CEREBROVASCULAR ACCIDENT Presented by: England Dan C. Estacion CEREBROVASCULAR ACCIDENT Also known as ischemic stroke or brain attack.

Sudden loss of function of a part of the brain. Results from disruption of blood supply. Approved thrombolytic therapy has a treatment window of 3 hours after onset. ISCHEMIC STROKE DIFFERENT TYPES Large artery thrombotic stroke Caused by atherosclerotic plaques. Thrombus formation and occlusion results in infarction.

Loss of balance, dizziness Sudden severe headache MOTOR LOSS Most common motor dysfunction is hemiplegia. Hemiparesis is another sign. Initial clinical features in the early stage of stroke: Flaccid paralysis Decrease or loss of deep tendon reflexes COMMUNICATION LOSS Stroke is the most common cause of aphasia. Dysfunctions of language and communication: Dysarthria (speaking difficulty) caused by paralysis of muscles for speech Dysphasia (impaired speech), or Aphasia (loss) Apraxia (inability to perform a previously learned action)

Small penetrating thrombotic stroke Most common type of ischemic stroke. Also known as Lacunar stroke because of the cavity created after death of brain tissue. DIFFERENT TYPES Cardiogenic embolic stroke Associated with cardiac dysrythmias, usually AFib. Also associated with valvular heart disease.

PERCEPTUAL DISTURBANCES Visual-perceptual dysfunctions Caused by disturbances of primary sensory pathways between the eye and visual cortex. Hemianopsia loss of half of visual field

Cryptogenic stroke No known cause. DIFFERENT TYPES

Visual-spatial disturbances Failure to appreciate space to one side. Loss of attention to one side. Male patient may no longer shave one side of his face.

VISUAL-SPATIAL DISTURBANCE Stroke from other causes illicit drug use, coagulopathies, migraine, spontaneous dissection of carotid or vertebral arteries. SENSORY LOSS Agnosias deficits in ability to recognize previously familiar objects. Other sensory losses: Slight impairment to touch. Loss of proprioception. Difficulty in interpreting visual, tactile, and auditory stimuli. COGNITIVE IMPAIRMENT AND PSYCHOLOGICAL EFFECTS Frontal lobe damage Impairment of learning, memory, and higher intellectual functions. Limited attention span, comprehension difficulties, forgetfulness, lack of motivation.

CLINICAL MANIFESTATIONS Depends on the location of the obstruction. Patient may present with any of the following: Numbness on one side of the body Confusion Trouble speaking or understanding speech Visual disturbances

Depression is common and exaggerated. Emotional lability, hostility, frustration. Resentment, lack of cooperation. ASSESSMENT AND DIAGNOSTIC FINDINGS Complete Physical and Neurologic Examination Initial assessment: Airway patency Cardiovascular status Gross neurologic deficits

warfarin is contraindicated. Platelet-inhibiting medications Aspirin Extended-release dipyridamole plus aspirin Clopidogrel Ticlopidine MEDICAL MANAGEMENT 3-hydroxy-2-methyl-glutaryl-coenzyme A reductase inhibitors Also known as statins Reduce coronary events and strokes ACE inhibitors Thiazide diuretics THROMBOLYTIC THERAPY Recombinant t-PA Binds to fibrin Converts plasminogen to plasmin for clot breakdown Stimulates fibrinolysis of atherosclerotic lesion Delays make patient ineligible for thrombolytic therapy Increases risk of cerebral edema and hemorrhage Revascularization develops after 3 hours THROMBOLYTIC THERAPY Contraindications Symptom onset >3 hours before admission INR >1.7 (after anticoagulation therapy) Recent intracranial pathology

Diagnostic tests: Non-contrast CT scan (initial) EKG, CT angiography, MRI, Transcranial Doppler, SPECT scan PREVENTION Leading healthy lifestyle Not smoking Maintaining healthy weight Following healthy diet Modest alcohol consumption Daily exercise

Dietary Approaches to Stop Hypertension (DASH diet) High in fruits and vegetables, moderate in low-fat dietary products, low in animal protein RISK FACTORS Non-modifiable Advanced age (>55 years old) Gender (Male) Race (African-Americans)

No anticoagulants for 24 hours if patient meets criteria of t-PA therapy. ELIGIBILITY CRITERIA FOR t-PA ADMINISTRATION Refer to Brunner & Suddarth s Textbook of Medical-Surgical Nursing, Twelfth Edition Unit 14, Chapter 62, Page 1900 Chart 62-2 THROMBOLYTIC THERAPY Before administering t-PA Assessment of stroke severity National Institutes of Health Stroke Scale (NIHSS) Score range from 0 (normal) to 42 (severe)

Modifiable Hypertension A-Fib Hyperlipidemia DM Smoking RISK FACTORS Modifiable (continued) Asymptomatic carotid stenosis Obesity Excessive alcohol consumption MEDICAL MANAGEMENT A-Fib dose-adjusted warfarin (aspirin if

Dosage for t-PA 0.9 mg/kg Maximum dose of 90 mg 10% of dose - IV bolus over 1 minute 90% - IV over 1 hour via infusion pump

THROMBOLYTIC THERAPY Patient is admitted to ICU/Acute stroke unit. Continuous cardiac and neurologic assessment. Obtain vital signs every 15 min. for first 2 hours. Every 30 min. for next 6 hours Every hour until 24 hours after treatment BP should be maintained <180/<105 mmHg

Level of consciousness Movement and muscle tone Eye opening Skin color and moisture Pulse and respiration Speaking ability Vital signs, I and O Bleeding RECOVERY Diagnoses Impaired physical mobility Acute pain Self-care deficits Disturbed sensory perception Impaired swallowing Impaired urinary elimination Disturbed thought processes Risk for impaired skin integrity Interrupted family processes RECOVERY Planning and Goals Improved mobility Pain relief Achievement of self-care Bowel and bladder continence Prevention of aspiration Improved thought and sensory processes Maintenance of skin integrity Absence of complications RECOVERY Nursing Interventions Correct positioning Exercise program (ROM exercises) Preparing for ambulation Preventing shoulder pain Enhancing self-care Assisting with Nutrition sOURCE MedSurge 2 MedSurge

SIDE EFFECTS Bleeding (most common) Intracranial bleeding (major complication) THERAPY FOR THOSE NOT RECEIVING t-PA IV Heparin (not recommended for acute ischemic stroke) Reduction of ICP Osmotic diuretic Elevate head Possible hemicraniectomy

Establish patent airway Continuous hemodynamic monitoring Neurologic assessment MANAGING POTENTIAL COMPLICATIONS Adequate oxygenation Other potential complications UTI Cardiac dysrhythmias Immobility

SURGICAL PREVENTION Plaque is a potential source of emboli. Carotid endarterectomy For patients with TIAs and mild stroke

Carotid stenting For severe stenosis NURSING MANAGEMENT Prevention of primary complications of carotid endarterectomy Maintain adequate BP levels post-op Neurologic flow monitoring

HEAD INJURY BY: Engie Lee Cocamas

HEAD INJURY is any trauma that leads to injury of the scalp, skull, or brain. The

RECOVERY Assessment

injuries can range from a minor bump

on the skull to serious brain injury.

2.Skull fractures-is a break in one or more of the bones in the skull caused by a head injury. It may occur with or without damage of the brain. Skull Fractures are classified as:

INCIDENCE: .90 % of nervous system trauma .Most common among males .Peak occurrence- evening, nights weekends CAUSE: .Accidents- motor vehicles, industrial .Falls- abuse .Blows- sports injuries, crime related injuries .Construction occupational hazards MECHANISM OF INJURY THAT CONTRIBUTED TO HEAD TRAUMA: 1. Acceleration- occurs when the immobile head is struck by a moving object. 2.Deceleration- moving head hits an immobile object. Example: head hit the steering wheel 3. Deformation- injuries in which the force results in deformation and disruption of the injury of the impacted body part (skull fracture)

>Simple >Comminuted >Depressed >Basilar

3.Brain injury: 1.Open head injuries-means you were hit with an object that broke the skull and entered the brain.

2.Closed-blunt trauma- means you received a hard blow to the head from striking an object, but the object did not break the skull. 3.Concussion- result in loss of consciousness for 5 min or less and retrograde amnesia , no break in the skull or dura and no visible damage 4.Contusion- cause more extensive damage , petechial and punctuate hemorrhage and bruised areas 5.Diffuse axonal injury- one of the most common and devastating types of traumatic brain injury, meaning that damage occurs over a more widespread area than in focal brain injury.

Category of head trauma: 1.closed- the head sustain a blunt force by striking against an object 2.Penetrating trauma- an objects breaks through the skull and enters the brain 3. Coup and countercoup injuries- the impact to the head can cause the brain to move within the skull ,causing the brain to impact the interior of the skull opposite the head-impact) Types of Primary Injury: 1.Scalp injuries- Isolated scalp trauma is generally classified as a minor injury. Because its many blood vessels constrict poorly , the blood bleeds profusely when injured.

.The major cause of damage in DAI is the disruption of axons, the neural processes that allow one neuron to communicate with another.

Types: Mild- loss of consciousness 6-24 hours Moderate- coma less than 24 hours, on complete recovery and awakening Severe- primary injury to brain stem DIAGNOSTIC TEST: Radiologic Examination Physical Examination and Evaluation of Neurologic Status CT scan

patient's body. This makes less water available to the brain for swelling. Mannitol

Clinical Manifestations: .Loss of consciousness, confusion, .Bradycardia, bradypnea, hypotension .Convulsions .Fracture in the skull or face- Fluid drainage from nose, mouth or ears .Stiff neck or vomiting .Pupil changes .Severe headache .Irritability, personality changes, or unusual behavior .Restless, clumsiness, or lack of coordination .Slurred speech or blurred vision .Inability to move one or more of your limbs Get medical help immediately if the person: Becomes unusually drowsy Behaves abnormally Develops a severe headache or stiff neck Loses consciousness, even briefly Vomits more than once

MRI ( Magnetic Resonance Imaging) Cerebral Angiography Neurosurgery Possible reasons for neurosurgery include: 1. haemorrhage (severe bleeding) inside your head, which puts pressure on the brain and may result in brain injury (brain damage) and, in severe cases, death 2. haematoma (blood clot) inside your head, which can also put pressure on the brain 3.cerebral contusions (bruises on the brain), which can develop into blood clots 4.skull fracture craniotomy Medications: 1.Anti-epileptic drugs Some people do suffer from seizures after brain injury. Often these occur only in the early stages of your recovery but they can be a permanent consequence of your brain injury. Such as Carbamazepine. 2.Antidepressants It is very common for people to experience symptoms of depression following a brain injury. Citalopram, Paroxetine, Fluoxetine 3.Diuretics are used to decrease the amount of water in the

HEAD INJURY PREVENTION .Safety equipments during activities .Obey traffic signals .Be visible. .Use age appropriate car seats for babies .Make sure children have safe area to play .Supervise children of any age .DO NOT DRINK and DRIVE DO NOT Do NOT wash a head wound bleeding a lot. Do NOT remove any object sticking out of a wound. Do NOT move the person unless needed.

Do NOT shake the person if he or she seems dazed. Do NOT remove a helmet Do NOT pick up a fallen child with any sign of head injury. Do NOT drink alcohol within 48 hours of a serious head injury. Nursing care: 1. Maintain airway *logroll patient onto his side to prevent aspiration *place support under pt. s head to keep his cervical spine straight 2. Check for presence of shock *elevate extremities 3.Check for evidence of Spinal Injury *do not move newly injured until proven there has no injury 4. Observe for scalp and skull injuries *cover open hand with cleanest material as possible *apply pressure to bleeding scalp only if there is no underlying fracture *don t attempt to remove foreign objects 5. Prevent infection *antibiotics/tetanus infections *never attempt to clean ears or nose

7. Observe for CSF leakages *CSF rhinorrhea- drainage from nose due to fracture of ethmoid bone *CSF otorrhea- drainage from ears due to fractureof temporal lobe Management: Place loose, sterile cotton buds at the opening of ear or nose to absorb the discharge. Instruct not to cough, sneeze or blow the nose don t use nasal section due to proximity of cerebrum and nasopharynx 8. Improve cognitive functioning