MINDANAO SANITARIUM AND HOSPITAL COLLEGE BRGY.

SAN MIGUEL, ILIGAN CITY

SCHOOL OF NURSING

ACUTE BIOLOGIC CRISIS REQUIREMENTS PRESENTED TO ROSELYN S. PACARDO, MAN,MM, RN, RM

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR NCM 106

MARY LYON FAJARDO BSN 4B KLUAI MAI FERNANDEZ BSN 4B

JUNE 21, 2011

CEREBROVASCULAR ACCIDENT (STROKE)

A stroke is damage to part of the brain when its blood supply is suddenly reduced or stopped. A stroke may also be called a cerebral vascular accident, or CVA. The part of the brain deprived of blood dies and can no longer function. Blood is prevented from reaching brain tissue when a blood vessel leading to the brain becomes blocked (ischemic) or bursts (hemorrhagic). The symptoms of a stroke differ, depending on the part of the brain affected and the extent of the damage. Symptoms following a stroke come on suddenly and may include: weakness, numbness, or tingling in the face, arm, or leg, especially on one side of the body trouble walking, dizziness, loss of balance, or coordination inability to speak or difficulty speaking or understanding, trouble seeing with one or both eyes, or double vision, confusion or personality changes, difficulty with muscle movements, such as swallowing, moving arms and legs, loss of bowel and bladder control, severe headache with no known cause, and loss of consciousness.

Classification
Ischemic
In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen: 1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally) 2. Embolism (obstruction due to an embolus from elsewhere in the body, see below),[2] 3. Systemic hypoperfusion (general decrease in blood supply, e.g., in shock)[12] 4. Venous thrombosis.[13] Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin); this constitutes 3040% of all ischemic strokes.[2][14] There are various classification systems for acute ischemic stroke. The Oxford Community Stroke Project classification (OCSP, also known as the Bamford or Oxford classification) relies primarily on the initial symptoms; based on the extent of the symptoms, the stroke episode is classified as total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI) orposterior circulation infarct (POCI). These four entities predict the extent of the stroke, the area of the brain affected, the underlying cause, and the prognosis.[15][16] The TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification is based on clinical symptoms as well as results of further investigations; on this basis, a stroke is classified as being due to (1) thrombosis or embolism due toatherosclerosis of a large artery, (2) embolism of cardiac origin, (3) occlusion of a small blood vessel, (4) other determined cause, (5) undetermined cause (two possible causes, no cause identified, or incomplete investigation).[2][17]

Hemorrhagic
Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. A distinction is made between intra-axial hemorrhage (blood inside the brain) andextra-axial hemorrhage (blood inside the skull but outside the brain). Intra-axial hemorrhage is due to intraparenchymal hemorrhage or intraventricular hemorrhage(blood in the ventricular system). The main types of extraaxial hemorrhage are epidural hematoma (bleeding between the dura mater and the skull), subdural hematoma (in the subdural space) and subarachnoid hemorrhage (between the arachnoid mater and pia mater). Most of the hemorrhagic stroke syndromes have specific symptoms (e.g., headache, previous head injury).

Pathophysiology

Diagnostic tests
CT scan without contrast: determine hemorrhage, tumors, aneurysms, ischemia, edema, tissue necrosis, shifting in intracranial contents Arteriography of cerebral vessels: reveals abnormal vessel structures, vasospasm, stenosis of arteries MRI: detect shifting of brain tissues resulting from hemorrhage or edema Positron emission tomography (PET), single-photon emission computed tomography (SPECT): examine cerebral blood flow distribution and metabolic activity of brain

Management and Nursing care

Medical management is directed at early diagnosis and early identification Maintain cerebral oxygenation and cerebral blood flow Maintain patent airway and turn patient to side if unconscious Elevate head and neck should not be flexed Hypertension may be reduced with vasodilators and calcium channel blockers Thrombolytic agents are given to dissolve the clot Intracerebral hemorrhage should be ruled out first Must be given within 3 hours of onset of manifestations E.g. streptokinase, urokinase and tissue plasminogen activator (alteplase) Antiplatelet and anticoagulants are given to prevent clot formation Heparin and warfarin Aspirin, clopidogrel (Plavix), ticlodipine (Ticlid) or dipyridamole (Persantine) Corticosteroids to treat cerebral edema, diuretics to reduce increased intracranial pressure and anticonvulsants to prevent seizures Hyperthermia is treated immediately Temperature elevations lead to increased cerebralmetabolic needs which in turn cause cerebral edemawhich can lead to further ischemia Antipyretics are used Causing the client to shiver should be avoided Aspiration precaution is done Oral food and fluids are generally withheld for 24-48 hours Tube feeding is done Prevent valsalva maneuver Maneuver increases ICP Straining stool, excessive coughing, vomiting, liftingand use of the arms to change position should beavoided Mild laxatives and stool softeners are often prescribed Compensate for perceptual difficulties For clients with visual deficits Approach the client from the unaffected side Place articles on the unaffected side Teach client to turn the head from side to side to see entire visual field Eye patch over one eye in clients with diplopia is helpful Assist and support client Prevent injury and falls

 Promote self-care and prevent skin breakdown Prevent complications Physical therapy to prevent contractures and to improve muscle strength and coordination Encourage bed exercise Facilitate ROM and isometric exercises or Do not force extremities beyond the point of initiating pain and spasm or Always support the joint and move the extremity smoothly Allow client to work on balance and proprioception skills