Stroke

Joan Marie Amamio BSN IV Report by:

A stroke, or cerebrovascular accident (CVA), is the rapid loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage. As a result, the affected area of the brain cannot function, which might result in an inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field. A stroke is a medical emergency and can cause permanent neurological damage, complications, and death. Risk factors for stroke include old age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke.[2] It is the second leading cause of death worldwide. An ischemic stroke is occasionally treated in a hospital with thrombolysis (also known as a "clot buster"), and some hemorrhagic strokes benefit from neurosurgery. Treatment to recover any lost function is termed stroke rehabilitation, ideally in a stroke unit and involving health professions such as speech and language therapy, physical therapy and occupational therapy. Prevention of recurrence may involve the administration of antiplatelet drugs such as aspirin and dipyridamole, control and reduction of hypertension, and the use of statins. Selected patients may benefit from carotid endarterectomy and the use of anticoagulants. Strokes can be classified into two major categories: ischemic and hemorrhagic.[4] Ischemic strokes are those that are caused by interruption of the blood supply, while hemorrhagic strokes are the ones which result from rupture of a blood vessel or an abnormal vascular structure. About 87% of strokes are caused by ischemia, and the remainder by hemorrhage. Some hemorrhages develop inside areas of ischemia ("hemorrhagic transformation"). It is unknown how many hemorrhages actually start as ischemic stroke.[2] Ischemic Main articles: Cerebral infarction and Brain ischemia In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen: 1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally)

2. Embolism (obstruction due to an embolus from elsewhere in the body,

see below),[2] 3. Systemic hypoperfusion (general decrease in blood supply, e.g., in shock)[5] 4. Venous thrombosis.[6] Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin); this constitutes 30-40% of all ischemic strokes.[2][7] There are various classification systems for acute ischemic stroke. The Oxford Community Stroke Project classification (OCSP, also known as the Bamford or Oxford classification) relies primarily on the initial symptoms; based on the extent of the symptoms, the stroke episode is classified as total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI) or posterior circulation infarct (POCI). These four entities predict the extent of the stroke, the area of the brain affected, the underlying cause, and the prognosis.[8][9] The TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification is based on clinical symptoms as well as results of further investigations; on this basis, a stroke is classified as being due to (1) thrombosis or embolism due to atherosclerosis of a large artery, (2) embolism of cardiac origin, (3) occlusion of a small blood vessel, (4) other determined cause, (5) undetermined cause (two possible causes, no cause identified, or incomplete investigation).[ Hemorrhagic Main articles: Intracranial hemorrhage and intracerebral hemorrhage

An intraparenchymal bleed (bottom arrow) with surrounding edema (top arrow) Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. A distinction is made between intra-axial hemorrhage (blood inside the brain) and extra-axial hemorrhage (blood inside the skull but outside the brain). Intra-axial hemorrhage is due to

intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular system). The main types of extra-axial hemorrhage are epidural hematoma (bleeding between the dura mater and the skull), subdural hematoma (in the subdural space) and subarachnoid hemorrhage (between the arachnoid mater and pia mater). Most of the hemorrhagic stroke syndromes have specific symptoms (e.g., headache, previous head injury). Signs and symptoms Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage. Causes This section needs additional citations for verification. (September 2008) Thrombotic stroke In thrombotic stroke a thrombus[18] (blood clot) usually forms around atherosclerotic plaques. Since blockage of the artery is gradual, onset of symptomatic thrombotic strokes is slower. A thrombus itself (even if non-occluding) can lead to an embolic stroke (see below) if the thrombus breaks off, at which point it is called an "embolus." Two types of thrombosis can cause stroke:

Large vessel disease involves the common and internal carotids, vertebral, and the Circle of Willis.[19] Diseases that may form thrombi in the large vessels include (in descending incidence): atherosclerosis, vasoconstriction (tightening of the artery), aortic, carotid or vertebral artery dissection, various inflammatory diseases of the blood vessel wall (Takayasu arteritis, giant cell arteritis, vasculitis), noninflammatory vasculopathy, Moyamoya disease and fibromuscular dysplasia. Small vessel disease involves the smaller arteries inside the brain: branches of the circle of Willis, middle cerebral artery, stem, and arteries arising from the distal vertebral and basilar artery.[20] Diseases that may form thrombi in the small vessels include (in descending incidence): lipohyalinosis (build-up of fatty hyaline matter in the blood vessel as a result of high blood pressure and aging) and fibrinoid degeneration[21] (stroke involving these vessels are known as lacunar infarcts) and microatheroma (small atherosclerotic plaques).[22]

Sickle-cell anemia,[23] which can cause blood cells to clump up and block blood vessels, can also lead to stroke. A stroke is the second leading killer of people under 20 who suffer from sickle-cell anemia.[24]

Embolic stroke An embolic stroke refers to the blockage of an artery by an arterial embolus, a travelling particle or debris in the arterial bloodstream originating from elsewhere. An embolus is most frequently a thrombus, but it can also be a number of other substances including fat (e.g., from bone marrow in a broken bone), air, cancer cells or clumps of bacteria (usually from infectious endocarditis). Because an embolus arises from elsewhere, local therapy solves the problem only temporarily. Thus, the source of the embolus must be identified. Because the embolic blockage is sudden in onset, symptoms usually are maximal at start. Also, symptoms may be transient as the embolus is partially resorbed and moves to a different location or dissipates altogether. Emboli most commonly arise from the heart (especially in atrial fibrillation) but may originate from elsewhere in the arterial tree. In paradoxical embolism, a deep vein thrombosis embolises through an atrial or ventricular septal defect in the heart into the brain. Cardiac causes can be distinguished between high and low-risk:[25]

High risk: atrial fibrillation and paroxysmal atrial fibrillation, rheumatic disease of the mitral or aortic valve disease, artificial heart valves, known cardiac thrombus of the atrium or ventricle, sick sinus syndrome, sustained atrial flutter, recent myocardial infarction, chronic myocardial infarction together with ejection fraction <28 percent, symptomatic congestive heart failure with ejection fraction <30 percent, dilated cardiomyopathy, Libman-Sacks endocarditis, Marantic endocarditis, infective endocarditis, papillary fibroelastoma, left atrial myxoma and coronary artery bypass graft (CABG) surgery. Low risk/potential: calcification of the annulus (ring) of the mitral valve, patent foramen ovale (PFO), atrial septal aneurysm, atrial septal aneurysm with patent foramen ovale, left ventricular aneurysm without thrombus, isolated left atrial "smoke" on echocardiography (no mitral stenosis or atrial fibrillation), complex atheroma in the ascending aorta or proximal arch.

Systemic hypoperfusion Systemic hypoperfusion is the reduction of blood flow to all parts of the body. It is most commonly due to cardiac pump failure from cardiac arrest or arrhythmias, or from reduced cardiac output as a result of myocardial infarction, pulmonary embolism, pericardial effusion, or bleeding. Hypoxemia (low blood oxygen content) may precipitate the hypoperfusion. Because the reduction in blood flow is global, all parts of the brain may be affected, especially "watershed" areas - border zone regions supplied by the major cerebral arteries. A watershed stroke refers to the condition when blood supply to these areas is compromised. Blood flow to these areas does not necessarily stop, but instead it may lessen to the point where brain damage can occur. This phenomenon is also referred to as "last meadow" to point to the fact that in irrigation the last meadow receives the least amount of water.

Venous thrombosis Cerebral venous sinus thrombosis leads to stroke due to locally increased venous pressure, which exceeds the pressure generated by the arteries. Infarcts are more likely to undergo hemorrhagic transformation (leaking of blood into the damaged area) than other types of ischemic stroke.[6] Intracerebral hemorrhage It generally occurs in small arteries or arterioles and is commonly due to hypertension,[26] intracranial vascular malformations (including cavernous angiomas or arteriovenous malformations), cerebral amyloid angiopathy, or infarcts into which secondary haemorrhage has occurred.[2] Other potential causes are trauma, bleeding disorders, amyloid angiopathy, illicit drug use (e.g., amphetamines or cocaine). The hematoma enlarges until pressure from surrounding tissue limits its growth, or until it decompresses by emptying into the ventricular system, CSF or the pial surface. A third of intracerebral bleed is into the brain's ventricles. ICH has a mortality rate of 44 percent after 30 days, higher than ischemic stroke or subarachnoid hemorrhage (which technically may also be classified as a type of stroke[2]). Silent stroke A silent stroke is a stroke that does not have any outward symptoms, and the patients are typically unaware they have suffered a stroke. Despite not causing identifiable symptoms, a silent stroke still causes damage to the brain, and places the patient at increased risk for both transient ischemic attack and major stroke in the future. Conversely, those who have suffered a major stroke are at risk of having silent strokes.[27] In a broad study in 1998, more than 11 million people were estimated to have experienced a stroke in the United States. Approximately 770,000 of these strokes were symptomatic and 11 million were first-ever silent MRI infarcts or hemorrhages. Silent strokes typically cause lesions which are detected via the use of neuroimaging such as MRI. Silent strokes are estimated to occur at five times the rate of symptomatic strokes.[28][29] The risk of silent stroke increases with age, but may also affect younger adults and children, especially those with acute anemia. Tests and diagnosis By Mayo Clinic staff To determine the most appropriate treatment for your stroke, your emergency team needs to evaluate the type of stroke you're having and the areas of your brain affected by the stroke. They also need to rule out other possible causes of your symptoms, such as a brain tumor or a drug reaction. Your doctor may use several tests to determine your risk of stroke, including:

Physical examination. Your doctor will ask you or a family member what symptoms you've been having, when they started and what you were doing when they began. Your doctor then will evaluate whether these symptoms are still present. Your doctor will want to know what medications you take and whether you have experienced any head injuries. You'll be asked about your personal and family history of heart disease, TIA or stroke.

Your doctor will check your blood pressure and use a stethoscope to listen to your heart and to listen for a whooshing sound (bruit) over your neck (carotid) arteries, which may indicate atherosclerosis. Your doctor may also use an ophthalmoscope to check for signs of tiny cholesterol crystals or clots in the blood vessels at the back of your eyes. Blood tests. You may have several blood tests, which give your care team important information such as how fast your blood clots, whether your blood sugar is abnormally high or low, whether critical blood chemicals are out of balance, or whether you may have an infection. Your blood's clotting time and levels of sugar and key chemicals must be managed as part of your stroke care. Infections also must be treated. Computerized tomography (CT) scan. Brain imaging plays a key role in determining if you're having a stroke and what type of stroke you may be experiencing. A CT scan uses a series of X-rays to create a detailed image of your brain. A CT scan can show a brain hemorrhage, tumors, strokes and other conditions. Doctors may inject a dye into your blood vessels to view your blood vessels in your neck and brain in greater detail (computerized tomography angiography). Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of your brain. An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages. Sometimes your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiography, or magnetic resonance venography). Carotid ultrasound. In this test, sound waves create detailed images of the inside of the carotid arteries in your neck. This test shows buildup of fatty deposits (plaques) and blood flow in your carotid arteries. Cerebral angiogram. In this test, your doctor inserts a thin, flexible tube (catheter) through a small incision, usually in your groin, and guides it through your major arteries and into your carotid or vertebral artery. Then your doctor injects a dye into your blood vessels to make them visible under X-ray imaging. This procedure gives a detailed view of arteries in your brain and neck. Echocardiogram. An echocardiogram uses sound waves to create detailed images of your heart. An echocardiogram can find a source of clots in your heart that may have traveled from your heart to your brain and caused your stroke. You sometimes may have a transesophageal echocardiogram. In this test, your doctor inserts a flexible tube with a small device (transducer) attached in your throat and down into your esophagus the tube that connects the back of your mouth to your stomach. Because your esophagus is directly behind your heart, a transesophageal echocardiogram can create clear, detailed ultrasound images of your heart and any blood clots.

Treatments and drugs By Mayo Clinic staff Emergency treatment for stroke depends on whether you're having an ischemic stroke blocking an artery the most common kind or a hemorrhagic stroke involving bleeding into the brain. Ischemic stroke To treat an ischemic stroke, doctors must quickly restore blood flow to your brain.

Emergency treatment with medications. Therapy with clot-busting drugs (thrombolytics) must start within 4.5 hours if they are given into the vein and the sooner, the better. Quick treatment not only improves your chances of survival but also may reduce the complications from your stroke. You may be given:

Aspirin. Aspirin, an anti-thrombotic drug, is an immediate treatment after an ischemic stroke to reduce the likelihood of having another stroke. Aspirin prevents blood clots from forming. In the emergency room, you may be given a dose of aspirin. The dose may vary, but if you already take a daily aspirin for its blood-thinning effect, you may want to make a note of that on an emergency medical card so doctors will know if you've already taken some aspirin. Other blood-thinning drugs, such as heparin, also may be given, but this drug isn't proven to be beneficial in the emergency setting so it's used infrequently. Clopidogrel (Plavix), warfarin (Coumadin), or aspirin in combination with extended release dipyridamole (Aggrenox) may also be used, but these aren't usually used in the emergency room setting.

Intravenous injection of tissue plasminogen activator (TPA). Some people who are having an ischemic stroke can benefit from an injection of a recombinant tissue plasminogen activator (TPA), also called alteplase, usually given through a vein in the arm. This potent clot-busting drug needs to be given within 4.5 hours after stroke symptoms begin if it's given into the vein. This drug restores blood flow by dissolving the blood clot causing your stroke, and it may help people who have had strokes recover more fully. Your doctor will consider certain risks, such as potential bleeding in the brain, to determine if TPA is the most appropriate treatment for you.

Emergency procedures. Doctors sometimes treat ischemic strokes with procedures that must be performed as soon as possible.

Medications delivered directly to the brain. Doctors may insert a long, thin tube (catheter) through an artery in your groin and thread it to your brain, and then release TPA directly into the area where the stroke is occurring. The time window for this treatment is somewhat longer than for intravenous TPA but still limited. Mechanical clot removal. Doctors may use a catheter to maneuver a tiny device into your brain to physically grab and remove the clot.

Other procedures. To decrease your risk of having another stroke or TIA, your doctor may recommend a procedure to open up an artery that's moderately to severely narrowed by plaque. Doctors sometimes recommend these procedures to prevent a stroke. Options may include:

Carotid endarterectomy. In a carotid endarterectomy, a surgeon removes fatty deposits (plaques) from your carotid arteries that run along each side of your neck to your brain. In this procedure, your surgeon makes an incision along the front of your neck, opens your carotid artery, and removes fatty deposits (plaques) that block the carotid artery. Your surgeon then repairs the artery with stitches or a patch made with a vein or artificial material (graft). The procedure may reduce your risk of ischemic stroke. However, a

carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions. Angioplasty and stents. In an angioplasty, a surgeon inserts a catheter with a mesh tube (stent) and balloon on the tip into an artery in your groin and guides it to the blocked carotid artery in your neck. Your surgeon inflates the balloon in the narrowed artery and inserts a mesh tube (stent) into the opening to keep your artery from becoming narrowed after the procedure.

Hemorrhagic stroke Emergency treatment of hemorrhagic stroke focuses on controlling your bleeding and reducing pressure in your brain. Surgery also may be used to help reduce future risk. Emergency measures. If you take warfarin (Coumadin) or anti-platelet drugs such as clopidogrel (Plavix) to prevent blood clots, you may be given drugs or transfusions of blood products to counteract their effects. You may also be given drugs to lower pressure in your brain (intracranial pressure), lower your blood pressure or prevent seizures. People having a hemorrhagic stroke can't be given clot-busters such as aspirin and TPA, because these drugs may worsen bleeding. Once the bleeding in your brain stops, treatment usually involves bed rest and supportive medical care while your body absorbs the blood. Healing is similar to what happens while a bad bruise goes away. If the area of bleeding is large, surgery may be used in certain cases to remove the blood and relieve pressure on the brain. Surgical blood vessel repair. Surgery may be used to repair certain blood vessel abnormalities associated with hemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if you're at high risk of a spontaneous aneurysm or arteriovenous malformation (AVM) rupture:

Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm, to stop blood flow to it. This can keep the aneurysm from bursting, or it can prevent re-bleeding of an aneurysm that has recently hemorrhaged. Coiling (endovascular embolization). In this procedure, a surgeon inserts a catheter into an artery in your groin and guides it to your brain using X-ray imaging. Your surgeon then guides tiny detachable coils into the aneurysm (aneurysm coiling). The coils fill the aneurysm, which blocks blood flow into the aneurysm and causes the blood to clot. Surgical AVM removal. Surgeons may remove a smaller AVM if it's located in an accessible area of your brain, to eliminate the risk of rupture and lower the risk of hemorrhagic stroke. However, it's not always possible to remove an AVM if it's too large or if it's located deep within your brain.

Arterial supply of oxygenated blood Four major arteries and their branches supply the brain with blood. The four arteries are composed of two internal carotid arteries (left and right) and two vertebral arteries that ultimately join on the

underside (inferior surface) of the brain to form the arterial circle of Willis, or the circulus arteriosus. The vertebral arteries actually join to form a basilar artery. It is this basilar artery that joins with the two internal carotid arteries and their branches to form the circle of Willis. Each vertebral artery arises from the first part of the subclavian artery and initially passes into the skull via holes (foramina) in the upper cervical vertebrae and the foramen magnum. Branches of the vertebral artery include the anterior and posterior spinal arteries, the meningeal branches, the posterior inferior cerebellar artery, and the medullary arteries that supply the medulla oblongata. The basilar artery branches into the anterior inferior cerebellar artery, the superior cerebellar artery, the posterior cerebral artery, the potine arteries (that enter the pons), and the labyrinthine artery that supplies the internal ear. The internal carotids arise from the common carotid arteries and pass into the skull via the carotid canal in the temporal bone. The internal carotid artery divides into the middle and anterior cerebral arteries. Ultimate branches of the internal carotid arteries include the ophthalmic artery that supplies the optic nerve and other structures associated with the eye and ethmoid and frontal sinuses. The internal carotid artery gives rise to a posterior communicating artery just before its final splitting or bifurcation. The posterior communicating artery joins the posterior cerebral artery to form part of the circle of Willis. Just before it divides (bifurcates), the internal carotid artery also gives rise to the choroidal artery (also supplies the eye, optic nerve, and surrounding structures). The internal carotid artery bifurcates into a smaller anterior cerebral artery and a larger middle cerebral artery. The anterior cerebral artery joins the other anterior cerebral artery from the opposite side to form the anterior communicating artery. The cortical branches supply blood to the cerebral cortex. Cortical branches of the middle cerebral artery and the posterior cervical artery supply blood to their respective hemispheres of the brain. The circle of Willis is composed of the right and left internal carotid arteries joined by the anterior communicating artery. The basilar artery (formed by the fusion of the vertebral arteries) divides into left and right posterior cerebral arteries that are connected (anastomsed) to the corresponding left or right internal carotid artery via the respective left or right posterior communicating artery. A number of arteries that supply the brain originates at the circle of Willis, including the anterior cerebral arteries that originate from the anterior communicating artery. In the embryo, the components of the circle of Willis develop from the embryonic dorsal aortae and the embryonic intersegmental arteries. The circle of Willis provides multiple paths for oxygenated blood to supply the brain if any of the principal suppliers of oxygenated blood (i.e., the vertebral and internal carotid arteries) are constricted by physical pressure, occluded by disease, or interrupted by injury. This redundancy of blood supply is generally termed collateral circulation.

Arteries supply blood to specific areas of the brain. However, more than one arterial branch may support a region. For example, the cerebellum is supplied by the anterior inferior cerebellar artery, the superior cerebellar artery, and the posterior inferior cerebellar arteries.

Stroke Nursing Diagnosis and Interventions

1. Ineffective cerebral tissue perfusion related to brain hemorrhage, edema

Goal : Adequate tissue perfusion with indicators: Adequate tissue perfusion is based on peripheral pulse pressure, skin warmth, adequate urine output and no interference with the respiras. Plan of action : Monitor neurologic status R /: Knowing the tendency of the level of awareness and potential increase in intra-cranial pressure and know the location. Area and progress damage the central nervous system.
o

Monitor respiratory status R: / respiratory irregularity can give the location of the damage / increase in intracranial pressure o Monitor heart sound R /: bradycardia may occur as a result of brain damage. o Place the head with a slightly elevated position and in a neutral position R /: Lowering arterial pressure to improve drainage and improve circulation o Manage medications R /: Prevention / treatment reduction intra-cranial pressure o Give Oxygen as indicated R /: Reducing hypoxia 2. Impaired physical mobility related to decreased muscle strength Criteria for outcome : o The joints are not stiff o There was no muscle atrophy Plan of action :
o

Exercise therapy Joint mobility Explain to the patient and the patients family, the purpose of joint movement exercises. Monitor the location and discomfort during exercise Use a loose-fitting clothing Assess the ability of patients to the movements Encourage active ROM Teach ROM active / passive on the patient and patients family. Change the position of the patient every 2 hours. Assess progress / advancement training. Self Care Assistance Monitor the independence of patients Assist the patient in terms of self-care: eating, bathing, toileting. Teach family in the fulfillment of self-care patients. The movement of the active / passive aims to maintain flexibility of joints Physical disability and psychological patient, can reduce the daily personal care and can be fulfilled with the help of personal hygiene for patients can be maintained. Nursing Diagnosis for Stroke 1. Impaired brain tissue perfusion related to intracerebral hemorrhage. 2. Impaired physical mobility related to hemiparese / hemiplegia 3. Impaired sensory perception related to sensory impairment, vision impairment 4. Impaired verbal communication related to the decrease in brain blood circulation 5. Impaired elimination (constipation) related to immobilization, inadequate fluid intake .

6. The risk of nutritional deficiencies related to muscle weakness of chewing and

swallowing.
7. Lack of compliance with self care related to hemiparese / hemiplegi . 8. The risk of disruption of skin integrity related long bed rest. 9. The risk of ineffective airway clearance related to the decrease in cough reflex

and swallowing.
10. Impaired elimination urine (urine incontinence) related to lesions in the upper

motor neuron. Lab Tests and Procedures If you have had a stroke or stroke warning signs, your doctor may need additional information to fully understand your problem or plan the best treatment. In addition to blood tests, you may need to schedule special tests or procedures to examine your brain, heart or blood vessels. Here are the tests doctors use most often in stroke diagnosis. Tests that View the Brain, Skull, or Spinal Cord

CT scan (CAT Scan, Computed axial tomography) A CT scan uses X-rays to produce a 3-dimensional image of your head. A CT scan can be used to diagnose ischemic stroke, hemorrhagic stroke, and other problems of the brain and brain stem.

MRI scan (Magnetic resonance imaging, MR) An MRI uses magnetic fields to produce a 3-dimensional image of your head. The MR scan shows the brain and spinal cord in more detail than CT. MR can be used to diagnose ischemic stroke, hemorrhagic stroke, and other problems involving the brain, brain stem, and spinal cord.

Tests that View the Blood Vessels that Supply the Brain

Carotid doppler (Carotid duplex, Carotid ultrasound) Painless ultrasound waves are used to take a picture of the carotid arteries in your neck, and to show the blood flowing to your brain. This test can show if your carotid artery is narrowed by arteriosclerosis (cholesterol deposition).

Transcranial doppler (TCD) Ultrasound waves are used to measure blood flow in some of the arteries in your brain.

MRA (Magnetic resonance angiogram) This is a special type of MRI scan (see above) which can be used to see the blood vessels in your neck or brain. Cerebral arteriogram (Cerebral angiogram, Digital subtraction angiography, [DSA]) A catheter is inserted in an artery in your arm or leg, and a special dye is injected into the blood vessels leading to your brain. X-ray images

show any abnormalities of the blood vessels, including narrowing, blockage, or malformations (such as aneurysms or arterio-venous malformations). Cerebral arteriogram is a more difficult test than carotid doppler or MRA, but the results are the most accurate.

Tests that View the Heart or Check its Function

Echocardiogram (2-d echo, Cardiac echo, TTE, TEE) Painless ultrasound waves are used to take a picture of your heart and the circulating blood. The ultrasound probe may be placed on your chest (trans-thoracic echocardiogram, TTE) or deep in your throat (transesophageal echocardiogram, TEE).

Electrocardiogram (EKG, ECG)

This is a standard test to show the pattern of electrical activity in your heart. 3-10 electrical leads are attached to your chest, arms and legs. Sometimes the EKG is recorded continuously over days, with the signals sent to a portable recorder (Holter monitor) or by radio to a hospital monitoring station (telemetry).

Routine Screening Tests

Chest x-ray (CXR) An x-ray of the heart and lungs is a standard test for patients with acute medical problems. Abnormalities may alert your doctor to important problems such as pneumonia or heart failure. Urinalysis (UA) A urine sample is often obtained to screen for bladder infection or kidney problems. If infection is suggested, a urine culture test may be required. Pulse oximetry (Blood oxygen) This painless test is sometimes done in the emergency room or hospital to determine if your blood is receiving enough oxygen from the lungs. A small probe with a red light is usually attached to one finger.

Other Neurologic Tests

Electroencephalogram (EEG) The EEG measures your brain waves through several electrical leads painlessly attached to your head. EEG is not routinely used for stroke diagnosis, but would be ordered if your doctor thinks that you may have had a seizure.

Lumbar puncture (LP, spinal tap) A needle is inserted in your lower back to obtain a sample of the fluid (cerebrospinal fluid, CSF) which surrounds your brain and spinal cord. LP is not routinely used for diagnosis of ischemic stroke. However, LP is often required if subarachnoid hemorrhage (bleeding from a cerebral

aneurysm) is suspected. LP may also be needed if your doctor suspects a nervous system infection (such as meningitis) or inflammation.

Electromyogram / Nerve conduction test (EMG / NCV) This test records the electrical activity of the nerves and muscles. EMG is not used for stroke diagnosis, but might be needed if your doctor suspects a problem with the nerves in your arms or legs.

Brain biopsy This is a surgical procedure in which a small piece of the brain is removed for microscopic examination. Biopsy is used to diagnose lesions (such as tumors) which cannot be identified by CT or MRI scan. It is very rarely used for stroke diagnosis, often only when cerebral vasculitis is suspected.

The Signs of a Stroke The most common signs of a stroke are: A numb, weak or paralyzed face, leg or arm. This can come on very quickly. It often happens to only one side of the body. For example, the person may not be able to use their right arm and their right leg.

The person can not speak. The person can not understand what other people are saying to them. Their eyes change. The person may have blurred vision. Trouble swallowing. Loss of balance. Dizziness. A very bad headache.

These signs can get worse over a day or more, as it gets worse. Some people may not have any signs of a stroke at all. At times, people may have some of these signs but when they last only a few minutes. These people are having a TIA or mini stroke and not a stroke. TIAs do not cause lasting damage to the person, but TIAs are a warning sign that a person may have a stroke soon. Stroke Risk Factors Some of the things that increase the chance of getting a stoke are:

Age. The older one gets, the greater the risk of stroke. Elderly people are at greatest risk of stroke. History of Stroke in the Family. A person is at risk for stroke if the person has a family member that has had a stroke or a TIA. Race. African Americans are more likely to have a stroke than other groups of people. The reason for this is because diseases, such as diabetes and high blood pressure, are found at a high rate in this race and these diseases lead to strokes. Gender. Men are more likely to have a stroke than a woman before the age of 55. After age 55, men and women are at the same risk. Things Like High Blood Pressure and Diabetes. Some of the same things that lead to high blood pressure and diabetes are the same for stroke. For example, people that weigh too much, those who do not eat a good diet and those who do not have regular exercise are at high risk for high blood pressure, diabetes and stroke.

Life Style. People that have poor habits are more likely to have a stroke. Cigarette smoking, drug use, alcohol abuse, a poor diet with a high intake of foods with fat, a lack of exercise and being over weight add to the risk of stroke. A History of a TIA. People that have had a TIA are at risk for a stroke.

Risk factors like race, gender and family history cannot be changed by a person to lower their chances of getting a stroke. But, a person can control life style habits like diet, exercise and cigarette smoking. Caring for the Patient After a Stroke About 20 percent of the people who get a stroke will die in the hospital as a result of it. Many people who have had a stroke will get better and be able to enjoy a full and happy life. Still more are not able to function as well as they used to. Others may never be able to speak, walk, or eat on their own after a stroke. A patient may have oxygen and an intravenous line (IV) right after their stroke. They may also get medicine to lower brain swelling.

Soon after the stroke, nursing care restores function and prevents complications. For example, rehabilitation, bladder and bowel function and the prevention of pressure sores become nursing care priorities shortly after a stroke. A loss of function or weakness to the left side of the body occurs when a person has a stroke to the right side of the brain. Likewise, when a person has a stroke on the left side of the body, losses of function will occur on the right side of the body. Paralysis and weakness to one side of the body is called hemiplegia. About 20% of stroke patients have aphasia. Aphasia gives the stroke patient trouble with speaking, reading, writing and understanding others. Other functions, such as bladder, bowel, swallowing, breathing, balance and vision, may be affected with both right sided and left sided brain damage as a result of a stroke. Rehabilitation Rehabilitation aims to restore some function by promoting the bodys ability to have a new part of the brain take over the lost function. It helps the person to increase their muscle strength, balance, gait, speech, confidence and communication abilities. It also helps to prevent pressure sores and contractions.

Rehabilitation usually begins right after a stroke. It continues for weeks or months after a stroke. It is given in a rehab center, in the patients own home, in a hospital and in a nursing home. Occupational therapists, physical therapists, speech and language therapists, recreation therapists, dietitians, doctors, nurses, nursing assistants, restorative and rehabilitation aides are members of the rehab team for stroke patients.

Occupational therapists

Occupational therapists help the person to do their activities of daily living. They work with the patient so they will be able to dress themselves, and do personal grooming after a stroke. Some people need special assistive devices after a stroke. They use special forks, plates and devices to pick items up from the floor. These things help with the activities of daily living. The occupational therapist uses these things with the patient so that they can be as independent as possible. Nursing assistants who take care of people after a stroke should help the person with their activities of daily living as planned by the occupational therapist and other members of the rehab team. They should help them with dressing, brushing their teeth and using any assistive devices that they have. Physical therapists Physical therapists help stroke patients with moving about in bed, ambulation, balance, gait and muscle strength.

Physical therapists use heat and cold treatments, massage, weight training, assistive devices, orthotic devices, range of motion exercise and other kinds of exercise to improve the patients level of functioning. Some of the assistive devices that a physical therapist uses to help the person walk are:

Canes Walkers Gait belts

Some of the orthotic devices that a physical therapist uses to support, align and prevent bodily deformities are:

Braces Splints

Speech and language therapists

Speech and language therapists assist their patients with communication. They also help patients with a swallowing disorder, something that often happens after a stroke. These therapists also use assistive devices. For example, they may use a word board so that a patient can communicate their needs to others with out the spoken word. Recreation therapists

Recreational therapists also work on the rehab team. They plan and conduct activities that are fun and also help the persons physical, mental and social skills. Some of these activities include:

Bingo Singing groups Wheelchair exercise groups Reading Current event group

Dietitians Dietitians provide good diets to patients. They adjust diets when a patient has a swallowing disorder. They also work with nursing staff members to prevent and treat pressure sores after a stroke. They help to plan restorative dining groups. These groups help patients to feed themselves, with some cues or help, using assistive devices, like a food guard plate, an easy hold cup and heavily padded forks, knives and spoons. Doctors, nurses, nursing assistants, restorative and rehabilitation aides Doctors, nurses, nursing assistants, restorative and rehabilitation aides carry out the plan of care for the rehab team during all of their interactions with the patient after the stroke. Nursing assistants must:

Prevent falls and make sure that the patient is safe. (Take our class called Preventing Falls for more information about falls and falls prevention.) Encourage and support the patient. It is important for all health care providers to give the stroke patient and their family members encouragement and support. This is a very difficult time for them. Rehab is also mentally and physically exhausting. Encourage as much independence as possible. Feed hemiplegia patients by placing the food on the good side of the mouth. (Take our class called Feeding Residents and Patients for more information feeding after a stroke.)

Provide good skin care. (Take our class called Preventing Pressure Ulcers for more information about skin care after a stroke) Assist the patient with their assistive and supportive devices. Follow the ordered bowel and bladder retraining program. Help the person with their activities of daily living. Help them bathe, get dressed and eat.

Assist the patient with mobility and ambulation. Do range of motion exercises with the person. Encourage and support the patient after the stroke.

Summary Stroke is a major health problem, especially among the elderly. Nursing assistants play a very important role in caring for patients that have had a stroke. They assist the patient with their restorative and rehabilitation treatments and they help to prevent some of the problems that stroke patients have, like falls, skin breakdown and the loss of independence.

Increased Intracranial Pressure (ICP)

Joan Marie Amamio BSN IV Report by: Introduction The cranium contains brain tissue (1,400 g), blood (75 mL), and CSF (75 mL). The volume and pressure of these three components are usually in a state of equilibrium and produce the ICP, which is 10 to 20 mm Hg and represents the pressure within the rigid skull. An increase in intracranial pressure is a serious medical problem. The pressure itself can damage the brain or spinal cord by pressing on important brain structures and by restricting blood flow into the brain. Causes of increased ICP include : >a rise in cerebrospinal fluid pressure, >increased pressure within the brain matter, >bleeding into the brain or fluid around the brain, or >Swelling within the brain matter itself. Pathophysiology

 Increased ICP is a syndrome that affects many patients with acute neurologic conditions. An elevated ICP is most commonly associated with head injury, secondary effect in other conditions, such as brain tumors, subarachnoid hemorrhage, and toxic and viral encephalopathies. Increased ICP from any cause decreases cerebral perfusion, stimulates further swelling (edema), and shifts brain tissue through openings in the rigid dura, resulting in brain herniation (next slide), a frequently fatal event. Clinical Manifestations
When ICP increases to the point at which the brains ability to adjust has

reached its limits, neural function is impaired; this may be manifested by clinical changes first in LOC and later by abnormal respiratory and vasomotor responses. Slowing of speech and delay in response to verbal suggestions are other early indicators. Restlessness (without apparent cause), confusion, or increasing drowsiness, has neurologic significance. These signs may result from compression of the brain due to swelling from hemorrhage or edema, an expanding intracranial lesion (hematoma or tumor), or a combination of both. As ICP increases, the patient becomes stuporous, reacting only to loud auditory or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required. As neurologic function deteriorates further, the patient becomes comatose and exhibits abnormal motor responses in the form of decorticate or decerebrate posture (see next slide). When the coma is profound, with the pupils dilated and fixed and respirations impaired, death is usually inevitable. Assessment and Diagnostic Findings The patient may undergo cerebral angiography, computed tomography (CT) scanning, or magnetic resonance imaging (MRI).

 Transcranial Doppler studies provide information about cerebral blood flow. The patient with increased ICP may also undergo electrophysiologic monitoring to monitor the pressure (next slide).

Lumbar puncture is avoided in patients with increased ICP because the sudden release of pressure can cause the brain to herniate. Medical Management Increased ICP is a true emergency and must be treated immediately through: Invasive monitoring of ICP to identify increased pressure early in its course (before cerebral damage occurs), to quantify the degree of elevation, to initiate appropriate treatment, to provide access to CSF for sampling and drainage, and to evaluate the effectiveness of treatment. Decreasing cerebral edema: Osmotic diuretics (mannitol) may be given to dehydrate the brain tissue and reduce cerebral edema. They reduce the volume of brain and extracellular fluid. Corticosteroids (eg, dexamethasone) help reduce cerebral edema when a brain tumor is the cause of increased ICP. Maintaining cerebral perfusion: The cardiac output may be manipulated to provide adequate perfusion to the brain. Inotropic agents such as dobutamine hydrochloride are used. The effectiveness of the cardiac output is reflected in the cerebral perfusion pressure, which is maintained at greater than 70 mm Hg. A lower cerebral perfusion pressure indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion. Cerebral perfusion pressure (CPP) is defined as the difference between mean arterial and intracranial pressures. Mean arterial pressure is the diastolic pressure plus one third of the pulse pressure (difference between the systolic and diastolic). MAP is thus between systolic and diastolic pressures. CPP = MAP - ICP

 Normal cerebral perfusion pressure is 80 mmHg, nearer diastolic. Lowering the volume of CSF and cerebral blood: CSF drainage is frequently performed because the removal of CSF with a ventriculostomy drain may dramatically reduce ICP and restore cerebral perfusion pressure. Controlling fever: Preventing a temperature elevation is critical because fever increases cerebral metabolism and the rate at which cerebral edema forms. Maintaining oxygenation: Arterial blood gases must be monitored to ensure that systemic oxygenation remains optimal. Hemoglobin saturation can also be optimized to provide oxygen more efficiently at the cellular level. Reducing metabolic demands: Cellular metabolic demands may be reduced through the administration of high doses of barbiturates when the patient is unresponsive to conventional treatment. Another method is the administration of pharmacologic paralyzing agents. Because the patient who receives these agents cannot respond or report pain, sedation and analgesia must be provided.

Nursing Process: The Patient With Increased ICP Assessment: Obtain a history of events leading to the present illness; it may be necessary to obtain this information from significant others. The neurologic examination should include an evaluation of mental status, level of consciousness (LOC), cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. Assessment of LOC includes eye opening; verbal and motor responses; pupils (size, equality, reaction to light). Because the patient is critically ill, ongoing assessment will be more focused, including pupil checks, assessment of selected cranial nerves, frequent measurements of vital signs and intracranial pressure, and use of the Glasgow Coma Scale (next

slide), which is a tool for assessing a patients LOC. Scores range from 3 (deep coma) to 15 (normal).. Glasgow Coma Scale Eye opening response Spontaneous To voice To pain None Best verbal response Oriented Confused Inappropriate words Incomprehensible sounds None Best motor response Obeys command Localizes pain Withdraws Flexion (decorticate) Extension (decerebrate) 2 None Total Nursing diagnoses: Ineffective airway clearance related to diminished protective reflexes (cough, gag) Ineffective breathing patterns related to neurologic dysfunction (brain stem compression, structural displacement) Ineffective cerebral tissue perfusion related to the effects of increased ICP 3 to 15 1 4 3 1 6 5 4 3 2 3 2 1 5 4

Planning and goals Maintenance of a patent airway Normalization of respiration Adequate cerebral tissue perfusion through reduction in ICP

Nursing Interventions: Maintaining patent airway. Assess the patency of the airway. Suction with care the secretions obstructing the airway, because transient elevations of ICP occur with suctioning. The patient is hyperoxygenated before and after suctioning to maintain adequate oxygenation. Discourage coughing because it increases ICP. Auscultate the lung fields at least every 8 hours to determine the presence of abnormal breath sounds. Elevate the head of the bed may aid in clearing secretions as well as improving venous drainage of the brain. Continued. Achieving an adequate breathing pattern Monitor the patient constantly for respiratory irregularities. This includes Cheyne-Stokes respirations (alternating periods of hyperpnea and apnea) (See picture below) and hyperventilation (increased rate and depth of breathing) (Next slide). Continued on Slide 23 Monitor PaCO2 (normal range 35 to 45 mm Hg) if hyperventilation therapy has been decided to reduce ICP (by causing cerebral vasoconstriction and a decrease in cerebral blood volume).

 Maintain a neurologic observation record. Repeated assessments of the patient are made frequently to immediately note improvement or deterioration. Prepare for surgical intervention in case of deterioration.

Optimising cerebral tissue perfusion Maintain head alignment and elevate head of bed 30 degrees. The rationale is that hyperextension, rotation, or hyperflexion of the neck causes decreased venous return. Avoid extreme hip flexion as this increases intra-abdominal and intrathoracic pressures, leading to rise in ICP. Avoid the Valsalva maneuver (straining at stool) as it raises ICP. Administer stool softeners as prescribed. If appropriate, provide high fiber diet. Note abdominal distention. Avoid enemas and cathartics (sorbitol, magnesium citrate, sodium sulfate). Continued
When moving or being turned in bed, instruct the patient to

exhale to avoid the Valsalva maneuver. If the patient is on mechanical ventilation, preoxygenate and hyperventilate him, before suction, using 100% oxygen on the ventilator. Suctioning should not last longer than 15 seconds. Avoid activities that raise ICP if possible. Space nursing interventions; this may prevent transient increases in ICP. During nursing interventions, the ICP should not rise above 25 mm Hg and should return to baseline levels within 5 minutes. Patients with Patients with the potential for a significant increase in ICP should receive sedation or paralyzation before initiation of many nursing activities.

 Avoid emotional stress, frequent arousal from sleep, and environmental stimuli (noise, conversation). Isometric muscle contractions (Pushing against an immovable wall) are also contraindicated because they raise the systemic blood pressure and hence the ICP.

Causes:

Causes of increased intracranial pressure can be classified by the mechanism in which ICP is increased:

mass effect such as brain tumor, infarction with edema, contusions, subdural or epidural hematoma, or abscesses all tend to deform the adjacent brain. generalized brain swelling can occur in ischemic-anoxia states, acute liver failure, hypertensive encephalopathy, pseudotumor cerebri, hypercarbia, and Reye hepatocerebral syndrome. These conditions tend to decrease the cerebral perfusion pressure but with minimal tissue shifts. increase in venous pressure can be due to venous sinus thrombosis, heart failure, or obstruction of superior mediastinal or jugular veins. obstruction to CSF flow and/or absorption can occur in hydrocephalus (blockage in ventricles or subarachnoid space at base of brain, e.g., by Arnold-Chiari malformation), extensive meningeal disease (e.g., infection, carcinoma, granuloma, or hemorrhage), or obstruction in cerebral convexities and superior sagittal sinus (decreased absorption).

Main article: hydrocephalus

increased CSF production can occur in meningitis, subarachnoid hemorrhage, or choroid plexus tumor. Idiopathic or unknown cause (idiopathic intracranial hypertension)

Signs and symptoms

In general, symptoms and signs that suggest a rise in ICP including headache, vomiting without nausea, ocular palsies, altered level of consciousness, back pain and papilledema. If papilledema is protracted, it may lead to visual disturbances, optic atrophy, and eventually blindness.

PHARMACOLOGIC MANAGEMENT a.Osmotic diuretics- most common is mannitol. Side effects of large dose include production of hyperosmolar state, decreased effectiveness with repeated use andaggravation of edema in some clients.

b.Loop diuretics- nonosmotic diuretic like furosemide (Lasix). For older clients atrisk for congestive heart failure, furosemide may improve the cardiovascular status. c.Steroids- dexamethasone (Decadron). Antacids or H2 blockers may also be prescribed to control gastrointestinal irritation and hemorrhage. d.Antihypersentives- caution is used to avoid cerebral vasodilation. e.Anticonvulsant- Phenytoin (Dilantin) and Phenobarbital are the usual agents. To prevent seizures. f.Barbiturate Therapy for uncontrolled ICP- Pentobarbital is the drug of choice. Theuse of this treatment requires sophisticated monitoring capacity and trained personnel, but its use has shown increased survival.

SURGICAL MANAGEMENT a.Surgical placement of a shunt to allow drainage if CSF is blocked b.Decompressive surgery- done by removing some brain tissue (e.g., part of thetemporal lobe) to give remaining structures room to expand.

RISK FACTORSClients at the highest risk of developing increased ICP are those who haveexpanding masses in the brain. Common clients are those who have had an injury to the head, surgery on the brain, hydrocephalus,, brain tumors and bleeding (e.g., subarachnoid bleeding)

PATHOPHYSIOLOGY

HEAD INJURY (most common cause)

ICP

EDEMA

SHIFTING OF BRAIN TISSUE THROUGH OPENING OF RIGID DURA.

HERNIATION

DEATH (frequently fatal event)