Prepared by: Bautista, Jovy Rose RN (soon2be) Gorgonio, Jeraldine RN (soon2be)

DESCRIPTION:
-CAN BE DIVIDED INTO TWO MAJOR CATEGORIES: ISCHEMIC HEMORRHAGIC

- BOTH CONDITION SHOULD HAVE SERIOUS MEDICAL EMERGENCY WHICH NECESSITATES IMMEDIATE INTERVENTION TO PREVENT PERMANENT DISABILITY

THROMBUS
EMBOLUS HEMORRHAGE RUPTURED ANEURYSM

ARTERIOVENOUS MALFORMATION

MODIFIABLE RISK FACTORS:

1.) Smoking 2.) Alcohol 3.) Substance Abuse

4.) Sedentary Lifestyle

5.) Diabetes Mellitus 6.) Hypertension

NONMODIFIABLE RISK FACTORS:

1.) Race 2.) Gender

3.) Older Adult

4.) Family History

A.) ISCHEMIC

1.)Transient Ischemic Attacks 2.) Reversible Ischemic Neurologic Deficit

B.) HEMORRHAGIC

A.) ISCHEMIC
- Result from occlusion of a

cerebral artery by a thrombus or embolus

1.) TRANSIENT ISCHEMIC ATTACKS

- temporary loss of neurological function often lasting less than 15 minutes and no more than 24hours.

2.) REVERSIBLE ISCHEMIC NEUROLOGIC DEFICIT

- is a temporary loss of neurological function lasting more than 24hrs but less than 1 week

B.) HEMORRHAGIC
-Interruption in the vessel wall integrity

a. Altered level of consciousness

b. Denial of disorder

c. Failure to make appropriate

decisions

d. Inappropriate judgment
e. Poor memory

f. Emotional stability

g. Proprioceptive or spatial difficulty decreased awareness of the body in space

h. Hemiplegia- one sided paralysis

i. Hemiparesis weakness in one side of the body j. Dysarthria- difficulty in speech articulation k. Alexia- difficulty reading

l. Agraphia difficulty writing m. Agnosia loss of recognition ability

n. Hemianopsia- blindness in one side of visual

field

o. Amaurosis fugax temporary blindness in one

eye p. Dysphagia difficulty swallowing q. Ptosis drooping eyelids

r. Aphasia Impaired Communication 1.) Expressive aphasia inability to express oneself (frontal lobe) 2.) Receptive aphasia inability to understand what someone else is saying (temporal lobe)

a. Complete history and physical assessment b. CBC

c. Thrombin and
prothrombin times

d. CSF Analysis
e. CT scan f. MRI Scan g. Angiography h. ECG

a. Primary prevention - instruct client and family on reducing modifiable risk factors b. Acute stroke mgnt - maintain ABC - assess LOC - perform cranial nerve assessment - administer prescribed antihypertensive - monitor fluid and electrolytes

- elevate head of bed 30 - monitor for ICP - administer prescribed analgesics - administer prescribed diuretics (mannitol or furosemide) - insert FC - administer prescribed anticoagulants (heparin or warfarin)

c. Intermediate stroke mgnt -Maintain patent airway - maintain upright position for 30min after eating -Initiate bladder training -Increase fiber and fluids - implement aphasia interventions

d. Rehabilitative nsg. Interventions -encourage pt. to participate in occupational therapy - encourage pt. to participate in speech therapy - instruct the client about medications - encourage importance of scheduled follow-up with health care provider - instruct client about importance of frequent BP checks

The end