Radio Frequency Ablation in Cardiology

CATHETER ABLATION/RADIOFREQUENCY ABLATION

Catheter ablation  is a medical procedure used to treat some types of arrhythmia 

During catheter ablation, a long, thin, flexible tube is put into a blood vessel in your arm, groin (upper thigh), or neck. This tube is called an ablation catheter. It's guided into your heart through the blood vessel.

A special machine, called a generator, sends energy through the ablation catheter to your heart. The energy modifies, via heating, or, less commonly, freezing, small areas of heart tissue where abnormal heartbeats may cause an arrhythmia to start.

Radiofrequency (RF) energy usually is used for catheter ablation. This type of energy uses radio frequency current to produce heat that modifies the heart tissue. Studies have shown that RF energy is safe and effective.

GENERAL INFORMATIONS:

• Catheter ablation is used to treat abnormal heart rhythms (arrhythmias) when medicines are not effective or for side effects.

• Medicines help to control the abnormal heart tissue that causes arrhythmias. Catheter ablation destroys the tissue.

• Catheter ablation is a low-risk procedure that is successful in about 90 percent of the people who have it.

• This procedure takes place in a special hospital room called an electrophysiology (EP) lab or a cardiac catheterization (cath) lab. It takes 2 to 4 hours.

Tests to be done prior to the procedure:

• EKG (electrocardiogram).
• Echocardiography.
• Stress testing. 
• Blood tests

Catheter ablation can stop atrial fibrillation from happening and can relieve symptoms. Your doctor can help you decide if ablation is a good choice based on your health.

Catheter ablation works better in people who have paroxysmal atrial fibrillation (episodes last 7 days or less) than in people who have persistent atrial fibrillation (episodes last more than 7 days). For both types, episodes may go away on their own or they go away after treatment. Ablation might be less likely to work the longer a person has persistent atrial fibrillation.4

Ablation works best for younger people who have paroxysmal atrial fibrillation and little or no structural heart disease.

Things that limit how well catheter ablation works include older age, other heart problems, obesity, and sleep apnea.

Catheter ablation is still being studied to see how well it works and how safe it is in the long term.

Paroxysmal atrial fibrillation

Research shows that ablation helps more than 70 to 80 out of 100 people.5 That means it does not help in about 20 to 30 out of 100 cases.

In a worldwide survey, ablation helped 84 out of every 100 people.6

Persistent atrial fibrillation

Research shows that ablation helps about 50 out of 100 people.4, 1 That means it doesn't work in about 50 out of 100 cases.

In a worldwide survey, ablation helped about 65 out of every 100 people.6

Repeated ablation procedures

If the first procedure doesn't get rid of atrial fibrillation completely, you may need to have it done a second time. Repeated ablations have a higher chance of success.Research shows that a second ablation is needed in 20 to 40 people out of 100. This means that 60 to 80 out of 100 people don't need another ablation.4

Risks

Catheter ablation is considered safe. Most people do well afterward.

Your doctor can help you decide whether the possible benefits of ablation outweigh these risks:

Problems during the procedure

If problems happen during the procedure, your doctor is prepared to fix them right away. In studies and a worldwide survey, serious problems happened in about 4 out 100 people.7, 6 These problems include an accidental hole in the heart, the need for emergency surgery, and nerve damage in the chest.

Rare problems include cardiac tamponade and stroke. They happen in about 1 out of 100 people.5 This means that they do not happen in about 99 out of 100 people. Another serious problem affects the pulmonary vein and happens in about 1 to 6 people out of 100 people.5, 7 This means that it does not happen in about 94 to 99 people out of 100.

Death from the procedure is very rare. It happens to about 1 out of 1,000 people.5 This means that 999 out of 1,000 people don't die from the procedure.

Problems after the procedure

Problems after the procedure can be minor (such as mild pain) or serious (such as bleeding). Your doctor will check you closely after the procedure. He or she can fix most of these problems.

The most common problems are related to the catheter that was inserted in a vein. Most of these vein problems aren't serious. They include minor pain, bleeding, and bruising. Vein problems happen in 0 to 13 people out of 100.4 This means that they don't happen in 87 to 100 people out of 100. In a worldwide survey, serious vein problems happened in 1 out every 100 people.6

Serious problems aren't common. These problems include stroke and new heart rhythm problems. A rare problem is a life-threatening problem with the esophagus (atrio-esophageal fistula) that happens to about 1 out of 1,000 people.5 This means it doesn't happen to 999 out of 1,000 people.

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Diabetes insipidus

Introduction

Diabetes insipidus (DI) is a condition which causes frequent urination. The reduction in production or release of ADH results in fluid and electrolyte imbalance caused by increased urinary output. Depending on the cause, Diabetes insipidus may be transient or life long condition. In its clinically significant forms, diabetes insipidus is a rare disease.

 

 

Definition

Diabetes insipidus (DI) is a group of conditions associated with a deficiency of secretion of anti-diuretic hormone characterized by the chronic excretion of abnormally large volumes (more than 50 mL/kg) of dilute urine.
 

Incidence

The true prevalence of DI is unknown, but it is usually underdiagnosed because the symptoms and signs are benign and many patients ignore them or are unaware of them. It commonly occur in older adults.
 

Types

• · Central (neurogenic) DI: it occurs when any lesion of the hypothalamus or posterior pituitary interferes with ADH synthesis, transport or release.
• · nephrogenic DI: it results from the decreased renal response to ADH despite presence of adequate ADH.
• · Primary polydipsia(dispogenic DI): excessive water intake caused by structural lesion in thirst center or psychologic disorder.
• · Gestational DI.
• Causes
• · Central (neurogenic) DI: Multiple causes include brain tumour, head injury, brain surgery, CNS infections.
• · nephrogenic DI: Caused by lithium therapy, renal damage, or hereditary renal disease.
• · Primary polydipsia(dispogenic DI): excessive water intake caused by structural lesion in thirst center or psychologic disorder.

Pathophysiology
The decrease in ADH results in fluid and electrolyte imbalances caused by increased urinary output and increased plasma osmolality. Tubular reabsorption of water reduces due to decreased tubular permiabilityto the water. This results in excessive urination which affects activities of daily living and interrupts sleep when nocturia occurs. Distended bladder leads to back flow of urine and hydronephrosis may develope as a complication. This will eventually leads to renal insufficiency.
Serum osmolality increases due to excessive urine output. Serum sodium level elevates in order to compensate for the fluid loss. severe thirst develops by osmoreceptor stimulation in response to the hypernatrmia. Patent intakes fluid to replace the loss. If hypernatremia persists restlessness, reduction in reflexes and seizures may develope. Cardiac output decreases and tachycardia develops if fluid volume is not restored. It will lead to hypotension and finally to hypovolemic shock.
 

Clinical manifestations

• Diabetes insipidus is characterized by increased thirst and increased urination. The primary character of DI is polyuria, excretion of large quantities of urine ( 5-20L per day)with a very low specific gravity(less than 1.005) and urine osmolality of < 100mmol/kg. In partial DI urine output may be lower(2-4L per day).
• Polydipsia (excessive intke of fluids) is also a characteristic feature of DI. Patient compensate for fluid loss by drinking great amount of water. The patient with central DI favours cold or iced drinks. Nocturia occurs due to frequent tendency to urinate which interrups sleep of the patient.
• Central DI usually occurs suddenly with excessive fluid loss. DI usually has a triphastic pattern: the acute phase with abrupt onset of polyuria, an interphase where urine volume apparently normalizes, and a third phase where DI is permanent.
• If fluid loss is not compensated, severe fluid volume de ficit results. This deficit is manifested by weight loss, hypotension, tachycardia with decreased cardiac output, poor tissue turgor, irritability, mental dullness. Hypovolemic shock may develop if fluid volume is not restored.

Diagnostic studies

• · Complete history collection regarding cause and origin of Diabetes Insipidus. Hourly intake and output should be recorded.
• · Physical examination: frequent monitoring of vital signs, body weight, skin turgor, level of consciousness are necessary.
• · Urine specific gravity less than 1.005 indicates Diabetes Insipidus.
• · Urine osmolality less than 100mmol/kg indicates Diabetes Insipidus..
• · Serum osmolality greater than 295mmol/kg indicates Diabetes Insipidus.

Water deprivation test:

Use to find cause of polyuria. All fluids are withheld for 8 to 16 hours. During the test patient’s blood pressure, weight and urine osmolality are assessed hourly. ADH is administered IV or subcutaneously and urine osmolality is measured one hour later. In central DI the rise in urine osmolality after vasopressin exceeds 9%. In nephrogenic DI there is no response to ADH.

Treatment

Goal: maintenance of fluid and electrolyte balance.

Pharmacological management.

• · Fluid replacement: hypotonic saline is administered intravenously.
• For central diabetes Insipidus-

Hormone replacement:

• Desmopressin acetate(DDAVP) can be administered orally,intravenously or as nasal spray.
• Aqueous vasopressin( pitressin)
• Vasopressin tenate
• Chlorpropamide( diabinese)
• Carbamazepine (tegretol)

For nephrogenic diabetes insipidus-

• Dietary measures: limiting sodium intake to less than 3 g per day help to reduce urine output.
• Thiazide diuretics: they are able to slow glomerular filtration rate and allows the kidney to reabsorb more water. E.g. hydrochlorothiazide (hydroDiuril), chlorothiazide (Diuril).
• Indomethacin (indocin).

 

Nursing diagnosis

1. Fluid volume deficit related to excessive urinary output as manifested by increased thirst and weight loss.
2. Sleeping pattern disturbances, insomnia related to nocturia as manifested by verbalization of patient about interrupted sleep
3. Activity intolerance related to fatigue and frequent urination as manifested by weakness and fatigue of the patient.
4. Anxiety related to course of disease and frequent urination as manifested by verbalization of anxious questions.
5. Ineffective coping related to frequent urination as manifested by verbalization of negative feeling by the patient.
6. Risk for complications related to excessive loss of fluid from the body as manifested by hypotension and weight loss.
7. Knowledge deficit regarding management of diabetes insipidus as manifested by verbalization of doubts by the patient.

Interventions

1. Fluid volume deficit related to excessive urinary output as manifested by increased thirst and weight loss.
Ø Assess the fluid level of the patient
Ø Monitor vital signs frequently
Ø Restrict oral fluid intake.
Ø Administer hypotonic saline intravenously.
Ø Administer medications if ordered.
 
2. Disturbed sleeping pattern, insomnia related to nocturia as manifested by verbalization of patient about interrupted sleep.
Ø Assess the sleeping pattern of the patient
Ø Give psychological support.
Ø Advice the patient to restrict oral fluids
Ø Provide calm and quiet environment.
 
3. Activity intolerance related to fatigue and frequent urination as manifested by fatigue and weakness of the patient.
Ø Assess the activity status of the patient
Ø Give psychological support to the patient.
 
4. Anxiety related to course of disease and frequent urination as manifested by verbalization of anxious questions.
Ø Assess the anxiety level of the patient.
Ø Explain the patient about the disease and treatment.
Ø Provide calm and quiet environment.
Ø Divert the attention of the patient by talking about different matter.
 
5. Ineffective coping related to frequent urination as manifested by verbalization of negative feeling by the patient.
Ø Assess the coping ability of the patient
Ø Explain the patient about the disease and treatment
Ø Give psychological support.
 
6.Risk for complications related to excessive loss of fluid from the body as manifested by hypotension and weight loss.
Ø Assess the fluid volume of the patient
Ø Monitor vital signs frequently.
Ø Take immediate measures to restore fluid volume such as IV fluid therapy
Ø Administer medications as ordered.
 
7. Knowledge deficit regarding management of diabetes insipidus as manifested by verbalization of doubts by the patient
Ø Assess the knowledge level of the patient.
Ø Explain the management of diabetes insipidus to the patient.
 
Summary
Diabetes insipidus cause frequent urination, even at night, which can disrupt sleep. Patient feels excessive thirst by the stimulation of osmoreceptor response. Because of the excretion of abnormally large volumes of dilute urine, patient may quickly become dehydrated if do not drink enough water. It can be treated with fluid replacement and hormone replacement therapy.

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ALZEIMERS DISEASE

 

DEFINITION

Alzheimer s disease is a chronic progressive degenerative disease of the brain.It is characterized by the permanent destruction of the brain cells

INCIDENCE

The incidence rate is same for all the ethnic group although the incidence will be more in African Americans and Hispanic Americans. Women are more likely to develop Alzeimers than that of men.Individuals with Down s syndrome are at high risk for developing Alzeimer s disease.Theymay develop clinical symptoms at the age of 20 or by the age of 40.Age is also a major risk factor for dementia.

ETIOLOGY

• The exact etiology is unknown.
• Age is a factor which influences the development of Alzeimersdisease.When AD develops in someone less than less than 60 years of age it is called it is referred to as early onset AD.When AD develops over 60 years it is called late onset AD.
• When family is influenced it is called familial Alzeimers disease.

PATHOPHYSIOLOGY

Genetic factors plays a major important role in how the brain processes the amyloid beta protein.Overproduction of the amyloid beta protein results in AD.Amyloid beta(A-Beta)is a part of larger protein called amyloid precursor protein(APP).Large amounts of APP are produced in the brain.Abnormally high levels of A Beta causes inflammatory response and ultimately neuron deathThree genes are said to produce AD.
An important part of the neurofibrillary tangle is a protein called as TAU.This provides support to the intracellular structures .If the tau protein is altered the microtubules twist together in a helical fashion.This ultimately forms neurofibrillary tangles which is observed in patients with AD.The presence of neuritic plaques or neurofibrillary tangles results in neuronal death
Autopsy report of the brain tissues of a patient with AD shows the presence of neurofibrilalry tangle formation
Cholinergic neurones are associated in patients with AD or dementia especially in regions essential for memory and cognition.Otherneurotransmittersystemsincludesserotoninn and norepinephrine.

FLOW CHART REPRESENTATION

CLINICAL MANIFESTATIONS

• EARLY WARNING SIGNS OF ALZEIMERS DISEASE
• Memory loss that affects job skills-Frequent forgetfulness or unexplained confusion in the home or in the workplace is a signal.This type of memory loss goes beyond forgetting an assignment,colleagues name or phone number.
• Difficulty in performing familial tasks-People with Alzeimers disease may cook a meal and forget to serve or will forget that the meal is made.
• Problems with language-Most people will find difficulty in finding the right word in time to time,theyamy also forget simple words and uses inappropriate words making their speech difficult to understand.
• Disorientation to time and place-The patient will forget the day or the time or the week
• Poor and decreased judgement-The patient will not dress according to the weather(not bringing a sweater in a cold evening)He may also wear a bathrobe or a sweater on a very hot day
• Problems with abstract thinking-The person willnot be able to recognize numbers or even to do simple calculations
• Misplacing things-Misplacing of keys,purses or wallets.The person with Alzeimers disease will place things in inappropriate placesEg:cooking utensils in the clothing drawers. But having no memory how they are inside that drawers
• Changes in mood or behaviour-Rapid mood swings with no apparent reason
• Changes in personality-The personality will change fOReg someone who is very easy going will become very angry
• Loss of initiative-The person becomes uninterested or uninvolved in activities
• The manifestations of dementia can be classified smild,moderate and severe.
• Some patients will develop psychotic manifestations(delusion,illusion,hallucination)
• Cognitive impairments like dysphasia(difficulty in oral communication)apraxia(inability to manipulate objects or perform purposeful acts),Visual agnosia(inability to recognize objects by sight),Dysgraphia(difficulty in communication by writing)
• The patient willnot be able to recall long term memory and loses the ability to recognize family members and friends
• Aggression and tendency to wander.

DIAGNOSTIC EVALUATIONS

• History collection and physical examination
• Neuropsychological testing including mini mental status examination
• Thyroid function tests
• Liver function test
• Screening for depression

MANAGEMENT

COLLABORATIVE THERAPY

• Drug therapy for cognitive problems
• Drug therapy for behavioural problems
• Behavioural modifications
• Moderate exercise
• Assistance for functional independence
• Music particularly for meals and bathing
• Assistance with support of the caregiver

PHARMACOLOGICAL THERAPY
DECREASED MEMORY AND COGNITION
Cholinesterase inhibitors

• Donepezil(Aricept)
• Rivastigmine(Exelon)
• Galantamine(Remenyl)

Depression
Selective serotonin reuptake inhibitors

• Sertraline
• Fluvoxamine
• Citalopram
• Tricyclic antidepressants
• Nortryptiline(Aventyl,Pamelor)
• Amytryptiline(Elavil)
• Imipramine(Tofranil)

Atypical antidepressants

• Trazadone
• Behavioural problems

Conventional antipsychotics

• Loxapine(Loxitane)
• Haloperidol(Haldol)

Atypical antipsychotics(Neuroleptics)

• Resperidone
• BOlanzapine
• Benzodiazepines
• Lorezepam
• Temezepam

Sleep disturbances

• Zolpidem

NURSING MANAGEMENT

NURSING ASSESSMENT
Subjective and objective data should be obtained from the patient.The usual questions asked are When did you first recognize the memory loss?How the memory loss progressed etc....

PLANNING
The overallplanning includes maintaining functional ability as long as possible.Maintaining safe environment with minimum injuries,have personal needs methave dignity maintained decrease the caregivers stress and cop up with the long term caregiving

NURSING DIAGNOSIS

INTERVENTIONS

• Include family members in planning and providing care and plan appropriate interventions
• Determine physical,social and psychological history of the patiet,habits and routines to maintain a familiar routines
• Prepare for interaction by eye to eye contact by touch and provide respect to the patient
• Give one single and simple direction at atime to reduce the confusion
• Use distractions
• Provide the patient ageneral information about the weather and use appropriate cues sucha s calenders,pictures and seasonal decorations to relieve anxiety.
• Refrain from arguing with the patient

Self caredeficit(bathing ,dressing,toileting)related to memory deficit and impairment s manifested by inability to bathe dress himself
Interventions
Self care assistance-

• Monitor the patients ability to perform self care activities
• Use continuous repetition of the daily routinesbecause memory loss impairs patients ability to plan sequential activities.
• Assist patient in ADL
• Teach the family members regarding the care of the patient

Self care assistance bathing and hygiene

• Provide desired personal articles such as bath soap and hair brush ,to enhance memory and provide care
• Facilitate patients bathing to facilitate independant hygiene

Self care assistance Dressing Grooming

• Provide patients clothing in appropriate area
• Provide assistance in dressing

Self care assistance-Toiletting

• Assist patient in toileting for maintaining regularity
• Facilitate toilet hygiene after completion of elimination to prevent skin breakdown

Risk for injury related to impaired judgement,possible gait instability,muscle weakness and sensory perceptual alteration

• Identify physical or cognitive deficits of the patient and decrese the chance of falling
• Provide assistive devices like walker,a steady gait and provide ambulation support
• Ensure that the patient is wearing the shoes appropriately,fasten securely and have a non-skid soles to provide support during ambulation
• Insist the patient to wear prescribed glassed to enhance vision

Ineffective coping related to depression in response to the diagnosis of Alzeimers disease as manifested by depression,fatigue and social isolation

• Encourage social and community activities to relieve depressioin
• Encourage the user of spiritual resourses to provide calming
• Encourage the family to verbalize feeling about the patient nd increase communication and mutual understanding among the family members
• Determine the risk of violent and self harm behaviour

Ineffective therapeutic regimen related to decreasing level of cognitive function and memory

• Assist the patient to identify possible upcoming situations
• Provide information about the patients behaviour, life expectations, and prepare the patient for the future needs of daily living
• Include the family members in planning and implementation of the interventions

Wandering related to disease as evidenced by getting lost numerous times a day and patient statement of “I dont know where i m “

• Monitor environment for potential safety hazards to prevent injury to the patient
• Monitor patient for alterations in the physical and cognitive function that may lead to unsafe behaviour to assess for changes that may occur.
• Provide appropriate level of supervision
• Provide appropriate activities as diversion from restlessness associated with wandering

Care giver role strain related to family members illness as manifested by statements about stress

• Assess the health status of the caregivers to determine if health planning is needed
• Refer for medical evaluation if appropriate
• Discuss effects of caregiving with the caregiver to determine staus of the caregiver and to enable open discussion of the needs
• Encorage the support of other family members
• Provide financial and social service referrals to provide support to the caregiver
• Acknowledge caregivers fear of being unable to take care of the family members.
• Counsel and support caregivers

Anxiety related to uncertain outcome,perceivedpowerlessness,possible changes in role function as manifested by helplessness,fear,irritability,forgetfulness and inability to concentrate

• Assess the physical and emotional health staus of the caregiver and provide appropriate interventions
• Collaborate with the caregiver to plan for interventions
• Assist for planning of continued care of the patient

COMMON NURSING INTERVENTIONS
FOR BEHAVIOURAL PROBLEMS

• Caregivers should be aware of the behavioural problems.they should be informed that behavioural problems are not manifested from the vaccum.It can be due to Pain frustrations,temperatureextremes,frustruations etc..
• Identify the factors that may trigger the behaviour eg extremes of temperature
• Distract the patientEg:Providesnacks,car drives favourite music or videotapes.
• Reassuring the patient involves letting the patient know that he/she will be protected from danger.
• The side effects of the drug should be taken into consideration.

SAFETY

• The dangers includes injuries from falls,injury from ingestion of poisonous substances,wandering,injury to others and self due to sharp objects,fire or burns
• Side rails should be there to prevent injury
• Extension cords should be removed because the client may strip over them
• In bathroom nonskid mats should be used
• Wandering should be considered.It may be due to loss of memory,side effects of the drug and physical and emotional problems.The family members should be aware of the wandering nature of the patient and should protect him

PAIN MANAGEMENT

• Patients will have difficulty in expressing the pain because of the impairment in verbal communication.
• Pain should be treated with drug therapies and the patients behaviour should be monitored.

EATING AND SWALLOWING DIFFICULTIES

• Loss of interest in the food and decreased ability to feed himself results in imbalanced nutrition
• Pureed foods,thickenedliquids and nutritional suppliments are used when the patients swallowing is affected
• Patient should be reminded to chew the food before swallowing
• Distractions in the mealtime includes television which should be avoided
• Low lighting,and music will improve the eating behaviour
• Encourage self feeding and liquids should be encouraged.
• When oral feeding is not possible nasogastric feeding is initiated
• Percutaneous endoscopic gastrostomy can be performed(PEG)

ORAL CARE

• Patient will pocket food in the mouth resulting in tooth decay
• The mouth must be regularly washed and flossed and oral care should be given

INFECTION PREVENTION

• Urinary tract infection and pneumonia are the potential complications.
• Reduced fluid intake,prostate hyperplasia and urinary drainage devices causes bladder infection.Manifestations includes behaviour,fever,cough,and pain on urination are evaluated and appropriately treated and evaluated.

SKIN CARE

• Skin should be monitored closely.
• Rashes,areas of redness,and skin breakdown should be monitored
• Patients with immobility should be monitored carefully
• The skin should be monitored closely and the position should be changed and the bony prominences should be monitored

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BELL’S PALSY

Bell’s palsy (facial paralysis)is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the affected side. Bell s palsy is a type of pressure paralysis. The inflamed edematous nerve becomes compressed to the point of damage or the blood supply is occluded, producing ischemic necrosis of the nerve. It affects the facial nerve the seventh cranial nerve.It affects men and women in the same incidence rate

ETIOLOGY

• The cause is unknown.
• Vascular ischemia, viral disease(herpes zoster, Herpes simplex),autoimmune disease or a combination of all these factors.

 

CLINICAL MANIFESTATIONS

• The face is distorted from paralysis of the facial muscles.
• Increased lacrimation.
• Painful sensation of the face behind the ear and in the eye.
• Speech difficulties and inability to eat on the affected side due to the weakness or paralysis of the facial muscles.

 

MEDICAL MANAGEMENT

• The objective of the treatment is to maintain the muscle tone of the face and to prevent or minimize denervation.
• Patient should be reassured that the recovery occurs within 3to5 weeks in most of the patients.
• Corticosteroid therapy(Prednisone)is prescribed to reduce inflammation sand to prevent edema. It reduces vascular compression and permits restoration of the blood supply to the nerve. Early administration of the corticosteroid therapy appears to diminish the severity of the disease., relieving the pain and prevent denervation.
• Facial pain is relieved by analgesic agents,hot may be applied to the involved side of the face to prevent muscle atrophy.
• Electrical stimulation is applied to the face to prevent muscle atrophy.
• Surgical exploration of the facial nerve is recommended if tumor is suspected.

 

NURSING MANAGEMENT

• Protection of the eye from the injury.the eyes doesnot close completely and the blink reflex is diminished,so the eye is vulnerable to injury from dust and foreign particles.Corneal irritation and ulceration occurs.The eyes should be covered with eye shield.Eye ointment is applied on the eyelids at bedtime to promote adherence of the eyelids and and to prevent injury during the sleep.The patient should be taught to manually close the eyes before going to sleep.Wrap around sun glasses or googles is worn during the daytime to decrease the evaporation from the eye.
• Suggest massaging the face several times dailyusing a gentle upward motion to maintain muscle tone.
• Facial exercises such as wrinkling of the forehead,blowing out of the cheeks and whistling may be performed with the aid of a mirror to prevent muscle atrophy.
• Exposure of the face to cold is avoided.

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ARTHROPOD BORNE VIRUS ENCEPHALITIS

Arthropod vectors transmits many vectors that causes encephalitis.Theprimary vector is mosquito.In case of West Nile virus,humans are the secondary host,birds are the primary host.Arbovirus infection occurs in specific geographic areas during summer.West Nile and St Louis are the most common type of arbovirus.

PATHOPHYSIOLOGY
1. Viral infection occurs at the site of mosquito bite
2. The host immune response attempts to control the viral replication
3. If the immune response is not adequate viremia occurs
4. The virus gains access to the central nervous system via cerebral capillaries(It spreads from  neuron  to neuron typically affecting the cortical gray matter,brain stem and the thalamus.
5. Meningeal exudates will be formed irritating the meninges resulting in increased ICP
6. Encephalitis

CLINICAL MANIFESTATIONS

• St Louis and West Nile are the most commonly affecting Encephalitis.Climate and environment contributes to occurrence of St Louis and West Nile encephalitis
• Arboviral encephalitis begins with flu like symptoms,neurological symptoms depends on the virus involved
• St Louis encephalitis presents with SIADH
• West Nile encephalitis presents with maculopapular or morbiliform rash on the neck,trunk,arms and legs and flassid paralysis
• Both encephalitis can result in Parkinsonian like movements reflecting inflammation of the basal ganglia.
• Seizures is a poor prognostic indicator and is seen most commonly in St Louis type.

ASSESSMENT AND DIAGNOSTIC FINDINGS

• History collection and physical examination
• Neuroimaging,MRI scan demonstrates inflammation of the basal ganglia.
• CSF evaluation.
• Immunoglobulin M antibodies are observed in serum and CSF in West Nile encephalitis.

MEDICAL MANAGEMENT

• No specific treatment exists for arboviral encephalitis
• Medical management is aimed at controlling increased ICP and seizures.
• Interferon is used for treating St Louis encephalitis.
• Ribavirin and Interferon alpha 2b is given for West Nile virus encephalitis.

NURSING MANAGEMENT

• If the patient is very ill hospitalization may be required.
• The nurse should carefully observe the patient and note for improvement or deterioration.
• Injury prevention due to falls and seizures.
• Family should be taught regarding the disease condition a nd the outcome
• Public should be educated regarding the prevention of arboviral encephalitis.
• Clothing should be used to reduce the bites
• Blood donation centres should screen all the blood foe West Nile virus.

REFER ENCEPHALITIS FOR MANAGEMENT

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BRAIN TUMORS

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place. Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

INCIDENCE

The annual rate of newly diagnosed brain tumors is 17000,with an estimate of 13100 deaths The brain is a frequent site of metastasis.Brain tumors rank as fourth cause for death of people between the age group of 35 to 54 years.Whites have a higher risk of malignant tumors compared with blacks.Meningiomas are the common brain tumors in Africa

TYPES

Brain tumors can be classified as:

• Primary-Arising from the tissues within the brain
• Secondary-It results from metastasis from a malignbant neoplasm that originates in some other parts of the body

Types of brain tumor depending on the tissue of origin

• Astrocytomas-These are called gliomas.It arises from star shaped cells called glial cells.It accounts for about 65% of the primary brain tumors.These tumors can range from low grade to moderate grade malignancy. In adults, astrocytomas most often arise in the cerebrum. In children, they occur in the brain stem, the cerebrum, and the cerebellum. A grade III astrocytoma is sometimes called an anaplastic astrocytoma. A grade IV astrocytoma is usually called a glioblastoma multiforme.
• Glioblastoma Multiforme-It arises from the primitive stem cells(glioblast).They are highly malignant and invasive, among the most devastating of primary brain tumors
• Oligodendroglioma-Tissue origin is Oligodendrocytes.It is characterized by benign encapsulation and calcification
• Ependymoma-It arises in the ependyaml epithelium.It ranges from benign to malignant,most are benign and encapsulated..
• Acoustic neuroma-(Schwannoma)-Cells arises from the myelin sheath around the nerves,commonly affects cranial nerve 8.They grows on both sides of the brain,usually benign or low grade malignancy
• Pituitory Adenoma-It arises in the pituitary gland.It is usually benign
• Hemangioblastoma-It arises from the blood vessels of the brain.It is rare and benign and the surgery is curative.
• Primary central nervous system lymphoma-It arises fromthe lymphocytes.It arises in in transplant recepients and acquired immunodeficiency syndrome(AIDS)patients.
• Metastatic tumors-It occurs in the lungs,breast,kidney,thyroid,prostate.It is malignant

Some types of brain tumors do not begin in glial cells. The most common of these are:

• Medulloblastoma - This tumor usually arises in the cerebellum. It is the most common brain tumor in children. It is sometimes called a primitive neuroectodermal tumor.
• Meningioma - This tumor arises in the meninges. It usually grows slowly.
• Schwannoma - A tumor that arises from a Schwann cell. These cells line the nerve that controls balance and hearing. This nerve is in the inner ear. The tumor is also called an acoustic neuroma. It occurs most often in adults.
• Craniopharyngioma - The tumor grows at the base of the brain, near the pituitary gland. This type of tumor most often occurs in children.
• Germ cell tumor of the brain - The tumor arises from a germ cell. Most germ cell tumors that arise in the brain occur in people younger than 30. The most common type of germ cell tumor of the brain is a germinoma.
• Pineal region tumor - This rare brain tumor arises in or near the pineal gland. The pineal gland is located between the cerebrum and the cerebellum.

Brain tumors can also be classified as

• Benign brain tumors do not contain cancer cells. Usually, benign tumors can be removed, and they seldom grow back.The border or edge of a benign brain tumor can be clearly seen. Cells from benign tumors do not invade tissues around them or spread to other parts of the body. However, benign tumors can press on sensitive areas of the brain and cause serious health problems. Unlike benign tumors in most other parts of the body, benign brain tumors are sometimes life threatening.
• Malignant brain tumors Very rarely, a benign brain tumor may become malignant containing cancer cells. Malignant brain tumors are generally more serious and often life threatening. They are likely to grow rapidly and crowd or invade the surrounding healthy brain tissue.Very rarely, cancer cells may break away from a malignant brain tumor and spread to other parts of the brain, to the spinal cord, or even to other parts of the body. The spread of cancer is called metastasis

BRAIN TUMOR LOCATIONS AND PRESENTING MANIFESTATIONS

• FRONTAL LOBE TUMORS –Unilateral hemiplegia,seizures,memory deficit,personality and judgement changes,visual disturbances.
• PARIETAL LOBE-Speech disturbance( If the tumor is in the dominant hemisphere inability to write,unilateral neglect
• OCCIPITAL LOBE-Blindness and seizures.
• SUBCORTICAL-Hemiplegia,other symptoms may depend on the area of infiltration
• MENINGEAL TUMORS-Symptoms are associated with compression of the brain
• METASTATIC TUMORS-Headache,nausea or vomiting because of increased ICP

CLINICAL MANIFESTATIONS

• Headaches (usually worse in the morning)
• Nausea or vomiting
• Changes in speech, vision, or hearing
• Problems balancing or walking
• Changes in mood, personality, or ability to concentrate
• Problems with memory
• Muscle jerking or twitching (seizures or convulsions)
• Numbness or tingling in the arms or legs

DIAGNOSTIC EVALUATION

• Physical examination - The doctor checks general signs of health.
• Neurologic examination - The doctor checks for alertness, muscle strength, coordination, reflexes, and response to pain. The doctor also examines the eyes to look for swelling caused by a tumor pressing on the nerve that connects the eye and brain.
• CT scan - An x-ray machine linked to a computer takes a series of detailed pictures of the head. The patient may receive an injection of a special dye so the brain shows up clearly in the pictures. The pictures can show tumors in the brain.
• MRI - A powerful magnet linked to a computer makes detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed. Sometimes a special dye is injected to help show differences in the tissues of the brain. The pictures can show a tumor or other problem in the brain.
• Angiogram - Dye injected into the bloodstream flows into the blood vessels in the brain to make them show up on an x-ray. If a tumor is present, the doctor may be able to see it on the x-ray.
• Skull x-ray - Some types of brain tumors cause calcium deposits in the brain or changes in the bones of the skull. With an x-ray, the doctor can check for these changes.
• Spinal tap - The doctor may remove a sample of cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). This procedure is performed with local anesthesia. The doctor uses a long, thin needle to remove fluid from the spinal column. A spinal tap takes about 30 minutes. The patient must lie flat for several hours afterward to keep from getting a headache. A laboratory checks the fluid for cancer cells or other signs of problems.
• Myelogram - This is an x-ray of the spine. A spinal tap is performed to inject a special dye into the cerebrospinal fluid. The patient is tilted to allow the dye to mix with the fluid. This test helps the doctor detect a tumor in the spinal cord.
• Biopsy - The removal of tissue to look for tumor cells is called a biopsy. A pathologist looks at the cells under a microscope to check for abnormal cells. A biopsy can show cancer, tissue changes that may lead to cancer, and other conditions. A biopsy is the only sure way to diagnose a brain tumor.

COMPLICATIONS

• If the tumor mass occludes the ventricles or occludes the outlet,ventricular enlargement (hydrocephalus)can occur
• The client should be continuously assessed for signs of altered level of consciousness,restlessness,blurred vision,vomiting without nausea and signs of infected shunts if shunts are placed to relieve the increased ICP. Such as high fever,persistent head ache etc..

TREATMENT

Treatment goals are aimed at identifying the tumor type and location,removing or decreasing the tumor massand preventing and managing increased ICP.

SURGICAL THERAPY

• Stereotactic surgical techniques are used with high frequency to perform a biopsy and to remove small tumors.
• Meningiomas and oligodendromyomas are completely removed where as invasive gliomas and medulloblastomas can be partially removed.Computer guided stereotactic biopsy ,ultrasound,functional MRI and cortical mapping is used to locate the brain tumors

RADIATION THERAPY AND RADIOSURGERY

• Radiation therapy is usually used in followup care.Radiation seeds can be implanted into the brain.Cerebral edema and rapidly increasing ICP can be a complication of radiation therapy.,they can be managed with high doses of corticosteroidsEg Dexamethasone,prednisolone.Stereotactic radiosurgery is a method of delivering high concentration of of radiation

CHEMOTHERAPY

• A group of chemotherapeutic agents called nitrosureas are administered.Eg:Carmustine,lomustine
• Chemotherapy laden biodegradable lesions Eg:Gliadel waferis implanted
• Methotrexate and Procrbazine
• Radiation can be delivered by Ommaya reservoir and intrathecal administration.
• Temozolomide is the first chemotherapeutic drug which crosses the blood brain barrier.
• Local hypothermia and biotherapy

NURSING MANAGEMENT

NURSING ASSESSMENT

• The initial data should contain the information about the present status of the client.
• Areas to be assessed includes LOC, state of consciousness, motor abilities,sensory perception integrated function including bowel and bladder function,balance and coordination and coping ability of the client.
• Watching the patient doing ADL and conversing to the patient is a method of assessment.
• The patient should be allowed to ventilate the feelings.
• Questions concerning medical history,intellectual abilities,educational level and history of nervous system infections and trauma should be collected.

NURSING DIAGNOSIS

Self care deficit related to loss of impairment of motor and sensory functionand decreased cognitive abilities

• Assess the level of cognitive function to obtain a baseline data
• Encourage the patient as wellas the family members to keep the patient as independant as possible
• Provide assistance with the self care activities
• The patient is encouraged to plan for each day to make the atmost of each day because the patient lives in uncertainity.
• An individualized exercise programme to maintain strength,endurance and range of motion

Altered nutrition less than body requirement related to cachexiadue to treatment and tumor effects,decreased nutritional intake and Malabsorption

• Assess the nutritional status of the client to obtain a baseline data.
• Symptoms like nausea,vomiting,breathlessness and pain should be managed.
• The nurse should teach the family members how to position the patient during feeding.
• The patient should be provided adequate rest to reduce the fatigue.
• The patient should be clean,comfortable and free of pain when on meals
• The environment should be attractive as possible.Avoid offensive sights,sounds and odours.
• Provide fluids and provide oppurtunities for socialization.
• Dietary suppliments provided should be rich in calories if it is advisable for the patient.
• If the patient cannot tolerate orally paranteral nutrition should be initiated.

Anxiety related to anticipation of death,uncertainity,change in appearance and altered lifestyle

• Assess the level of anxiety to obtain a baseline data.
• Explain about the disease condition and the treatment measures undertaken
• Encourage the family members and the friends to be with the patient
• Provide psychological support and provide oppurtunities to ventilate the feelings
• Open communication is encouraged
• If the patients emotional response is very intense additional help is taken from a clergy,social worker or a mental health professional.

Potential for altered family process related to anticipatory grief and the burdens imposed by the care of the person with terminal illness

• The family must be reassured that their loved one is receiving the maximum care.
• When the patient is not able to carry out the basic needs the family members should provide support
• Psychological support should

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BRAIN ABSCESS

DEFINITION

A brain abscess is a collection of infectious material within the tissue of the brain.Bacteria is the most common causative organisms.The most common predisposing factors for abscess among immunocompetant people are ottitis media and sinusitis.

ETIOLOGY

• Ottitis media and sinusitis.
• Intracranial surgery ,penetrating injury or tongue piercing.
• Wound or intra abdominal infection.
• Ottitis media, sinusitis,mastoiditis,dental infections and systemic infections.

 

CLINICAL MANIFESTATIONS

• Head ache usually worse in the morning
• Fever,vomiting and focal neurological deficits.(weakness and decreasing vision reflects the area which is involved)
• Increased ICP and decreased level of consciousness

 

PATHOPHYSIOLOGY

The mechanisms to the entry of the micro organisms are as follows:

• Direct extension-Infections stemming from the sinus,middle ear or mastoid may gain access into the venous drainage of the brain via valveless emissary veins and drain into this region. Because of the antibiotic therapy for this infections incidence rate due to this type of spread has been decreased to a greater extent
• Haematogenous spread-This includes the spread via blood
• Following penetrating head injury or neurosurgery-Most cases can also occur as a result of penetrating head injury or trauma.

 

ASSESSMENT AND DIAGNOSTIC FINDINGS

• History collection and physical examination
• MRI and CT scan demonstrates a ring around the hypodense area.
• Aspiration of the abscess guided by CT scan or mRI helps to identify the organism
• Blood cultures if the origin of the abscess is from a distant sourse
• Chest X-ray to rule out predisposing lung infections
• CT Scan to evaluate the bony structure of the ear and the sinus

 

MEDICAL MANAGEMENT

• The goal of the treatment is to drain the abscess and to provide antibiotic therapy for the infection detected.
• Large IV doses of antibiotics are given to penetrate the blood brain barrier and to reach the site of infection.
• The choice of the antibiotic depends on the causative organism being identified by culture.
• Corticosteroids are prescribed to reduce the inflammatory cerebral edema.
• Antiseizure medications(Phenytoin and phenobarbitone )is prescribed to prevent or to reduce seizure.

 

NURSING MANAGEMENT

• Nursing care focuses on the assessment of neurological status,administering the medication,assessing the response to the treatment and providing supportive care.
• Blood laboratory test results especiallyblood glucose and serum potassium levels has to be monitored and corticosteroids are prescribed.
• Administration of insulin or electrolyte replacement is required to return this values to the normal state.
• The level of consciousness and the physical status has to be monitored constantly
• Observe for neurological deficits like hemiparesis,seizures,visual deficits etc..

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DEGENERATIVE DISC DISEASE

Low back pain is a significant public health disorder. Acute low back pain lasts for less than 3 months or longer. Most back pains are due to disc disease.

CLINICAL MANIFESTATION

Pain occurs in the involved part of the spinal cord.ie..Cervical, thoracic or lumbar. The clinical manifestations depends on the location, rate of development (acute or chronic)and the effect on the surrounding structures.

PATHOPHYSIOLOGY

1. The intervertebral disc is a cartilaginous plate that forms a cushion between the vertebral bodies. This tough fibrous material is incorporated in a capsule. A ball like cushion in the centre of the disc is called nucleus pulposus.
2. In herniation of the intervertebral disc (ruptured disk) the nucleus of the disc protrudes into the annulus (fibrous ring around the disk)with subsequent nerve compression.
3. Protrusion or rupture of the nucleus pulposus usually is preceded with degenerative changes that occur with aging.
4. Loss of protein polysaccharides in the disc decreases the water content of the nucleus pulposus.
5. Radiating cracks develops in the annulus weakens resistance to the nucleus herniation.
6. With the degeneration the capsule pushes back into the spinal canal.
7. This sequence produces pain due to radiculopathy(pressure in the area of disturbance of the involved nerve endings.

ASSESSMENT AND DIAGNOSTIC FINDINGS

• A Thorough health history and physical examination
• CT Scan and MRI
• Neurological examination
• Electromyelography

MEDICAL MANAGEMENT

Herniation of the cervical and lumbar disc occurs commonly and are managed with bed rest and medication

SURGICAL MANAGEMENT

Surgical management is usually done if there is progressive neurologic deficit, muscle weakness or atrophy, loss of sensory and motor function, loss of sphincter control and continuing pain or sciatica(leg pain resulting from sciatic nerve involvement)The goal is to reduce the pressure on the nerve root to prevent pain. The following surgeries are usually performed.

• Disectomy-Removal of the herniated or extruded fragments of the intervertebral disc.
• Laminectomy-Removal of the bone between the spinal process and the facet pedicle junction to expose the neural elements in the spinal canal, this allows the surgeon to inspect the spinal canal, identify and remove the pathological tissue, and relieve the compression of the spinal cord and the nerve roots.
• Hemilaminectomy-Removal of the part of the lamina and part of the posterior arch of the vertebra.
• Partial laminectomy or Laminotomy-Creation of a hole in the lamina of the vertebra.
• Dissectomy with Fusion-A bone graft(from the iliac crest or the bone bank)is used to fuse the vertebral spinous process.
• Foraminotomy-Removal of the intervertebral foramen to increase the space for exit of the spinal nerve, resulting in reduced pain, compression and edema.

HERNIATION OF THE CERVICAL INTERVERTEBRAL DISC

The cervical spine is subjected to stressors that result from disc degeneration(due to aging, occupational stress)and spondylosis(degenerative changes occurring in a disc and other supportive structures)Cervical disc degeneration can lead to lesions that can cause damage to the spinal cord and its roots cervical disc degeneration usually occurs at C5-C6 and C6-C7interspaces.

CLINICAL MANIFESTATIONS

• Pain and stiffness in the neck and the top of the shoulders and the region of the scapula.Sometimes the pain is interpreted as signs of heart problem and bursitis.
• Pain in the upper extremities and the head accompanied by parasthesia.(Tingling or a pins or needle sensation.Cervical MRI confirms the diagnosis.

MEDICAL MANAGEMENT

The goal of the medical management is to rest and immobilize the cervical spine to give the soft tissues time to heal. And to reduce the inflammation in the subcutaneous tissues and the affected nerve roots in the spinal cord.

• Bedrest is recommended and the patient s head should be supported.
• The cervical spine can be immobilized by a cervical collar,cervical traction and a brace.The collar increases the vertebral separation and thus relieves the pressure on the nerve roots.
• The head should be elevated and counter traction should be given.If the skin becomes irritated the halter can be padded.A male patient should be told not to shave because beard offers a natural form of padding.

PHARMACOLOGICAL THERAPY

• Analgesics,NSAID,propoxyphene(Darvon),Oxycodone(Tylox)orHydrocodone(Vicodin)is given to relieve the pain.
• Sedatives are administered to relieve anxiety associated with cervical disc disease.
• Muscle relaxants(Cyclobenzaprine,Methocarbamol,Metaxalone)
• Corticosteroids are prescribed to relieve inflammation.Hot moist compresses(for 10-20 minutes)is applied to the back of the neckseveral times daily to increase the blood flow.

SURGICAL MANAGEMENT

A cervical dissectomy with or without fusion is performed to relieve the symptoms.An anterior or a posterior approach may be used.Potential complications associated with anterior approach are carotid or vertebral artery injuryrecurrent laryngeal nerve irritation,esophageal perforation and airway obstruction. Complications of posterior approach are damage of the nerve root of the spinal cord due to retraction or contusion.Micro surgery ,such as endoscopic micro dissectomy is performed in certain patients with their magnifying effect.

NURSING PROCESS

THE PATIENT UNDERGOING CERVICAL DISSECTOMY

• Assessment-The patient is asked regarding the past injuries to the neck (whiplash) because unresolved trauma can cause persistent discomfort, pain and tenderness, and symptoms of arthritis in the injured joint of the cervical spine. Assessment includes determining the onset, location and radiation of the pain and assessing for parasthesias,limited movement ,and
  • diminished function of the neck,shoulders,and upper extremities.The patient should be educated about the surgical management. Strategies of pain management should be informed.
  
  
  

  NURSING DIAGNOSIS

  • Acute pain related to surgical procedure.
  • Impaired physical mobility related to post operative surgical regimen.
  • Deficient knowledge about the post operative course and home care management.
  Complications-Hematoma at a surgical site, resulting in cord compression and neurological deficit. Reccurent or persistent pain after the surgery.
  
  

  NURSING INTERVENTIONS

  Relieving pain and discomfort-

  • The patient must be kept flat in the bed for 12-24hours.
  • If the patient has pain monitor the donor site for hematoma formation, administering the prescribed analgesic agent, positioning the patient and reassuring the patient that the pain will be relieved. If the patient experiences a sudden pain extrusion of the graft may have occurred which requires reoperation. A sudden increase in the pain should be reported to the surgeon
  • The patient may experience sore throat, hoarseness and dysphagia due to temporary edema.This symptoms are relieved by throat lozenges, voice rest and humidification. A pureed diet can be given if the patient has dysphagia.
   
  

  Improving mobility

  • Postoperatively a cervical collar is worn resulting in limited neck movement. The patient is instructed to turn the body rather than the neck while turning from side to side. The patient s neck should be kept in neutral position.
  • The patient is assisted during position changes to make sure that the head, shoulders and thorax are kept aligned. While keeping the patient in sitting position the nurse supports the patient s neck and shoulders.
  
  

  Monitoring and managing potential complications

  • The patient is evaluated for bleeding and hematoma formation by assessing for excessive pressure in the neck or severe pain in the incision area. The dressing is checked for serosanguinous drainage, which suggests a dural leak. A complaint of headache requires careful evaluation.
  • Neurological checks are made for swallowing deficits and upper and lower extremity weakness because cord compression may produce rapid or delayed onset of paralysis.
  • The patient should be monitored thoroughly for signs of respiratory difficulty, because retractors used during the surgery may injure the laryngeal nerve resulting in hoarseness and inability to clear the cough effectively.
  • The blood pressure and pulse are monitored to evaluate the cardiovascular status.
  • Severe pain which is not relieved by anaesthesia should be reported to the physician. A change in the neurological status should be reported to the physician because hematoma formation can result in permanent sensory and motor deficits.
  • Promoting home and community based care.

  Teaching patients self care

  • The patient and the family members should be educated regarding the care.
  • If a cervical collar is worn care has to be given. Instruct the client to limit the body movements with tasks that require greater body movement.
  • The patient is instructed about the signs of complications and regarding pain management
  • The nurse should assist in activities of daily living.
  • A discharge teaching plan has to be maintained. Topics include proper body mechanics, maintenance of optimal body weight, proper exercise techniques and modification in activity. The patient is instructed to see the physician at regular intervals and to document for complications.
  
  

  EVALUATION AND EXPECTED PATIENT OUTCOMES

  • Reports decrease severity in the frequency of pain.
  • Is knowledgeable about the post operative complications, and home care management
  • Reports absence of complications.

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CEREBRO VASCULAR DISORDERS (STROKE)

Cerebro vascular disorders is an umbrella term that refers to the functional abnormality of the central nervous system that occurs when the normal blood supply to tha brain is distrupted.It is a leading disease which causes death and even life time disability in people.

DEFINITION

Stroke occurs when there is ischemia(distrupted blood supply)To a aprt of the brain or hemorrhage into the brain that results in the death of the brain cells.Functions such as movements,sensations or emotions that are controlled by the particular part is affected

INCIDENCE

African Americans have a higher incidence of stroke and higher death rates due to stroke when compared to whites.It is the third leading cause of death beyond cancer and heart disease

TYPES

Stroke is divided into two major categories:

• Ischemic Stroke-It occurs due to vascular occlusion and severe hypoperfusion.
• Hemorrhagic stroke-It occurs due to extravasation of blood into the brain and subarachnoid space.

ISCHEMIC STROKE

An ischemic stroke or cerebrovascular accident or brain attack is the sudden loss of functioning resulting from the distruption of the blood supply to a part of the brain.Early treatment with thrombolytic therapy for ischemic stroke results in fewer symptoms and less loss of function.Thrombolytic therapy has a treatment window only 3 hours after the onset of stroke.

TYPES OF ISCHEMIC STROKE

• Large artery thrombolytic stroke-It is caused by atherosclerotic plaques in the large blood vesselsof the brain.Thrombus formation and occlusion at the site of the atherosclerosis results in ischemia and infarction(deprivation of blood supply)

• Small penetrating artery thrombolytic stroke-This affects one or more blood vessels and and are the most common types of ischemic stroke.Small artey thrombolytic stroke are also called lacunar stroke because of the cavity that is created after the death of the infracted brain tissue.

• Cardiogenic stroke-It is associated with cardiac dysrrythmias usually atrial fibrillation.Emboli orginates from the heart and circulate to the cerebral vasculature,most commonly the middle cerebral artery is affected.Embolic strokes can be prevented by starting anti coagulation therapy in patients with atrial fibrillation.
• Cryptogenic Stroke-It doesn’t have any specific cause,it may be due to drug use,coagulopathies,migraine,and spontaneous dissection of the carotid artery.

PATHOPHYSIOLOGY steps

• Due to etiological factors
• Distruption of the cerebral blood flow due to obstruction of cerebral blood vessel
• Cellular metabolic events called ischemic cascade develops(ischemic cascade begins when the cerebral blood flow is decreased to less than 25 ml per minute)
• Mitochondria performs anaerobic respiration which generates large amount of lactic acid causing change in the Ph level
• Neuron becomes incapable of producing sufficient amount of ATP(Adenosine triphosphate) to fuel the depolarization
• The cells will stop functioning(Early in the cascade ,an area of low cerebral blood flow exists around the area of infarction,this area is called penumbra.
• Depolarization of the cellwall leads to increase in the intracellular calcium and release of glutamate
• More amount of calcium and glutamate occurs
• Vasoconstriction occurs in the cerebral artery
• Destruction of the cell membrane occurs
• This process results in the enlargement of the area of infarction

CLINICAL MANIFESTATIONS

• Numbness or weakness of the face,arm or leg especially on one side of the body
• Confusion or change in the mental status
• Visual disturbances
• Difficulty in walking ,dizziness or loss of balance and coordination
• Sudden severe headache

Visual field deficits

Homonymous hemianopsia(loss of half of the visual field)

• Clinical manifestations-The person will be unaware of the persons or objects on the side of the visual loss,neglect of one side of the body,difficulty in judging the distances
• Nursing Implications-Place the objects within the intact field of vision.Approach the patient from the side of intact field of vision,encourage the use of eye glasses if available

Loss of peripheral vision

• Clinical manifestations-Difficulty in seeing at night,unaware of the objects and the borders of the objects
• Nursing Implications-Place the objects atethe centre of the patients visual field,Encourage the use of cane or or any other object to identify objects in the periphery of the visual field,Driving ability should be evaluated.

Diplopia(Double vision)

• Clinical manifestations- Double vision
• Nursing Implications-Explain the location of the object when placing at near to the patient,place the objects in the same position

Motor deficits

Hemiparesis-

• Clinical manifestations-Weakness of the face arm and leg on the same side due to lesion on the opposite side.
• Nursing Implications-Place objects on the non affected site within the patients reach,instruct the patient to exercise and increase the strength of the unaffected side.

Hemiplegia-

• Clinical manifestations Paralysis of the face arm and leg on the same side(due to lesion in the opposite hemisphere)
• Nursing Implications-Encourage the patient for range of motion exercises on the affected side,provide immobilization as needed to the affected side

Ataxia

• Clinical manifestations-Staggering unsteady gait,inability to keep the feets together,needs a broad base to stand
• Nursing Implications-Support the patient during initial ambulation phase.,provide supportive walking device to the patient.(cane stick,walker etc...)

Dysarthria

• Clinical manifestations-Difficulty in forming words
• Nursing Implications-Provide the patient with alternative methods of communication,allow the patient sufficient time to respond to verbal communication,support the patient and the family to relieve frustration

Dysphagia

• Clinical manifestations-Difficulty in swallowing
• Nursing Implications-Test the patients pharyngeal reflexex before offering food or fluids,assist the patient with the meals.,place food on the unaffected side of the mouth,allow ample time to eat.

SENSORY DEFICITS

• Parasthesia-It occurs on the side opposite to the lesion
• Clinical manifestations-Numbness and tingling of the extremity,
• Nursing Implications-Instruct the patient that sensation can be altered,provide range of motion in the affected area and apply corrective devices as needed

Verbal deficits

• Expressive aphasia-Unable to form words that are understandable.
• Nursing Implications-Encourage the patient to repeat the words of the alphabet,explore the students alternative ways of communication,

Cognitive deficits

• Clinical manifestations-Short and long term memory loss,decreased attention span,impaired ability to concentrate,altered judgement.
• Nursing Implications-Reorient patient to time,place and person,provide familiar objects(family photographs,favourite photographs,use of uncomplicated language,minimize distracting noises while teaching the patient,repeat and reinforce instructions frequently

Emotional deficits

• Clinical manifestations-Loss of self control,emotional instability,decreased tolerance to stressful situations,depression,withdrawal,fear hostility and anger,feelings of isolation
• Nursing Implications-Support the patient during uncontrollable outbursts,educate the patient that the outbursts are due to the disease condition,encourage the patient to participate in group activity,control stressful situations,provide a safe environment.

RISK FACTORS

• Hypertension
• Atrial fibrillation
• Hyperlipedemia
• Diabetes insipidus
• Smoking
• Asymptomatic carotid stenosis
• Obesity
• Excessive alcohol consumption

ASSESSMENTS AND DIAGNOSTIC FINDINGS

History collection and physical examination

Neurological examination

• Initial assessment focuses on the patency of airway,respiratory status ,cardiovascular status,(including blood pressure,cardiac rhythm and rate etc..)
• Monitor for transcient ischemic attack.It is manifested by sudden loss of motor,sensory or visual function.The symptoms results from temporary ischemia(impairment of blood flow) to a specific region in the brain.Transcient ischemic attack is a warning sign of stroke.
• CT Scan has to be performed to determine whether the stroke is ischemic or hemorrhagic.
• ECG
• Cerebral Angiography
• Doppler flow studies
• Transthoracic and transesophageal echocardiography
• MRI of the brain,neck or both.
• SPECT Scan

PREVENTION

• Stroke risk screening helps to identify the people at risk
• Educate the community and the people regarding the prevention of stroke
• Recent research has found that low dose heparin will lower the risk of stroke
• Identify the high risk groups which includes certain non modifiable risk factors like age ,gender,sex,ethnicity etc..
• Modifiable risk factors are hypertension,atrial fibrillation,hyperlipedemia,obesity,smoking and diabetes.Other modifiable risk factors are endocarditis,prosthetic heart valves,periodontal diseases etc..
• Patients with moderate to severe carotid stenosis is treated with carotid endarterectomy.
• In patients with atrial fibrillation administration of Warfarin will prevent the clot formation.

MEDICAL MANAGEMENT

THROMBOLYTIC THERAPY(ELIGIBILTY CRITERIA FOR t PA ADMINISTRATION

• Age 18 years or older
• Clinical diagnosis of ischemic stroke
• Time of onset of stroke known and is 3 hours or less.
• Systolic blood pressure<185 mmhg diastolic <110 mmhg
• No seizure at the onset of stroke
• Not taking Warfarin(Coumadin)
• Not receiving heparin during the past 48 hours
• No prior intracranial hemorrhage,neoplasm,artereovenous malformation or aneurysm
• No major surgical procedure within 14 days..
• No stroke,serious head injury or intracranial surgery within 3 months
• No gastrointestinal or urinary bleeding within 21 days.
• Patients who has experienced TIA or stroke should take medical management for secondary prevention
• Atrial fibrillation patients are treated with dose adjusted Warfarin sodium(Coumadin) unless contraindicated
• If Warfarin is contraindicated then aspirin is the next choice.
• Platelet inhibiting medications(Eg:Aspirin,Clopidogrel)reduces the risk of cerebral infarction.
• 3-hydroxy-2-methyl-glutaryl coenzyme A reductase inhibitors reduces stroke(Statin medications)Eg:Simvastatin
• Antihypertensives

THROMBOLYTIC THERAPY

• Thrombolytic agents are used to treat ischemic stroke by dissolving the blood clot that blocks blood to the brain.
• Rapid diagnosis of the stroke and initiation of thrombolytic therapy(within 3 hours )reduces the risk because revascularization of the necrotic tissue(which develops after 3 hours)increases the risk of cerebral edema and hemorrhage.

DOSAGE AND ADMINISTRATION

• Patient is weighed to determine the dosage of medication.Dosage for tpA is 0.9mg/kg. .10% of the calculated dose is administered as an IV bolus over minute.The remaining dose(90%)is administeres over 1 hour via infusion pump
• Patient is admitted in intensive care unit and continuously monitored
• Neurological assessment has to be done continuously.
• Vital signs should be assessed evey 15 minutes,for first 2 hours ,every 30 minutes for the next 6 hours,then every hour until 24 hours of initiating the treatment.
• Blood pressure should be monitored with systolic less than 180mmhg and diastolic less than 105mmhg.

SIDE EFFECTS

Bleeding is the most common side effect(observe closely for any bleeding in the IV insertion site endotracheal tube ,urine,stool,emesis other secretions etc...

THERAPIES FOR PATIENTS NOT RECEIVING t PA

• Anticoagulant administration (IV heparin or low molecular
• Increased ICP increases the complications ,so measures has to be followed to reduce intracranial pressure so mannitol is usually administered.

OTHER TREATMENTS

• Elevation of the head end of the bed to promote venous drainage and to reduce iCP
• Endotracheal intubation to establish patent airway
• Continuous hemodynamic monitoring
• Neurological assessment to rule out complications

SURGICAL MANAGEMENT

CAROTID ENDARTERECTOMY-It is the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.This surgery is indicated in patients with mild strokeand symptoms of mild TIA
SELECTED COMPLICATIONS OF THE SURGERY AND MEASURES UNDERTAKEN

INCISION HEMATOMA

• Clinical features-It occurs in 5.5%of the patients.Large or rapidly expanding hematomas requires immediate treatmentIf the airway is obstructed by the hematoma the incision may be opened at the bedside
• Nursing Interventions-Monitor neck discomfort and wound expansion.Report swelling,subjective feelings of pressure in the neck,difficulty in breathing

HYPERTENSION

• Clinical features-Poorly controlled hypertension increases the risk of postoperative complications, including hematoma and hyper perfusion syndrome. There is an increased incidence of neurological impairment and death due to intracerebral hemorrhage.May be related to surgically induced abnormalities of the carotid baroreceptor sensitivity.
• Nursing Interventions-Risk is highest in first 48hours after the surgery. Check BP frequently and report deviations from baseline.Observe for and report new onset of neurological deficits.

POSTOPEREATIVE HYPOTENSION

• Clinical features-Occurs in approximately 5% of the patients.It is treated with fluids and loe dose phenylephrine infusion.Usually resolves in 24 to 48 hours.Patients with hypotension should have serial ECG to rule out myocardial infarction.
• Nursing Interventions-Monitor blood pressure and observe for signs and symptoms of hypotension.

INTRACEREBRAL HEMORRHAGE

• Clinical features-Increased risk with advanced age,hypertension,presence of high grade stenosis,poor collateral flow,and slow flow in the region of the middle cerebral artery
• Nursing Interventions-Monitor the neurological status and report any changes in the mental staus or neurological functioning immediately

NURSING PROCESS

The patient recovering from Ischemic stroke
The acute phase of ischemic stroke may last 1-3 days but ongoing monitoring of all the bodysystems is required as long as the patient requires care.After the stroke is complete management focuses on the initiation of rehabilitation of deficits

ASSESSMENT

The following things has to be taken into consideration

• Change in the level of consciousness or responsiveness as evidenced by movement,resistance to changes in position,response to stimulation and orientation to time place and person
• Presence or absence of voluntary or involuntary movements of the extremities
• Stiffness or flaccidity of the neck
• Eye opening,comparative size of the pupils and papillary reaction to light.
• Colour of the face and extremities and also temperature.
• Quality of the rate of pulse and respiration,arterial blood gas values,body temperature and arterial pressure.
• Ability to speak.
• Volume of fluids ingested or administered,volume of urine excreted within 24 hours.
• Presenceof bleeding
• Maintanance of blood pressure within the desired limits
• After the acute phase the nurse assess for mental status(memory,attention span,perception ,orientation etc..)
• Ongoing assessment should include any deterioration in the performance of ADL

NURSING DIGNOSIS

Impaired physical mobility related to hemiparesis,loss of balance and coordination,spasticity and brain injury

• Correct positioning is required to prevent contractures
• Measures are taken to relieve pressure
• Assist in maintaining good body alignment
• Since flexor muscles are stronger than extensor muscles,a posterior splint applied at the night will prevent flexion and maintain correct position during night.

Acute pain (painful shoulder)related to hemiplegia and diffuse

• A pillow is placed under the axilla when there is limited external rotation,this keeps the arm away from the chest
• A pillow is placed under the arm and arm is placed in a neutral (slightly flexed)position,the distal joints are placed higher than the proximal joints(elbow is placed higher than the shoulder and the wrist higher than the elbow.This prevents edema and resultant joint fibrosis.
• Medications are helpful in maintain post stroke pain.Amytryptilline hydrochloride is used ,but it has got cognitive problems and it will induce sleep.
• Antiseizure mediaction Lamotrigine is effective in managing post stroke pain,it is an alternative for patients who cannot tolerate amytryptilline

Self care deficit(bathing,grooming,toilettingdressing and feeding)related to stroke sequalae

• Assess the level of selfcare ability of the client.
• The patient is encouraged to perform the regular activities such as combing the hair,brushing the teeth,shaving with electric razor,eventhough the patient will feel awkward in the beginning he can achieve performing the activities by repetitive actions.The nurse must be sure that the patient is not neglecting the affected side.
• Assistive devices will make up some patients deficits
• The family members are instructed to bring a cloth that is larger than the usual size of the patient.Clothing with front and side fastners are more easier.The clothing is placed in the affected side of the patient.The clothes are arranged in the order to be worn.A mirror is placed in the front,so that the patient will get an awareness regarding what he is putting
• Support and encouragement are provided for preventing the patient from becoming over fatigued

Disturbed sensory perception related to altered sensory reception,transmissionand integration

• Assess the sensory perception level of the patient.
• Patients with decreased field of vision should be approached on the side where visual perception is intact
• All visual stimuli(clock,calendar,television)should be placed on this side.
• The patient should maintain eye to eye contact with the patient and encourage the patient to concentrate on the affected side.
• The nurse should encourage the patient to visualize the things in the room
• Providing artificial glasses in the room and providing eye glasses helps to increase the vision
• The patient with homonymous hemiapnosia (loss of half of the visual field)will be able to see only the half of the visual field ie only half of the food in the tray will be visible and only half of the room will be visible.This condition is called amorphosynthesis.The nurse should remind the patient regarding the sffected side of the body.
• The nurse should remind the patient regarding the extremities on the affected side

Imbalanced nutrition less than body requirement realted to dysphagia

• Assess the nutritional status of the client
• Patient should be observed for paroxysms of coughing,dribbling of food,or pooling of the food on the side of the mouth,food retained for long periods of time in the mouth or nasal regurgitation while swallowing liquids.Swallowing difficulties will place the patient at risk of aspiration,pneumonia,malnutrition and dehydration.
• A speech therapist should evaluate the patients gag reflex and swallowing reflex.
• Advice the patient to take small amounts of food and teach the patient which all foods are easy to swallow.
• The patient can be instructed to start a thick pureed or liquid diet because it is easier to swallow mainly in the initial stage.The diet can be advanced as the swallowing ability increases
• Enteral tubes can be nasogastric or nasoenteric to prevent aspiration.
• Nurses responsibility includes elevating the head end atleast 30 degrees to prevent aspiration of the food.
• The position of the tube should be checked frequently to prevent the risk of aspiration.

Total urinary incontinence related to flaccid bladder,detrussor instability,confusion or difficulty in communication

• Assess the voiding pattern of the patient and a urinal or bed pan is offered
• In the initial stage frequent urinary catheterization is carried out
• If the patient has constipation high fibre rich diet is given.,and increase the fluid intake of the client (2-3L per day)
• The diet should be provided at a regular time to enhance toileting.

Disturbed thought process related to brain damage confusion or inability to follow instructions

• Assess the cognitive,behavioural and emotional deficits,a considerable degree of function can be regained as all the parts of the brain are not equally affected
• After assessment that delineates the patients deficits,a neuropsychiatrist,physician,nurse and other professionals initiates a training programme using visual imagery,reality orientation to compensate the losses.
• The nurses role is supportive.The nurse reviews the reviews the result of neuropsychological testing and reports the progress.

Impaired verbal communication realted to brain damage

• Assess the communication capacity of the client
• The speech therapist assists the communication needs of the stroke patient and suggests the overall method of communication.The inability to speak i Creases the frustration.So psychological support should be given to the patient .
• If the patient cannot talk encourage the patient to write and communicate.
• When talking to the patient it is important to draw the attention of the patient,speak slowly and draw the attention of the patient.
• Encourage the use of gestures.

Risk for impaired skin integrity related to hemiparesis,hemiplegia or decreased mobility

• Assess the level of skin integrity of the patient.
• Give more importance to the bony prominences.
• A regular turning schedule has to be practised(Turn the patient every 2 nd hourly)
• The patients skin should be kept clean and dry, gentle massage of the healthy(non reddened skin)and adequate nutrition and other factors to maintain the normal skin integrity

HEMORRAHGIC STROKE

• Hemorrhagic stroke accounts for 15-20% of the cerebrovascular disorders and are primarily caused by intracranial or subarachnoid hemorrhage.Hemorrhagic stroke is caused by bleeding into the brain tissue,ventricles or subarachnoid space.

ETIOLOGY

• Primary intracerebral hemorrhage from a spontaneous rupyure of small vessels accounts for approximately 80%of the hemorrhagic strokes and is caused by uncontrolled hypertension.
• Subarachnoid hemorrhage results from ruptured intracranial aneurysm(a weakening in the arterial wall)
• Intracerebral hemorrhage is caused by cerebral amyloid angiopathy which involves damage caused by deposit of beta amyloid protein in the small and medium sized blood vessels of the brain
• Secondary intracerebral hemorrhage is associated with arterivenous malformations,intracranial aneurysms,intracranial neoplasms or certain medications(anticoagulants,amphetamines)

PATHOPHYSIOLOGY

• Due to primary hemorrahge,aneurysm,pressing of AVM on the nearby cranial nerves or due to the rupture of AVM,reduced perfusion pressure and vasospasm
• The intracranial pressure increases
• The brain will be exposed to blood from the sudden entry of blood into the subarachnoid space
• The normal brain metabolism is distrupted
• The brain tissue will be compressed and injured

INTRACEREBRAL HEMORRHAGE

• Intracerebral hemorrhage or bleeding into the barin substance is common in patients with hypertension and cerebral atherosclerosis resulting in the rupture of the blood vessel.An intracerebral hemorrhage can also result from certain type of arterial pathology,brain tumors and due to the use of certain mediactions(anticoagualnts,ampheatmines)
• Bleeding usually occurs in the cerebral lobes,basal gangli ,thalamus,pones etc..Occassionally the bleeding ruptures the lateral ventricles and and causes intraventricular hemorrhage which is usually fatal.

INTRACRANIAL (CEREBRAL )ANEURYSM

• An intracranial aneurysm occurs from the dilatation of the walls of the cerebral artery that develops as a result of the weakening of the arterial wall.The cause of aneurysm is not known.An aneurysm may be due to atherosclerosis which results in the defect in the vessel wallwhich causes subsequent weakness of the wall,congenital defect of the vessel wall,hypertensive vascular disease,head trauma or advancing age
• Any artery within the brain can be a site of cerebral aneurysm,but the lesions occurs at the bifurcations of the large arteries of the Circle of Willis.The cerebral arteries most commonly affected are internal carotid artery(ICA),anterior cerebral artery(ACA),anterior communicating artery(ACOA),posterior communicating artery(PCOA),posterior cerebral artery(PCA),middle cerebral artery(MCA)

ARTERIOVENOUS MALFORMATIONS

It is caused by abnormal embryonal development that results in the tangling of the arteriesand veins in the brain that lacks a capillary bed.The absence of capillary bed leads to dilatation of the arteries and the veins and eventually rupture.AVM is a common cause of hemorrhagic stroke among younger people.

SUBARACHNOID HEMORRHAGE

• A subarachnoid hemorrhage(hemorrhge into the subarachnoid space occurs as a result of AVM,intracranial aneurysm,trauma or hypertension.The most common cause is the leaking aneurysm in the area of Circle of Willisand a congenital aVM of the brain

CLINICAL MANIFESTATIONS

• Neurological deficits(motor,sensory,cognitive and other functions)
• Conscious patients reports severe headache
• Vomiting
• Sudden change in the level of consciousness
• Focal seizures due to frequent brain stem involvement

Patients with intracranial aneurysm or AVM

• Sudden severe headache and loss of consciousness for a variable period of time
• Nuchal rigidity(pain and rigidity at the back of the neck nd spine due to meningeal irritation
• Visual disturbances(visual loss,ptosis,diplopia)
• Tinnitus,dizziness,hemiparesis.
• If severe bleeding occurs it results in severe cerebral damage,coma and death.

ASSESSMENT AND DIAGNOSTIC FINDINGS

• History collection and physical examination
• CT Scan and MRI to determine the size and location of the hematoma and presence and absence of ventricular blood and presence of hydrocephalus
• CT Scan and Cerebral angiography for the diagnosis of intracranial aneurysm or AVM.
• Lumbar puncture is done if there is no evidence of increased ICP.Lumbar puncture in presence of increased ICP will cause herniation and bleeding

PREVENTION

• Primary prevention is the best approach which includes managing hypertension and identifying the risk factors of the disease.
• Control of hypertension in people older than 55 years of age controls hypertension.
• Additional risk factors are age,male gender,excessive alcohol intake etc..
• Public awareness regarding association between phenylpropanolamine(PPA an ingredient found in appetite suppressants as well as cold and cough agents)and hemorrhagic stroke

COMPLICATIONS

• Cerebral hypoxia and decreased cerebral blood flow.
• Vasospasm
• Increased ICP
• Systemic hypertension

MEDICAL MANAGEMENT

• The goals of medical management is to allow the brain to recover from the initial insult,to prevent and minimize the risk of rebleeding and to prevent and to treat complications.
• Ongoing clinical trials are going on to see whether use of recombinant activator factor 7 can reduce bleeding after intracerebral hemorrhage.
• Management is supportive which consists of bedrest with sedation to prevent agitation and stress,management of vasospasm and surgical and medical treatment to prevent rebleeding.
• Analgesics(codeine,acetaminophen)is prescribed to relieve head and neck pain
• Patient is fitted with compression devices to prevent deep vein thrombosis

SURGICAL MANAGEMENT

• If the diameter of the hematoma exceeds more than 3cmsand the glascowcoma score decreases surgical evacuation is recommended for patients with cerebellar hemorrahge.Surgical evacuation is done by craniotomy.Then patient with intracranial aneurysm is prepared for surgery as soon as the condition is stable.The goal of the surgery is to prevent further bleeding.This objective is accomplished by isolating the aneurysm from the circulation or by strengthening the arterial wall.An aneurysm may be excluded from the cerebral circulation by means of a ligature or a clip across the neck
• Other less invasive intravascular treatments includes
• Endovascular treatment-Occlusion of the parent artery
• Aneurysm coiling-Obstruction of the aneurysm site with a coil.

Post operative complications

Psychological symptoms(disorientation,amnesia,Korsakoff s syndrome, personality changes),intraoperative embolization,post operative internal artery occlusion, fluid and electrolyte disturbance and gastrointestinal bleeding

NURSING PROCESS

ASSESSMENT-A complete neurological assessment is performed which includes the following:

• Altered level of consciousness
• Sluggish papillary reaction.
• Motor and sensory dysfunction
• Cranial nerve deficits(intraocular eye movements, facial droop, presence of ptosis)
• Speech difficulties and visual disturbance
• The patients should be monitored in the intensive care units
• Neurological findings should be recorded and reported
• Any changes in the patients condition requires thorough documentation, changes should be reported immediately

NURSING DIAGNOSIS

Ineffective tissue perfusion(cerebral) related to bleeding or vasospasm

• The patient is continuously monitored for neurological deterioration resulting fromrecurrent bleeding,increasing ICP or vasospasm.
• The blood pressure,pulse,level of consciousness(indicator of cerebral perfusion),papillary response and motor function is checked hourly.
• Respiratory status is monitored because a reduction in the oxygen in the areas of the brain results in impaired autoregulation resulting in cerebral infarction
• Any changes should be monitored immediately.
• Cerebral aneurysm precautions are implemented in patients with aneurysm.The patient should be placed in a quiet,nonstimulating environment,to prevent increase in ICP and further bleeding.,because activity ,painand anxiety increases the blood pressure that can result in bleeding.
• Visitors except the family members are restricted
• The head is elevated to about 15-30 degrees to decrease ICP and to promote venous drainage.
• Any activity which causes a sudden increase in the blood pressure should be avoided.This includes straining,forceful sneezing,acute flexion or rotation of the head and the neck which compromises the jugular veins.and cigarette smoking
• Any activity which requires exertion is contraindicated.
• The patient is instructed to exhale through the mouth during voiding and defecation.
• No enemas are prescribed but stool softners and laxatives are given
• Dim light is given because photophobia is common
• Coffee and tea unless decaffeinated are usually avoided.
• Thigh high elastic compression stockings are given to reduce the incidence of DVT.
• The nurse helps in the self care activities of the client and helps to prevent any exertion
• External stimulation should be minimum including no television,no radio and no reading.
• Visitors are restricted and a sign indicating restriction should be placed on the door,the patient and the family members should be aware regarding this
• Disturbed sensory perception related to medically imposed restrictions(aneurysm precautions)
• Anxiety related to medically imposed restrictions(aneurysm precautions)
• Sensory precautions should be kept on minimum for patient on aneurysm precautions
• For the patients who are alert awake and oriented an explanation of the restrictions reduces the sense of isolation
• Keep the patient well informed regarding the plan of care and reassure and provide psychological support to the patient.

COMPARISON BETWEEN THE MAJOR TYPES OF STROKE

ITEM	ISCHEMIC	HEMORRHAGIC
CAUSES	LARGE ARTERY THROMBOSIS SMALL PENETRATING ARTERY THROMBOSIS CADIOGENIC EMBOLIC CRYPTOGENIC OTHER	INTRACEREBRAL HEMORRHAGE SUBARACHNOID HEMORRHAGE CEREBRAL ANEURYSM AVM
SYMPTOMS	NUMBNESS OR WEAKNESS OF THE FACE ,ARM OR LEG,ESPECIALLY ON ONE SIDE OF THE BODY	EXPLODING HEADACHE,DECREASED LEVEL OF CONSCIOUSNESS

CONCLUSION

Cerebro vascular disorders refers to the functional abnormality of the central nervous system that occurs when the normal blood supply to tha brain is distrupted.If the patients are not taken care it may lead to life time complication sin the client.

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