Brain Attack (STROKE) DEFINITION: - Schemia is inadequate blood flow - Brain attack (Stroke) occurs when there is ischemia

to a part of the brain that results in death of brain cells A stroke, or cerebrovascular accident (CVA), is the rapid loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage. As a result, the affected area of the brain cannot function, which might result in an inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field. A stroke is a medical emergency and can cause permanent neurological damage and death. Risk factors for stroke include old age, high blood pressure, previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, tobacco smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke. It is the second leading cause of death worldwide. An ischemic stroke is occasionally treated in a hospital with thrombolysis (also known as a "clot buster"), and some hemorrhagic strokes benefit from neurosurgery. Treatment to recover any lost function is termed stroke rehabilitation, ideally in a stroke unit and involving health professions such as speech and language therapy, physical therapy and occupational therapy. Prevention of recurrence may involve the administration of antiplatelet drugs such as aspirin and dipyridamole, control and reduction of high blood pressure, and the use of statins. Selected patients may benefit from carotid endarterectomy and the use of anticoagulants

INCIDENCE: - 3rd Cause of death in US and Canada STATISTICS 2/3 in people >65 = in men and women Higher incidence and death rates among African-Americans, Hispanics, NativeAmerican, Asian Americans RISK FACTORS: Non Modifiable Age Gender Race Heredity

Modifiable Obesity HTN Smoking Heavy alcohol consumption Hypercoagulability Hyperlipidemia Asymptomatic carotid stenosis Diabetes mellitus Heart disease, atrial fibrillation Oral contraceptives Physical inactivity Sickle cell disease REVIEW OF CEREBRAL CIRCULATION:

BLOOD SUPPLY IN ARTERIES: Blood is supplied to the brain by two major pairs of arteries Internal carotid arteries Vertebral arteries Carotid arteries branch to supply most of the Frontal, parietal, and temporal lobes Basal ganglia Part of the diencephalon -Thalamus -Hypothalamus Vertebral arteries join to form the basilar artery, which supply the Middle and lower temporal lobes Occipital lobes Cerebellum

Brainstem Part of the diencephalon

Brain Attack means: Blood flow to the brain is totally interrupted ETIOLOGY: Atherosclerosis - Disease of the arteries; hardening and thickening of the arterial wall because of soft deposits of intraarterial fat and fibrin that harden over time. COMMON SITES FOR THE DEVELOPMENT OF ATHEROSCLEROSIS:

Transient Ischemic Attack (TIA) Transient ischemic attack (TIA) is a temporary focal loss of neurologic function caused by ischemia Most TIAs resolve within 3 hours TIAs are a warning sign of progressive cerebrovascular disease TYPES OF STROKE: Strokes are classified based on the underlying pathophysiologic findings Schemic Hemorrhagic Ischemic vs. Hemorrhagic

Schemic Stroke

o Ischemic strokes result from inadequate blood flow to the brain from partial or complete occlusion of an artery - 85% of all strokes are ischemic strokes Ischemic Stroke Thrombotic or Embolic - Most patients with ischemic stroke do not have a decreased level of consciousness in the first 24 hours - May progress in the first 72 hours Thrombotic stroke Thrombosis occurs in relation to injury to a blood vessel wall and formation of a blood clot Result of thrombosis or narrowing of the blood vessel Most common cause of stroke Embolic stroke Occur when an embolus lodges in and occludes a cerebral artery Results in infarction and edema of the area supplied by the involved vessel Second most common cause of stroke Majority of emboli originate in the inside layer of the heart, with plaque breaking off from the endocardium and entering the circulation Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms Hemorrhagic Stroke Account for approximately 15% of all strokes Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles Intracerebral hemorrhage Bleeding within the brain caused by a rupture of a vessel Hypertension is the most important cause Hemorrhage commonly occurs during periods of activity Manifestations include neurologic deficits, headache, nausea, vomiting, decreased levels of consciousness, and hypertension Subarachnoid hemorrhage Occurs when there is intracranial bleeding into cerebrospinal fluid-filled space between the arachnoid and pia mater Commonly caused by rupture of a cerebral aneurysm - Affects many body functions Motor activity Elimination Spatial-perceptual alterations

 Personality Affect Sensation Communication Brain attack - Term increasingly being used to describe stroke and communicate urgency of recognizing stroke symptoms and treating their onset as a medical emergency Clinical Manifestations: Motor Function - Most obvious effect of stroke - Include impairment of Mobility Respiratory function Swallowing and speech Gag reflex Self-care abilities - An initial period of flaccidity may last from days to several weeks and is related to nerve damage - Spasticity of the muscles follows the flaccid stage and is related to interruption of upper motor neuron influence Communication - Patient may experience aphasia when a stroke damages the dominant hemisphere of the brain Aphasia is a total loss of comprehension and use of language Dysphasia refers to difficulty related to the comprehension or use of language and is due to partial disruption or loss Dysphasia can be classified as nonfluent or fluent Dysarthria does not affect the meaning of communication or the comprehension of language It does affect the mechanics of speech Affect - Patients who suffer a stroke may have difficulty controlling their emotions - Emotional responses may be exaggerated or unpredictable Intellectual Function - Both memory and judgment may be impaired as a result of stroke - A left-brain stroke is more likely to result in memory problems related to language Spatial-Perceptual Alterations - Stroke on the right side of the brain is more likely to cause problems in spatialperceptual orientation - However, this may occur with left-brain stroke - Spatial-perceptual problems may be divided into four categories

Incorrect perception of self and illness Erroneous perception of self in space Inability to recognize an object by sight, touch, or hearing Inability to carry out learned sequential movements on command

Elimination - Most problems with urinary and bowel elimination occur initially and are temporary - When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is excellent DIAGNOSTIC STUDIES: - When symptoms of a stroke occur, diagnostic studies are done to Confirm that it is a stroke Identify the likely cause of the stroke - CT is the primary diagnostic test used after a stroke - Additional studies Complete blood count Platelets, prothrombin time, activated partial thromboplastin time Electrolytes, blood glucose Renal and hepatic studies Lipid profile COLLABORATIVE CARE: Prevention - Goals of stroke prevention include Health management for the well individual Education and management of modifiable risk factors to prevent a stroke - Antiplatelet drugs are usually the chosen treatment to prevent further stroke in patients who have had a TIA - Aspirin is the most frequently used antiplatelet drug - Surgical interventions for the patient with TIAs from carotid disease include Carotid endarterectomy Transluminal angioplasty Stenting Extracranial-intracranial bypass Acute Care - Assessment findings Altered level of consciousness Weakness, numbness, or paralysis Speech or visual disturbances Severe headache or heart rate Respiratory distress Unequal pupils

- Interventions Initial Ensure patient airway Remove dentures Perform pulse oximetry Maintain adequate oxygenation IV access with normal saline Maintain BP according to guidelines Remove clothing Obtain CT scan immediately Perform baseline laboratory tests Position head midline Elevate head of bed 30 degrees if no symptoms of shock or injury - Interventions Ongoing Monitor vital signs and neurologic status Level of consciousness Motor and sensory function Pupil size and reactivity O2 saturation Cardiac rhythm - Recombinant tissue plasminogen activator (tPA) is used to Reestablish blood flow through a blocked artery to prevent cell death in patients with acute onset of ischemic stroke symptoms - Thrombolytic therapy given within 3 hours of the onset of symptoms disability But at the expense of in deaths within the first 7 to 10 days and in intracranial hemorrhage - Surgical interventions for stroke include immediate evacuation of Aneurysm-induced hematomas Cerebellar hematomas (>3 cm) Rehabilitation Care After the stroke has stabilized for 12-24 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning Patient may be transferred to a rehabilitation unit NURSING MANAGEMENT: Nursing Implementation - Respiratory System Management of the respiratory system is a nursing priority Risk for aspiration pneumonia Risks for airway obstruction May require endotracheal intubation and mechanical ventilation

Neurologic System - Monitor closely to detect changes suggesting Extension of the stroke ICP Vasospasm Recovery from stroke symptoms Cardiovascular System Monitoring vital signs frequently Monitoring cardiac rhythms Calculating intake and output, noting imbalances Regulating IV infusions Adjusting fluid intake to the individual needs of the patient Monitoring lung sounds for crackles and rhonchi (pulmonary congestion) Monitoring heart sounds for murmurs or for S3 or S4 heart sounds Musculoskeletal System Trochanter roll at hip to prevent external rotation Hand cones to prevent hand contractures Arm supports with slings and lap boards to prevent shoulder displacement Integumentary System Skin of the patient is susceptible to breakdown related to loss of sensation, Circulation, and immobility Compounded by patient age, poor nutrition, dehydration, edema, and incontinence Pressure relief by position changes, special mattresses, or wheelchair cushions Good skin hygiene Emollients applied to dry skin Early mobility Position patient on the weak or paralyzed side for only 30 minutes Gastrointestinal System After careful assessment of swallowing, chewing, gag reflex, and pocketing, oral feedings can be initiated Feedings must be followed by scrupulous oral hygiene Communication Nurses role in meeting psychologic needs of the patient is primarily supportive Patient is assessed both for the ability to speak and the ability to understand Speak slowly and calmly, using simple words or sentences Sensory-Perceptual Alterations Blindness in the same half of each visual field is a common problem after stroke Other visual problems may include diplopia (double vision), loss of the corneal reflex, and ptosis (drooping eyelid)

Ambulatory and Home Care - The rehabilitation nurse assesses the patient and family with Rehabilitation potential of the patient Physical status of all body systems Presence of complications caused by the stroke or other chronicconditions Cognitive status of the patient The patient is usually discharged from the acute care setting to home, an intermediate or long-term care facility, or a rehabilitation facility Nurses have an excellent opportunity to prepare the patient and family for discharge through o Education o Demonstration o Practice o Evaluation of self-care skills

Submitted by: Jacqueline Lim BSN !V- Group 4

Submitted to: Mrs. Luzviminda Agahan, RN