Pillows, rolled towels and sand bags are used to support normal body alignment with particular attention to preventing external rotation of the hip

• Special care to avoid excess pressure or pull on the shoulder joint, which is extremely vulnerable to joint subluxation and adduction contractures should be put in place

• Heels should be elevated off the mattress to avoid pressure injury and foot positioning to prevent foot drop

• Hands are splint firmly. Supine position is avoided to prevent aspiration. A side-lying position with the head of the bed elevated 10 to 20° should be maintained

• Pressure area care and prevention of sore formation with the use of elbow and heel protection is done

OBSERVATIO

• Immediately after the patient’s admission the focus of nursing care is on monitoring the patient’s neurological status and preventing complications, while assessing the severity of stroke

• Vital signs and neurological checks are performed regularly to rule out the presence of IIP

• The Glasgow coma scale is used to assess the level of consciousness and neurological responses

• Assess for signs of pressure, shearing or friction damage during each position change

• Change the patient’s position every 2 hourly and record on the chart. Ensure strict input and output recording.

• The patient will have an indwelling urethral catheter, therefore assess for any presence of infection. Get urine samples for examination

NUTRITION AND FLUID

• Depending on the condition of the patient, feeding may be through NGT. Assess the swallowing reflexes of the patien

• Ensure that the tube is in the right place to Prevent chocking the patient

• A highly nutritious diet should be given through an NGT such as milk, soup, custard and light porridge.

• Ensure that feeds are at an acceptable temperature; prevent burning the gut of the patient

• Fluids are strictly given to prevent cerebral edema

• IV fluids will be maintained if there is IIP; hypertonic fluids to reduce cerebral edema will be given

ELIMINATIO

• Ensure that the patient is not constipated. Stool softeners may be given to prevent straining

• Patient may have uncontrolled bowel movements, ensure that a barrier-cream is applied to the buttock (perineal area) to prevent skin excoriation

HYGIEN

• Since the patient depends totally on the nurse, all hygienic needs should be done for her, i.e. bedpans, pressure area care, mouth care and catheter toilet

• Ensure that the patient is in a dry, clean environment.

EXERCISES AND REHABILITATI

• The rehabilitation plan incorporates active physical therapy, but the nurse needs to incorporate a variety of interventures into the patients daily care routines

• Positioning is fundamental to preventing complications such as contractures and skin breakdown

• Coughing and deep breathing exercises and frequent position changes prevent pooling of mucus and encourage ventilation of all areas of the lungs

• Encourage patient with hemiplegia to exercise while they are still in bed not only prepares them for later activities but also offers hope and a sense of optimism about recovery

• Perform passive ROM exercises four times daily after the first 24hours following a stroke

• Frequent ROM prevents joint immobility, tendon contractures, and muscle atrophy and weakness. They also stimulate circulation and help re-establish neuromuscular pathways

• Help patient out of bed as soon as it is medically permitted. Involve physiotherapist to assist with exercises. Help patient use walker with guidance/ use of crutches

• Assist patient to be on a wheel chair or use a wheel chair

• Speech therapist should be consulted to re-train the patient on speech if it has been affected. The client may be taught to use the other hand which is not affected

HEALTH EDUCATIO

• If the patient is to be discharged home, the family needs clear understanding of the residual deficits. The family and patient need to have realistic expectations about the patient’s abilities

• Emphasis on the need of physiotherapy if there’s residue disability as rehabilitative measure

• Patient should avoid high cholesterol diet and high Na⁺ intake

• Patient has to reduce weight if he is obese

• Reduce or stop smoking/alcohol beverages. Patient has to avoid prolonged bed rest and stressful life-styles.CEREBRAL VASCULAR ACCIDENDEN

CEREBRAL VASCULAR ACCIDE