cvasah-200509063331.pptx cerebro vascular accidents

cva

1. CEREBRO VASCULAR ACCIDENT / STROKE K.PRAVEEN KUMAR

2. INTRODUCTION :- Brain is the largest and most complex part of the nervous system. It is composed of more than 100 billion neurons and associated fibers. Any deterioration to brain function leads to a number of deficits in body specially in case of disruption of blood supply. “Circle of willis ” is responsible for blood supply to brain, rupture of any of the artery or occlusion may lead to CVA

3. DEFINITION: Cerebro vascular accident is the sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an artery to the brain. CVA or stroke is a term used to describe the neurologic changes caused by an interruption in the blood supply to a part of the brain.

4. According to WHO “stroke is a focal neurological deficit due to local disruption in blood supply to brain. Its onset is usually abrupt but may extend over a few hours or longer” If neurological deficits exists for > 24 hours, only then it is termed as STROKE or CVA. If neurological deficits exist < 24 hours, it is called as Transient Ischaemic Stroke (TIA)

5. INCIDENCE :- Stroke is a frequent cause of death . It is the 3 rd biggest killer in India after heart attacks and cancers. A Stroke happens every 40 seconds and every 4 minutes, someone dies of stroke. The incidence of stroke increases with age. Mainly people between 40-60years are affected. Brain infarct or stroke occurs 30 percent more frequently in men then in women. It is projected that by 2020 the number of cases of stroke would increase to 1.6 million in the country.

6. Gender differences :- Men :- Stroke is more common in men than women. More likely to have a thrombotic stroke. More likely to have a embolic stroke. Have better chance of surviving from a stroke. Women :- At all ages , more women than men die from strokes. More likely to have a hemorrhagic stroke. Oral contraceptive use and pregnancy contribute to stroke risk.

7. RISK FACTORS: Modifiable risk factors:- Hypertension Heart disease. Smoking . Excessive alcohol consumption. Obesity. Sleep apnoea. Metabolic syndrome. Lack of physical exercise. Poor diet. Drug abuse. Non-modifiable risk factors :- Age Gender Race . Family history Heredity .

8. CAUSES :- 1) Cerebral thrombosis : Atheromatous plaque of hard fatty degenerative material may form in the artery of brain, resulting in clot formation. It may increase in size, finally blocking the blood vessels completely. 2) Cerebral embolism : a clot may have formed in vessel outside the brain such as one of big vessels in neck or thorax, or heart itself. Piece of clot may break and moved by blood until it lodge in a vessel which is too small to allow them to pass further.

9. 3) Cerebral hemorrhage: wall of the cerebral vessel ruptures and blood rushes into and through the brain destroying the brain tissue by its sheer force. It occurs due to; Weakness in vessel wall (atheromas) High BP Age of 55 years or more Cerebral aneurysm Arterio venous malformations.

10. TYPES :- 1) Ischaemic stroke It accounts for 83% of all types of stroke. It is of two types; Embolic thromboti c 2) Hemorrhagic stroke It accounts for 17% of all types of stroke It is of two types; Intra cerebral Sub arachonoid

11. PATHOPHYSIOLOGY

12. CLINICAL MANIFESTATIONS : Warning signs General signs and symptoms Symptoms specific to blood vessel affected Hemisphere involvement

13. Lobes of brain

14. DIAGNOSIS:- History collection Physical examination CT head plain, rarely MRI Cerebral angiography (optional) Lumbar puncture (optional, during recovery phase to look for chronic meningitis) Other routine investigations i.e. blood investigations, triglyceride level, urine examinations

15. MANAGEMENT :- Medical management Surgical management Nursing management

16. MEDICAL MANAGEMENT:- Aspirin .  Aspirin is an immediate treatment given in the emergency room to reduce the likelihood of having another stroke. Aspirin prevents blood clots from forming. Tab aspirin 325mg/ od is given orally Intravenous injection of tissue plasminogen activator (TPA).  Some people can benefit from an injection of a recombinant tissue plasminogen activator (TPA), also called alteplase . An injection of TPA is usually given through a vein in the arm. This potent clot-busting drug needs to be given within 4.5 hours after stroke symptoms begin if it's given in the vein

17. The recommended dose of t-PA for acute ischemic stroke is 0.9 mg/kg (maximum 90 mg) infused over 60 minutes with 10% of the total dose administered as an initial intravenous bolus over 1 minute. In cerebral venous thrombosis, low dose heparin as 5000 IU subcutaneously is given 8 hourly for 7 days.

18. SURGICAL MANAGEMENT :- For ischaemic stroke, Carotid end arterectomy : surgical procedure to open or clean blockage in carotid artery Bypass graft : in case of patient with intracranial occlusion such as of internal carotid artery or middle cerebral artery. Thrombectomy : for patients with an identified thrombus, inorder to restore circulation.

19. For hemorrhagic , In case of aneurysm: Surgical clipping : clip is placed in neck of aneurysm to stop bleeding. Surgical coiling : a long thin tube is inserted through the tube into the aneurysm “ baloon ” to fill the space and seal off the bleeding. In case of hematoma , caniotomy may be required.

20. NURSING MANAGEMENT :- Nursing management of patient with stroke varies according to specific stroke syndrome and neurological and functional deficits. Care during acute phase Care during post acute phase Meeting psychological needs Rehabilitation Discharge planning and continuity of care

21. a) Care during acute phase (first 24-48 hours) Early treatment and nursing care is recognized as a key factor in optimizing outcomes. Patient during acute phase may be unconscious/ having altered sensorium and may be unable to maintain airway. Damage to brain tissue and raised ICP inhibits the respiratory center resulting inadequate ventilation so Maintain clear airway for adequate ventilation and to prevent hypoxia. Observe and record vital signs and neurological status as frequently as necessary

22. Draw blood for necessary investigations Provide necessary care for patient on mannitol drip and heparin therapy Provide necessary personal hygiene as per patient condition If patient is in altered sensorium , maintain NPO status, ryles tube feeding to be given to compensate for nutritional needs. Assess type of communication deficits and develop appropriate methods for communication. Use strict aseptic technique while doing any procedures.

23. b) Care during post acute phase Even after returning to conscious level, couging and swallowing reflexes may be impaired for sometime so, Maintain clear airway to prevent hypoxia Maintain safe environment Establish effective communication Encourage mobilization/ prevent contractures Meet nutritional needs Assess elimination pattern and perform necessary interventions Maintain general personal hygiene Provide diversion from hospital anxiety

24. c) Psychological needs Reassure patient and family Control the environment and maintain routines as much as possible, remove stimuli that are upsetting Anticipate needs and meet them in time Clarify any misconceptions. Allow patient to verbalize his/her feelings Provide positive feedback.

25. d) Rehabilitation Rehabilitation begins once the patient is stabilized. Encourage the patient to do as much of his/her work as possible with increased independence Teach activities of daily living (ADL) with respect to ways to compensate patient’s disability. ADL includes bathing, dressing, toileting, gait training and so forth. Teach patient transfer techniques (e.g. bed to chair, chair to bed) Encourage family participation.

26. e) Discharge planning and continuity of care Stress importance of follow up care. Make patient and family members aware of community resources which they can utilize for rehabilitation. Depression is comon after stroke (40-50% of patients) so patient’s family should be prepared for this possibility and assess the psychological status of patient. Advice family to; Avoid doing things for patient that he/she can do himself/herself Be supportive, optimistic but firm and direct. Install hand rails in toilet and shower and safety rails in bed Encourage patient to adhere to exercise program Explain that patient becomes fatigued easily so see to that patient has rest periods. To bring patient for regular follow up.

27. COMPLICATIONS Deep vein thrombosis Pulmonary embolism Aspiration pneumonia Spasticity Joint contractures with associated pain Post stroke depression Recurrent stroke Bed sore Hospital acquired sepsis