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CEREBROVASCULAR ACCIDENT. PATIENT PRESENTATION- 1 Mr.X,67yrs Mr.X,67yrs C/O weakness of RUL and RLL for 10 days C/O weakness of RUL and RLL for 10 days.

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Presentation on theme: "CEREBROVASCULAR ACCIDENT. PATIENT PRESENTATION- 1 Mr.X,67yrs Mr.X,67yrs C/O weakness of RUL and RLL for 10 days C/O weakness of RUL and RLL for 10 days."— Presentation transcript:

1 CEREBROVASCULAR ACCIDENT

2 PATIENT PRESENTATION- 1 Mr.X,67yrs Mr.X,67yrs C/O weakness of RUL and RLL for 10 days C/O weakness of RUL and RLL for 10 days C/O slurred speech for 10 days C/O slurred speech for 10 days K/C/O T2 DM and on treatment (uncontrolled) K/C/O T2 DM and on treatment (uncontrolled) K/C/O systemic hypertension K/C/O systemic hypertension H/O lt leg diabetic foot below great toe H/O lt leg diabetic foot below great toe H/O IHD H/O IHD

3 Assessment O/E conscious, obeying commands O/E conscious, obeying commands Speech dysarthria Speech dysarthria EOM-restricted EOM-restricted Right facial palsy, gag reflex(N) Right facial palsy, gag reflex(N) Motor-hemiplegia Motor-hemiplegia Sensory-pain/touch impaired on right side Sensory-pain/touch impaired on right side DTR-++/++ DTR-++/++ No neck stiffness No neck stiffness

4 Investigations urine for c/s-no growth urine for c/s-no growth ECG: normal sinus rhythm ECG: normal sinus rhythm Blood investigations Blood investigations Cholesterol-294(200) Cholesterol-294(200) Triglyceride-129(150) Triglyceride-129(150) HDL-25/11.8(60) HDL-25/11.8(60) LDL-201( ) LDL-201( )

5 MRI-Acute infarct in the medial aspect of pons MRI-Acute infarct in the medial aspect of pons Age related atrophic changes Age related atrophic changes BP-150/90 mmhg BP-150/90 mmhg HR-98b/mt HR-98b/mt Spo2-100 Spo2-100 RR-30b/mt RR-30b/mt Temp-98.6°f Temp-98.6°f

6 Medications Inj. Clexane 0.4ml s/c od Inj. Clexane 0.4ml s/c od Inj. Magnex forte 1.5gm in 100ml NS IV bd Inj. Magnex forte 1.5gm in 100ml NS IV bd Inj. Rantac 50mg IV bd Inj. Rantac 50mg IV bd Inj. H.Actrapid according to CBG s/c tds Inj. H.Actrapid according to CBG s/c tds T. Clopitab 75 mg RT T. Clopitab 75 mg RT T. Nicardia R 10 mg RT T. Nicardia R 10 mg RT 1-0-1

7 PATIENT PRESENTATION- 2 Mr. Y 60/m Mr. Y 60/m C/O neck pain x 4 days C/O neck pain x 4 days H/O fever x 2 days, low grade H/O fever x 2 days, low grade H/O one episode of giddiness x vomiting, slurring of speech H/O one episode of giddiness x vomiting, slurring of speech Pain and touch impaired on the right side Pain and touch impaired on the right side Known HTN x 5yrs Known HTN x 5yrs Lt eye ptosis, nystagmus-gaze evoked ataxia, ltUL-4/5 RUL-5/5 Lt eye ptosis, nystagmus-gaze evoked ataxia, ltUL-4/5 RUL-5/5

8 Assessment BP-140/80 mmhg BP-140/80 mmhg HR-92b/mt HR-92b/mt Spo2-99% Spo2-99% RR-20breaths/mt RR-20breaths/mt Temp-98.6°f Temp-98.6°f

9 Medications Inj. Fraseda 30 mg IV 100ml NS Inj. Fraseda 30 mg IV 100ml NS Inj. Rantac 50 mg IV Inj. Rantac 50 mg IV Inj. Strocit 500 mg IV Inj. Strocit 500 mg IV T Clopilet 75 mg p/o T Clopilet 75 mg p/o T Atorva 10 mg p/o T Atorva 10 mg p/o 0-0-1

10 Investigations RBS-177 PPBS-141 RBS-177 PPBS-141 Na- 130 Na- 130 Cholesterol-239 Cholesterol-239 Triglyceride-207 Triglyceride-207 HDL-31/7.7 HDL-31/7.7 LDL-177 LDL-177

11 MRI-Sub acute infarct MRI-Sub acute infarct Chronic infarct-rt cerebellum Chronic infarct-rt cerebellum Carotid Doppler- Carotid grade II intimal changes Carotid Doppler- Carotid grade II intimal changes Non visualization of the mid and distal portion of the basilar artery with very thin caliber vertebral arteries. Non visualization of the mid and distal portion of the basilar artery with very thin caliber vertebral arteries. Vertebral Doppler study-lt vertebral minimal flow, rt vertebral normal Vertebral Doppler study-lt vertebral minimal flow, rt vertebral normal

12 PATIENT PRESENTATION- 3 Mr.Z,40yrs/M Mr.Z,40yrs/M Rt MCA infarct Rt MCA infarct C/O weakness of LUL and LL for 4 days C/O weakness of LUL and LL for 4 days H/O slurring of speech H/O slurring of speech Mouth deviating to rt side Mouth deviating to rt side Chronic smoker and alcoholic-25yrs Chronic smoker and alcoholic-25yrs BP 150/80 mmhg BP 150/80 mmhg Lt-UL:0/5,LL-0/5 Lt-UL:0/5,LL-0/5 rt- UL:5/5,LL-5/5 rt- UL:5/5,LL-5/5

13 Assessment GCS:15/15 GCS:15/15 Pupils:2mm reacting to light Pupils:2mm reacting to light Reflexes:++/++ Reflexes:++/++ Alk phophatase:105 Alk phophatase:105 Cholesterol-155 Cholesterol-155 Triglycerides-112 Triglycerides-112 HDL-35 HDL-35 LDL-98 LDL-98 CT brain: Acute infarct-Rt MCA territory CT brain: Acute infarct-Rt MCA territory MRI: Rt MCA infarct MRI: Rt MCA infarct

14 Medications T.Nicardia R 10mg p/o tds T.Nicardia R 10mg p/o tds T.clopilet 75 mg p/o od T.clopilet 75 mg p/o od T.Statin 10 mg p/o od T.Statin 10 mg p/o od Inj Fraseda 30mg in 100ml Ns IV bd Inj Fraseda 30mg in 100ml Ns IV bd Inj Neksium 70 mg IV bd Inj Neksium 70 mg IV bd

15 15 What is a Stroke? “Stroke” is a term used to describe neurological changes lasting more than 24 hours caused by an interruption in the blood supply to a part of the brain. If the blood flow ceases for an extended period of time, the cerebral tissues involved die causing permanent neurological deficits. “Stroke” is a term used to describe neurological changes lasting more than 24 hours caused by an interruption in the blood supply to a part of the brain. If the blood flow ceases for an extended period of time, the cerebral tissues involved die causing permanent neurological deficits.

16 CEREBRAL CIRCULATION

17 17 LOCATION

18 CLINICAL MANIFESTATIONS

19 COMMON EFFECTS OF A RIGHT HEMISPERIC STROKE Left visual field loss (homonymous hemianopsia) Left visual field loss (homonymous hemianopsia) Dysphagia Dysphagia Usually retain language ability but may have difficulty producing speech (dysarthria) Usually retain language ability but may have difficulty producing speech (dysarthria) Left-sided weakness (hemi paresis) or paralysis (hemiplegia) Left-sided weakness (hemi paresis) or paralysis (hemiplegia) Sensory impairment Sensory impairment Denial of paralysis, “forget” or “ignore” objects or people on their left side (neglect) Denial of paralysis, “forget” or “ignore” objects or people on their left side (neglect) Impaired ability to judge spatial relationships (misjudge distances and depth leading to falls, unable to guide hands to button a shirt, problems with directions such as up / down, no concept of time) Impaired ability to judge spatial relationships (misjudge distances and depth leading to falls, unable to guide hands to button a shirt, problems with directions such as up / down, no concept of time) Impaired ability to locate and identify body parts Impaired ability to locate and identify body parts Short-term memory impairments (difficulty remembering new information) and apraxia (inability to carry out learned movement in the absence of weakness or paralysis) Short-term memory impairments (difficulty remembering new information) and apraxia (inability to carry out learned movement in the absence of weakness or paralysis) Behavioral changes such as impaired judgement or insight into limitations, overestimate physical ability, impulsivity, inappropriateness and difficulty comprehending and expressing emotions Behavioral changes such as impaired judgement or insight into limitations, overestimate physical ability, impulsivity, inappropriateness and difficulty comprehending and expressing emotions

20 COMMON EFFECTS OF A LEFT HEMISPERIC STROKE Right visual field loss (homonymous hemianopsia) Right visual field loss (homonymous hemianopsia) Dysphagia Dysphagia May develop aphasia (loss of language including spoken, written, reading and comprehension) but may also have dysarthria May develop aphasia (loss of language including spoken, written, reading and comprehension) but may also have dysarthria Right-sided weakness ( hemiparesis) or paralysis (hemiplegia) Right-sided weakness ( hemiparesis) or paralysis (hemiplegia) Sensory impairment Sensory impairment Usually have normal perception Usually have normal perception Usually judgement is intact with good insight into limitations Usually judgement is intact with good insight into limitations Short-term memory impairments (difficulty remembering new information) and apraxia (inability to carry out learned movement in the absence of weakness or paralysis) Short-term memory impairments (difficulty remembering new information) and apraxia (inability to carry out learned movement in the absence of weakness or paralysis) Often develop a slow and cautious behavioral style. They need frequent instructions and feedback to complete tasks Often develop a slow and cautious behavioral style. They need frequent instructions and feedback to complete tasks Better able to comprehend and express emotions Better able to comprehend and express emotions

21 TYPES OF STROKE Ischemic % Ischemic % Caused by blockage of the artery resulting in reduction of blood flow and cell death Caused by blockage of the artery resulting in reduction of blood flow and cell death Include thrombotic, lacunar, embolic cryptogenic Include thrombotic, lacunar, embolic cryptogenic CT scan negative until a few days post stroke then hypodense area - indicates infarction CT scan negative until a few days post stroke then hypodense area - indicates infarction

22 THROMBOTIC STROKE Atherosclerosis in cerebral arteries Atherosclerosis in cerebral arteries Similar to CAD – leading to MI Similar to CAD – leading to MI Atherogenesis – decades long process Atherogenesis – decades long process In thrombotic stroke lumen of artery narrows to point of obstruction In thrombotic stroke lumen of artery narrows to point of obstruction

23 LACUNAR STROKE Atherosclerosis in cerebral arteries Atherosclerosis in cerebral arteries Similar to CAD – leading to MI Similar to CAD – leading to MI Atherogenesis – decades long process Atherogenesis – decades long process In thrombotic stroke lumen of artery narrows to point of obstruction In thrombotic stroke lumen of artery narrows to point of obstruction

24 EMBOLIC STROKE A clot travels from source outside of brain A clot travels from source outside of brain Encounters vessel with lumen narrow enough to block its passage Encounters vessel with lumen narrow enough to block its passage Clot lodges there, blocking blood flow Clot lodges there, blocking blood flow Most common source - heart Most common source - heart Common conditions - atrial fibrillation, valvular disease, ventricular thrombi, atherosclerosis of the proximal aorta Common conditions - atrial fibrillation, valvular disease, ventricular thrombi, atherosclerosis of the proximal aorta

25 HEMORRHAGIC STROKE A clot travels from source outside of brain A clot travels from source outside of brain Encounters vessel with lumen narrow enough to block its passage Encounters vessel with lumen narrow enough to block its passage Clot lodges there, blocking blood flow Clot lodges there, blocking blood flow Most common source - heart Most common source - heart Common conditions - atrial fibrillation, valvular disease, ventricular thrombi, atherosclerosis of the proximal aorta Common conditions - atrial fibrillation, valvular disease, ventricular thrombi, atherosclerosis of the proximal aorta

26 EMERGENCY MANAGEMENT Neurological vital signs Neurological vital signs Blood pressure Blood pressure Glycemic control Glycemic control Control of body temperature Control of body temperature Oxygenation Oxygenation Hydration Hydration

27 HEMORRHAGIC STROKE Treatment based on the underlying cause of the bleed and the extent of brain damage Treatment based on the underlying cause of the bleed and the extent of brain damage Treatment includes medication and surgical intervention Treatment includes medication and surgical intervention Management of  ICP with antihypertensives or surgical evacuation of hematoma Management of  ICP with antihypertensives or surgical evacuation of hematoma In patients with ruptured aneurysm - clip or embolization In patients with ruptured aneurysm - clip or embolization

28 Strategies to prevent a stroke - Maintain a healthy weight - eat a reduced-fat diet - Maintain a healthy weight - eat a reduced-fat diet –Reduce alcohol intake to 1-2 drinks / day –Exercise - 30 minutes 3-4 times / week –Become smoke free and drug free –Management of hypertension (ACE inhibitors) –Management of heart disease (anticoagulants), diabetes and hyperlipidemia (statins) –Carotid endarterectomy may be indicated with stenosis –Antiplatelets for plaque / clot formation

29 NURSING DIAGNOSIS Ineffective tissue perfusion r/t decreased cerebral blood flow or cerebral edema Ineffective tissue perfusion r/t decreased cerebral blood flow or cerebral edema Ineffective airway clearance r/t inability to raise secretions,ineffective cough Ineffective airway clearance r/t inability to raise secretions,ineffective cough Impaired physical mobility r/t neuromuscular and cognitive impairment, decreased muscle strength and control Impaired physical mobility r/t neuromuscular and cognitive impairment, decreased muscle strength and control Impaired verbal communication r/t residual aphasia Impaired verbal communication r/t residual aphasia Risk for aspiration r/t inability to protect the airway Risk for aspiration r/t inability to protect the airway Altered sensory perceptual r/t altered LOC, impaired sensation and vision. Altered sensory perceptual r/t altered LOC, impaired sensation and vision.

30 Unilateral neglect r/t visual field deficit and sensory loss on one side of the body Unilateral neglect r/t visual field deficit and sensory loss on one side of the body Impaired urinary elimination r/t impaired impulse to void or manage tasks of voiding Impaired urinary elimination r/t impaired impulse to void or manage tasks of voiding Impaired swallowing r/t weakness or paralysis of affected muscles Impaired swallowing r/t weakness or paralysis of affected muscles Situational low self esteem r/t actual or perceived loss of function. Situational low self esteem r/t actual or perceived loss of function.

31 NURSING MANAGEMENT Airway management/ventilator management Airway management/ventilator management Assessment and evaluation of neurologic status to detect patient deterioration Assessment and evaluation of neurologic status to detect patient deterioration Blood pressure management Blood pressure management General supportive care and prevention of complications associated with: General supportive care and prevention of complications associated with: –Dysphagia, HTN, hyperglycemia, dehydration, malnourishment, fever, cerebral edema, infection, and DVT, immobility, falls, skin care, bowel and bladder dysfunction.

32 SIGNS OF ↑ ICP Early signs: Early signs: –Decreased LOC –Deterioration in motor function –Headache –Changes in vital signs Late signs Late signs –Pupillary abnormalities –Changes in respiratory pattern –Changes in ABG’s

33 Airway management adequate O2 saturation Airway management adequate O2 saturation Preventing increased ICP and providing supportive care. Preventing increased ICP and providing supportive care. Hourly vitals/neuros including ICP, CPP, CVP. Hourly vitals/neuros including ICP, CPP, CVP. Maintaining BP to ensure adequate CPP Maintaining BP to ensure adequate CPP Seizure precautions Seizure precautions Antibiotic prophylaxis Antibiotic prophylaxis Stabilization Stabilization Prevention of complications Prevention of complications Monitoring neuro status Monitoring neuro status Family support and education Family support and education

34 REHABILITATION

35 Do with the patient not for the patient Do with the patient not for the patient Management of impairment disability or handicap Management of impairment disability or handicap Patient family and others Patient family and others

36 Positioning Positioning Exercise Exercise Skin Skin Communication Communication Swallowing Swallowing Elimination Elimination

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