PRESENTORS

Daluma, Moh. Ashraf Dato, Rowena Dequeros, Hannah Angeleah De Pablo Ma. Catherine Ruby Gargoles, Liezle Gumayao, Jeanette Guro, Hanieyah Honghong, Ma. Sofia Mae Jacinto, Jane Lacsi, Paul Garret

BSN - 4C

TABLE OF CONTENTS
PAGE

Objectives....................................................................................................................................................................................................................................... 1 Glossary.......................................................................................................................................................................................................................................... 2 Introduction ................................................................................................................................................................................................................................... 3 Review of Normal Anatomy and Physiology............................................................................................................................................................................... 5 Simplified Pathophysiology........................................................................................................................................................................................................... 8 Physical Examination and Review of Systems............................................................................................................................................................................ 10 Diagnostic Tests.............................................................................................................................................................................................................................. 13 Pharmacology................................................................................................................................................................................................................................. 20 Nursing Care Plans........................................................................................................................................................................................................................ 30 Surgical Managements................................................................................................................................................................................................................... 43 Health Education Plan................................................................................................................................................................................................................... 45 Discharge Plan................................................................................................................................................................................................................................ 46 Prognosis......................................................................................................................................................................................................................................... 48 Bibliography.................................................................................................................................................................................................................................... 49

OBJECTIVES
Presentor-Centered After 1 and hour of case presentation, the presentors will be able to: 1. Explain what cerebrovascular accident is and be able to enumerate and discuss its various types. 2. Compare the types of cardiovascular accident including their causes, clinical manifestations, and medical management. 3. Describe the incidence and social impact of cerebrovascular disorders. 4. Conduct a review on the anatomy and physiology of the systems and organs involved. 5. Identify the risk factors for cerebrovascular accident and related measures for prevention. 6. Discuss the principles of nursing management to the care of a patient recovering from an ischemic stroke or of a patient with a hemorrhagic stroke. 7. Identify essential elements for family teaching and preparation for home care of the patient who has had a stroke. Critique Group - Centered After 1 and hour of case presentation, the audience, particularly the students will be able to: 1. State a summary description of cerebrovascular accident and be able to identify its major types. 2. Explain the difference between the types of cerebrovascular accident by comparing its causes, clinical manifestations and medical management 3. Give details on the epidemiology of cerebrovascular accident both locally and internationally. 4. Determine the different assessment parameters in assessing client with cerebrovascular accident 5. Describe and discuss the purpose of each diagnostic test that will be tackled. 6. Identify the contributing factors including the predisposing and precipitating factors associated in the variety of illnesses. 7. Discuss managements on how to handle patients with same diagnosis. 8. Raise sensible and relevant questions or clarifications on the case that is going to be presented. CI-Centered After 1 and hour of class presentation, the clinical instructors will be able to: 1. Share additional information about the case that is going to be presented. 2. Ask clarifications or questions if some information presented were unclear or erroneous. 3. Provide suggestions on how to improve the study.

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GLOSSARY

Agnosia: Impairment of the ability to recognize or comprehend the meaning of various sensory stimuli. Aneurysm: A weakening or bulge in an arterial wall. Aphasia: Inability to express oneself or to understand language Apraxia: Disorder of voluntary movement consisting of impairment of the performance of skilled or purposeful movements despite physical ability and willingness to move. Atheroma: A fibrous cap composed of smooth muscle cells that forms over lipid deposits within arterial vessels and that protrudes into the lumen of the vessel, narrowing the lumen and obstructing blood flow; also called plaque. Atherosclerosis: Abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen. Atrial fibrillation: Most common form of irregular heartbeat and a risk factor for embolic ischemic stroke. The condition can cause a pooling of blood in the heart, which can make it easier for clots to form. Carotid stenosis: Buildup of hardened plaque on the carotid artery wall. This is the leading cause of ischemic stroke. Cerebral edema: Swelling of the brain. Contralateral: Refers to the other side. Stroke affecting the right side of the brain may cause paralysis, affecting the left arm and leg. Dysarthria: Difficulty in articulating words due to disease of the central nervous system (CNS). Dysphagia: Difficulty in swallowing. Embolic stroke: Occurs when a clot is carried into cerebral circulation and causes a localized cerebral infarct. Embolus: Blood clot that forms in one area of the body and moves to another. Expressive aphasia: Inability to express oneself; often associated with damage to the left frontal lobe area. Hemianopsia: Blindness of half of the field of vision in one or both eyes.

Hemiparesis: Weakness one side of the body, or part of it, due to an injury in the motor area of the brain. Hemiplegia: Paralysis of one side of the body, or part of it, due to an injury in the motor area of the brain. Infarction: A zone of tissue deprived of blood supply. Ipsilateral: Refers to the same side. A stroke on the right side of the brain causes some symptoms on the right side of the body, as opposed to contralateral (the other side). Ischemia: Insufficient tissue oxygenation. Korsakoffs syndrome: Disorder characterized by psychosis, disorientation, delirium, insomnia, and hallucinations. Penumbra region: Area of low cerebral blood flow receptive aphasia: inability to understand what someone else is saying; often associated with damage to the temporal lobe area. Thrombosis: Obstruction of a blood vessel by a clot formed at the site of obstruction. Thrombotic stroke: Type of ischemic stroke usually seen in aging population. It is due to atherosclerosis (plaque buildup), eventually narrowing the lumen of the artery. The symptoms are much more gradual and less dramatic than other strokes due to the slow, ongoing process that produces it. The stroke is completed when the condition stabilizes. Transient ischemic attack (TIA): Temporary lack of adequate blood and oxygen to the brain that causes stroke warning signs but no permanent damage. Generally lasts about 1 minute, but can last up to 5 minutes.

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WHAT IS CVA?
CEREBROVASCULAR ACCIDENT Cerebrovascular accident (CVA, stroke or brain attack) is injury or death to parts of the brain caused by an interruption in the blood supply to that area causing disability, such as paralysis or speech impairment. It can be divided into two major categories: ischemic (85%), in which vascular occlusion and significant hypoperfusion occur, and hemorrhagic (15%), in which there is extravasation of blood into the brain or subarachnoid space. Although there are some similarities between the two broad types of stroke, differences exist in etiology, pathophysiology, medical management, surgical management, and nursing care. The term brain attack has been promoted to highlight that time-dependent tissue damage occurs and to raise awareness of the need for rapid emergency treatment, similar to that with heart attack. TYPES Ischemic stroke An ischemic stroke, cerebrovascular accident (CVA), or brain attack is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. The term brain attack is being used to suggest to health care practitioners and the public that a stroke is an urgent health care issue similar to a heart attack. Urgency is needed on the part of the public and health care practitioners for rapid transport of the patient to a hospital for assessment and administration of the medication. Ischemic strokes are subdivided into five different types based on the cause: large artery thrombotic strokes (20%), small penetrating artery thrombotic strokes (25%), cardiogenic embolic strokes (20%), cryptogenic strokes (30%), and other (5%). Large artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction (deprivation of blood supply). Small penetrating artery thrombotic strokes affect one or more vessels and are the most common type of ischemic stroke. Small artery thrombotic strokes are also called lacunar strokes because of the cavity that is created after the death of infarcted brain tissue. Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. Embolic strokes can also be associated with valvular heart disease and thrombi in the left ventricle. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting in a stroke. Embolic strokes may be prevented by the use of anticoagulation therapy in patients with atrial fibrillation. The last two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. Ischemia may be transient and resolve within 24 hours, be reversible with resolution of symptoms over a period of 1 week (reversible ischemic neurological deficit [RIND]), or progress to cerebral infarction with variable effects and degrees of recovery. Hemorrhagic stroke Hemorrhagic strokes are caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space. Hemorrhagic strokes are primarily caused by intracranial or subarachnoid hemorrhage. The most common predisposing factors are advancing age and hypertension. Other causes of hemorrhage are aneurysm, trauma, erosion of the vessels by tumors, arteriovenous malformations, blood coagulation disorders, vasculitis, and drugs. EPIDEMIOLOGY According to the World Health Organization, 1 in ten in the 55 million deaths that occurs every year worldwide is due to stroke and two-thirds of which occur in people living among developing countries. Strokes are much more common among older people than among younger adults, usually because the disorders that lead to strokes progress over time. Over two thirds of all strokes occur in people older than 65. Slightly more than 50% of all strokes occur in men, but more than 60% of deaths due to stroke occur in women, possibly because women are on average older when the stroke occurs. According to the latest WHO data published in April 2011 Stroke Deaths in Philippines reached 40,245 or 9.55% of total deaths. The age adjusted Death Rate is 82.77 per 100,000 of population ranks Philippines #106 in the world. RISK FACTORS Among the major risk factors for stroke are age (65-74 years old), sex (male: 19% greater risk), race (African Americans: 60% greater risk), family history, hypertension, smoking, diabetes mellitus, asymptomatic carotid stenosis, sickle cell disease, hyperlipidemia, and atrial fibrillation. Other less well-documented risk factors include obesity, physical inactivity, alcohol and drug abuse, hypercoagulability disorders, hormone replacement therapy, and oral contraceptive use. 5|P age

CLINICAL MANIFESTATIONS Ischemic Stroke An ischemic stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion (which vessels are obstructed), the size of the area of inadequate perfusion, and the amount of collateral (secondary or accessory) blood flow. The patient may present with any of the following signs or symptoms:

COMPARISON OF LEFT AND RIGHT HEMISPHERIC STROKES Left Hemispheric Stroke Paralysis or weakness on right side of the body Right visual field deficit Aphasia (expressive, receptive or global) Altered intellectual ability Slow cautious behavior Right Hemispheric Stroke Paralysis or weakness on left side of the body Left visual field deficit Spatial-perceptual deficits Increased distractibility Impulsive behavior and poor judgment Lack of awareness of deficits

Numbness or weakness of the face, arm, or leg, especially on one side of the body Confusion or change in mental status Trouble speaking or understanding speech Visual disturbances Difficulty walking, dizziness, or loss of balance or coordination Sudden severe headache

Motor, sensory, cranial nerve, cognitive, and other functions may be disrupted. Hemorrhagic Stroke The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache. A comprehensive assessment reveals the extent of the neurologic deficits. Many of the same motor, sensory, cranial nerve, cognitive, and other functions that are disrupted after ischemic stroke are also altered after a hemorrhagic stroke. Other symptoms that may be observed more frequently in patients with acute intracerebral hemorrhage (compared with ischemic stroke) are vomiting, an early sudden change in level of consciousness, and possibly focal seizures due to frequent brain stem involvement. In addition to the neurologic deficits (similar to those of ischemic stroke), the patient with an intracranial aneurysm or AVM may have some unique clinical manifestations. Rupture of an aneurysm or AVM usually produces a sudden, unusually severe headache and often loss of consciousness for a variable period of time. There may be pain and rigidity of the back of the neck (nuchal rigidity) and spine due to meningeal irritation. Visual disturbances (visual loss, diplopia, ptosis) occur if the aneurysm is adjacent to the oculomotor nerve. Tinnitus, dizziness, and hemiparesis may also occur.

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REVIEW OF NORMAL ANATOMY AND PHYSIOLOGY

THE CENTRAL NERVOUS SYSTEM THE BRAIN The brain accounts for approximately 2% of the total body weight; in an average young adult, the brain weighs approximately 1400g, whereas in an average elderly person, the brain weighs approximately 1200g. The brain is divided into three major areas: the cerebrum, the brain stem, and the cerebellum. The cerebrum is composed of two hemispheres, the thalamus, the hypothalamus, and the basal ganglia. The brain stem includes the midbrain, pons, and medulla. The cerebellum is located under the cerebrum and behind the brain stem (Fig. 1). Cerebrum The outside surface of the hemispheres has a wrinkled appearance that is the result of many folded layers or convolutions called gyri, which increase the surface area of the brain, accounting for the high level of activity carried out by such a small-appearing organ. Between each gyrus is a sulcus or fissure that serves as an anatomic division. In between the cerebral hemispheres is the great longitudinal fissure that separates the cerebrum into the right and left hemispheres. The two hemispheres are joined at the lower portion of the fissure by the corpus callosum. The external or outer portion of the hemispheres (the cerebral cortex) is made up of gray matter approximately 2 to 5 mm in depth; it contains billions of neuron cell bodies, giving it a gray appearance. White matter makes up the innermost layer and is composed of myelinated nerve fibers and neuroglia cells that form tracts or pathways connecting various parts of the brain with one another. These pathways also connect the cortex with lower portions of the brain and spinal cord. The cerebral hemispheres are divided into pairs of lobes as: Frontal - the largest lobe, located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It contains Brocas area, which is located in the left hemisphere and is critical for motor control of speech. The frontal lobe is also responsible in large part for a persons affect, judgment, personality, and inhibitions. Parietal - a predominantly sensory lobe posterior to the frontal lobe. This lobe analyzes sensory information and relays the interpretation of this information to other cortical areas and is essential to a persons awareness of body position in space, size and shape discrimination, and rightleft orientation. Temporal - located inferior to the frontal and parietal lobes, this lobe contains the auditory receptive areas and plays a role in memory of sound and understanding of language and music. Occipital - located posterior to the parietal lobe, this lobe is responsible for visual interpretation and memory. The corpus callosum (Fig. 2), a thick collection of nerve fibers that connects the two hemispheres of the brain, is responsible for the transmission of information from one side of the brain to the other. Information transferred includes sensation, memory, and learned discrimination. Right-handed people and some left-handed people have cerebral dominance on the left side of the brain for verbal, linguistic, arithmetic, calculation, and analytic functions.

The nondominant hemisphere is responsible for geometric, spatial, visual, pattern, and musical functions. Nuclei for cranial nerves I and II are also located in the cerebrum. The basal ganglia are masses of nuclei located deep in the cerebral hemispheres that are responsible for control of fine motor movements, including those of the hands and lower extremities. The thalamus (see Fig. 2) lies on either side of the third ventricle and acts primarily as a relay station for all sensation except smell. All memory, sensation, and pain impulses pass through this section of the brain. The hypothalamus (see Fig. 2) is located anterior and inferior to the thalamus, and beneath and lateral to the third ventricle. The infundibulum of the hypothalamus connects it to the posterior pituitary gland. The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through 7|P age

hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. In addition, the hypothalamus is the site of the hunger center and is involved in appetite control. It contains centers that regulate the sleepwake cycle, blood pressure, aggressive and sexual behavior, and emotional responses (ie, blushing, rage, depression, panic, and fear). The hypothalamus also controls and regulates the autonomic nervous system. The optic chiasm (the point at which the two optic tracts cross) and the mamillary bodies (involved in olfactory reflexes and emotional response to odors) are also found in this area. Brain Stem The brain stem consists of the midbrain, pons, and medulla oblongata (see Fig. 1). The midbrain connects the pons and the cerebellum with the cerebral hemispheres; it contains sensory and motor pathways and serves as the center for auditory and visual reflexes. Cranial nerves III and IV originate in the midbrain. The pons is situated in front of the cerebellum between the midbrain and the medulla and is a bridge between the two halves of the cerebellum, and between the medulla and the midbrain. Cranial nerves V through VIII originate in the pons. The pons also contains motor and sensory pathways. Portions of the pons help regulate respiration. Motor fibers from the brain to the spinal cord and sensory fibers from the spinal cord to the brain are located in the medulla. Most of these fibers cross, or decussate, at this level. Cranial nerves IX through XII originate in the medulla. Reflex centers for respiration, blood pressure, heart rate, coughing, vomiting, swallowing, and sneezing are located in the medulla as well. The reticular formation, responsible for arousal and the sleepwake cycle, begins in the medulla and connects with numerous higher structures. Cerebellum The cerebellum is posterior to the midbrain and pons, below the occipital lobe (see Fig. 1). The cerebellum integrates sensory information to provide smooth coordinated movement. It controls fine movement, balance, and position (postural) sense or proprioception (awareness of where each part of the body is). Cerebral Circulation The brain does not store nutrients and requires a constant supply of oxygen. These needs are met through cerebral circulation; the brain receives

approximately 15% of the cardiac output, or 750mL per minute of blood flow. Brain circulation is unique in several aspects. First, arterial and venous circulation are not parallel as in other organs in the body; this is due in part to the role the venous system plays in CSF absorption. Second, the brain has collateral circulation through the circle of Willis, allowing blood flow to be redirected on demand. Third, blood vessels in the brain have two rather than three layers, which may make them more prone to rupture when weakened or under pressure. Arteries Arterial blood supply to the brain originates from the common carotid artery, the first bifurcation off the aorta. The internal carotid arteries arise at the bifurcation of the common carotid and supply much of the anterior circulation of the brain. Branches of the internal carotid arteries, anterior and middle cerebral arteries, along with their connections, anterior and posterior communicating arteries, form the circle of Willis (Fig. 3). The vertebral arteries branch from the subclavian arteries to supply most of the posterior circulation of the brain. At the level of the brain stem, the vertebral arteries join to form the basilar artery. The basilar artery divides to form the two branches of the posterior cerebral arteries. Functionally, the posterior portion of the circulation and the anterior or carotid circulation usually remain separate. However, the circle of Willis can provide collateral circulation if one of the vessels supplying it becomes occluded or is ligated. The bifurcations along the circle of Willis are frequent sites of aneurysm formation. Aneurysms are outpouchings of the blood vessel due to vessel wall weakness. Aneurysms can rupture and cause a hemorrhagic stroke. Veins Venous drainage for the brain does not follow the arterial circulation as in other body structures. The veins reach the brains surface, join larger veins, then cross the subarachnoid space and empty into the dural sinuses, which are the vascular channels laying within the dura (see Fig. 4). The network of the sinuses carries venous outflow from the brain and empties into the internal jugular veins, returning the blood to the heart. Cerebral veins are unique because, unlike other veins in the body, they do not have valves to prevent blood from flowing backward and depend on both gravity and blood pressure for flow.

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BloodBrain Barrier The CNS is inaccessible to many substances that circulate in the blood plasma (eg, dyes, medications, and antibiotics) because of the bloodbrain barrier. This barrier is formed by the endothelial cells of the brains capillaries, which form continuous tight junctions, creating a barrier to macromolecules and many compounds. All substances entering the CSF must filter through the capillary endothelial cells and astrocytes. The bloodbrain barrier has a protective function but can be altered by trauma, cerebral edema, and cerebral hypoxemia; this has implications in the treatment and selection of medication for CNS disorders.

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SIMPLIFIED PATHOPHYSIOLOGY
PRECIPITATING FACTORS Hypertension Smoking Hyperlipidemia Atrial fibrillation. Obesity Physical inactivity Alcohol and drug abuse Hormone replacement therapy Oral contraceptive use Diabetes mellitus Asymptomatic carotid stenosis Sickle cell disease

PREDISPOSING FACTORS Advance age (65-74 years old) Sex (male: 19% greater risk) Race (African Americans: 60% greater risk) Family history

promote

Atheroma/Thrombus formation in the cerebral artery

causes

Embolus formation from outside of the brain (Plaque, Clots, Tumor, Bacteria, Air)
which may

Structural change of arterial wall

progresses to

Arterial stenosis
leads to

Travel to the blood stream

and then

Arterial wall thinning and loss of elasticity

leads to

Lodges in a cerebral artery Narrowing of an arterial lumen

results to which results to

Rupture of an artery
leads to

ISCHEMIC STROKE

causes

Partial/Total occlusion of a cerebral artery

Intracranial Hemorrhage
results to

results to

Decrease cerebral tissue Perfusion

leads to

results to

HEMORRHAGIC STROKE
may result to

Cerebral Ischemia

Increase ICP Hypovolemic Shock

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causes

Energy Failure

results to

Acidosis

Ion imbalance
leads to

Increase intracellular calcium

results to

Depolarization
promotes

Breakdown of cell membranes and proteins

leads to

Increase Glutamate formation

Cell injury and death

results to

Brain infarction
results to

Neurologic Deficits

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PHYSICAL EXAMINATION AND REVIEW OF SYSTEM

AREAS General Health Survey SUBJECTIVE FINDINGS (Patient may report) Feelings of helplessness, hopelessness OBJECTIVE FINDINGS (Patient may exhibit) Emotional lability Depression Withdrawal Exaggerated or inappropriate responses to anger, sadness, happiness Inappropriate use of defense mechanisms Difficulty expressing self Guarding, distraction behaviors Restlessness Staggering, unsteady gait Unable to keep feet together; needs a broad base to stand Inability to respond to pressure and discomfort Hypoxia Hypercapnia >2 sec CRT Muscle or facial tension Facial droop, presence of ptosis Pupil size and reaction: May be unequal; dilated and fixed pupil on the ipsilateral side may be present with Difficulty seeing at night Double vision Difficulty seeing objects on left side (right CVA) Chewing and swallowing problems Loss of gag or cough reflexes PROBLEM IDENTIFIED Ineffective cerebral tissuepPerfusion Impaired verbal [and/or written] Communication Disturbed Sensory Perception Disturbed thought process Risk for Ineffective Coping risk for Injury Risk for fall situational low Self-Esteem Anxiety Disturbed sensory perception Risk for Impaired Skin Integrity Risk for decreased tissue perfusion Acute Pain Impaired physical Mobility Impaired Swallowing Disturbed thought process Unilateral Neglect Risk for Injury Risk for fall Risk for aspiration Risk for imbalanced Nutrition: Less than Body Requirements Situational low Self-Esteem Risk for disturbed Body Image Impaired physical Mobility Impaired breathing pattern Risk for decreased tissue perfusion Risk for ineffective airway clearance Risk for impaired spontaneous ventilation Risk for aspiration Risk for decreased cardiac output Risk for decreased tissue perfusion

Integumentary System

Tingling and numbness

HEENT

Headache of varying intensity Numbness or weakness of the face. Loss of sensation in tongue, cheek, and throat Dysphagia Disturbance in senses of taste, smell

Neck Respiratory System History of smoking

Nuchal Rigidity Labored and irregular respirations Hypoventilation Hypoxemia Loss of cough reflexes Noisy respirations, rhonchi (aspiration of secretions) Arterial hypertension, which is common unless CVA is due to embolism or vascular malformation Pulse rate may vary due to various factors, such as preexisting heart conditions, medications, effect of stroke on vasomotor center Dysrhythmias, electrocardiographic (ECG) changes

Cardiovascular System

History of cardiac diseasemyocardial infarction (MI), rheumatic and valvular heart disease, heart failure (HF), bacterial endocarditis, polycythemia

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Gastrointestinal System and Abdomen

Lack of appetite Nausea or vomiting during acute event (increased intracranial pressure [ICP]) Loss of sensation in tongue, cheek, and throat Dysphagia

Bruit in carotid, femoral, or iliac arteries, or abdominal aorta may or may not be present Slow bounding pulse. Chewing and swallowing problems Distended abdomen May have absent or diminshed bowel sounds if neurogenic paralytic ileus present Change in voiding patternsincontinence, anuria,, retention Distended bladder Sexual Problems

Impaired Swallowing Risk for Imbalanced Nutrition: Less than Body Requirements Risk for Constipation Urinary Retention Risk impaired Urinary Elimination Sexual dysfunction Sexual dysfunction Impaired physical Mobility Self-Care Deficit Unilateral Neglect Risk for Injury Risk for fall Risk for acute pain Disturbed Sensory Perception Situational low Self-Esteem Risk for disturbed Body Image Impaired verbal [and/or written] Communication Disturbed Sensory Perception Disturbed thought process Self-Care Deficit Ineffective Coping Impaired Swallowing Unilateral Neglect Risk for Injury Risk for fall Risk for aspiration Situational low Self-Esteem Anxiety

Genitourinary System

Reproductive System Musculoskeletal System Difficulty with activity due to weakness, loss of sensation, or paralysis (hemiplegia) Tires easily Difficulty resting, pain or muscle twitching Numbness of arm or leg, especially on one side of the body

Altered muscle toneflaccid or spastic; generalized weakness One-sided paralysis Flaccid shoulder joint

Neurologic System

History of TIA Dizziness or syncope before stroke or transient during TIA Severe headache can accompany intracerebral or subarachnoid hemorrhage Tingling, numbness, and weakness commonly reported during TIAs, found in varying degrees in other types of stroke; involved side seems dead Visual deficitsblurred vision, partial loss of vision (monocular blindness), double vision (diplopia), or other disturbances in visual fields

Altered level of consciousness (LOC) Coma usually presents in the initial stages of hemorrhagic disturbances. Altered behaviorlethargy, apathy, combativeness Altered cognitive functionmemory, problem-solving, sequencing Extremities: Weakness and paralysis contralateral with all kinds of stroke; unequal hand grasp; diminished deep tendon reflexes (contralateral) Facial paralysis or paresis (ipsilateral) Aphasia: May be expressive (difficulty producing speech), receptive (difficulty comprehending speech), or global (combination of the two) Agnosia Altered body image awareness, neglect or denial of contralateral side of body (unilateral neglect); disturbances in perception Apraxia Dysarthria (Difficulty in forming words) Pupil size and reaction: May be unequal; dilated and fixed pupil on the ipsilateral side may be present with hemorrhage or herniation Nuchal rigiditycommon in hemorrhagic stroke Seizurescommon in hemorrhagic stroke

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 Problems with vision Changes in perception of body spatial orientation (right CVA), neglect Difficulty seeing objects on left side (right CVA) Being unaware of affected side Inability to recognize familiar objects, colors, words, faces Diminished response to heat and cold, altered body temperature regulation Swallowing difficulty, inability to meet own nutritional needs Loss of gag or cough reflex Impaired judgment, little concern for safety, impatience, lack of insight (right CVA) Speech problems Inability to communicate Inappropriate behavior

REFERENCES: Castillo and Reinoso. (1999) Respiratory Dysfunction Associated with Acute Cerebrovascular Events. Doenges et. al. (2008). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8 th edition. Smeltzer et. al. (2010). Brunner and Suddarths Medical Surgical Nursing, 12 th edition.

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DIAGNOSTIC TESTS
DIAGNOSTIC TESTS DESCRIPTION RESULT & INTERPRETATION Normal result/s No abnormalities. Abnormal result/s Abscess Arteriovenous malformation Cerebral aneurysms Cerebral infarction Hemorrhage/hematoma Hydrocephalus Meningiomas Multiple sclerosis Neoplasms Ventricular displacement Ventricular enlargement PROCEDURE The patient is assisted to a supine position on the CT scan table. A maintenance IV line is initiated. The contrast dye is administered by IV injection. Resuscitation and suctioning equipment should be readily available. The patient is then placed in the CT scanner. Films are made, during which the patient may be asked to hold his or her breath. NURSING RESPONSIBILITIES Pretest Explain to the patient the purpose of the test. Provide any written teaching materials available on the subject. Note that minimal discomfort during the test is due to the venipuncture, and that during injection of the dye, transient sensations including warmth, flushing, a salty taste, and nausea may be experienced. Explain that no movement is allowed during the procedure. Check for allergies to iodine, shellfish, or contrast medium dye. Inform the radiologist of such possible allergy and obtain order for an antihistamine and steroid to be administered prior to the test. Patients receiving metformin (Glucophage) for Type 2 diabetes mellitus should discontinue the drug 2 days before elective surgery or angiographic exams. This is due to the possible occurrence of lactic acidosis, a potentially fatal complication of biguanide therapy. Baseline BUN and creatinine levels are obtained. Fasting for at least 4 hours is required prior to the test if contrast dye is to be administered. The patient should be well hydrated prior to the beginning of the fasting period. Obtain a signed informed consent. For CT of brain, instruct the patient to remove any metal items from the hair or mouth prior to the procedure. Post-test Most allergic reactions to radiopaque dye occur within 30 minutes of administration of the contrast medium. Observe the patient closely for: respiratory distress, hypotension, edema, hives, rash, tachycardia, and/or laryngeal stridor. Emergency resuscitation equipment must be readily accessible. Observe for allergic reaction to the dye for 24 hours. Discontinue the IV infusion. Apply pressure at venipuncture site. Apply dressing, periodically assessing for continued bleeding. Resume the patients diet. Encourage fluid intake of at least three glasses of liquid to speed the excretion of the dye from the body. Monitor urinary output. 15 | P a g e

Computed Tomography CT of the brain is particularly sensitive to the presence of blood. It is especially useful after trauma and when neurologic symptoms suggest a stroke and/or hemorrhage due to embolus, arteriovenous malformation (AVM), angioma, or aneurysm. Noncontrast CT of the brain is currently the examination of choice for initial imaging of suspected acute stroke. Contrast-enhanced CTs do not consistently visualize low-grade tumors or the full extent of infiltrative neoplasms and associated edema as well as magnetic resonance imaging does.

 Inform the patient that if oral contrast dye was ingested, diarrhea may occur. Renal function should be assessed before metformin is restarted. Report abnormal findings to the primary care provider. Positron Imaging Tomography Determines the amount of blood flow to the brain. Reveals how adequately the brain uses blood or nutrients, such as oxygen . Normal Result/s Normal patterns of tissue metabolism Abnormal Result/s Alzheimers disease Cerebrovascular accident Coronary artery disease Dementia Epilepsy Huntingtons chorea Malignant tumors Metastatic tumors Migraine headache Parkinsons disease Schizophrenia The patient is assisted to a supine position on the scanning table. An IV line is initiated. The patient is moved within the PET scanner. The radionuclide is administered either via the IV line or by inhalation of radioactive gas. Images are taken at various times, depending on the particular tissue being scanned. Pre-test Explain to the patient the purpose of the test and the procedure to be followed. Explain to the patient that movement is not allowed during the test. To assist with relaxation and to block any noises which occur during the testing, encourage the patient to listen to an audiotape during the procedure. Fasting for an average of 6 hours is required prior to the test. Gum, sugar, and caffeine must be avoided. Water is allowed. Instruct patients to refrain from vigorous exercise prior to the exam. CT films from previously completed exams need to be available for comparison with PET images. Obtain a signed informed consent. Pre-procedure sedation may be ordered. If used, it cannot be given until 30 minutes post injection of the radioisotope, since it will affect glucose metabolism of the brain. The patient is instructed to void prior to the exam. Post-test Assist the patient to slowly rise from the lying position to avoid postural hypotension. Discontinue the IV site and check the site for bleeding. If a woman who is lactating must have this procedure, she should not breast feed the infant until the radionuclide has been eliminated, possibly for 3 days. Although the amount of diagnostic radionuclide excreted in the urine is low, the urine should not be used for any laboratory tests for the time period indicated by the nuclear medicine department. Gloves are worn whenever dealing with the urine. Encourage fluid intake to enhance elimination of the radionuclide from the body. Report abnormal findings to the primary care provider. Cerebral Angiography The purposes of cerebral angiography are to detect cerebrovascular abnormalities such as aneurysm or arteriovenous (A-V) malformation, to study The patient is assisted to a supine Normal Result/s Normal vasculature without occlusion position on the examination table. A maintenance intravenous line is initiated. Abnormal Result/s Arterial spasm The area of the puncture site is Arteriosclerosis shaved if necessary, cleansed, and Pre-test Explain to the patient the purpose of the test. Provide any written teaching materials available on the subject. Note that discomfort involved with this test is primarily due to lying on a hard table for an extended period of time and the needle puncture. Explain that an intense hot flushing may be 16 | P a g e

vascular displacement due to such problems as tumor or hydrocephalus, and to evaluate the postoperative status of blood vessels. The test involves the introduction of a radiopaque catheter into either the femoral, carotid, or brachial artery, and injecting a contrast medium dye. The most commonly used site is the femoral artery.

Arteriovenous malformations Brain tumor Cerebral aneurysm Cerebral fistula Cerebral occlusion Cerebral thrombosis Increased intracranial pressure

then anesthetized. The needle puncture of the artery is made and a guide wire is placed through the needle. The catheter is then inserted over the wire and into the artery. The radiopaque catheter is advanced into the desired artery. Positioning is monitored via fluoroscopy. Once the catheter is in the correct position, contrast dye is injected through the catheter. Radiographic films are taken. After films of satisfactory quality are obtained, the catheter is removed and pressure held on the puncture site for at least 15 minutes. Gloves are worn throughout the procedure.

experienced for 1530 seconds when the dye is injected. Check for allergies to iodine, shellfish, or contrast medium dye. Inform the radiologist of such possible allergy and obtain order for an antihistamine and steroid to be administered prior to the test. Baseline laboratory data (CBC, PT, PTT, creatinine) are obtained. Pregnancy test should be obtained on women of childbearing age. Note any medications, such as anticoagulants or aspirin, which may prolong bleeding. Patients receiving metformin (Glucophage) for Type 2 diabetes mellitus should discontinue the drug 2 days before angiographic exams. This is due to the possible occurrence of lactic acidosis, a potentially fatal complication of biguanide therapy. Fasting for at least 8 hours is required prior to the test. Obtain a signed informed consent. Administer any pretest sedation after consent form is signed. Assess and document patients peripheral pulses bilaterally prior to the test. Perform and document a baseline neurologic assessment. For angiography using peripheral puncture sites: Assess and document patients peripheral pulses bilaterally prior to the test. Mark the location of the pulses with a marking pen. Post-Test Most allergic reactions to radiopaque dye occur within 30 minutes of administration of the contrast medium. Observe the patient closely for: respiratory distress, hypotension, edema, hives, rash, tachycardia, and/o laryngeal stridor. Emergency resuscitation equipment must be readily accessible. A pressure dressing is applied to the puncture site. Check the dressing for bleeding and the area around the puncture site for swelling at frequent intervals. For angiography using peripheral puncture sites: The patient is to remain on bedrest for 812 hours with the affected extremity immobilized. Maintain pressure on the puncture site with a sandbag. Monitor vital signs every 15 minutes for one hour, then every 30 minutes for 2 hours, then every hour for 4 hours, and then every 4 hours. Monitor neurological status with each vital sign assessment. Monitor urinary output. Encourage fluid intake to promote dye excretion. Renal function should be assessed to be adequate before 17 | P a g e

metformin is restarted. Report abnormal findings to the primary care provider. Transcranial Ultrasonography Identifies problems with circulation, such as diminished blood flow or presence of atherosclerotic plaques. Normal Result/s Normal Doppler signal with no evidence of vessel occlusion Abnormal Result/s Arterial occlusion Arterial stenosis Arteriosclerosis Venous disease Venous occlusion The patient is assisted to a supine position on the ultrasonography table, with the head turned slightly to one side. The patient must remain very still during the exam. A coupling agent, such as a waterbased gel, is applied to the area to be evaluated. A transducer is placed on the skin and moved as needed to provide clearly emitted sounds. The sound waves are transformed into audible sounds which are then printed in graphic form. The patient is assisted into a sidelying position with the knees drawn up to the abdomen and the chin on the chest. This flexion of the spine provides easy access to the lumbar subarachnoid space. Assist the patient in maintaining the proper position by placing one arm around the patients knees and the other arm around his or her neck. The skin is cleansed and draped. A local anesthetic is administered to the area. Ask the patient to report any pain or tingling sensations throughout the procedure which may indicate irritation or puncture of a nerve root. The spinal needle is inserted in the midline, usually between the third and fourth lumbar vertebrae. The stylet is removed from the needle and a stopcock and manometer are attached to the needle to measure initial CSF pressure. A sample of the CSF is collected in a sterile container. Pre-test Explain to the patient the purpose of the test. Provide any written teaching materials available on the subject. Note that there is no discomfort involved with this test. Explain the importance of limiting movement during the test to ensure accurate measurements. No fasting is required prior to the test. Post-test Cleanse the patients skin of remaining coupling agent. Report abnormal findings to the primary care provider.

Lumbar Puncture with Cerebrospinal Fluid Analysis

Measures intracerebral pressure. Collected fluid analysis assists in diagnosis of cause of CVA.

Normal Result/s Cell count White blood cells: 05 mononuclear cells/L (05 106 cells/L SI units) Red blood cells: None Chloride: 110125 mEq/L (110125 mmol/L SI units) Color: Clear, colorless Glucose: 5075 mg/dL (2.84.2 mmol/L SI units) Pressure: 50180 mm H20 Protein: 1545 mg/dL (0.150.45 g/L SI units) Gamma globulin: 312% of total protein Abnormal Result/s Increased WBCs Abscess Acute infection Brain infarction Demyelinating disease Meningitis Onset of chronic illness Tumor Increased RBCs

Pre-test Explain to the patient the purpose of the test. Provide any written teaching materials available on the subject. Note that discomfort during the test is due to the injection of the local anesthetic and penetration of the dura mater with the needle The patient must remain still while the procedure is performed. No fasting is required before the procedure. Obtain a signed informed consent. Post-test Instruct the patient to maintain bedrest for 8 hours with no more than a 30 elevation of the head of the bed. This will help to minimize the occurrence of postlumbar puncture headache. Encourage the patient to take in fluids. Observe the puncture site for swelling and drainage and assess the movement and sensation to the lower extremities frequently for the first 4 hours after the procedure. Report abnormal findings to the primary care provider.

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Hemorrhage Traumatic tap Color Bloody: Subarachnoid, intracerebral, or intraventricular hemorrhage Spinal cord obstruction Traumatic tap Cloudy: Infection Protein in CSF Orange, yellow, or brown: Erythrocyte breakdown (old blood), elevated protein Increased Glucose Systemic Hyperglycemia Decreased Glucose Bacterial Infection Fungal Infection Meningitis Mumps Post-subarachnoid Hemorrhage Systemic Hypoglycemia TB Increased Pressure Hemorrhage Infection Trauma Tumor Decreased Pressure Diabetic Coma Shock Spinal Subarachnoid Obstruction Syncope

A final pressure reading is taken, and the needle is removed. A sterile dressing is applied to the puncture site. Gloves are worn throughout the procedure.

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Electrocardiogram

Electrocardiography is the recording of the electrical current generated by the heart. May be done to rule out cardiac origin as source of embolus.

Normal Result/s Normal rate, rhythm, and waveforms

Abnormal Result/s Bundle branch blocks Cardiac arrest Conduction defects Electrical impulses, Dysrhythmias generated by the heart during Electrolyte imbalances its depolarization and Myocardial infarction repolarization, are detected Myocardial ischemia by monitoring electrodes Pericarditis placed on the body. Ventricular hypertrophy

The patient is assisted to a supine position. The semi-Fowlers position may be used for patients with respiratory problems. The skin where electrodes are to be applied is cleansed with alcohol. Shaving of the skin may be needed to ensure proper adhesion of the electrodes. Electrodes are applied: One monitoring electrode is applied to the left arm, right arm, and left leg. A grounding electrode is placed on the right leg. A total of six electrode positions are used on the chest. The patient is to remain still while the recording is completed. Many ECG machines are now able to record all 12 leads simultaneously. The patient is assisted to a supine position on the padded table and moved into the MRI cylinder. The patient and MRI staff may communicate via microphone during the procedure. As the radio signals are switched on and off and images produced, the patient hears a variety of noises.

Pre-test Explain to the patient the purpose of the test and the need for electrodes to be attached to the chest and extremities. Note that the test causes no discomfort, but that the patient will need to lie still and not speak during the procedure. No fasting is required prior to the test. Post-test Remove the electrodes and cleanse the skin of any residual gel or adhesive. Report abnormal findings to the primary care provider.

Magnetic Resonance Imaging

Demonstrates structural abnormalities and presence of edema, hematoma, ischemia, and infarction.

Normal Result/s No evidence of pathology Abnormal Result/s Abscesses Arteriovenous malformation Atherosclerotic plaques Avascular necrosis Cerebral infarction Cerebral lesions Dementia Edema Hemorrhage Seizures Subarachnoid hemorrhage Tumor detection and staging

Pre-test Explain to the patient the purpose of the test and the procedure to be performed. Note that no radiation exposure is involved in this test. Explain that the patient will be moved into a large cylinder for the test and will need to remain completely still during the test. A variety of noises will be heard during the test. No fasting is required prior to the test. Obtain a signed informed consent. Pre-procedure medication with antianxiety drugs for those patients with claustrophobia may be needed. Remove all metal objects from the body, including medication patches, prior to the test. Instruct the patient to void prior to the test. Sedation may be ordered for patients who are very young, who are uncooperative, or who are claustrophobic. Post-test If sedation was given prior to the exam, ensure the patient is fully awake prior to ambulation. Report abnormal findings to the primary care provider.

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OTHER TESTS 1. Complete Blood Count 2. Platelet and Clotting Studies 3. Erythrocyte Sedimentation Rate 4. Metabolic panel

Various laboratory studies may be done to rule out systemic causes of stroke.

REFERENCES: Doenges et. al. (2008). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition. Smeltzer et. al. (2010). Brunner and Suddarths Medical Surgical Nursing, 12th edition. Wilson, N. D. (2008) Manual of Laboratory & Diagnostic Tests.

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MEDICAL MANAGEMENT: Pharmacology

DRUG Warfarin (Coumadin) Classification Oral Anticoagulant INDICATIONS Treatment of thromboembolic complications of atrial fibrillation with embolization, and cardiac valve replacement. MECHANISM OF ACTION Interferes with the hepatic synthesis of vitamin K dependent clotting factors (factors II-prothrombin, VII, IX, and X), resulting in their eventual depletion and prolongation of clotting times. DOSAGE Adults: Initially, 2.5 to 10 mg P.O. or I.V. daily for 2 to 4 days, then adjusted based on prothrombin time (PT) or International Normalized Ratio (INR). Usual maintenance dosage is 2 to 10 mg P.O. daily. ADVERSE REACTIONS GI: nausea, vomiting, diarrhea, abdominal cramps, stomatitis, anorexia GU: hematuria Hematologic: eosinophilia, bleeding, hemorrhage, agranulocytosis, leukopenia Hepatic: hepatitis Skin: rash, dermatitis, urticaria, pruritus, alopecia dermal necrosis Other: fever, purple toes syndrome (bilateral painful, purple lesions on toes and sides of feet), hypersensitivity reaction INTERACTIONS Drug-drug. Abciximab, acetaminophen (chronic use), androgens, aspirin, capecitabine, cefamandole, cefoperazone, cefotetan, chloral hydrate, chloramphenicol, clopidogrel, disulfiram, eptifibatide, fluconazole, fluoroquinolones, itraconazole, metronidazole (including vaginal use), nonsteroidal antiinflammatory drugs, plicamycin, quinidine, quinine, sulfonamides, thrombolytics, ticlopidine, tirofiban, valproic acid, zafirlukast: increased response to warfarin, greater risk of bleeding Barbiturates, hormonal contraceptives containing estrogen: decreased anti coagulant effect Drug-diagnostic tests. Alanine aminotransferase, aspartate aminotransferase, INR: increased values Partial thromboplastin time, PT: pro- longed Drug-food. Vitamin Krich foods (large amounts): antagonism of anticoagulant effect Drug-herbs. Angelica: prolonged PT Anise, arnica, asafetida, bromelain, chamomile, clove, danshen, devils claw, dong quai, NURSING CONSIDERATIONS Monitor PT, INR, and liver function tests. Watch for signs and symptoms of bleeding and hepatitis. Explain therapy to patient. Stress importance of adhering to schedule for laboratory tests. Instruct patient to promptly report unusual bleeding or bruising. Caution patient to consult prescriber before taking overthe-counter prepa- rations or herbs. Advise patient to inform all other health care providers (including dentist) that hes taking warfarin. Tell patient not to vary his intake of foods high in vitamin K (such as leafy green vegetables, fish, pork, green tea, and tomatoes), to avoid alterations in drugs anticoagulant effect. Instruct females of childbearing age to report pregnancy immediately. Stress importance of avoiding contact sports and other activities that could cause injury and bleeding. Caution patient to avoid alcohol during therapy.

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fenugreek, feverfew, garlic, ginger, ginkgo, ginseng, horse chestnut, licorice, meadowsweet, motherwort, onion, papain, parsley, passionflower, quassia, red clover, Reishi mushroom, rue, sweet clover, turmeric, white willow others: increased risk of bleeding Coenzyme Q10, green tea, St. Johns wort: decreased anticoagulant effect Drug-behaviors. Alcohol use: enhanced warfarin activity Aspirin (Aspergum) Classification Anti-inflammatory, antiplatelet, antipyretic, nonopioid analgesic To reduce the risk of recurrent transient ischemic attacks or stroke in men Aspirin inhibits platelet aggregation by interfering with production of thromboxane A2, a substance that stimulates platelet aggregation. Aspirin acts on the heat regulating center in the hypothalamus and causes peripheral vasodilation, diaphoresis, and heat loss. CHEWABLE TABLETS, CHEWING GUM, CONTROLLEDRELEASE TABLETS, ENTERICCOATED TABLETS, SOLUTION, TABLETS, TIMED-RELEASE TABLETS, SUPPOSITORIES Adults. 650 mg b.i.d. or 325 mg q.i.d. CNS: Confusion, CNS depression EENT: Hearing loss, tinnitus GI: Diarrhea, GI bleeding, heartburn, hepatotoxicity, nausea, stomach pain, vomiting HEME: Decreased blood iron level, leukopenia, prolonged bleeding time, shortened life span of RBCs, thrombocytopenia SKIN: Ecchymosis, rash, urticaria Other: Angioedema, Reyes syndrome, salicylism (dizziness, tinnitus, difficulty hearing, vomiting, diarrhea, confusion, CNS depression, diaphoresis, headache, hyperventilation, and lassitude) with regular use of large doses Drug-drug ACE inhibitors: Decreased antihypertensive effect activated charcoal: Decreased aspirin absorption antacids, urine alkalinizers: Decreased aspirin effectiveness anticoagulants: Increased risk of bleeding; prolonged bleeding time carbonic anhydrase inhibitors: Salicylism corticosteroids: Increased excretion and decreased blood level of aspirin heparin: Increased risk of bleeding ibuprofen: Possibly reduced cardioprotective and stroke preventive effects of aspirin methotrexate: Increased blood level and decreased excretion of methotrexate, causing toxicity nizatidine: Increased blood aspirin level NSAIDs: Possibly decreased blood NSAID level and increased risk of adverse GI effects sulfonylureas: Possibly Dont crush timed-release or controlledrelease aspirin tablets unless directed. Ask about tinnitus. This reaction usually occurs when blood aspirin level reaches or exceeds maximum for therapeutic effect. WARNING Advise parents not to give aspirin to a child or adolescent with chickenpox or flu symptoms because of risk of Reyes syndrome (rare lifethreatening reaction characterized by vomiting, lethargy, belligerence, delirium, and coma). Tell them to consult prescriber for alternative drugs. Advise adult patient taking lowdose aspirin not to also take ibuprofen because it may reduce the cardioprotective and stroke preventive effects of aspirin. Instruct patient to take aspirin with food or after meals because it may cause GI upset if taken on an empty stomach. Advise patient with tartrazine allergy not to take aspirin. Tell patient to consult prescriber before taking aspirin

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Alteplase (Activase rt-PA)

Acute Ischemic Stroke

Classification Thrombolytic

Binds to fibrin in a thrombus and converts trapped plasminogen to plasmin. Plasmin breaks down fibrin, fibrinogen, and other clotting factors, which dissolves the thrombus.

Acute Ischemic Stroke To avoid acute bleeding complications, treatment for acute ischemic stroke must begin within 3 hr after onset of stroke symptoms and only after computed tomography or other diagnostic imaging method excludes intracranial hemorrhage. I.V. INFUSION Adults. 0.9 mg/kg infused over 60 min, with 10% of total dose given as bolus over first min. Maximum: 90 mg.

CNS: Cerebral edema, cerebral herniation, fever, seizure, stroke CV: Arrhythmias (including bradycardia and electromechanical dissociation), cardiac arrest, cardiac tamponade, cardiogenic shock, cholesterol embolism, coronary thrombolysis, heart failure, hypotension, mitral insufficiency, myocardial reinfarction or rupture, pericardial effusion, pericarditis, venous thrombosis and embolism EENT: Epistaxis, gingival bleeding, laryngeal edema GI: GI bleeding, nausea, retroperitoneal bleeding, vomiting GU: GU bleeding RESP: Pleural effusion, pulmonary edema, pulmonary reembolization SKIN: Bleeding at puncture sites, ecchymosis, rash, urticaria Other: Anaphylaxis

enhanced effect of sulfonylureas with large doses of aspirin urine acidifiers (such as ammonium chloride, ascorbic acid): Decreased aspirin excretion vancomycin: Increased risk of ototoxicity Activities alcohol use: Increased risk of ulcers Drug-Drug drugs that alter platelet function, such as abciximab, acetylsalicylic acid, and dipyridamole; heparin; vitamin K antagonists: Increased risk of bleeding

with any prescription drug for blood disorder, diabetes, gout, or arthritis. Tell patient not to use aspirin if it has a strong vinegar-like odor.

WARNING To avoid acute bleeding complications, treatment for acute ischemic stroke must begin within 3 hr after onset of stroke symptoms and only after computed tomography or other diagnostic imaging method excludes intracranial hemorrhage. Immediately before use reconstitute alteplase with sterile water for injection only. Swirl gently to dissolve powder; dont shake. Monitor patient for bleeding, especially at arterial puncture sites. Monitor blood pressure and heart rate and rhythm frequently during and after therapy. WARNING Alteplase therapy may cause arrhythmias from sudden reperfusion of the myocardium.Monitor continuous ECG for arrhythmias during drug therapy. Minimize bleeding from noncompressible sites by avoiding internal jugular and subclavian venous puncture sites. Discontinue alteplase immediately if serious bleeding occurs. After administering alteplase, apply pressure for at least 30 minutes, followed by a pressure

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dressing. Store reconstituted solution at room temperature (about 86 F [30 C]) or refrigerated (36 to 46 F [2.2 to 7.7 C). Dipyridamole (Persantine) Classification Coronary vasodilator, diagnostic aid, platelet aggregation inhibitor To prevent thromboembolic complications of cardiac May increase the intraplatelet level of adenosine, which causes coronary vasodilation and inhibits platelet aggregation. Dipyridamole also may increase the intraplatelet level of cyclic adenosine monophosphate (cAMP) and may inhibit formation of the potent platelet activator stimulant thromboxane A2, which decreases platelet activation. Vasodilation and increased blood flow occur preferentially in nondiseased coronary vessels, which results in redistribution of blood away from significantly diseased vessels. These changes in perfusion are observed during thallium imaging studies. Binds to adenosine diphosphate (ADP) receptors on the surface of activated platelets. This action blocks ADP, which deactivates nearby glycoprotein IIb/IIIa receptors and prevents fibrinogen from attaching to receptors. Without fibrinogen, platelets cant aggregate and form TABLETS Adults. 75 to 100 mg q.i.d. with coumarin or indanedione derivative anticoagulant. CNS: Dizziness, headache CV: Angina, arrhythmias, ECG changes (specifically, ST-segment and T-wave changes) GI: Abdominal pain, diarrhea, nausea, vomiting RESP: Dyspnea SKIN: Flushing, pruritus, rash adenosine: Potentiated effects of adenosine cefamandole, cefoperazone, cefotetan, plicamycin, valproic acid: Possibly hypoprothrombinemia and increased risk of bleeding heparin, NSAIDs, thrombolytics: Possibly increased risk of bleeding theophylline: Reversal of coronary vasodilation caused by dipyridamole, possibly falsenegative thallium imaging result Protect I.V. form of dipyridamole from direct light and freezing. Monitor blood pressure, pulse rate and rhythm, and breath sounds every 10 to 15 minutes during I.V. infusion. Keep parenteral aminophylline available to relieve adverse reactions to dipyridamole infusion. At therapeutic doses, expect adverse reactions to be minimal and transient. They typically resolve with long-term use.

Clopidogrel (Plavix) Classification Platelet aggregation

To reduce atherosclerotic events, such as stroke and MI, in patients with atherosclerosis documented by recent stroke, MI, or peripheral artery disease

TABLETS Adults. Loading dose: 300 mg. Maintenance: 75 mg daily.

CNS: Confusion, depression, dizziness, fatigue, hallucinations, headache CV: Chest pain, edema, hypercholesterolemia, hypertension, hypotension, vasculitis EENT: Altered taste; conjunctival, ocular, or retinal bleeding; epistaxis; rhinitis; taste disorders GI: Abdominal pain; acute liver failure; colitis; diarrhea; duodenal, gastric, or peptic ulcer; elevated liver function test results; gastritis; indigestion; nausea; noninfectious hepatitis; pancreatitis GU: Elevated serum creatinine level, glomerulopathy, UTI

Drug-Drug DRUGS aspirin: Increased risk of bleeding CYP2C19 inhibitors, such as cimetidine, esomeprazole, etravirine, felbamate, fluconazole, fluoxetine, fluvoxamine, ketoconazole, omeprazole, ticlopidine, voriconazole: Decreased plasma clopidogrel level, decreased platelet inhibition fluvastatin, phenytoin, tamoxifen, tolbutamide, torsemide: Interference with metabolism

Avoid clopidogrel in patients who have a genetic variation in CYP2C19 or are receiving CYP2C19 inhibitors. Platelet inhibition may decline, increasing the risk of adverse cardiovascular effects after MI. Use clopidogrel cautiously in patients with severe hepatic or renal disease, risk of bleeding from trauma or surgery, or conditions that predispose to bleeding (such as peptic ulcer disease or thrombotic thrombocytopenic purpura). In patient with acute coronary syndrome, expect to give aspirin with clopidogrel.

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HEME: Agranulocytosis, aplastic anemia, neutropenia, pancytopenia, prolonged bleeding time, thrombocytopenic purpura, thrombotic thrombocytopenic purpura, unusual bleeding or bruising MS: Arthralgia, back pain, myalgia RESP: Bronchitis, bronchospasm, cough, dyspnea, interstitial pneumonitis, upper respiratory tract infection SKIN: Erythema multiforme, lichen planus, pruritus, purpura, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis Other: Anaphylaxis, angioedema, flulike symptoms, serum sickness Ticlopidine (Ticlid) Classification Antithrombotic, platelet aggregation inhibitor To reduce the risk of initial thrombotic stroke in patients who have experienced transient ischemic attack, to reduce the risk of recurrent stroke in patients who have previously experienced thrombotic stroke Normally, platelets dont adhere to bloodv vessel walls. However, when a thrombotic stroke or other disorder damages blood vessel walls, platelets are activated and adhere within seconds. Once activated, platelets release adenosine diphosphate (ADP). This causes fibrinogen to bind to glycoprotein IIb/IIIa (GP IIb/IIIa) receptors on the surface of activated platelets and connect with other activated platelets. Then a thrombus forms. Ticlopidine inhibits the release of ADP from activated platelets, which prevents fibrinogen from binding to GP IIb/IIIa receptors on the surface of activated platelets, as shown below. This action prevents platelets from aggregating to form a thrombus, which prevents thrombosis of an implanted stent or recurrence of stroke. TABLETS Adults. 250 mg b.i.d. CNS: Dizziness CV: Hypercholesterolemia, vasculitis EENT: Tinnitus GI: Abdominal pain, anorexia, diarrhea, elevated liver function test results, flatulence, indigestion, nausea, vomiting HEME: Agranulocytosis, aplastic anemia, hemolysis, hemolytic anemia, neutropenia, pancytopenia, thrombocytopenia, thrombotic thrombocytopenia, thrombotic thrombocytopenic purpura SKIN: Pruritus, purpura, rash Other: Hyponatremia, serum sickness like reaction

of these drugs NSAIDs: Increased risk of GI bleeding, interference with NSAID metabolism warfarin: Prolonged bleeding time, interference with warfarin metabolism

WARNING Clopidogrel prolongs bleeding time; expect to stop it 5 days before elective surgery. Obtain blood cell count, as ordered, whenever signs and symptoms suggest a hematologic problem. Monitor patient who takes aspirin closely because risk of bleeding is increased.

Drug-drug aluminum- and magnesiumcontaining antacids: Possibly decreased peak blood ticlopidine level antineoplastics, antithymocyte globulin, heparin, NSAIDs, oral anticoagulants, platelet aggregation inhibitors, salicylates, strontium-89 chloride, thrombolytics: Increased risk of bleeding cimetidine: Reduced clearance of ticlopidine, increased risk of adverse reactions cyclosporine, digoxin: Decreased blood level and possibly reduced effects of these drugs porfimer: Decreased effectiveness of porfimer photodynamic therapy xanthines (aminophylline, oxytriphylline, theophylline): Decreased theophylline clearance, increased risk of toxicity

Give ticlopidine with food to maximize GI absorption and minimize any GI distress. Avoid I.M. injections of other drugs because excessive bleeding, bruising, or hematoma may occur. During first 3 months of therapy, monitor CBC every 2 weeks, as ordered (more frequently in patients with depressed Neutrophil count). Be aware that ticlopidine therapy typically is used for patients with stroke or an increased risk of stroke who cant tolerate aspirin because of the risk of neutropenia or agranulocytosis. WARNING Be aware that ticlopidine therapy irreversibly affects platelet aggregation. Expect prescriber to discontinue drug 10 to 14 days before surgical procedures to prevent uncontrolled bleeding. Monitor serum cholesterol level during first month of ticlopidine therapy for expected increase. Hypercholesterolemia may persist for duration of treatment.

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Atorvastatin calcium (Lipitor) Classification Lipid-lowering Agent (statins)

Prevention of stroke and myocardial infarction in patients with type 2 diabetes who have multiple risk factors for CHD but without clinically evident CHD; Adjunct to diet for controlling LDL, total cholesterol, apo-lipoprotein B, and triglyceride levels and to in-crease HDL levels in patients with pri-mary hypercholesterolemia and mixed dyslipidemia; primary dysbetalipoproteinemia in patients unresponsive to diet alone; adjunct to diet to reduce elevated triglyceride levels

Inhibits HMG-CoA reductase, which catalyzes first step in cholesterol synthesis; this action reduces concentrations of serum cholesterol and low-density lipoproteins (LDLs), linked to increased risk of coronary artery disease (CAD). Also moderately increases concentration of highdensity lipoproteins (HDLs), associated with decreased risk of CAD.

Adults: Initially, 10 mg P.O. daily; in-crease to 80 mg P.O. daily if needed.

CNS: amnesia, abnormal dreams, emotional lability, headache, hyperactivity, poor coordination, malaise, paresthesia, peripheral neuropathy, drowsiness, syncope, weakness CV: orthostatic hypotension, palpitations, phlebitis, vasodilation, arrhythmias EENT: amblyopia, altered refraction, glaucoma, eye hemorrhage, dry eyes, hearing loss, tinnitus, epistaxis, sinusitis, pharyngitis GI: nausea, vomiting, diarrhea, constipation, abdominal cramps, abdominal or biliary pain, colitis, indigestion, dyspepsia, flatulence, stomach ulcers, gastroenteritis, melena, tenesmus, glossitis, mouth sores, dry mouth, dysphagia, esophagitis, pancreatitis, rectal hemorrhage GU: hematuria, nocturia, dysuria, urinary frequency or urgency, urinary retention, cystitis, nephritis, renal calculi, abnormal ejaculation, decreased libido, erectile dysfunction, epididymitis Hematologic: anemia, thrombocytopenia Hepatic: jaundice, hepatic failure, hepatitis Metabolic: hyperglycemia, hypoglycemia Musculoskeletal: bursitis, joint pain, back pain, leg cramps, gout, muscle pain or aches, myositis, myasthenia gravis, neck rigidity, torticollis, rhabdomyolysis Respiratory: dyspnea, pneumonia, bronchitis Skin: alopecia, acne, contact dermatitis, eczema, dry skin, pruritus, rash, urticaria, skin ulcers, seborrhea, photosensitivity, diaphoresis Other: taste loss, gingival bleeding, fever, facial paralysis, facial or generalized edema, flulike symptoms, infection, appetite changes, weight gain, allergic reaction

Drug-drug. Antacids, colestipol: decreased atorvastatin blood level Azole antifungals, cyclosporine, erythromycin, fibric acid derivatives, niacin, other HMG-CoA inhibitors: increased risk of myopathy Digoxin: increased digoxin level, greater risk of toxicity Hormonal contraceptives: increased estrogen level Drug-diagnostic tests. Alanine aminotransferase, aspartate aminotransferase, creatine kinase: increased levels Drug-food. Grapefruit juice: increased drug blood level, greater risk of adverse effects Drug-herbs. Red yeast rice: increased risk of adverse effects

Monitor patient for signs and symptoms of allergic response. Evaluate for muscle weakness (a symptom of myositis and possibly rhabdomyolysis). Monitor liver function test results and blood lipid levels. Tell patient he may take drug with or,without food. Advise patient to immediately report allergic response, irregular heartbeats, unusual bruising or bleeding,unusual tiredness, yellowing of skin or eyes, or muscle weakness. Instruct patient to avoid grapefruit juice during therapy. Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration, alertness, and vision. Advise patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of fluids. Inform patient taking hormonal contraceptives that drug increases estrogen levels. Instruct her to tell all prescribers shes taking drug.

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Vitamin (AquaMEPHYTON) Classification Vitamins

Hypoprothrombinemia secondary to vitamin K malabsorption, drug therapy, or excessive vitamin A dosage; hypoprothrombinemia secondary to effect of oral anticoagulants; prevention of hemorrhagic disease of newborn prevention of hypoprothrombonemia related to vitamin K deficiency for longterm parenteral nutrition; prevention of hypoprothrombinemia in infants receiving less than 0.1 mg/liter vitamin K in breast milk or milk substitute.

An antihemorrhagic actor that promotes hepatic formation of active prothrombin.

I.M. INJECTION Adults. 5 to 10 mg/wk. Children. 2 to 5 mg/wk.

dizziness, transient hypotension after IV administration, rapid and weak pulse, diaphoresis,flushing, erythema, pain, swelling and hematoma at injection site.

Warfarin (Coumadin: decrease the effectiveness of warfarin (Coumadin).

Captopril (Capoten) Classification Angiotensinconverting enzyme (ACE) inhibitor Anti-hypertensive

Hypertension

Prevents conversion of angiotensin I to angiotensin II, which leads to decreased vasoconstriction and, ultimately, to lower blood pressure. Also decreases blood pressure by increasing plasma renin secretion from kidney and reducing aldosterone secretion from adrenal cortex. Decreased aldosterone secretion prevents sodium and water retention.

Adults: 12.5 to 25 mg P.O. two to three times daily; may be increased up to 150/mg/day at 1to 2-week intervals. Usual dosage is 50 mg t.i.d. If patient is receiving diuretics, start with 6.25 to 12.5 mg P.O. two to three times daily. If blood pressure isnt adequately controlled after 1 to 2 weeks, add diuretic, as prescribed. If further blood pressure decrease is needed, dosage may be raised to 150 mg P.O. t.i.d. while patient continues on diuretic. Maximum dosage is 450 mg/day.

CNS: headache, dizziness, drowsiness, fatigue, weakness, insomnia CV: angina pectoris, tachycardia, hypotension EENT: sinusitis GI: nausea, diarrhea, anorexia GU: proteinuria, erectile dysfunction, decreased libido, gynecomastia, renal failure Hematologic: anemia, agranulocytosis, leukopenia, pancytopenia, thrombocytopenia Metabolic: hyperkalemia Respiratory: cough, asthma, bronchitis, dyspnea, eosinophilic pneumonitis Skin: rash, angioedema Other: altered taste, fever

Drug-drug. Allopurinol: increased risk of hypersensitivity reaction Antacids: decreased captopril absorption Antihypertensives, general anesthetics that lower blood pressure, nitrates, phenothiazines: additive hypotension Cyclosporine: hyperkalemia Digoxin, lithium: increased blood levels of these drugs, increased risk of toxicity Epoetin alfa: additive hyperkalemia Indomethacin: reduced antihypertensive effect of captopril

Be aware that severe adverse reactions, including anaphylaxis, cardiac and respiratory arrest, hypersensitivity, and shock, may occur during or immediately after I.M. or I.V. administration of vitamin K1, even if its diluted to avoid rapid infusion. Administer vitamin by SubQ route whenever possible. If vitamin K1 must be administered I.V., do not exceed rate of 1 mg/min, as prescribed. Be aware that some vitamin K1 solutions contain benzyl alcohol.Dont administer these solutions to neonates or immature infants because of a risk of fatal toxic syndrome, which may include CNS, respiratory, circulatory, and renal impairment and metabolic acidosis. Take precautions to protect vitamin K1 solution from exposure to light becauseits light sensitive. Monitor for sudden blood pressure drop within 3 hours of initial dose if patient is receiving concurrent diuretics and on a low-sodium diet. Monitor hematologic, kidney, an liver function test results. Check for proteinuria monthly and after first 9 months of therapy. Tell patient to take drug 1 hour before meals on empty stomach. Advise patient to report fever, rash, sore throat, mouth sores, fast or irregular heartbeat, chest pain, or cough. Inform patient that dizziness, fainting, and lightheadedness usually disappear once his body adjusts to drug. Tell patient his ability to taste

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Mannitol (Osmitrol) Classification

To reduce intracranial or intraocular pressure

Elevates plasma osmolality, causing water to flow from tissues, such as brain and eyes, and from CSF, into extracellular fluid, thereby decreasing intracranial and intraocular pressure. As an osmotic diuretic, mannitol increases the osmolarity of glomerular filtrate, which decreases water reabsorption. This leads to increased excretion of water, sodium, chloride, and toxic substances. As an irrigant, mannitol minimizes the hemolytic effects of water used as an irrigant and reduces the

I.V. INFUSION Adults and adolescents. 0.25 to 2 g/kg as 15% to 25% solution given over 30 to 60 min. If used before eye surgery, 1.5 to 2 g/kg 60 to 90 min before procedure. Maximum: 6 g/kg daily. DOSAGE ADJUSTMENT For small or debilitated patients, dosage reduced to 0.5 g/kg.

CNS: Chills, dizziness, fever, headache, seizures CV: Chest pain, heart failure, hypertension, tachycardia, thrombophlebitis EENT: Blurred vision, dry mouth, rhinitis GI: Diarrhea, nausea, thirst, vomiting GU: Polyuria, urine retention RESP: Pulmonary edema SKIN: Extravasation with edema and tissue necrosis, rash, urticaria Other: Dehydration, hyperkalemia, hypernatremia, hypervolemia, hypokalemia, hyponatremia (dilutional), metabolic acidosis, water intoxication

Nonsteroidal anti-inflammatory drugs: decreased antihypertensive response Potassium-sparing diuretics, potassium supplements: hyperkalemia Probenecid: decreased elimination and increased blood level of captopril Drug-diagnostic tests. Alanine amino- transferase, alkaline phosphatase, aspartate aminotransferase, bilirubin, blood urea nitrogen, creatinine, potassium: increased levels Granulocytes, hemoglobin, platelets, red blood cells, sodium, white blood cells: decreased levels Urine acetone: false-positive result Drug-food. Any food: decreased captopril absorption Salt substitutes containing potassium: hyperkalemia Drug-herbs. Capsaicin, yohimbine: cough Drug-behaviors. Acute alcohol ingestion: additive hypotension Drug-drug. digoxin: Increased risk of digitalis toxicity from hypokalemia diuretics: Possibly increased therapeutic effects of mannitol

may decrease during first 2 to 3 months of therapy. Caution patient to avoid overthe- counter medications unless approved by prescriber. As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, herbs, and behaviors mentioned above.

If crystals form in mannitol solution exposed to low temperature, place solution in hot-water bath to redissolve crystals. Use a 5-micron in-line filter when administering drug solution of 15% or greater. During I.V. infusion of mannitol, monitor vital signs, central venous pressure, and fluid intake and output every hour. Measure urine output with indwelling urinary catheter, as appropriate. Check weight and monitor BUN and serum creatinine electrolyte levels daily. Provide frequent mouth care to

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Furosemide (Lasix) Classification Antihypertensive, diuretic

To manage mild to moderate hypertension, as adjunct to treat acute pulmonary edema and hypertensive crisis

movement of hemolyzed blood from the urethra to the systemic circulation, which prevents hemoglobinemia and serious renal complications. Inhibits sodium and water reabsorption in the loop of Henle and increases urine formation. As the bodys plasma volume decreases, aldosterone production increases, which promotes sodium reabsorption and the loss of potassium and hydrogen ions. Furosemide also increases the excretion of calcium, magnesium, bicarbonate, ammonium, and phosphate. By reducing intracellular and extracellular fluid volume, the drug reduces blood pressure and decreases cardiac output. Over time, cardiac output returns to normal.

relieve thirst and dry mouth.

ORAL SOLUTION, TABLETS Adults. Initial: 40 mg b.i.d., adjusted until desired response occurs. Maximum: 600 mg daily. I.V. INFUSION OR INJECTION Adults with normal renal function. 40 to 80 mg as a single dose over several minutes. Adults with acute renal failure or pulmonary edema. 100 to 200 mg as a single dose over several minutes. DOSAGE ADJUSTMENT For patients with acute pulmonary edema without hypertensive crisis, dosage reduced to 40 mg followed by 80 mg 1 hr later if therapeutic response doesnt occur.

CNS: Dizziness, fever, headache, paresthesia, restlessness, vertigo, weakness CV: Orthostatic hypotension, shock, thromboembolism, thrombophlebitis EENT: Blurred vision, oral irritation, ototoxicity, stomatitis, tinnitus, transient hearing loss (rapid I.V. injection), yellow vision ENDO: Hyperglycemia GI: Abdominal cramps, anorexia, constipation, diarrhea, gastric irritation, hepatocellular insufficiency, indigestion, jaundice, nausea, pancreatitis, vomiting GU: Bladder spasms, glycosuria HEME: Agranulocytosis (rare), anemia, aplastic anemia (rare), azotemia, hemolytic anemia, leukopenia, thrombocytopenia MS: Muscle spasms SKIN: Bullous pemphigoid, erythema multiforme, exfoliative dermatitis, photosensitivity, pruritus, purpura, rash, urticaria Other: Allergic reaction (interstitial nephritis, necrotizing vasculitis, systemic vasculitis), dehydration, hyperuricemia, hypochloremia, hypokalemia, hyponatremia, hypovolemia

Drug-drug. ACE inhibitors: Possibly firstdose hypotension aminoglycosides, cisplatin: Increased risk of ototoxicity amiodarone: Increased risk of arrhythmias from hypokalemia chloral hydrate: Possibly diaphoresis, hot flashes, and hypertension digoxin: Increased risk of digitalis toxicity related to hypokalemia insulin, oral antidiabetic drugs: Increased blood glucose level lithium: Increased risk of lithium toxicity NSAIDs: Possibly decreased diuresis phenytoin, probenecid: Possibly decreased therapeutic effects of furosemide propranolol: Possibly increased blood propranolol level thiazide diuretics: Possibly profound dieresis and electrolyte imbalances ACTIVITIES alcohol use: Possibly increased hypotensive and diuretic effects of furosemide

WARNING Use furosemide cautiously in patients with advanced hepatic cirrhosis, especially those who also have a history of electrolyte imbalance or hepatic encephalopathy; drug may lead to lethal hepatic coma. Obtain patients weight before and periodically during furosemide therapy to monitor fluid loss. For once-a-day dosing, give drug in the morning so patients sleep wont be interrupted by increased need to urinate. Prepare drug for infusion with normal saline solution, lactated Ringers solution, or D5W. Administer drug slowly I.V. over 1 to 2 minutes to prevent ototoxicity. Expect patient to have periodic hearing tests during prolonged or high-dose I.V. therapy. Monitor blood pressure and hepatic and renal function as well as BUN, blood glucose, and serum creatinine, electrolyte, and uric acid levels, as appropriate. Be aware that elderly patients are more susceptible to hypotensive and electrolytealtering effects and thus are at greater risk for shock and thromboembolism. If patient is at high risk for hypokalemia, give potassium supplements along with furosemide, as prescribed. Expect to discontinue furosemide at maximum dosage if oliguria persists for more than 24 hours.

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 Be aware that furosemide may worsen left ventricular hypertrophy and adversely affect glucose tolerance and lipid metabolism. Notify prescriber if patient experiences hearing loss, vertigo, or ringing, buzzing, or sense of fullness in her ears. Drug may need to be discontinued.

REFERENCE: Learning, Jones and Barlett (2011). Nurses Drug Handbook, 10th edition.

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NURSING CARE PLANS

PRIORITY: Number 1
Nursing Diagnosis: Ineffective cerebral tissue perfusion May be related to: Interruption of blood flowocclusive disorder, hemorrhage; cerebral vasospasm, cerebral edema Cause Analysis: Cerebrovascular disorders is an umbrella term that refers to a functional abnormality of the central nervous system (CNS) that occurs when the normal blood supply to the brain is disrupted. In ischemic stroke, significant hypoperfusion occur because of vascular occlusion. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1896) Cues Objective Cues Altered LOC; memory loss Changes in motor or sensory responses; restlessness Sensory, language, intellectual, and emotional deficits Changes in vital signs Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Demonstrate stable vital signs and absence of signs of increased ICP. Display no further deterioration or recurrence of deficits. Long-term Objective Within 3 days of providing nursing interventions, the patient will: Maintain usual or improved LOC, cognition, and motor and sensory function. Independent Determine factors related to individual situation, cause for coma, decreased cerebral perfusion, and potential for ICP. Influences choice of interventions. Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity, which requires that client be admitted to critical care area for monitoring of ICP and for specific therapies geared to maintaining ICP within a specified range. If the stroke is evolving, client can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is completed, the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence. Assesses trends in LOC and potential for increased ICP and is useful in determining location, extent, and progression or resolution of CNS damage. May also reveal TIA, which may resolve with no further symptoms or may precede thrombotic CVA. Nursing Interventions Rationale

Monitor and document neurological status frequently and compare with baseline. (Refer to CP: Craniocerebral TraumaAcute Rehabilitative Phase, ND: ineffective cerebral tissue Perfusion for complete neurological evaluation. Monitor vital signs noting: Hypertension or hypotension; compare blood pressure (BP) readings in both arms

Fluctuations in pressure may occur because of cerebral pressure or injury in vasomotor area of the brain. Hypertension or hypotension may have been a precipitating factor. Hypotension may follow stroke because of circulatory collapse. Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA, for example, stroke after MI or from valve dysfunction. Irregularities can suggest location of cerebral insult or increased ICP and need for further intervention, including possible respiratory support. (Refer to CP: Craniocerebral TraumaAcute Rehabilitative Phase, ND: risk for ineffective Breathing Pattern.) Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brainstem is intact. Pupil size and equality is determined by balance between parasympathetic and sympathetic enervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves. Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions.

Heart rate and rhythm; auscultate for murmurs

Respirations, noting patterns and rhythmperiods of apnea after hyperventilation, Cheyne-Stokes respiration

Evaluate pupils, noting size, shape, equality, and light reactivity.

Document changes in vision, such as reports of blurred vision and alterations in visual field or depth perception.

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Assess higher functions, including speech, if client is alert. (Refer to ND: impaired verbal [and/or written] Communication.) Position with head slightly elevated and in neutral position.

Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate increased ICP. Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation and perfusion. Continual stimulation can increase ICP. Absolute rest and quiet may be needed to prevent recurrence of bleeding, in the case of hemorrhagic stroke.

Maintain bedrest, provide quiet environment, and restrict visitors or activities, as indicated. Provide rest periods between care activities, limiting duration of procedures. Prevent straining at stool or holding breath.

Valsalvas maneuver increases ICP and potentiates risk of bleeding.

Assess for nuchal rigidity, twitching, increased restlessness, irritability, and onset of seizure activity. Collaborative Administer supplemental oxygen, as indicated. Administer medications, as indicated, for example Intravenous thrombolytics, such as tissue plasminogen activator (tPA), alteplase (Activase), and recombinant prourokinase (Prourokinase)

Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures may reflect increased ICP or reflect location and severity of cerebral injury, requiring further evaluation and intervention.

Reduces hypoxemia.

As the only proven therapy for early acute ischemic stroke, tPA is useful in minimizing the size of the infarcted area by opening blocked vessels that are occluded with clot. Treatment must be started within 3 hours of initial symptoms to improve outcomes. Note: These agents are contraindicated in several instancesintracranial hemorrhage as diagnosed by CT scan, recent intracranial surgery, serious head trauma, and uncontrolled hypertension. May be used to improve cerebral blood flow and prevent further clotting when embolus or thrombosis is the problem.

Anticoagulants, such as warfarin sodium (Coumadin); lowmolecular- weight heparin, for example, enoxaparin (Lovenox) and dalteparin (Fragmin); and direct thrombin inhibitor, such as ximelagatran (Exanta) Antiplatelet agents, such as aspirin (ASA), aspirin with extended-release dipyridamole (Aggrenox), ticlopidine (Ticlid), and clopidogrel (Plavix)

Antiplatelet agents are used following an ischemic stroke or TIA.

Antihypertensives

Preexisting or chronic hypertension requires cautious treatment because aggressive management increases the risk of extension of tissue damage during an evolving stroke. Transient hypertension often occurs during acute stroke and usually resolves without therapeutic intervention. Used to improve collateral circulation or decrease vasospasm.

Peripheral vasodilators, such as cyclandelate (Cyclospasmol), papaverine (Pavabid), and isoxsuprine (Vasodilan) Neuroprotective agents, such as calcium channel blockers, excitatory amino acid inhibitors, and gangliosides

These agents are being researched as a means to protect the brain by interrupting the destructive cascade of biochemical eventsinflux of calcium into cells, release of excitatory neurotransmitters, buildup of lactic acidto limit ischemic injury.

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Phenytoin (Dilantin) and Phenobarbital.

May be used to control seizures and for sedative action. Note: Phenobarbital enhances action of antiepileptics. May be necessary to resolve hemorrhagic situation and reduce neurological symptoms and risk of recurrent stroke. Provides information about effectiveness and therapeutic level of anticoagulants when used.

Prepare for surgery, as appropriatecarotid endarterectomy, microvascular bypass, and cerebral angioplasty. Monitor laboratory studies as indicated, such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and Dilantin level. References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p242-244

PRIORITY: Number 2
Nursing Diagnosis: Impaired physical Mobility May be related to: Neuromuscular involvement: weakness, paresthesia; flaccid, hypotonic paralysis (initially); spastic paralysis, Perceptual or cognitive impairment Cause Analysis: A stroke is an upper motor neuron lesion and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate (cross), a disturbance of voluntary motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1897) Cues Objective Cues Inability to purposefully move within the physical environment Impaired coordination Limited range of motion (ROM), Decreased muscle strength and control Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Maintain or increase strength and function of affected or compensatory body part. Maintain optimal position of function as evidenced by absence of contractures and footdrop. Long-term Objective Within 3 days of providing nursing interventions, the client will: Demonstrate techniques and behaviors that enable resumption of activities. Maintain skin integrity. Independent Positioning Assess functional ability and extent of impairment initially and on a regular basis. Classify according to a 0 to 4 scale. (Refer to CP: Craniocerebral TraumaAcute Rehabilitative Phase, ND: impaired physical Mobility.) Change positions at least every 2 hours (supine, side lying) and possibly more often if placed on affected side. Nursing Interventions Rationale

Identifies strengths and deficiencies and may provide information regarding recovery. Assists in choice of interventions because different techniques are used for flaccid and spastic types of paralysis. Reduces risk of tissue ischemia and injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown and pressure ulcers. Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe. Prevents contractures and footdrop and facilitates use when or if function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side. During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and shoulder-hand syndrome. Flexion contractures occur because flexor muscles are stronger than extensors. Prevents adduction of shoulder and flexion of elbow. Promotes venous return and helps prevent edema formation. Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in a functional position. Maintains functional position. Prevents external hip rotation. Continued use after change from flaccid to spastic paralysis can cause excessive pressure on the ball of the foot, enhance spasticity, and actually increase plantar flexion.

Position in prone position once or twice a day if client can tolerate.

Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head.

Use arm sling when client is in upright position, as indicated.

Evaluate use of and need for positional aids and splints during spastic paralysis: Place pillow under axilla to abduct arm. Elevate arm and hand. Place hard hand-rolls in the palm with fingers and thumb opposed.

Place knee and hip in extended position. Maintain leg in neutral position with a trochanter roll. Discontinue use of footboard, when appropriate.

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Observe affected side for color, edema, or other signs of compromised circulation. Inspect skin regularly, particularly over bony prominences.

Edematous tissue is more easily traumatized and heals more slowly.

Pressure points over bony prominences are most at risk for decreased perfusion and ischemia. Circulatory stimulation and padding help prevent skin breakdown and decubitus ulcer development.

Gently massage any reddened areas and provide aids such as sheepskin pads, as necessary.

Exercise Therapy: Muscle Control Begin active or passive ROM to all extremities (including splinted) on admission. Encourage exercises, such as quadriceps or gluteal exercise, squeezing rubber ball, and extension of fingers and legs and feet. Minimizes muscle atrophy, promotes circulation, and helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. Note: Excessive and imprudent stimulation can predispose to recurrence of bleeding. Aids in retraining neuronal pathways, enhancing proprioception and motor response.

Assist client to develop sitting balance (such as raise head of bed; assist to sit on edge of bed, having client use the strong arm to support body weight and strong leg to move affected leg; increase sitting time) and standing balance put flat walking shoes on client, support clients lower back with hands while positioning own knees outside clients knees, and assist in using parallel bars and walker. Get client up in chair as soon as vital signs are stable except following cerebral hemorrhage.

Helps stabilize BP, restoring vasomotor tone, and promotes maintenance of extremities in a functional position and emptying of bladder and kidneys, reducing risk of urinary stones and infections from stasis. Note: If stroke is not completed, activity increases risk of additional bleeding and infarction. Reduces pressure on the coccyx and prevents skin breakdown.

Pad chair seat with foam or water-filled cushion, and assist client to shift weight at frequent intervals. Set goals with client/significant other (SO) for increasing participation in activities, exercise, and position changes. Encourage client to assist with movement and exercises using unaffected extremity to support and move weaker side. Collaborative Positioning Provide egg-crate mattress, water bed, flotation device, or specialized bed, such as kinetic, as indicated.

Promotes sense of expectation of progress and improvement, and provides some sense of control and independence. May respond as if affected side is no longer part of body and need encouragement and active training to reincorporate it as a part of own body.

Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown and pressure ulcer formation. Specialized beds help with positioning, enhance circulation, and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia. Individualized program can be developed to meet particular needs and deal with deficits in balance, coordination, and strength. May assist with muscle strengthening and increase voluntary muscle control, as well as pain control. May be required to relieve spasticity in affected extremities.

Exercise Therapy: Muscle Control Consult with physical therapist regarding active, resistive exercises and client ambulation. Assist with electrical stimulationtranscutaneous electrical nerve stimulator (TENS) unit, as indicated. Administer muscle relaxants and antispasmodics as indicated, such as baclofen (Lioresal) and dantrolene (Dantrium). References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p244-245

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PRIORITY: Number 3
Nursing Diagnosis: Impaired verbal [and/or written] Communication May be related to: Impaired cerebral circulation; neuromuscular impairment, loss of facial or oral muscle tone and control; generalized weakness and fatigue Cause Analysis: The cortical area that is responsible for integrating the myriad pathways required for the comprehension and formulation of language is called Brocas area. It is located in a convolution adjoining the middle cerebral artery. This area is responsible for control of the combinations of muscular movements needed to speak each word. Brocas area is so close to the left motor area that a disturbance in the motor area often affects the speech area. This is why so many patients who are paralyzed on the right side (due to damage or injury to the left side of the brain) cannot speak, whereas those paralyzed on the left side are less likely to have speech disturbances. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1908) Cues Objective Cues Impaired articulation; soft speech or does not or cannot speak Inability to modulate speech, find and name words, identify objects; inability to comprehend written or spoken language, global Aphasia Inability to produce written communication, expressive aphasia Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Be able Indicate understanding of the communication problems. Long-term Objective Within 3 days of providing nursing interventions, the client will: Establish method of communication in which needs can be expressed. Use resources appropriately. Differentiate aphasia from dysarthria. Independent Assess type and degree of dysfunction, such as receptive aphasiaclient does not seem to understand words, or expressive aphasiaclient has trouble speaking or making self understood: Helps determine area and degree of brain involvement and difficulty client has with any or all steps of the communication process. Client may have trouble understanding spoken words (damage to Wernickes speech area), speaking words correctly (damage to Brocas speech areas), or may experience damage to both areas. Choice of interventions depends on type of impairment. Aphasia is a defect in using and interpreting symbols of language and may involve sensory and/or motor components, such as inability to comprehend written or spoken words or to write, make signs, and speak. A dysarthric person can understand, read, and write language, but has difficulty forming or pronouncing words because of weakness and paralysis of oral musculature, resulting in softly spoken speech. Client may lose ability to monitor verbal output and be unaware that communication is not sensible. Feedback helps client realize why caregivers are not understanding and responding appropriately and provides opportunity to clarify content and meaning. Tests for receptive aphasia. Nursing Interventions Rationale

Listen for errors in conversation and provide feedback.

Ask client to follow simple commands, such as Shut your eyes, Point to the door; repeat simple words or sentences. Point to objects and ask client to name them. Have client produce simple sounds, such as sh, cat.

Tests for expressive aphasiaclient may recognize item but not be able to name it. Identifies dysarthria because motor components of speech (tongue, lip movement, breath control) can affect articulation and may or may not be accompanied by expressive aphasia. Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia. Allays anxiety related to inability to communicate and fear that needs will not be met promptly. Call bell that is activated by minimal pressure is useful when client is unable to use regular call system. Provides for communication of needs or desires based on individual situation or underlying deficit.

Ask client to write name and/or a short sentence. If unable to write, have client read a short sentence. Post notice at nurses station and clients room about speech impairment. Provide special call bell if necessary.

Provide alternative methods of communication, such as writing or felt board and pictures. Provide visual cluesgestures, pictures, needs list, and demonstration. Anticipate and provide for clients needs.

Helpful in decreasing frustration when dependent on others and unable to communicate desires. Reduces confusion and anxiety at having to process and respond to large amount of information at one time. As retraining progresses, advancing complexity of

Talk directly to client, speaking slowly and distinctly. Use yes/no questions to start, progressing in complexity as client responds.

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communication stimulates memory and further enhances word and idea association. Speak with normal volume and avoid talking too fast. Give client ample time to respond. Talk without pressing for a response. Client is not necessarily hearing impaired and raising voice may irritate or anger client. Forcing responses can result in frustration and may cause client to resort to automatic speech, such as garbled speech and obscenities. It is important for family members to continue talking to client to reduce clients isolation, promote establishment of effective communication, and maintain sense of connectedness with family. Promotes meaningful conversation and provides opportunity to practice skills. Enables client to feel esteemed because intellectual abilities often remain intact.

Encourage SO and visitors to persist in efforts to communicate with client, such as reading mail and discussing family happenings even if client is unable to respond appropriately. Discuss familiar topicsjob, family, hobbies, and current events. Respect clients preinjury capabilities; avoid speaking down to client or making patronizing remarks.

Collaborative Consult with or refer to speech therapist. Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits and therapy needs.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p246-247

PRIORITY: Number 4
Nursing Diagnosis: Disturbed Sensory Perception May be related to: Altered sensory reception, transmission, integrationneurological trauma or deficit Psychological stressnarrowed perceptual fields caused by anxiety Cause Analysis: Perception is the ability to interpret sensation. Stroke can result in visual-perceptual dysfunctions, disturbances in visual- spatial relations, and sensory loss. Sensory Impairment can result from a lesion anywhere from the brainstem to the cortex. The higher up the brain injury, the more likely discriminative sensory functions, such as recognition of shape, size or weight of objects are impaired, as opposed to primary sensations of touch, temperature or pain. Impairment may result in the patient being unable to feel a particular sensation, or they may have a crude awareness of a sensation but be unable to differentiate intensities or the qualities of the stimulus. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1897) Cues Objective Cues Disorientation to time, place, person Change in behavior pattern and usual response to stimuli; exaggerated emotional responses Poor concentration, altered thought processes, bizarre thinking Reported or measured change in sensory acuity: hypoparesthesia, altered sense of taste or smell Inability to tell position of body parts (proprioception) Inability to recognize or attach meaning to objects (visual agnosia) Altered communication patterns Motor incoordination Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Acknowledge changes in ability and presence of residual involvement. Demonstrate behaviors to compensate for or overcome deficits. Independent Environmental Management Review pathology of individual condition. Nursing Interventions Rationale

Awareness of type and area of involvement aids in assessing for and anticipating specific deficits and planning care. Individual responses are variable, but commonalities, such as emotional lability, lowered frustration threshold, apathy, and impulsiveness, may complicate care. Eight-level Los Ranchos Scale aids in documenting progress during initial weeks following insult. Reduces anxiety and exaggerated emotional responses and confusion associated with sensory overload. Client may have limited attention span or problems with comprehension. These measures can help client attend to communication. Assists client to identify inconsistencies in reception and integration of stimuli and may reduce perceptual distortion of reality.

Observe behavioral responses such as hostility, crying, inappropriate affect, agitation, and hallucination by using Los Ranchos Scale, as appropriate. (Refer to CP: Craniocerebral TraumaAcute Rehabilitative Phase, ND: disturbed Thought Processes.) Eliminate extraneous noise and stimuli as necessary.

Long-term Objective Within 3 days of providing nursing interventions, the client will: Regain and maintain usual LOC and perceptual functioning.

Speak in calm, quiet voice, using short sentences. Maintain eye contact. Ascertain and validate clients perceptions. Reorient client frequently to environment, staff, and procedures.

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Evaluate for visual deficits. Note loss of visual field, changes in depth perception (horizontal or vertical planes), and presence of diplopia Approach client from visually intact side. Leave light on; position objects to take advantage of intact visual fields. Patch affected eye or encourage wearing of prism glasses if indicated. Peripheral Sensation Management Assess sensory awareness, such as differentiation of hot and cold, dull or sharp, position of body parts, and muscle and joint sense.

Presence of visual disorders can negatively affect clients ability to perceive environment and relearn motor skills and increases risk of accident and injury. Provides for recognition of the presence of persons or objects; may help with depth perception problems; and prevents client from being startled. Patching may decrease the sensory confusion of double vision, and prism glasses may enhance vision across midline, decreasing neglect of affected side. Diminished sensory awareness and impairment of kinesthetic sense negatively affects balance and positioning (proprioception) and appropriateness of movement, which interferes with ambulation, increasing risk of trauma. Aids in retraining sensory pathways to integrate reception and interpretation of stimuli. Helps client orient self spatially and strengthens use of affected side. Promotes client safety, reducing risk of injury.

Stimulate sense of touchgive client objects to touch and grasp. Have client practice touching walls or other boundaries. Protect from temperature extremes; assess environment Recommend testing warm water with unaffected hand. for hazards.

Note inattention to body parts and segments of environment and lack of recognition of familiar objects or persons.

Presence of agnosia (loss of comprehension of auditory, visual, or other sensations, although sensory sphere is intact) may lead to unilateral neglect, inability to recognize environmental cues or meaning of commonplace objects, considerable self-care deficits, and disorientation or bizarre behavior. Use of visual and tactile stimuli assists in reintegration of affected side and allows client to experience forgotten sensations of normal movement patterns.

Encourage client to watch feet when appropriate and consciously position body parts. Make client aware of all neglected body parts using sensory stimulation to affected side and exercises that bring affected side across midline, reminding person to dress and or care for affected (blind) side.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p247-248

PRIORITY: Number 5
Nursing Diagnosis: Self-Care Deficit May be related to: Neuromuscular impairment, decreased strength and endurance, loss of muscle control and coordination, Perceptual or cognitive impairment, Pain, discomfort, Depression Cause Analysis: As many as 72% of patients who have had a stroke have pain in the shoulder (Duncan, Zorowitz, Bates, et al., 2005). That pain may prevent them from learning new skills and affect their quality of life. Shoulder function is essential in achieving balance and performing transfers and self-care activities. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1906) Cues Objective Cues Impaired ability to perform ADLs, such as inability to bring food from receptacle to mouth; inability to wash body part(s) or regulate temperature of water; impaired ability to put on and take off clothing; difficulty completing toileting tasks Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Demonstrate techniques and lifestyle changes to meet self-care needs. Independent Self-Care Assistance Assess abilities and level of deficit (0 to 4 scale) for performing ADLs. Avoid doing things for client that client can do for self, providing assistance as necessary. Nursing Interventions Rationale

Aids in anticipating and planning for meeting individual needs. These clients may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for client to do as much as possible for self to maintain self-esteem and promote recovery. May indicate need for additional interventions and supervision to promote client safety. Clients need empathy and to know caregivers will be consistent in their assistance.

Long-term Objective Within 3 days of providing nursing interventions, the client will: Perform self-care activities within level of own ability.

Be aware of impulsive behavior or actions suggestive of impaired judgment.

Maintain a supportive, firm attitude. Allow client sufficient time to accomplish tasks.

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 Identify personal and community resources that can provide assistance as needed.

Provide positive feedback for efforts and accomplishments. Create plan for visual deficits that are present, such as the following: Place food and utensils on the tray related to clients unaffected side Situate the bed so that clients unaffected side is facing the room with the affected side to the wall Position furniture against wall, out of travel path

Enhances sense of self-worth, promotes independence, and encourages client to continue endeavors. Client will be able to see to eat the food. Will be able to see when getting in or out of bed and observe anyone who comes into the room. Provides for safety when client is able to move around the room, reducing risk of tripping and falling over furniture. Enables client to manage for self, enhancing independence and self-esteem; reduces reliance on others for meeting own needs; and enables client to be more socially active.

Provide self-help devices, such as button or zipper hook, knifefork combinations, long-handled brushes, extensions for picking things up from floor, toilet riser, leg bag for catheter, and shower chair. Assist and encourage good grooming and makeup habits. Encourage SO to allow client to do as much as possible for self.

Reestablishes sense of independence and fosters self-worth and enhances rehabilitation process. Note: This may be very difficult and frustrating for the SO/caregiver, depending on degree of disability and time required for client to complete activity. Client may have neurogenic bladder, be inattentive, or be unable to communicate needs in acute recovery phase, but usually is able to regain independent control of this function as recovery progresses. Assists in development of retraining program (independence) and aids in preventing constipation and impaction (longterm effects).

Assess clients ability to communicate the need to void and ability to use urinal or bedpan. Take client to the bathroom at frequent and scheduled intervals for voiding if appropriate. Identify previous bowel habits and reestablish normal regimen. Increase bulk in diet. Encourage fluid intake and increased activity.

Collaborative Administer suppositories and stool softeners. Consult with rehabilitation team, such as physical or occupational therapist. May be necessary at first to aid in establishing regular bowel function. Provides assistance in developing a comprehensive therapy program and identifying special equipment needs that can increase clients participation in self-care.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p248-249

PRIORITY: Number 6
Nursing Diagnosis: Ineffective Coping May be related to: Situational crises, vulnerability, cognitive perceptual changes Cause Analysis: The patients disability affects not only the patient but also the entire family. In many cases, family therapy is helpful in working through issues as they arise. Rejection of the disability causes self-destructive neglect and noncompliance with the therapeutic program, which leads to more frustration and depression. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1945) Cues Objective Cues Inappropriate use of defense mechanisms Inability to cope or difficulty asking for help Change in usual communication patterns Inability to meet basic needs or role Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Talk or communicate with SO about situation and changes that have occurred. Verbalize awareness of own coping Independent Coping Enhancement Assess extent of altered perception and related degree of disability. Determine Functional Independence Measure score. Identify meaning of the loss and dysfunction or change to client. Note ability to understand events and provide realistic appraisal of situation. Nursing Interventions Rationale

Determination of individual factors aids in developing plan of care, choice of interventions, and discharge expectations. Independence is highly valued in American society, but is not as significant in some other cultures. Some clients accept and manage altered function

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expectations Difficulty problem-solving

abilities. Long-term Objective Within 3 days of providing nursing interventions, the client will: Verbalize acceptance of self in situation. Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources. Determine outside stressors, including family, work, social, and future nursing and healthcare needs.

effectively with little adjustment, whereas others have considerable difficulty recognizing and adjusting to deficits. In order to provide meaningful support and appropriate problem-solving, healthcare providers need to understand the meaning of the stroke and limitations to the client. Helps identify specific needs, provides opportunity to offer information and support and begin problem-solving. Consideration of social factors, in addition to functional status, is important in determining appropriate discharge destination. Demonstrates acceptance of and assists client in recognizing and beginning to deal with these feelings. Suggests rejection of body part or negative feelings about body image and abilities, indicating need for intervention and emotional support. Helps client see that the nurse accepts both sides as part of the whole individual. Allows client to feel hopeful and begin to accept current situation.

Encourage client to express feelings, including hostility or anger, denial, depression, and sense of disconnectedness. Note whether client refers to affected side as it or denies affected side and says it is dead. Acknowledge statement of feelings about betrayal of body; remain matter-offact about reality that client can still use unaffected side and learn to control affected side. Use words such as weak, affected, and right-left, that incorporate that side as part of the whole body. Identify previous methods of dealing with life problems. Determine presence and quality of support systems. Emphasize and provide positive I-messages for small gains either in recovery of function or independence. Support behaviors or efforts such as increased interest and participation in rehabilitation activities. Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope, lethargy, and withdrawal.

Provides opportunity to use behaviors previously effective, build on past successes, and mobilize resources. Consolidates gains, helps reduce feelings of anger and helplessness, and conveys sense of progress. Suggests possible adaptation to changes and understanding about own role in future lifestyle. May indicate onset of depression (common aftereffect of stroke), which may require further evaluation and intervention.

Collaborative Refer for neuropsychological evaluation and counseling, if indicated. May facilitate adaptation to role changes that are necessary for a sense of feeling and being a productive person. Note: Depression is common in stroke survivors and may be a direct result of the brain damage or an emotional reaction to sudden-onset disability.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p249-250

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PRIORITY: Number 7
Nursing Diagnosis: Risk for impaired Swallowing May be related to: Neuromuscular or perceptual impairment Cause Analysis: Stroke can result in swallowing problems (dysphagia) due to impaired function of the mouth, tongue, palate, larynx, pharynx, or upper esophagus. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th ed, p.1907) Cues Objective Cues Paroxysms of coughing Food dribbling out of or pooling in one side of the mouth Food retained for long periods in the mouth, Nasal regurgitation when swallowing liquids Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Demonstrate feeding methods appropriate to individual situation, with aspiration prevented. Independent Swallowing Therapy Review individual pathology and ability to swallow, noting extent of paralysis, clarity of speech, facial and tongue involvement, ability to protect airway and episodes of coughing or choking; presence of adventitious breath sounds and amount and character of oral secretions. Weigh periodically, as indicated. Have suction equipment available at bedside, especially during early feeding efforts. Promote effective swallowing using methods such as the following: Schedule activities and medications to provide a minimum of 30 minutes of rest before eating. Provide pleasant environment free of distractions, such as TV. Assist client with head control or support, and position based on specific dysfunction. Nursing Interventions Rationale

Nutritional interventions, including choice of feeding route, are determined by these factors.

Timely intervention may limit amount and untoward effect of aspiration.

Long-term Objective Within 3 dayss of providing nursing interventions, the client will: Maintain desired body weight.

Promotes optimal muscle function and helps to limit fatigue.

Promotes relaxation and allows client to focus on task of eating and swallowing. Counteracts hyperextension, aiding in prevention of aspiration and enhancing ability to swallow. Optimal positioning can facilitate intake and reduce risk of aspirationhead back for decreased posterior propulsion of tongue, head turned to weak side for unilateral pharyngeal paralysis, and lying down on either side for reduced pharyngeal contraction. Uses gravity to facilitate swallowing and reduces risk of aspiration. Clients with dry mouth require a moisturizing agent, such as artificial saliva or alcohol-free mouthwash, before and after eating; clients with excess saliva will benefit from use of a drying agent, such as lemon or glycerin swabs, before meal and a moisturizing agent afterward. Increases salivation, improving bolus formation and swallowing effort.

Place client in upright position during and after feeding, as appropriate. Provide oral care based on individual need prior to meal.

Season food with herbs, spices, and lemon juice according to clients preference, within dietary restrictions. Serve foods at customary temperature and water always chilled.

Lukewarm temperatures are less likely to stimulate salivation, so foods and fluids should be served cold or warm as appropriate. Note: Water is the most difficult to swallow. Aids in sensory retraining and promotes muscular control.

Stimulate lips to close or manually open mouth by light pressure on lips or under chin, if needed. Place food of appropriate consistency in unaffected side of mouth.

Provides sensory stimulation (including taste), which may increase salivation and trigger swallowing efforts, enhancing intake. Food consistency is determined by individual deficit. For example: Clients with decreased range of tongue motion require thick liquids initially, progressing to thin liquids, whereas clients with delayed pharyngeal swallow will handle thick liquids and thicker foods better. Note: Pureed food is not recommended because client may not be able to recognize what is being eaten. Most milk products, peanut butter, syrup, and bananas are avoided because they produce mucus and are sticky.

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Touch parts of the cheek with tongue blade or apply ice to weak tongue.

Can improve tongue movement and control necessary for swallowing and inhibits tongue protrusion. Feeling rushed can increase stress and level of frustration, may increase risk of aspiration, and may result in clients terminating meal early. Prevents client from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after client has finished eating solids. Although use may strengthen facial and swallowing muscles, if client lacks tight lip closure to accommodate straw or if liquid is deposited too far back in mouth, risk of aspiration may be increased. Provides familiar tastes and preferences. Stimulates feeding efforts and may enhance swallowing and intake. Helps client manage oral secretions and reduces risk of regurgitation. If swallowing efforts are not sufficient to meet fluid and nutrition needs, alternative methods of feeding must be pursued. May increase release of endorphins in the brain, promoting a sense of general well-being and increasing appetite.

Feed slowly, allowing 30 to 45 minutes for meals.

Offer solid foods and liquids at different times.

Limit or avoid use of drinking straw for liquids.

Encourage SO to bring favorite foods.

Maintain upright position for 45 to 60 minutes after eating. Maintain accurate intake and output (I&O); record calorie count.

Encourage participation in exercise or activity program.

Collaborative Review results of radiographic studies, such as video fluoroscopy. Aids in determining phase of swallowing difficultiesoral preparatory, oral, pharyngeal, or esophageal phase. May be necessary for fluid replacement and nutrition if client is unable to take anything orally. Inclusion of dietitian and speech and occupational therapists can increase effectiveness of long-term plan and significantly reduce risk of silent aspiration.

Administer intravenous (IV) fluids and/or tube feedings.

Coordinate multidisciplinary approach to develop treatment plan that meets individual needs. References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p251-252

PRIORITY: Number 8
Nursing Diagnosis: Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs May be related to: Lack of exposure, unfamiliarity with information resources, Cognitive limitation, information misinterpretation, lack of recall Cause Analysis: Clients have a variety of learning needs and their education is a major aspect of nursing practice and an important independent nursing function. This is multifaceted, involving promoting, protecting and maintaining health. (Fundamentals of Nursing by Kozier p384) Cues Objective Cues Request for information Statement of misconception Inaccurate follow-through of instructions Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Participate in learning process. Independent Teaching: Disease Process Evaluate type and degree of sensory-perceptual involvement. Nursing Interventions Rationale

Deficits affect the choice of teaching methods and content and complexity of instruction.

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 Development of preventable complications

Verbalize understanding of condition, prognosis, and potential complications. Verbalize understanding of therapeutic regimen and rationale for actions.

Include SO and family in discussions and teaching.

These individuals will be providing support and care and have great impact on clients quality of life. Aids in establishing realistic expectations and promotes understanding of current situation and needs. Prompt evaluation and intervention reduces risk of complications and further loss of function.

Discuss specific pathology and individual potentials. Long-term Objective Within 3 days of providing nursing interventions, the client will: Initiate necessary lifestyle changes. Identify signs and symptoms requiring further follow-up, such as changes or decline in visual, motor, sensory functions; alteration in mentation or behavioral responses; and severe headache. Review current restrictions or limitations and discuss planned or potential resumption of activities, including sexual relations. Review and reinforce current therapeutic regimen, including use of medications to control hypertension, hypercholesterolemia, and diabetes, as indicated and use of aspirin or similar-acting drug, such as ticlopidine (Ticlid) and warfarin sodium (Coumadin). Identify ways of continuing program after discharge.

Promotes understanding, provides hope for future, and creates expectation of resumption of more normal life. Recommended activities, limitations, and medication and therapy needs are established on the basis of a coordinated interdisciplinary approach. Followthrough is essential to progression of recovery and prevention of complications. Note: Long-term anticoagulation may be beneficial for clients prone to clot formation; however, these drugs are contraindicated for CVA resulting from hemorrhage. Provides visual reinforcement and reference source after discharge.

Provide written instructions and schedules for activity, medication, and important facts. Encourage client to refer to lists, written communications or notes, and memory book. Discuss plans for meeting self-care needs.

Provides aids to support memory and promotes improvement in cognitive skills.

Varying levels of assistance may be required and need to be planned for based on individual situation. Home environment may require evaluation and modifications to meet individual needs. Enhances coping abilities and promotes home management and adjustment to impairments for both stroke survivors and caregivers. Note: Recent innovations include such programs as Menu-Direct, which provides fully prepared meal programs with nutrition-rich foods. Some entrees have souffllike consistency to help trigger swallowing response. Multiple or concomitant stimuli may aggravate confusion and impair mental abilities. Some clients, especially those with right CVA, may display impaired judgment and impulsive behavior, compromising ability to make sound decisions. Promotes general well-being and may reduce risk of recurrence. Note: Obesity in women has been found to have a high correlation with ischemic stroke.

Refer to discharge planner or home care supervisor and visiting nurse.

Identify community resources, such as National Stroke Association, American Heart Associations Stroke Connection, stroke support clubs, senior services, Meals on Wheels, adult day care or respite program, and visiting nurse.

Suggest client reduce or limit environmental stimuli, especially during cognitive activities. Recommend client seek assistance in problem-solving process and validate decisions as indicated. Identify individual risk factorshypertension, cardiac dysrhythmias, obesity, smoking, heavy alcohol use, atherosclerosis, poor control of diabetes, and use of oral contraceptives and discuss necessary lifestyle changes. Review importance of a balanced diet, low in cholesterol and sodium, if indicated. Discuss role of vitamins and other supplements. Refer to and reinforce importance of follow-up care by rehabilitation team, such as physical, occupational, speech, and vocational therapists. References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p252-253

Improves general health and well-being and provides energy for life activities.

Diligent work may eventually overcome or minimize residual deficits.

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PRIORITY: Number 9
Nursing Diagnosis: Unilateral Neglect May be related to: Left hemiplegia from CVA of right hemisphere Cause Analysis: A stoke patient with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1896) Cues Objective Cues Failure to move eyes, head, limbs, trunk in the neglected hemisphere despite being aware of a stimulus in that space Appears unaware of positioning of neglected limbs Lack of safety precautions with regard to the neglected side Failure to eat food from left side of plate and dress or groom neglected side Failure to notice people approaching from neglected side Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Acknowledge presence of impairment. Identify adaptive or protective measures for the situation. Independent Unilateral Neglect Management Reinforce to client the reality of the dysfunction and need to compensate, avoiding participation in clients use of denial. Instruct client and SO/caregiver in treatment strategies focused on training attention on the neglected side: Approach client from unaffected side. Long-term Objective Within 3 days of providing nursing interventions, the client will: Be able adapt to Physical Disability Demonstrate behaviors, lifestyle changes necessary to promote physical safety. Discuss affected side while touching, manipulating, and stroking affected side; provide items of varied size, weight, and texture for client to hold. Have client look at and handle affected side, bring across midline during care activities. Assist client to position affected extremity carefully and to routinely visualize placement or use a mirror to adjust placement. Instruct SO/caregiver to monitor alignment of limbs and to inspect skin regularly. Discuss environmental safety concerns and assist in developing plan to correct risk factors. Encourage client to turn head and eyes to scan the environment. Nursing Interventions Rationale

Enhances dealing with reality of situation, thus avoiding scenarios (denial) that can limit progress and attainment of goals. Promotes involvement of all individuals in addressing problem, which may enhance recovery. Enhances clients awareness and promotes interaction. Helps client compensate for visual field loss, increasing awareness of environment. Focuses clients attention on left side, and limb activation treatment provides tactile stimuli to promote use of affected limb in neglected hemisphere. Encourages client to accept affected limb or side as part of self even though it does not feel like it belongs. Promotes safety awareness, reducing risk of injury.

Decreased sensation and positional awareness may result in pressure injuries.

Client may continue to have some ongoing degree of functional impairment, including difficulty with navigating in familiar environments (Barrett & John, 2007). Maximizes recovery and enhances independence. Note: Research indicates that most clients with neglect show early recovery, particularly within the first month, and marked improvement within 3 months (Barrett & John, 2007).

Reinforce continuation of prescribed rehabilitation activities and neuropsychological therapies, as indicated. References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p252-253

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SURGICAL MANAGEMENTS
ENDARTERCTOMY Carotid endarterectomy is the most widely used surgical procedure to prevent progressing stroke in symptomatic clients with recurrent TIAs or carotid stenosis. The purpose of a carotid endarterectomy is to remove atherosclerotic plaque from the inner lining of the carotid artery. The goal is to open the artery enough to reestablish blood flow and decrease stroke risk. EXTRACRANIAL- INTRACRANIAL BYPASS The surgeon performs a craniotomy and bypasses the blocked artery by making a graft or a bypass from the first artery to the second artery. This procedure establishes blood flow around the blocked artery and re-establishes blood flow to the involved areas. The two most common techniques are the superficial middle temporal artery-to-middle cerebral artery (STA-MCA) graft and the occipitalto-posterior inferior cerebellar artery (PICA) bypass.

DECOMPRESSIVE CRANIOTOMY Occasionally, a large stroke can lead to significant brain swelling. When this happens and medicines are not successful in relieving the swelling, a surgical intervention may be required to prevent the pressure buildup within the skull from causing further damage to the brain. In this procedure, the doctor may temporarily open a flap of bone overlaying the swelling in order to alleviate the pressure. If the stroke is of the hemorrhagic type (bleeding), the blood clot may also be removed to prevent further brain injury.

CAROTID ARTERY ANGIOPLASTY Although angioplasty was introduced in the mid-1980s, it was rarely used in the carotid arteries. However, with the development and refinement of vascular stents, carotid artery angioplasty has become more common. A device called a distal protection device (DSP) can make carotid angioplasty safer than endarterectomy. The DSP is placed beyond the stenosis, which catches any debris that breaks off during the angioplasty/ stenting procedure.this interventional radiology procedure is done under moderate sedation and may eventually be performed as an outpatient procedure. 45 | P a g e

CARDIAC THROMBOSIS SURGERY A blood clot can form on the valves or in the chambers of the heart. This can also happen with a prosthetic heart or valve. If the blood clot is not reduced with medication, surgery may be performed. Catheter assisted or open surgical procedures may be necessary to remove the clot. A newer technique called thrombus aspiration may also be employed to remove the blood clot in or around the heart. This technique uses a small vacuum to suction the clot during surgery. ENDOVASCULAR COIL EMBOLIZATION A procedure (endovascular coil embolization) is to repair a brain aneurysm that is the cause of a hemorrhagic stroke. A small coil is inserted into the aneurysm to block it off and stop or prevent bleeding.

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HEALTH EDUCATION PLAN

Objectives: 1. To teach client the importance of taking the medication strictly for prevention of complication and re-occurrence of the disease. 2. To teach clients various ways on how to do exercises for the prevention of the disease and further eliminating their current illness. 3. To educate the client about the healthy diet and lifestyle of the patient. Materials needed:.Visual aids. GENERAL HEALTH TEACHINGS Exercise SPECIFIC HEALTH TEACHINGS

Motivate to start an exercise program especially among people who are sedentary can be deficient Regular exercise such as PASSIVE ROM Aerobic exercise such as brisk walking as prescribe by physician Moderate intensity activities like gardening and walking. Wear shoes with good traction and cushioning and to examine the feet daily and after exercise Instruct the client in the purpose and action of each medication Instruct the client how to properly store the medication Inform the client of possible of drug to food interaction, as appropriate Provide written meals plan, as appropriate Observe the client selection of foods appropriate meals Encourage patient to eat food that is low in cholesterol, low in saturated fat and high fiber Eat fruit with the skin to increase the fiber intake Ate fruits and vegetables rich in vitamins and nutrients Add vegetables to a sandwich, pizza or stir fry to increase intake Avoid drinking excessive amount of alcoholic drinks and caffeine-containing beverages and tobacco Ate fruits and vegetables rich in vitamins and nutrients Eat high in fiber Eat fruit with the skin to increase the fiber intake Add vegetables to a sandwich, pizza or stir fry to increase intake

Medication

Diet

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DISCHARGE PLAN
MEDICATIONS Instruct patient to have all of prescriptions filled before he go home. Inform that him that it is very important to follow the dosage as prescribed by the doctor. Also instruct not take any other drugs, supplements, vitamins, or herbs without asking the doctor about them first. Educate patient about the medications to be taken at home, which may include the following: a. Antiplatelet drugs (aspirin or Clopidogrel) help keep your blood from clotting. b. Beta blockers or ACE inhibitor medicines may help protect your heart. c. Diuretics (or water pills), ACE inhibitors, Beta-blockers, and other medications will help control blood pressure. d. Statins or other drugs that lower your cholesterol. e. If you have diabetes, control your blood sugar at the level your doctor or nurse recommends. ENVIRONMENT TREATMENTS HEALTH KNOWLEDGE OF DISEASE Inform patient that moving around and doing normal tasks may be hard after a stroke. So, instruct him and his significant others to make their home is safe. Teach patient and his family about what you they can do to prevent falls and injury. Encourage patient to always seek professional medical advice about any treatment or change in treatment plans. Educate patient about other medical or surgical managements that could improvement of his condition. Provide health education about cerebrovascular accident, its causes, risk factors, manifestations and complications. Because of possible injury to the brain from the stroke, inform patient that he may notice problems with:

Changes in behavior Doing easy tasks Memory Moving one side of the body Muscle spasms Paying attention Sensation or awareness of one part of the body Swallowing Talking or understanding others Thinking Seeing to one side (hemianopia) Problems taking drugs for muscle spasms Problems moving your joints (joint contracture) Problems moving around or getting out of your bed or chair Skin sores or redness Pain that is becoming worse Recent falls Choking or coughing when eating Signs of a bladder infection (fever, burning when you urinate, or frequent urination) 48 | P a g e

OUTPATIENT REFERRALS

Instruct patient and caregiver to call doctor if patient experiences:

Tell them to call 911 if the following symptoms develop suddenly or are new:

Numbness or weakness of the face, arm, or leg Blurry or decreased vision Not able to speak or understand Dizziness, loss of balance, or falling Severe headache

If patient will be using a wheelchair, instruct patient to follow-up visits to make sure it fits well are important to prevent skin ulcers. Instruct patient and caregivers to:

Check every day for pressure sores at the heels, ankles, knees, hips, tailbone, and elbows. Change positions in the wheelchair several times per hour during the day to prevent pressure ulcers.

Provide information to the patient and caregivers about other treatments or therapies to improve patients quality of life, which may include the following:

Physiotherapy Speech therapy

DIET

Encourage patient to: AVOID FATS AND CHOLESTEROL Inform the patient and caregiver that limiting or avoiding foods that are high in trans-fats, saturated fats and cholesterol may help lower cholesterol levels. If patient wants to eat meat, instruct to choose lean cuts of meat, and to remove all visible fat and skin. Instruct to broil meats and to pour visible fat off pan-fried foods. Do not use partially hydrogenated oils, use low-fat or fat-free dairy products, and limit sugary foods and drinks. AVOID SODIUM Inform the patient and the family that blood pressure may be partially controlled by decreasing salt, or sodium, intake. Tell them that sodium intake should be limited to no more than 1,500 g per day. Encourage to reduce sodium intake by omitting salt from their table and cooking. Also, encourage to limit canned goods, and if theyll use them, instruct to rinse the contents with water before eating EAT FIBER Educate about the advantage of eating foods high in fiber. Inform that this helps lower cholesterol and reduce risk of further strokes. Instruct to incorporate at least five fruits and vegetables into his diet each day, and to switch from white bread products to whole grain or whole wheat. Encourage that instead of using breadcrumbs in meatloaf, use oatmeal.

SPIRITUAL CARE

Encourage patient to strengthen his faith to God and to pray, trust and ask guidance from Him. Provide inspirational messages from the bible.

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PROGNOSIS

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Disability affects 75% of stroke survivors enough to decrease their employability. Stroke can affect people physically, mentally, emotionally, or a combination of the three. The results of stroke vary widely depending on size and location of the lesion. Dysfunctions correspond to areas in the brain that have been damaged. The outlook depends on: The type of stroke How much brain tissue is damaged What body functions have been affected How quickly you get treated

Recovery rates vary depending on the part of the brain affected and the extent of the stroke. Function will be restored in about half of patients with moderate to severe paralysis on one side of the body (hemiplegia) and about 10% will have complete neurologic recovery (Beers). Stroke (all types) has an overall mortality rate of 60.2 per 100,000 individuals; higher mortality occurs in older individuals, in brain stem stroke, or hemorrhagic stroke with alterations of consciousness (Jauch). About 10% to 18% of stroke survivors have a second stroke within a year. Control of risk factors such as high blood pressure, atrial fibrillation, atherosclerosis, obesity, and high lipid levels is important to prevent additional strokes. Of the 4 million people who have had a stroke, about 33% experience mild disability, 20% moderate disability, and 16% require placement in an assisted living facility (Jauch). Rehabilitation is a significant factor in stroke outcomes. In adults who have had an ischemic stroke, problems that remain after 6 months are likely to be permanent, but children continue to improve slowly for many months. Older people fare less well than younger people. For people who already have other serious disorders (such as dementia), recovery is more limited. The risk for a second stroke is highest during the weeks or months after the first stroke. Then the risk begins to decrease.

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BIBLIOGRAPHY
I. BOOKS

Doenges et. al. (2008). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition. Ignatavicius D, and Workman M. (2006). Medical- Surgical Nursing Critical Thinking for Collaborative Care 5th edition Learning, Jones and Barlett (2011). Nurses Drug Handbook, 10th edition. Smeltzer et. al. (2010). Brunner and Suddarths Medical Surgical Nursing, 12th edition. Wilson, N. D. (2008) Manual of Laboratory & Diagnostic Tests.

II. INTERNET Castillo and Reinoso. (1999) Respiratory Dysfunction Associated with Acute Cerebrovascular Events. Retrieved from http://www.medicosecuador.com/revecuatneurol/vol8_n12_1999/respiratory_dysfunction%20.htm. Neff, D. N. (2012) Surgical Procedures for Stroke. Retrieved from http://www.bidmc.org/YourHealth/TherapeuticCenters/Stroke.aspx?ChunkID=20426
Stroke Health Center (2012) Stroke Surgery. Retrieved from http://www.webmd.com/stroke/guide/stroke-surgery. MD Guidelines (2012) Cerebrovascular Accident. Retrieved from http://www.mdguidelines.com/cerebrovascular-accident/prognosis

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