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Cerebral Vascular Accident

Case Study
by
Ms. Qing Xie
Objective
♀ To review the anatomy and physiology of
brain
♂ To describe the pathophysiology of CVA
♀ To show the complications & clinical
manifestations of CVA
♂ To describe the medical treatment of CVA
♀ To discuss nursing management after
intracranial surgery
♂ To identify the nursing diagnosis &
interventions of CVA
Anatomy & Physiology of Brain
Brainstem - The lower extension of the brain where it
connects to the spinal cord. Neurological functions located in
the brainstem include those necessary for survival (breathing,
digestion, heart rate, blood pressure) and for arousal (being
awake and alert). Most of the cranial nerves come from the
brainstem. The brainstem is the pathway for all fiber tracts
passing up and down from peripheral nerves and spinal cord
to the highest parts of the brain.

Cerebellum - The portion of the brain (located at the back)


which helps coordinate movement (balance and muscle
coordination). Damage may result in ataxia which is a
problem of muscle coordination. This can interfere with a
person's ability to walk, talk, eat, and to perform other self
care tasks.
Pathophysiology
The following part of pathophysiology contains two diseases: ruptured
aneurysm & hydrocephalus
Ruptured Aneurism
An aneurysm rupture usually occurs at the
thin-walled dome of the aneurysm, causing
blood under high pressure to be forced into
the sub-arachnoid space. Concurrently,
intracranial pressure (ICP) increases and
cerebral perfusion pressure decreases.
Fibrin, platelets, and fluid form a clot, which
seals the rupture site. This clot can occlude
the area. The blood irritates the brain tissue,
which in turn sets up an inflammatory
response, promoting cerebral edema.
Hydrocephalus
Hydrocephalus is caused by excess CSF
produced abnormally during its productive
circulation, and then intracranial pressure
increases, which makes the space of CSF
lives in expands, subsequently, intracranial
pressure increases and ventricles amplify.
There are many cases for as much as the
obstacle in the CSF circulation
passageway, however, also a little case
for excess CSF produced.
Classification of ruptured
aneurysm severity
In outlining symptoms of ruptured cerebral aneurysm, it is useful to make
use of the Hunt and Hess scale of subarachnoid hemorrhage severity:
Grade 1: Asymptomatic; or minimal headache and slight nuchal rigidity.
Approximate survival rate 70%.
Grade 2: Moderate to severe headache; nuchal rigidity; no neurologic deficit except
cranial nerve palsy. 60%.
Grade 3: Drowsy; minimal neurologic deficit. 50%.
Grade 4: Stuporous; moderate to severe hemiparesis; possibly early
decerebrate rigidity and vegetative disturbances. 20%.
Grade 5: Deep coma; decerebrate rigidity; moribund. 10%.
Grade 6: Instant Death. 0%

The Fisher Grade classifies the appearance of subarachnoid hemorrhage


on CT scan:
Grade 1: No hemorrhage evident.
Grade 2: Subarachnoid hemorrhage less than 1 mm thick.
Grade 3: Subarachnoid hemorrhage more than 1 mm thick.
Grade 4: Subarachnoid hemorrhage of any thickness with intra-ventricular
hemorrhage (IVH) or parenchymal extension.
Complications
• Increased fluid pressure inside the skull
• Loss of movement in one or more parts of the body
• Other neurological problems (such as vision
changes, difficulty speaking, or cognitive decline)
• Permanent loss of sensation of any part of the face or
body
• Seizures, epilepsy
• Stroke
• Subarachnoid hemorrhage
Risk Factors
♫ Smoking
♫ Hypertension
♫ Previous Aneurysm Family History of
Brain Aneurysm
♫ Older Age
♫ Female Gender
Clinical Manifestations

• First Symptoms
Once the aneurysm starts growing, then
symptoms will begin. These will include
problems seeing, problems speaking,
problems with coordination, dizziness,
severe mood swings, inability to
concentrate and inability to handle the
smallest decision or task.
 Warning Symptoms

Symptoms of a leaking aneurysm or


one just about to burst include sudden
severe headache, nausea, vomiting,
stiff neck, extreme sensitivity to light,
vision problems such as blurred or
double vision, one eyelid drooping down
lower than the other and extreme
confusion.
Medical Treatment
What is a shunt?
It is a drainage system which will transport the excess of CSF collected in
the head to other parts of the body where it can be reabsorbed. The most
frequent places are the abdomen and the heart.

How does a shunt work?


Each shunt has 2 parts:
1. Ventricular catheter: a small
flexible tube which goes in the brain, in
one of the cavities where the CSF is
being retained.
2. Reservoir: a small pump which
regulates the amount of fluid that goes
out. Through this the doctor can also
check the working state of the shunt,
as well as take CSF samples, when
necessary, with a needle.
What are the symptoms of shunt malfunction?

• persistent headache
• vomiting without diarrhea
• double vision
• irritability
• tiredness
• fits
• bulging of the fontanel, if this is
still open
Nursing Management
Guidelines for Care of the Person after
intracranial surgery:
 Preoperative Care
1. Baseline data of neurological and physiologic status should be
recorded
2. Patient and family should be encouraged to verbalize fears
3. Treatments and procedures are explained fully, even if unsure whether
patient understands
4. If head is shaved, it is usually done in the operating room
5. Antiseptic shampoo may be ordered night before surgery and may be
repeated in morning
6. If hair is shaved, it is saved and given to patient or family
7. Prepare family for appearance of patient after surgery
a. Head dressing
b. Edema and ecchymosis of face common
c. Temporary decreased mental status (possible)
 Postoperative Care

1. Monitoring
• Assess neurological status frequently for any decrease in mental
status
• Observe for symptoms of subdural hematoma, one of the possible
side effects of the surgery
• Monitor for symptoms of over-drainage, as evidenced by headache,
especially when patient is sitting upright or standing
• Assess degree and characteristics of drainage
-Amount of drainage and bleeding should be minimal
-Reinforce dressing as needed
-Often incision areas are left open to air after several days

2. Maintaining gastrointestinal status


• Check frequently for signs of paralytic ileus, because the
manipulation of the bowel that occurs with the placement of the
peritoneal part of the shunt can predispose the patient to this
• Patient is usually kept NPO for first day, and then clear liquids are
started
• Regular diet is resumed as soon as good bowel sounds are present
and patient tolerates liquids
3. Promoting comfort
a. Patient may need more frequent pain medication because of
involvement of abdominal area
b. Keep pressure off incision sites

4. Promoting mobility
a. Turning position either side is permitted
c. Patient is encouraged to ambulate as much as possible to encourage
adaptation to decreased ICP
Client’s History
Client: Mrs. A Age: 62-years old
Sex: Female Room/Bed: 706-A
Admission Date: March, 14, 2009
Medical Diagnosis:
–Recurrent ruptured left anterior communicating artery aneurysm
–Obstructive hydrocephalus
–Deep vein thrombosis
–Hypertension
Post operation:
–Intravenous cholangiography filter (25/01/09) –Ventriculo-peritoneal
shunt implantation (03/02/09) –Tracheostomy(17/02/09)
–Cerebral angiogram with GDC embolization (07/03/09)
–Right frontal ventriculostomy with continuous cerebrospinal fluid
drainage and removal of VP shunt (07/03/09)
Chief Complaints: Both arms & legs weakness
Present Illness: December, 30, 2008: Hypertension, stroke, ruptured
aneurysm, deep vein thrombosis, and hydrocephalus
Past Illness:
– Hypertension
Nursing Diagnosis & Interventions
(1) ND: Ineffective breathing pattern related to altered level of consciousness &
respiratory muscle weakness.
Nursing intervention and reasons:
• Assess reparatory status, such as, rate, pattern, lung sounds, and depth of breath
to detect early signs of respiratory compromise
• Assess change in mental status (↑consciousness, dyspnea, restlessness, ↑pulse
rate) can be early signs of cerebral hypoxia
• Provide O2 on tracheotomy tube with collar mask 3L/min. as ordered to meet the
need of O2 in body
• Arrange semi-Fowler’s position to promote lungs excursion and chest expansion
• Provide airway suctioning as needed to maintain airway clearance
• Observer characteristic of secretion from airway such as color, odor, and amount
to early detect infection of airway
• Encourage fluid intake and perform percussion to loosed secretions
• Administer Beradual NGq 12 hour to treat COPD w/ reversible bronchospasm
(monitor ADR of drug: dizziness, headache, nervousness, palpitations,
tachycardia)
• Administer Fluimucil 60mg 1x2 ☉pc to treat resp. tract affection w/ abundant
mucus secretions (monitor ADR of drug: bronchospasm, GI upset, headache)
(2) ND: Risk for disuse syndrome related to (3) ND: Self care deficit related to impaired
physical immobility physical mobility and alteration in cognitive
process

Nursing intervention and reasons: Nursing intervention and reasons:


• Assess functional ability and extent of •Assess degree of functional ability level in
impairments; record and monitor changes performing self-care activities (eg: bathing,
and improvements feeding, toileting) to determine realistic
• Turn and reposition every 2hr. to facilitate
amount of required assistance
comfort
• Elevate affected limbs on pillows to prevent •Provide skin care every 4hr. and maintain
swelling a clean environment to reduce
• Provide massage to promote blood microorganisms
circulation and prevent muscle contraction •Perform passive ROM exercise to prevent
• Perform passive ROM exercise to all muscle weakness and joint stiffness
extremities to relieve muscle soreness, •Provide good nutrition with vitamin, iron,
weakness and deep vein embolism potassium, sodium, and phosphorus to
• Keep side-rails up and bed in low position to
promote good resistance
maintain safe environment
• Administer Folic acid 1x1☉pc. to restore •Provide feeding via NG tube and monitor
physical activities weakened w/ advancing daily bowel movement
aging •Administer tracheotomy tube care by
Barthel Index: Feeding; wheelchair; cleaning and changing gauze as needed
grooming; toilet transfer; bathing; level •Provide good environment with fresh and
walking; stairs; dressing; bladder clean air to prevent lung infection again
control; bowel control (Each item is
positively scored using 3-point scale:
independent, assistive needed, and
Thank You
For
Your Attention

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