2. PATIENT PRESENTATION- 1
Mr.X,67yrs
C/O weakness of RUL and RLL for 10 days
C/O slurred speech for 10 days
K/C/O T2 DM and on treatment (uncontrolled)
K/C/O systemic hypertension
H/O lt leg diabetic foot below great toe
H/O IHD
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3. Assessment
O/E conscious, obeying commands
Speech dysarthria
EOM-restricted
Right facial palsy, gag reflex(N)
Motor-hemiplegia
Sensory-pain/touch impaired on right side
DTR-++/++
No neck stiffness9/15/2014
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4. Investigations
urine for c/s-no growth
ECG: normal sinus rhythm
Blood investigations
Cholesterol-294(200)
Triglyceride-129(150)
HDL-25/11.8(60)
LDL-201(100-159) 9/15/2014
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5. MRI-Acute infarct in the medial aspect of pons
Age related atrophic changes
BP-150/90 mmhg
HR-98b/mt
Spo2-100
RR-30b/mt
Temp-98.6f
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6. Medications
Inj. Clexane 0.4ml s/c od
Inj. Magnex forte 1.5gm in 100ml NS IV bd
Inj. Rantac 50mg IV bd
Inj. H.Actrapid according to CBG s/c tds
T. Clopitab 75 mg RT 0-1-0
T. Nicardia R 10 mg RT 1-0-19/15/20146www.drjayeshpatidar.blogspot.com
7. PATIENT PRESENTATION- 2
Mr. Y 60/m
C/O neck pain x 4 days
H/O fever x 2 days, low grade
H/O one episode of giddiness x vomiting, slurring of speech
Pain and touch impaired on the right side
Known HTN x 5yrs
Lt eye ptosis, nystagmus-gaze evoked ataxia, ltUL-4/5 RUL-5/59/15/20147www.drjayeshpatidar.blogspot.com
11. MRI-Sub acute infarct
Chronic infarct-rt cerebellum
Carotid Doppler-Carotid grade II intimal changes
Non visualization of the mid and distal portion of the basilar artery with very thin caliber vertebral arteries.
Vertebral Doppler study-lt vertebral minimal flow, rt vertebral normal
9/15/201411www.drjayeshpatidar.blogspot.com
12. PATIENT PRESENTATION- 3
Mr.Z,40yrs/M
Rt MCA infarct
C/O weakness of LUL and LL for 4 days
H/O slurring of speech
Mouth deviating to rt side
Chronic smoker and alcoholic-25yrs
BP 150/80 mmhg
Lt-UL:0/5,LL-0/5
rt-UL:5/5,LL-5/5
9/15/201412www.drjayeshpatidar.blogspot.com
14. Medications
T.Nicardia R 10mg p/o tds
T.clopilet 75 mg p/o od
T.Statin 10 mg p/o od
Inj Fraseda 30mg in 100ml Ns IV bd
Inj Neksium 70 mg IV bd9/15/2014
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15. 15
What is a Stroke?
“Stroke” is a term used to describe neurological changes lasting more than 24 hours caused by an interruption in the blood supply to a part of the brain. If the blood flow ceases for an extended period of time, the cerebral tissues involved die causing permanent neurological deficits.
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19. COMMON EFFECTSOF A RIGHT HEMISPERIC STROKE
Left visual field loss (homonymous hemianopsia)
Dysphagia
Usually retain language ability but may have difficulty producing speech(dysarthria)
Left-sided weakness (hemi paresis)or paralysis (hemiplegia)
Sensory impairment
Denial of paralysis, “forget” or “ignore” objects or people on their left side(neglect)
Impaired ability to judge spatial relationships (misjudge distances and depth leading to falls, unable to guide hands to button a shirt, problems with directions such as up / down, no concept of time)
Impaired ability to locate and identify body parts
Short-term memory impairments (difficulty remembering new information) and apraxia(inability to carry out learned movement in the absence of weakness or paralysis)
Behavioral changes such as impairedjudgement or insight into limitations, overestimate physical ability, impulsivity, inappropriateness and difficulty comprehending and expressing emotions9/15/201419www.drjayeshpatidar.blogspot.com
20. COMMON EFFECTS OF A LEFT HEMISPERIC STROKE
Right visual field loss (homonymous hemianopsia)
Dysphagia
May developaphasia (loss of language including spoken, written, reading and comprehension)but may also havedysarthria
Right-sided weakness (hemiparesis)or paralysis (hemiplegia)
Sensory impairment
Usually have normal perception
Usually judgement is intact with good insight into limitations
Short-term memory impairments (difficulty remembering new information) and apraxia(inability to carry out learned movement in the absence of weakness or paralysis)
Often develop a slow and cautious behavioral style. They need frequent instructions and feedback to complete tasks
Better able to comprehend and express emotions9/15/201420www.drjayeshpatidar.blogspot.com
21. TYPES OF STROKE
Ischemic 80 -84%
Caused by blockage of the artery resulting in reduction of blood flow and cell death
Include thrombotic, lacunar, embolic cryptogenic
CT scan negative until a few days post stroke then hypodense area -indicates infarction 9/15/2014
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22. THROMBOTIC STROKE
Atherosclerosis in cerebral arteries
Similar to CAD –leading to MI
Atherogenesis –decades long process
In thrombotic stroke lumen of artery narrows to point of obstruction9/15/201422www.drjayeshpatidar.blogspot.com
23. LACUNAR STROKE
Atherosclerosis in cerebral arteries
Similar to CAD – leading to MI
Atherogenesis – decades long process
In thrombotic stroke lumen of artery narrows to point of obstruction9/15/201423www.drjayeshpatidar.blogspot.com
24. EMBOLIC STROKE
A clot travels from source outside of brain
Encounters vessel with lumen narrow enough to block its passage
Clot lodges there, blocking blood flow
Most common source -heart
Common conditions -atrial fibrillation, valvular disease, ventricular thrombi, atherosclerosis of the proximal aorta9/15/201424
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25. HEMORRHAGIC STROKE
A clot travels from source outside of brain
Encounters vessel with lumen narrow enough to block its passage
Clot lodges there, blocking blood flow
Most common source -heart
Common conditions -atrial fibrillation, valvular disease, ventricular thrombi, atherosclerosis of the proximal aorta9/15/201425www.drjayeshpatidar.blogspot.com
26. EMERGENCY
MANAGEMENT
Neurological vital
signs
Blood pressure
Glycemic control
Control of body
temperature
Oxygenation
Hydration
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27. HEMORRHAGIC STROKE
Treatment based on the underlying cause of the bleed and the extent of brain damage
Treatment includes medication and surgical intervention
Management of ICP with antihypertensives or surgical evacuation of hematoma
In patients with ruptured aneurysm -clip or embolization 9/15/201427www.drjayeshpatidar.blogspot.com
28. Strategies to prevent a stroke
-Maintain a healthy weight -eat a reduced-fat diet
–Reduce alcohol intake to 1-2 drinks / day
–Exercise -30 minutes 3-4 times / week
–Become smoke free and drug free
–Management of hypertension (ACE inhibitors)
–Management of heart disease (anticoagulants), diabetes and hyperlipidemia (statins)
–Carotid endarterectomy may be indicated with stenosis
–Antiplatelets for plaque / clot formation9/15/201428www.drjayeshpatidar.blogspot.com
29. NURSING DIAGNOSIS
Ineffective tissue perfusion r/t decreased cerebral blood flow or cerebral edema
Ineffective airway clearance r/t inability to raise secretions ,ineffective cough
Impaired physical mobility r/t neuromuscular and cognitive impairment, decreased muscle strength and control
Impaired verbal communication r/t residual aphasia
Risk for aspiration r/t inability to protect the airway
Altered sensory perceptual r/t altered LOC, impaired sensation and vision. 9/15/201429www.drjayeshpatidar.blogspot.com
30. Unilateral neglect r/t visual field deficit and sensory loss on one side of the body
Impaired urinary elimination r/t impaired impulse to void or manage tasks of voiding
Impaired swallowing r/t weakness or paralysis of affected muscles
Situational low self esteem r/t actual or perceived loss of function. 9/15/201430www.drjayeshpatidar.blogspot.com
31. NURSING MANAGEMENT
Airway management/ventilator management
Assessment and evaluation of neurologic status to detect patient deterioration
Blood pressure management
General supportive care and prevention of complications associated with:
–Dysphagia, HTN, hyperglycemia, dehydration, malnourishment, fever, cerebral edema, infection, and DVT, immobility, falls, skin care, bowel and bladder dysfunction.
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32. SIGNS OF ↑ICP
Early signs:
–Decreased LOC
–Deterioration in motor function
–Headache
–Changes in vital signs
Late signs
–Pupillary abnormalities
–Changes in respiratory pattern
–Changes in ABG’s9/15/201432www.drjayeshpatidar.blogspot.com
33. Airway management adequate O2 saturation
Preventing increased ICP and providing supportive care.
Hourly vitals/neuros including ICP, CPP, CVP.
Maintaining BP to ensure adequateCPP
Seizure precautions
Antibiotic prophylaxis
Stabilization
Prevention of complications
Monitoring neuro status
Family support and education9/15/201433www.drjayeshpatidar.blogspot.com
35. Do with the patient not for the patient
Management of impairment disability or handicap
Patient family and others9/15/201435www.drjayeshpatidar.blogspot.com
