Cerebral Vascular Accident-THE MULAS.pptx

An outline of the CVA, its management and nursing 3

1. CEREBRAL VASCULAR ACCIDENT(CVA) .

2. Definition Cerebral Vascular Accident (CVA) is a sudden interruption of cerebral circulation in one or more of the blood vessels supplying the brain resulting in permanent or temporary neurological dysfunction lasting longer than 24hours. CVA interrupts or diminishes oxygen supply and commonly causes damage or necrosis in brain tissues.

3. Types of strokes Strokes are either classified as ischemic (occlusive) 85% or haemorrhagic15% Most ischemic strokes are either thrombotic strokes or embolitic strokes. Therefore stroke may fall under the following types: Thrombotic stroke (61%) Embolitic stroke (24%) Haemorrhagic stroke (15%)

4. Causes Cerebral Thrombosis This is the most common cause of CVA. It is common in middle-aged and elderly people. Atherosclerosis also plays a role in this type of stroke It results from obstruction of a blood vessel by a thrombus (clot) Has gradual onset.

5. Causes cont Cerebral Embolism . This is the second commonest cause of CVA. Can occur at any age especially patients with history of RHD, Endocarditis, post-traumatic valvular disease, myocardial fibrillation, and other cardiac arrhythmias. It usually develops rapidly and without warning

6. Causes cont Cerebral Haemorrhage . This is the third commonest cause of CVA. Like embolism, it may suddenly occur at any age. Haemorrhage results from chronic hypertension or aneurysms which cause sudden rapture of a cerebral artery.

7. Risk factors History of atherosclerosis. Hypertension. Smoking. Hypercholesterolemia. Rheumatic Heart Disease. Diabetes Mellitus. Age 60-75% of all strokes occur in persons over 65years of age

8. Risk factors cont Lack of exercise (sedentary life style). Diabetes Mellitus Cardiac enlargement. A family history of cerebral vascular disease. Atrial fibrillation Obesity Raised haematocrit

9. Pathophysiologic change in the brain The brain is unable to store glucose and therefore must receive constant flow of blood to provide oxygen and glucose In addition blood flow removes metabolic waste, carbon dioxide and lactic acid Interruption of blood supply to the brain for more than a few minutes may lead to death of cerebral tissue This can cause death as well as varying degrees of disability depending on the location and amount brain tissue affected

10. Clinical manifestations Vary according to artery affected and severity (extent of damage) Sudden loss of consciousness or deterioration in level of consciousness. Paralysis – left or right sided paralysis (hemiplegia). If CVA occurs in the left hemisphere there will be paralysis on the right side and vice-versa.

11. Clinical manifestations cont In some patients there may be a sudden onset of hemiparesis (numbness) or partial paralysis. Gradual onset of dizziness, mental disturbances, or seizures. Aphasia (loss of speech) Changes in level of consciousness.

12. Clinical features cont Difficulties with comprehension. Forgetfulness. Urinary incontinence. Visual impairment. Loss of sensory perception. (may have difficulties in visual, tactile and auditory perception). Emotional lability and unpredictability

13. Diagnostic test History may reveal risk factor e.g. hypertension Cerebral Angiography – shows disrupted blood supply. Computerised Tomography (CT scan) – detects structural abnormalities, oedema, and lesions, aneurysms. Magnetic Resonance Imaging (MRI) – allows evaluation of the lesions location and size without exposing the patient to radiation.

14. Diagnostic tests cont Ophthalmoscopy – may show signs of hypertension and artherosclerotic changes in retinal arteries. EEG – may detect reduced electrical activity in an area of brain. Coagulation studies. May show coagulation problems Full Blood Count . May reveal increased haematocrit

15. Treatment. Medical management commonly includes physical rehabilitation , dietary and drug regimes and care measures to help patient adapt to specific deficits such as speech impairment and paralysis. Drugs. Anticonvulsants such as phenytoin or phenobarbitone to treat or prevent seizures. phenobarbitone 80-180mg nocte or phenytoin 3-4mg/kg body weight daily Oxygen therapy 5litres/minute

16. Treatment cont. Corticosteroids – such as Dexamethasone 0.5-20mg IV slowly to minimise associated cerebral oedema. Analgesics such as panadol 1g tds 3/7 to relieve headache. Anticoagulants such as Heparin may be used in cases of cerebral haemorrhage. 10000-20000 units bd. Or warfarin 15-30mg initially then maintenance dose according to prothrombin time.

17. Treatment cont. Anti hypertensives e.g. Calcium channel blockers Nifedipine 20mg bd for 5/7 Intermittent positive pressure ventilation (IPPV

18. Complications Infection such as Encephalitis, Brain Abscess, Pneumonia. Sensory impairment. Visual impairment. Aspiration pneumonia. Contractures. Post stroke depression

19. Nursing management. AIMS To maintain a clear airway. To maintain patient’s nutritional status. To prevent complications. To rehabilitate the patient. Prevent injury to the patient

20. Environment During acute phase the patient is nursed in a quiet place free of disturbances. To protect the patient from injury I will provide bed with rails The room should be clean, warm and well ventilated to promote comfort of the patient. To ensure a patent air way I will ensure that oxygen apparatus and suction machine are available to for maintenance of a patent airway and oxygenation.

21. Maintenance of patent air way Loosen tight clothes to prevent interfering with normal breathing. Aspirate secretions from the mouth or nose to maintain a patent airway. Insert an artificial airway, and start mechanical ventilation or supplemental oxygen if necessary. If unconscious the patient should be nursed in recumbent position with head tilted to one side to allow drainage of secretions.

22. Observation Level of consciousness using the Glasgow coma scale. which assesses the eye opening, best verbal response and motor response as indicators of the level of consciousness. If it is increasing it means patient is responding and decreasing will indicate deterioration of consciousness.

23. Observations cont I will also observe for the signs of increased ICP, e.g. persistent headache and nausea and vomiting in order to inform the doctor for immediate interventions. I will watch for signs of pulmonary emboli such as shortness of breath, cyanosis, tachycardia, fever and changed sensory. Observe vital signs that is, temperature, pulse and respirations in order to note any further deviation from normal and patient response to treatment

24. Psychological care Provide psychological support, and establish rapport with the patient and alley anxiety. Explain his deficits and strengths in order to promote cooperation. Involve the loved ones in the care of the patient to make him feel loved and improve his will to live I will explain the tests, treatments and rehabilitation to promote cooperation

25. Psychological care cont I will encourage the relative and the patient to ask questions in order to clear misconceptions and alley anxiety I will get someone whose suffered from the condition to come and talk to the patient in order to accord my patient time to ask questions of interest thereby alley anxiety and promote cooperation

26. Prevention of complications I will use a foot board during the flaccid period after the stroke I will position my patient in the anatomical position to prevent contractures and deformity I will apply a splint and braces as needed to support the limbs in anatomical position to prevent contracture Encourage early ambulation according to the patient’s ability to do so to prevent deep vein thrombosis

27. Nutrition and fluid Maintain fluid and electrolyte balance to prevent dehydration and electrolyte imbalance. Administer IV fluids as advised and never to give too much as this can increase the ICP. Initially patient will be o IV fluids e.g. Dextrose 5%, Normal saline. Etc to maintain nutrition

28. Nutrition and fluid cont NG tube feeding may be used if patient is unconscious for a long period to maintain nutritional status As condition improves, give light diet and progress to normal diet in order to provide the needed nutrients. I will remind my patient to chew on the unaffected side to ensure food is properly chewed before swallowing

29. Nutrition and fluids cont Provide oral care to promote appetite and thereby maintain nutritional status. Don’t give solid foods to patient who has dysphagia or one-sided facial paralysis in order to prevent discomfort

30. Hygiene Clean and irrigate the patient’s mouth to remove food particles. Provide meticulous eye care to prevent eye problems. Do baths to promote blood circulation and remove dirt from the skin Change soiled linen to promote patients comfort

31. Elimination I will perform intermittent or in dwelling bladder catheterization during the acute stage in order to ensure bladder emptying I will also establish regular schedules of voiding like every 2-3 hours once the bladder tone returns For bowel motions I will provide the bed pain and also screen the bed during its use to promote bowel motions and privacy respectively.

32. Eye care and pressure sore prevention Remove secretions with a cotton ball from the eyes. Instil eye drops as ordered. Patch the patient’s eye if he can’t close his eyelid. 2 hourly turnings in acute phase to prevent pressure sore formation. Assist the patient with exercise to maintain muscle tone and promote blood circulation Teach and encourage patient to use unaffected side.

33. Communication Establish and maintain communication with the patient to enable him air his concerns and alley anxiety. If he is aphasic use simple method of communicating basic needs such as sign language and pen and paper if patient is able to write and read. In the acute phase I will provide a bell for the patient to use whenever he needs help

34. Information Education and Communication I will teach patient and family about the disorder in order to raise the knowledge level and promote patient care at home. If necessary, teach patient self care activities such as combing hair, dress, washing etc so as to promote self care and improve self esteem I will instruct the family in management of aphasia in order to avoid frustration of both the patient and loved one and also promote communication at home

35. Information Education and Communication cont Involve Speech Therapist if available to assist patient with speech problems. Physiotherapist should also assist in the rehabilitation of the patient this should continue at home to help the patient attain the use of the affected part as much as possible. Teach patient and family on drugs diet and importance of reducing weight if obese.. Emphasise the importance of review dates in order to promote full recovery. Teac the patient on need to correct risk factors to prevent the recurrence of the condition.

36. General nursing care applies Thank you for your attention (Mwila B.C. 2009)