NOW LOADING . . . . . .

OUTLINE

Cerebrovascular accident also called as Stroke Brain attack a True Emergency occurs when a blood clot blocks an artery or a blood vessel breaks, interrupting blood flow to an area of the brain. Leading to cell injury and cell death

 Attacks millions of people worldwide every year Higher incidence and death rates among African-Americans, Hispanics, Native-American, Asian Americans In the Phil 2nd Leading cause of Death & Leading cause of chronic disability 30-30-30 situation Mortality: women > men 2/3 people >65

Non Modifiable Age Gender Race Heredity Prior Stroke/Heart Attack

Modifiable HTN Smoking Diabetes mellitus Asymptomatic carotid stenosis Heart disease, atrial fibrillation Sickle cell disease

Hyperlipidemia Oral contraceptives Poor Diet Physical inactivity Hypercoagulability Heavy alcohol consumption Obesity

MASTER CONTROL UNIT

-coordinates and controls all activities of the body

CNS Brain
- complex computer

Spinal Cord
large cable integrator

PNS Cranial Nerves 12 Spinal Nerves 31

Structure

Cerebral hemispheres
form the largest part of the human brain
situated above most other brain structures. covered with a cortical layer with a

convoluted topography. Underneath the cerebrum lies the brainstem

Cerebrum

large, main, superior component of the brain. Cerebrum is ones conscious brain. It is separated into two hemispheres and each hemisphere into five lobes. That means there are 2 of each lobe (one in each hemisphere) in the brain. Below are the lobes and what they are associated with.

Frontal Lobe

Associated with reasoning, planning, parts of speech, voluntary motor function of skeletal muscles, emotions, memory and problem solving, personality and inhibitions

Parietal Lobe

Associated with movement, orientation, recognition, and perception of stimuli. Awareness in space and spatial relations and of body shape

Occipital Lobe
Associated

with visual processing/ interpretation.

Temporal Lobe
Associated

with perception and recognition of auditory stimuli, storage and recall of memories, language, comprehension, smell

Cerebellum

At the rear of the brain, beneath the cerebrum and behind the brainstem, is the cerebellum. associated with regulation and coordination of movement, posture, and balance

Brain Stem

Resembling a stalk on which the cerebrum is attached. This structure is responsible for basic vital life functions such as breathing, heartbeat, and blood pressure.

Pons
Relay

messages from the cerebrum to the cerebellum and spinal cord

Medulla Oblangata
Located above spinal cord. It regulates vital functions, such as heartbeat and breathing. The Medulla Oblongata is responsible for the 6 Crazy Dwarfs: 1.Coughing 2.Sneezing 3.Vomiting 4. Salivating 5. Swallowing 6. Gaging

Cranial Bones
Provides

a rigid support and protection for the brain

Connective Tissue (Meninges)

Blood supply by arteries

Blood is supplied to the brain by two major pairs of arteries

Internal carotid arteries Vertebral arteries

Blood supply by arteries

Carotid arteries branch to supply most of the

Frontal, parietal, and temporal lobes
Basal ganglia Part of the diencephalon Thalamus Hypothalamus

Blood supply by arteries

Vertebral arteries join to form the basilar artery, which supply the
Middle and lower temporal lobes Occipital lobes

Cerebellum
Brainstem Part of the diencephalon

Lysed or moved thrombus from the vessels Vascular wall becomes fragile and thickens Leaking of blood from the fragile blood vessel Obstruction of blood vessels / Vascular occlusion

CEREBRAL HEMORRHAGE

CEREBRAL HYPOPERFUSSION

Blood seeps into the ventricles

Cerebral ISCHEMIA

Obstruction of CSF passageway

Accumulation of CSF in the ventricles

Initiation of ISCHEMIC CASCADE

Ventricles dilated to the point of obstruction

Anaerobic metabolism of Mitochondria

Increased ICP

Increased Lactic Acid

Decreased ATP Failed energy dependent process

Unrelieved obstruction

METABOLIC ACIDOSIS

Release of Glutamate
Secondary Hydrocephalus Influx of Calcium

Production of oxygen free radicals and other oxygen reactive species

Irreversible brain damage

CEREBRAL EDEMA

Compression of brain tissue

Middle Cerebral Artery Frontal, Parietal, Temporal Lobes, Basal Ganglia

Contralateral hemiperesis or hemiplegia, unilateral neglect, altered LOC, homonymous hemianposia, visual changes, dyslexia, dysgraphia, aphasia, agnosia, memory deficits, vomiting Contralateral hemiperesis (foot and leg > arm), foot drop, disturbances in gait, contralateral hemisensory alteration, expressive aphasia, confusion, amnesia, flat affect, apathy, apraxia, shortened span of attention, incontinence, Mild contralateral hemiperesis,intention tremors, diffused sensory loss, pupillary dysfinction, loss of conjugate gaze, nystagmus, loss of depth perception, cortical blindness, homonymous hemianopsia, dyslexia, visual hallucinations, memory deficits Contralateral hemiperesis with facial assymetry, contralateral sensory alterations, homonymous hemianposia, ipsilateral periods of blindness, aphasia if dominant sphere is affected, mild Horners syndrome, carotid bruits

Anterior Cerebral Artery Frontal Lobe

Posterior Cerebral Artery Occipital and Temporal Lobe Internal Carotid Artery Branches to opthalmic, PCA, ACA, MCA and anterior choriodal

Vertibrobasillar Artery Cerebellum and Brainstem

Alternating motor weakness, ataxic gait, dysmetria, contralateral hemisensory impairment, double vision, homonymous hemianposia, nystagmus, conjugate gaze, disorientation, hearing loss, tinnitus, vertigo, coma

Anteroinferior Cerebellar Cerbellum

Ipsilateral ataxia, facial paralysis, ipsilateral loss of sensation in face, sensation changges in trunks and limbs, nystagmus, tinnitus and hearing loss

Posteroinferior Cerebellar Cerebellum

Paralysis of larynx and soft palate, ataxia, ipsilateral loss of sensation in face, nystagmus, dysarthia, hiccups, vertigo, coughing, nausea and vomiting

Presented by: Ms. Rhea Carla Erica Balog, R.N

 utal (stuttering) T - tabingi ang mukha o tindig (uneven facial expression) A - angal nang angal ng sakit ng ulo (rants of headache) K - kumilos at komunsulta agad! (act and consult a doctor)
U

Goals For Management Of Stroke Presented by: Ms. Rhea Carla Erica Balog, R.N.

Goals for Management of Patients With Suspected Stroke Algorithm.

Copyright American Heart Association

 Identify signs and symptoms of possible stroke

Activate Emergency Response

Critical EMS Assessment and Actions

Support ABCs; give oxygen if needed
Perform prehospital stroke assessment Establish time of symptom onset (last normal) Triage to stroke center Alert hospital Check glucose if possible

Immediate General Assessment and Stabilization

Assess ABCs and VS
Provide oxygen if hypoxemic Obtain IV access and perform laboratory assessments Check glucose, treat if indicated Perform neurologic screening assessment Activate stroke team Order emergent CT or MRI of brain Obtain 12 lead ECG

Immediate Neurologic Assessment by Stroke Team or designee

Review patient history
Establish time of symptom onset (or last known

normal) Perform neurologic examination

DOES CT SCAN SHOW HEMORRHAGE?

NO HEMORHHAGE: Probable Acute Ischemic Stroke: consider fibrinolytic therapy: Check for fibrinolytic exclusions Repeat neurologic exams: are deficits rapidly improving to normal?

Patient remains candidate for fibrinolytic therapy

If candidate: Review risks/benefits with patient and family. If acceptable: Give rtPA No anticoagulants or anti platelet treatment for 24 hours

 Begin post rtPA stroke pathway

Aggresively monitor: BP per protocol For neurologic deterioration Emergent admission to stroke unit or ICU

IF NOT A CANDIDATE FOR FIBRINOLYTIC THERAPY:

Administer aspirin

Begin stroke or hemorrhage pathway Admit to stroke unit or ICU

DOES CT SCAN SHOW HEMORRHAGE

IF HEMORHHAGE:
Consult neurologist or neurosurgeon: consider transfer

if not available
Begin stroke or hemorrhage pathway Admit to stroke unit or ICU

Brain Computed Tomography

is a painless test that uses x rays to take clear, detailed pictures of your brain can show bleeding in the brain or damage to the brain cells from a stroke. The test also can show other brain conditions that may be causing the symptoms.

CAROTID ULTRASOUND

is a test that uses dye and special x rays to show the insides of the carotid arteries. For this test, a small tube called a catheter is put into an artery, usually in the groin. The tube is then moved up into one of the carotid arteries. The doctor will inject a substance (called contrast dye) into the carotid artery. The dye helps make the artery visible on x-ray pictures.

measures the cholesterol levels both the bad (low-density lipoprotein, or LDL) and the good (high-density lipoprotein, or HDL). High cholesterol is a major risk factor for stroke and may indicate that you are at greater risk of having a stroke.

including prothrombin time (PT), partial thromboplastin time (PTT), and international normalized ratio (INR), check the speed at which the blood clots. Abnormal bleeding is a potential cause of hemorrhagic stroke abnormal clotting is a potential cause of ischemic stroke.

Blood chemistry tests Homocysteine level tests

the level of the amino acid homocysteine in the blood, which is thought to contribute to increased stroke risk and atherosclerosis, a known risk factor for stroke.

Contra Indications: Hypersensitivity, severe pulmonary congestion, progressive renal disease or dysfunction. Adverse Reactions: CNS: seizures, dizziness, headache. CV: hypotension, tachycardia, chest pain. EENT: blurred vision, rhinitis. GI: thirst, dry mouth, nausea, vomiting, diarrhea. GU: urine retention Metabolic: fluid and electrolyte imbalance, dehydration.

Nursing Considerations: Monitor vital signs, and fluid intake and output. Check weight, renal function, serum and urine sodium and potassium daily. Patient Teachings: Tell patient he may feel thirsty or have a dry mouth. Instruct patient to promptly report adverse reactions and discomfort at I.V site.

Classification: CNS Stimulants Indications: CVD in acute and recovery phase, symptoms and signs of cerebral insufficiency, dizziness, memory loss, poor concentration and recent cranial trauma. Contra Indication: Parasympathetic hypertonia

Adverse Reaction: GI disorders Nursing Considerations: Assess patient before giving the medication, Monitor vital signs.

Classification: Nootropics and Neurotonics

Indication: Cerebral Circulatory insufficiency and chronic manifestations of CVA. Contra Indication: Cerebral Hemorrhage and ESRD.

Adverse Reaction: Hyperkinesia, weight gain, astheria, nervousness, agitation, irritability, anxiety or sleep disturbance, fatigue or drowsiness, GI disturbances

Nursing Consideration: Observe the patients for possible untoward reactions

Adverse Reactions: CNS: dizziness, fainting, headache, malaise, fatigue. CV: tachycardia, hypotension. GI: Abdominal pain, anorexia, dry mouth, nausea and vomiting. Respiratory: dyspnea, dry cough.

Nursing Considerations: Monitor patients vital signs especially blood pressure and cardiac rate, Drug is linked with the most frequent occurrence of cough.

Classification: Antihyperlipidaemic Agents Indication: Reduction of the risk of CHD death, major vascular and coronary events, stroke, hospitalization for angina pectoris and developing propheral macrovascular complications.

Contra Indications: Hypersensitivity to drug. And in those with active liver disease or conditions that cause unexplained persistent elevations of serum transaminase levels. Pregnancy and breast-feeding women. Adverse Reactions: CNS: headache GI: Abdominal pain Hepatic: elevated liver enzyme levels. Respiratory: URTI

Nursing Considerations: Use cautiously in patients who consume substantial quantities of alcohol or have a history of liver disease. Instruct patient to take drug with evening meal.

Classification: Laxatives
Indication: Constipation, stool softeners. Contra Indication: Contra indicated in patients on a low galactose diet.

Adverse Reactions: GI: abdominal cramps, diarrhea, gaseous distention, flatulence, nausea and vomiting.
Nursing Considerations: Use cautiously in patients with diabetes mellitus. To minimize sweet taste, dilute with water or fruit juice or give with food. Inform patient about adverse reactions and notify the nurse.

is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury and stroke.

Craniotomy is any bony opening that is cut into the skull. A section of skull, called a bone flap, is removed to access the brain underneath. There are many types of craniotomies, which are named according to the area of skull to be removed .

Insert an intracranial pressure (ICP) monitor remove a small sample of abnormal tissue (needle biopsy) drain a blood clot (stereotactic hematoma aspiration) insert an endoscope to remove small tumors and clip aneurysms

1. Ineffective Cerebral Tissue Perfusion Stroke (CVA)

ASSESSMENT OBJECTIVE: Hemiplegia Altered mental status Restlessness Changes in pupillary reaction Difficulty in swallowing NURSING DIAGNOSIS Ineffective Cerebral Tissue Perfusion May be related to Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vasospasm, cerebral edema Possibly evidenced by Altered level of consciousness; memory loss Changes in motor/sensory responses; restlessness Sensory, language, intellectual, and emotional deficits Changes in vital signs PLANNING Maintain usual/improved level of consciousness, cognition, and motor/sensory function. Demonstrate stable vital signs and absence of signs of increased ICP. Display no further deterioration/re currence of deficits INTERVENTION Determine factors related to individual situation/cau se for coma/decrea sed cerebral perfusion and potential for increased ICP. RATIONALE Influences choice of interventions. Deterioration in neurological signs/symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity requiring patient be transferred to critical care area for monitoring of ICP, other therapies. If the stroke is evolving, patient can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is completed, the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence EVALUATION Maintain/increase strength and function of affected or compensatory body part. Maintain optimal position of function as evidenced by absence of contractures, footdrop. Demonstrate techniques/behaviors that enable resumption of activities. Maintain skin integrity.

Monitor/document neurological status frequently and compare with baseline.

Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression/resolution of CNS damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA. Fluctuations in pressure may occur because of cerebral pressure/injury in vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse). Increased ICP may occur because of tissue edema or clot formation. Subclavian artery blockage may be revealed by difference in pressure readings between arms.Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (e.g., stroke after MI or from valve dysfunction).Irregularities can suggest location of cerebral insult/increasing ICP and need for further intervention, including possible respiratory support.

Evaluate pupils, noting size, shape, equality, light reactivity.

Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brainstem is intact. Pupil size/equality is determined by balance between parasympathetic and sympathetic enervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves. Changes in cognition and speech content are an indicator of location/degree of cerebral involvement and may indicate deterioration/increased ICP. Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation/perfusion.

Assess higher functions, includingg speech, if patient is alert

Position with head slightly elevated and in neutral position.

 Maintain bedrest; provide quiet environment; restrict visitors/activities as indicated. Provide rest periods between care activities, limit duration of procedures.

Continual stimulation/activity can increase ICP. Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage.

Prevent straining at stool, holding breath

Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity.

Valsalva maneuver increases ICP and potentiates risk of rebleeding. Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may reflect increased ICP/cerebral injury, requiring further evaluation and intervention.

Administer supplemental oxygen as indicated.

Reduces hypoxemia, which can cause cerebral vasodilation and increase pressure/edema formation.

ASSESSMENT NURSING DIAGNOSIS PLANNING OBJECTIVE Right hemipleg ia Limited ROM Difficulty turning Slowed moveme nt Gait changes Impaired Physical Mobility may be R/T Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic paralysis possibly evidenced by Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength/control

INTERVENTION Assess functional ability/extent of impairment initially and on a regular basis. Classify according to 04 scale. Change positions at least every 2 hr (supine, sidelying) and possibly more often if placed on affected side. Position in prone position once or twice a day if patient can tolerate. Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head

RATIONALE Identifiesstrengths/deficiencies and may provide information regarding recovery. Assists in choice of interventions, because different techniques are

EVALUATION

Maintain/incre ase strength and function of affected or compensatory body part. Maintain optimal position of function as evidenced by absence of contractures, footdrop. Demonstrate techniques/beh aviors that enable resumption of activities. Maintain skin integrity.

Patient shall have participated in the Activities necessary for him/her Patient shall have used for flaccid and spastic paralysis. improved/ Reduces risk of tissue ischemia/injury. increased Affected side has poorer circulation strength and and reduced sensation and is function of more predisposed to skin affected body breakdown/decubitus ulcer part Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe. Prevents contractures/footdrop and facilitates use when/if function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side.

Maintain leg in neutral position with a trochanter roll; Observe affected side for color, edema, or other signs of compromised circulation. Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary. Provide egg-crate mattress, water bed, flotation device, or specialized beds (e.g., kinetic), as indicated.

Prevents external hip rotation. Edematous tissue is more easily traumatized and heals more slowly. Pressure points over bony prominences are most at risk for decreased perfusion/ischemia. Circulatory stimulation and padding help prevent skin breakdown and decubitus development. Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown/decubitus formation. Specialized beds help with positioning,enhance circulation, and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia.

ASSESSMENT OBJECTIVE: w/slurred speech disoriented difficulty expressing thoughs verbally Difficulty in comprehen ding or maintaining usual communica tion pattern Inability or difficulty in use of facial or body expression s

NURSING DIAGNOSIS PLANNING Impaired verbal communication maybe related to Impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle tone/control; generalized weakness/fatigue Possibly evidenced by Impaired articulation; does not/cannot speak (dysarthria) Inability to modulate speech, find and name words, identify objects; inability to comprehend written/spoken language Inability to produce written communication

INTERVENTION Assess type/degree of dysfunction: e.g., patient does not seem to understand words or has trouble speaking or making self understood.

RATIONALE Helps determine area and degree of brain involvement and difficulty patient has with any or all steps of the communication process.

to Establish method of communicatio n in which needs can be expressed.

Listen for errors in conversation Patient may lose ability to and provide feedback monitor verbal output and be unaware that communication is not sensible. Feedback helps patient realize why caregivers are not understanding/responding appropriately and provides opportunity to clarify content/meaning. Provide special call bell if necessary. Call bell that is activated by minimal pressure is useful when patient is unable to use regular call system. Provides for communication of needs/desires based on individual situation/underlying deficit.

EVALUATION . Establish method of communicat ion in which needs can be expressed. Use resources appropriatel y.

Provide alternative methods of communication, visual clues gestures, pictures, needs list,

Anticipate and Helpful in decreasing frustration provide for patients when dependent on others and needs. unable to communication desires.

Talk directly to Reduces confusion/anxiety at patient, speaking having to process and respond to slowly and distinctly. large amount of information at one Use yes/no questions time to begin with, progressing in complexity as patient responds.

Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Talk without pressing for a response.

Patient is not necessarily hearing impaired, and raising voice may irritate or anger patient. Forcing responses can result in frustration

Respect patients Enables patient to feel esteemed, preinjury because intellectual abilities often capabilities; avoid remain intac speaking down to patient or making patronizing remarks.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

Objective:
Pt is physically immobile and unable to get out of bed. An area on the pts buttocks was reddened and warm to touch.

Risk for impaired skin integrity R/T Immobilit y

Short Term: After 8hrs. of nursing interventions, the patient will not develop any further skin breakdown.

Goal met. the pt at least Patients skin once every two has no signs of hours. worsening or advanced Rationale: impairment Positioning and skin interventions integrity has reduce pressure not been and shearing further force to the compromised. skin. (Potter & Perry, 2009, p. 1305)

1. Reposition

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

2. Keep the

Pt is incontinent of her bowels, which leads to moisture on her skin.

skin clean and dry Rationale: Moisture softens the skin and causes a break in the skin integrity. (Potter & Perry, 2009, p. 1302)

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

3. Monitor

skin condition at least once a day for color or texture changes, dermatologica l conditions, or lesions. Rationale: Systematic inspection can identify impending problems early. (Ackley & Ladwig, 2008, p. 754)

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

Long Term: Patient will verbalize the measures needed to promote good skin integrity by discharge.

1. Educate pt on the importance of proper dieting and food intake. Rationale: Nutrition is fundamental to normal cellular integrity and tissue repair. (Potter and Perry, 2008, p. 1310)

Hypothetically, once the patient was oriented, she would be taught the needed measures to promote good skin integrity and she would verbalize her understanding.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

2. Educate the pt on the importance of keeping the skin clean and dry. Rationale: Moisture softens the skin and causes a break in the skin integrity. (Potter & Perry, 2009, p. 1302)

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

Objective:

Disturbed Sensory Disoriented to Perception time, place R/T and person Neurological Impairment

Short Term: After 8hrs. of nursing interventions, the patient will be able to demonstrate behavior to overcome deficits.

1. Orient patient to time, place and persons frequently. Rationale: Orientation minimizes anxiety and promotes cognitive function.

Goal Met: The patient cooperates with nursing care.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

Long Term: Regain usual level of consciousness and perceptual functioning

2. Provide a consistent physical environment and a daily routine.

Rationale: Routine eliminates the element of surprise, overstimulatio n, and further confusion.

Goal met: patient was oriented to time, place and significant other.

3. Provide access to familiar objects when possible.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

Rationale: Familiarity helps reduce confusion. 4. Provide for adequate rest, sleep, and daytime naps. Rationale: Reduces overstimulation and fatigue which can be contributing factors to confusion.

ASSESSMENT

NURSING DIAGNOSIS

PLANNI NG

INTERVENTION

EVALUATION

5. Use calm and unhurried approach when interacting.

Rationale: Promotes communication that enhances persons sense of dignity. 6. Speak to the client in a slow, distinct manner with appropriate volume.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

Rationale: The client who has difficulty of hearing will be better to lip read and comprehends speech. 7. Use simple words and short sentences as appropriate. Rationale: Using simple terms facilitates understanding and minimize anxiety.

REMEMBER!
Maintain a patent airway to promote adequate

oxygenation Administer oxygen therapy with possible intubation and mechanical ventilation to ensure adequate tissue perfusion Monitor O2 Sat ABG levels as ordered Place patient on cardiac monitor and WOF arrhythmias: Correct cardiovascular abnormalities, such as atrial fibrillation, that may be contributing factors

 Administer dexamethasone to reduce cerebral edema

Maintain bed rest to minimize

metabolic requirements Provide I.V. fluids to support blood pressure and maintain volume Administer anticoagulants and antiplatelet drugs for thrombotic conditions after hemorrhage has been ruled out Administer sedatives, such as Phenobarbital, to decrease metabolic requirements Assess the patients neurologic status; observe for CVA progression and level of consciousness (LOC) change as evidenced by decreasing numerical score on the GLASGOW COMA SCALE at every hour or more frequently

 If cerebral edema if suspected, maintain ICP sufficient

for adequate cerebral perfusion but not low enough to avoid BRAIN HERNATION. Elevate head of bed 2o to 30 degrees Turn patient often Use antiembolic stockings Provide ROM exercises Provide meticulous eye and oral care Set up simple method of communicating aphasic pts Consider surgical procedures to correct circulatory impairment, prevent repeated hemorrhage, or relieve cerebral pressure Provide psychological support