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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