Bicol University College of Nursing Legazpi City

CASE PRESENTATION
(Cerebrovascular Accident)

Submitted by: GROUP 8 Logoc, Angela Jiselle Malacad, Dane Carmela Monsalve, Kerensa Gentica, Karissa Novora, Francis Morco, Cyrus Santos, Bryan Ace Ozaeta, Fatima Pantino, Stephanie Mae Rafanan, Salvacion Rodrigueza, Rachel

Submitted to: Evangeline Datu, RN, MN Clinical Instructor

INTRODUCTION

Cerebrovascular Accident is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. Stroke, also called brain attack or ischemic stroke, happens when the arteries leading to the brain are blocked or ruptured. When the brain does not receive the needed oxygen supply, the brain cells begin to die, a stroke can cause paralysis, inability to talk, inability to understand, and other conditions brought on by brain damage. Four types of stoke: 1. Cerebral Thrombosis- caused by blood clots. 2. Cerebral Embolism- caused by blood clots. 3. Cerebral Hemorrhage- caused by bleeding inside the brain. 4. Subarachnoid Hemorrhage- caused by bleeding inside the brain. Cerebral Thrombosis The most common type of brain attack. Occurs when a blood clot (thrombus) forms and blocks blood flow in an artery leading to the brain arteries primarily affected by atherosclerosis and more susceptible to blood clots. Most often occurs at night or in the morning when blood pressure in low. Often preceded by a transient ischemic attack (TIA) or mini-stroke. Cerebral Embolism Occurs when a wondering clot (embolus) or some other particle forms in a blood vessel away from the brain, usually in the heart. The clot then travels and lodges in an artery leading on the brain. Cerebral Hemorrhage Occurs when a defective artery in the brain busts. Subarachnoid Hemorrhage Occurs when a blood vessel on the surface of the brain ruptures and bleeds into the space between the brain and the skull. The World Health Organization (WHO) definition of stroke is rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of (1) Noncommunicable disease. WHO Geneva (2) vascular origin (3) By applying this definition transient ischemic attack (TIA), which is defined to less than 24 hours, and patients with stroke symptoms caused by subdural hemorrhage, tumors, poisoning, or trauma, are excluded.

Based from the data gathered from TCGPH records section, there were 10 reported cases of CVA as of January 2009 until December 2009 comprises of 2 mortality cases and 8 morbidity cases. PATIENTS PROFILE

NAME: AGE: 70y/o ADDRESS:

Capadocia, Evangelina SEX: Female Tiwi Albay

CIVIL STATUS: MARRIED

History of HPN Diabetic DATE OF ADMISSION: Sept 22, 2013

ANATOMY AND PHYSIOLOGY The anatomy of the brain is complex due its intricate structure and function. Thisamazing organ acts as a control center by receiving, interpreting, and directing sensoryinformation throughout the body. There are three major divisions of the brain. They arethe forebrain, the midbrain, and the hindbrain.

Anatomy of the Brain: Brain Divisions

The anatomy of the brain is complex due its intricate structure and function. Thisamazing organ acts as a control center by receiving, interpreting, and directing sensoryinformation throughout the body. There are three major divisions of the brain. They arethe forebrain, the midbrain, and the hindbrain.

Anatomy of cerebral circulation Arterial supply of oxygenated bloodFour major arteries and their branches supply the brain with blood. The four arteries arecomposed of two internal carotid arteries (left and right) and two vertebral arteries thatultimately 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 initiallypasses into the skull via holes (foramina) in the upper cervical vertebrae and theforamen magnum. Branches of the vertebral artery include the anterior and posterior spinal arteries, the meningeal branches, the posterior inferior cerebellar artery, and themedullary 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 vertebra l arteries) divides into left and right posterior cerebral arteries that are connected (anastomosed) 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. Venous return of deoxygenated blood from the brain Veins of the cerebral circulatory system are valve-less and have very thin walls. The veins pass through the subarachnoid space, through the arachnoid matter, the dura, and ultimately pool to form the cranial venous sinus. There are external cerebral veins and internal cerebral veins. As with arteries, specific areas of the brain are drained by specific veins. For example, the cerebellum is drained of deoxygenated blood by veins that ultimately form the great cerebral vein. External cerebral veins include veins from the lateral surface of the cerebral hemispheres that join to form the superficial middle cerebral vein.

PATHOPHYSIOLOGY

Cerebrovascular disease is a group of brain dysfunctions related to disease of the blood vessels supplying the brain. Hypertension is the most important cause; it damages the blood vessel lining, endothelium, exposing the underlying collagen where platelets aggregate to initiate a repairing process which is not always complete and perfect. Sustained hypertension permanently changes the architecture of the blood vessels making them narrow, stiff, deformed, uneven and more vulnerable to fluctuations in blood pressure. A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue. The most common symptom of a stroke is sudden weakness or numbness of the face, arm or leg, most often on one side of the body. Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; fainting or unconsciousness. The effects of a stroke depend on which part of the brain is injured and how severely it is affected.

A very severe stroke can cause sudden death, the 1990 Global Burden of Disease (GBD) study provided the first global estimate on the burden of 135 diseases, and cerebro vascular diseases ranked as the second leading cause of death after ischemic heart disease.

During the past decade the quantity of especially routine mortality data has increased, and is now covering approximately one-third of the worlds population. The increase in data availability provides the possibility for updating the estimated global burden of stroke. Additionally, cerebrovascular disease is the leading cause of disability in adults and each year millions of stroke survivors has to adapt to a life with restrictions in activities of daily living as a consequence of cerebrovascular disease. Many surviving stroke patients will often depend on other peoples continuous support to survive.

MEDICAL MANAGEMENT Treatment for Stroke Early treatment for stroke can help minimize damage to brain tissue and improve the outcome (prognosis). Treatment depends on whether the stroke is ischemic or hemorrhagic and on the underlying cause of the condition. Hemorrhagic stroke usually requires surgery. The long-term goals of treatment include rehabilitation and prevention of additional strokes. Treatment for Ischemic Stroke Initial treatment for ischemic stroke involves removing the blockage and restoring blood flow. Tissue plasminogen activator (t-PA) is a medication that can break up blood clots and restore blood flow when administered within 3 hours of the event. This medication carries a risk for increased intracranial hemorrhage and is not used for hemorrhagic stroke. Mannitol, a diuretic, may be administered intravenously (through an IV) to reduce intracranial pressure during an ischemic stroke. Antihypertensives such as labetalol (Normodyne) and enalapril (Vasotec) may be used alone or in combination with diuretics to treat high blood pressure. Side effects are usually mild and include dizziness, fatigue, and headache. Antiplatelet agents such as aspirin, clopidogrel bisulfate, and aspirin with dipyridamole (Aggrenox) may be prescribed to reduce the risk for recurrent stroke. Aspirin may also improve the outcome of a stroke when administered within 48 hours. Side effects include stomach pain, heartburn, nausea, and gastrointestinal bleeding. Aggrenox is taken orally, twice a day, and may also cause headache. Clopidogrel bisulfate (Plavix) is an antiplatelet medication that is taken orally, once a day, to help prevent the formation of blood clots. It is prescribed for patients with atherosclerosis who have had a recent stroke and is used to prevent recurrence. Patients with medical conditions that may cause internal bleeding (e.g., stomach ulcers) should not use clopidogrel. Side effects include abdominal pain, rash, diarrhea, and headache. Serious side effects (e.g., gastrointestinal hemorrhage) are rare. Physicians and dentists should be informed that a patient is taking clopidogrel before any surgery is scheduled. Anticonvulsants such as diazepam (Valium) and lorazepam (Ativan) may be prescribed for patients who experience recurrent seizures after a stroke. Side effects include drowsiness, fatigue, and weakness. Anticoagulants such as warfarin (Coumadin) may be prescribed to prevent the formation of blood clots. Patients taking warfarin may require regular blood tests to monitor coagulation (blood clot formation) and prevent abnormal bleeding.

DRUG STUDY MANNITOL BRAND NAME: Osmitrol THERAPEUTIC ACTIONS: Elevates the osmolarity of the glomerular filtrate, thereby hindering the reabsorption of water and leading to a loss of water, sodium, chloride (used for diagnosis of glomerular filtration rate); creates an osmotic gradient in the eye between plasma and ocular fluids, thereby reducing intraocular pressure; creates an osmotic effect, leading to decreased swelling in post-transurethral prostatic resection. INDICATIONS: Prevention and treatment of the oliguric phase of renal failure Reduction of intracranial pressure and treatment of cerebral edema; of elevated intraocular pressure when the pressure cannot be lowered by other means Promotion of the urinary excretion of toxic substances Measurement of glomerular filtration rate (diagnostic use) Irrigant in transurethral prostatic resection or other transurethral procedures Contraindications/cautions Anuria due to severe renal disease, pulmonary congestion, active intracranial bleeding (except during craniotomy), dehydration, renal disease, CHF

DOSAGE: Available Forms: Injection--5%, 10%, 15%, 20%, 25%; solution--5 g/100 mL Adult: IV infusion only; individualize concentration and rate of administration. Dosage is 50--200 g/d. Adjust dosage to maintain urine flow of 30---50 mL/h. Prevention of oliguria: 50---100 g IV as a 5%---25% solution. Treatment of oliguria: 50---100 g IV of a 15%---25% solution. Reduction of intracranial pressure and brain mass: 1.5---2 g/kg IV as a 15%---25% solution over 30---60 min. Evidence of reduced pressure should be seen in 15 min. Reduction of intraocular pressure: Infuse 1.5---2 g/kg IV as a 25% solution, 20% solution, or 15% solution over 30 min. If used preoperatively, use 1---1 1/2 h before surgery.

Adjunctive therapy to promote diuresis in intoxications: Maximum of 200 g IV of mannitol with other fluids and electrolytes. Measurement of glomerular filtration rate: Dilute 100 mL of a 20% solution with 180 mL of sodium chloride injection. Infuse this 280 mL of 7.2% solution IV at a rate of 20 mL/min. Collect urine with a catheter for the specified time for measurement of mannitol excreted in mg/min. Draw blood at the start and at the end of the time for measurement of mannitol in mg/mL plasma.

Test dose of mannitol: 0.2 g/kg IV (about 60 mL of a 25% solution, 75 mL of a 20% solution, or 100 mL of a 15% solution) in 3---5 min to produce a urine flow of 30---50 mL/h. If urine flow does not increase, repeat dose. If no response to second dose, reevaluate patient situation.

Pediatric: Dosage for children <12 y not established.

ADVERSE EFFECTS CNS: Dizziness, headache, blurred vision, convulsion GI: Nausea, anorexia, dry mouth, thirst CV: Hypotension, hypertension, edema, thrombophlebitis, tachycardia, chest pain Respiratory: Pulmonary congestion, rhinitis Hematologic: Fluid and electrolyte imbalances GU: Diuresis, urinary retention Dermatologic: Uriticaria, skin necrosis

NURSING CONSIDERATIONS Assessment History: Pulmonary congestion, active intracranial bleeding, dehydration, renal disease, CHF Physical: Skin color, lesions, edema, hydration; orientation, reflexes, muscle strength, pupils; pulses, BP, perfusion; R, pattern, adventitious sounds; urinary output patterns; CBC, serum electrolytes, urinalysis, renal function tests Implementation Do not give electrolyte-free mannitol with blood. If blood must be given, add at least 20 mEq of sodium chloride to each liter of mannitol solution.

Do not expose solutions to low temperatures; crystallization may occur. If crystals are seen, warm the bottle in a hot water bath, then cool to body temperature before administering. Make sure the infusion set contains a filter if giving concentrated mannitol. Monitor serum electrolytes periodically with prolonged therapy.

PARACETAMOL (acetaminophen) It is a pain reliever and a fever reducer. The exact mechanism of action of is not known. Paracetamol is used to treat many conditions such as headache, muscle aches, arthritis, backache, toothaches, colds, and fevers. It relieves pain in mild arthritis. INDICATIONS: Paracetamol has good analgesic and antipyretic properties. It is suitable for the treatment of pains of all kinds (headaches, dental pain, postoperative pain, pain in connection with colds, post-traumatic muscle pain). Migraine headaches, dysmenorrhea and joint pain can also be influenced advantageously. In cancer patients, paracetamol is used for mild pain or it can be administered in combination with opioids (e.g. codeine). Paracetamol has been compared to many other analgesics and is considered approximately equipotent to aspirin (acetylsalicylic acid) . However, it does not always reach the efficacy of usual doses of modern non-steroidal analgesics (especially ibuprofen). In general, paracetamol is less efficacious than salicylates and other antirheumatic agents for problems that require anti-inflammatory treatment. Paracetamol is well suited for use in children. It represents a preferred alternative when aspirin (acetylsalicylic acid) is contraindicated (e.g. because of a history of ulcer or viral infection in the child). Paracetamol (as a single substance) appears to have little potential for dependence. SIDE EFFECT: Rare

Bloody or black, tarry stools bloody or cloudy urine fever with or without chills (not present before treatment and not caused by the condition being treated) pain in the lower back and/or side (severe and/or sharp) pinpoint red spots on the skin skin rash, hives, or itching sore throat (not present before treatment and not caused by the condition being treated) sores, ulcers, or white spots on the lips or in the mouth sudden decrease in the amount of urine unusual bleeding or bruising unusual tiredness or weakness yellow eyes or skin

Get emergency help immediately if any of the following symptoms of overdose occur while taking acetaminophen: Symptoms of overdose Diarrhea increased sweating loss of appetite nausea or vomiting stomach cramps or pain swelling, pain, or tenderness in the upper abdomen or stomach area

CITICOLINE Is a brain chemical that occurs naturally in the body. As a medicine, it is taken by mouth as a supplement or given by IV or as a shot. Citicoline is used for Alzheimer's disease and other types of dementia, head trauma, cerebrovascular disease such as stroke, agerelated memory loss, Parkinson's disease, attention deficit-hyperactive disorder (ADHD), and glaucoma. INDICATION: Oral Head injury Adult: 200-600 mg daily in divided doses. Oral Cerebrovascular disorders Adult: 200-600 mg daily in divided doses. Oral Parkinsonism Adult: 200-600 mg daily in divided doses. Parenteral Head injury Adult: Up to 1 g IM/IV daily. Parenteral Cerebrovascular disorders Adult: Up to 1 g IM/IV daily. Parenteral Parkinsonism Adult: Up to 1 g IM/IV daily.

MECHANISM OF ACTION: Citicoline increases blood flow and O2 consumption in the brain. It is also involved in the biosynthesis of lecithin. SIDE EFFECT: Citicoline seems to be safe when taken short-term (up to 90 days). The safety of long-term use is not known. Most people who take citicoline don't experience problematic side effects. But some people can have side effects such as trouble sleeping (insomnia), headache, diarrhea, low or high blood pressure, nausea, blurred vision, chest pains, and others.

TELMISARTAN BRAND NAME: Micardis INDICATION: treatment of essential hypertension ADMINISTRATION: The usually effective dose telmisartan is 4080 mg once daily. Some patients may already benefit at a daily dose of 20 mg. In cases where the target blood pressure is not achieved, telmisartan dose can be increased to a maximum of 80 mg once daily. CONTRAINDICATIONS: It is contraindicated during pregnancy. Like other drugs affecting the renin-angiotensin system (RAS), telmisartan can cause birth defects,stillbirths, and neonatal deaths. It should not be taken by breastfeeding women since it is not known whether the drug passes into the breast milk.[3]Also it is contraindicated in bilateral Renal artery stenosis in which it can cause renal failure. Color doppler should be done to rule out renal artery stenosis.

SIDE EFFECTS: Side effects are similar to other angiotensin II receptor antagonists and include tachycardia and bradycardia (fast or slow heartbeat), hypotension (low blood pressure), edema (swelling of arms, legs, lips, tongue, or throat, the latter leading to breathing problems), and allergic reactions.