Case study on CVA rehabilitation

Area: Male Medicine ward Topic: Cerebro vascular accident

HISTORY COLLECTION
Introduction: As a part our medical surgical nursing II clinical posting I got posting in NIMHANS Bangalore. I was posted in male rehabilitation ward I selected Mr. Ramegowda for writing case study. He diagnosed as cerebro vascular arrest. I started care on 18/3/09 and ended on 20/3/09. Demographic data: Name Age Sex Religion Hindu Education Occupation 8th standard agriculture Marietal status Married Date & time of Admission 15/3/09

Mr. 55yrs male Ramegowda

Date and time of history collection 18/03/2009 Informant : Patient himself, Patient relatives and case sheet. Ward: male medicine ward IP No 768453 Address: door no.23 Siddartha layout Mysore Diagnosis: Cerebro vascular arrest with right side hemiplegia Present history of illness Mr. Ramegowda is admitted on 15/3/09 with complaints of sudden onset of fever and cough and breathing difficulty since 10 days. Mr. Ramegowda developed fever 10 days before and fever was intermittent and moderate grade. The fever will more during night. Along with fever he got cough also. While coughing sputum is not expectorate. Sputum is thick and mucoid and not having any foul smell. At the time of admission his SPO2 WAS 89% Muscle strength was RT LT Upper limb: Lower limb Deep tendon reflexes were RT 2/5 2/5 BJ 3+ 5//5 5/5 TJ + SJ ++ KJ 0 AJ +

LT

++

++

++

++

Patient had crackles on auscultation, swallowing difficulty. Patient had slurring of speech. Later patient diagnosed as CVA with right side hemiplegia. At present he is on nasogasrtic tube feeding. He is having fever, headache and cough and he is on oxygen supply. He is not able to move his right side limbs. He is on urinary catheter.

Past history of illness He had history of hypertension about 1year and on treatment. He is taking tablet aten 50mg BD. He had a history of CVA since 1 year. He did not have any history of Diabetes Mellitus, Epilepsy, Bronchial Asthma etc. in the past. He had history of hospitalization in the past for the same problems.. Family history Mr. Ramegowda is living with his wife and son.T here is no history of any illness like Diabetes Mellitus, Hypertension, Tuberculosis and Asthma in the family.

Key - Male Patient Male

- Female

Socio economic history He belongs to a middle class family. He is a agriculturist. After he got CVA, he was not doing any work. But son is earning Their monthly income is about Rs 5000/-. He is having good relationship with family members and neighbours. Life style, habits and beliefs Mr. Ramegowda is moderately built and moderately nourished. He believes in god. He takes mixed diet. His bowel pattern is normal and he is on urinary catheter. He is having good exposure to mass media. He had the habit of, smoking and alcoholism since 10 years. He used to smoke I packet beedies per day. He used to drink every day. He is not having the habit of doing exercises. If he suffered from any disease he used to go local clinics and takes medication. History of any allergy Mr. Ramegowda is not having any allergy towards dusts, drugs, spores, foods and medications. PHYSICAL EXAMINATION General Examination Body built Nourishment Hygiene Temperature PR RR BP - Moderately built - Moderately nourished - Good -1020F -86 beats/min - 26breaths/min( on ventilator) - 130/90 mm of Hg

Subjective data Head Mr. Ramegowda says that, I have headache

Objective data

Inspection - Hairs are equally distributed - Guarding the fore head - No dandruff - No lesion Palpation: - No lesion/ wound - VAS 7/8 Vision Mr. Ramegowda says that, I can see you properly

Inspection: - External Eye structures are normal. 4

- No signs of any infection of eye, - Normal pupillary reaction - No discoloration of sclera - No discharge or periorbital odema Palpation: - No lesion - Eye opens while calling her name Hearing Mr. Ramegowda says that, I can hear you properly Speech and orientation Mr. Ramegowda says that, I cant speak properly

Webers test =positive Rinnies test= positive He is having slurring of speech and he is oriented to time, place and person Posterior thorax Inspection: Size, shape, configuration is normal and either side of the chest is equally expands..Secretions present. Thick and yellow color secretions Palpation: Absence of lesions, Thorasic expansion =2cm Percussion: dullness on right side of the chest Auscultation: crackles sound heard Anterior Thorax Inspection: Size, shape and configuration is normal Palpation: Absence of lesions. Percussion: dullness Auscultation: crackles sound heard Inspection Temparature- 1020F BP- 130/90 mm of Hg - Absence of clubbing, cyanosis and there is no signs of peripheral vascular disease - Iv canula present on Left hand - Neck vessels-Not distended Palpation: PR-86 beats/mt Capillary refill is 2sec 5

Respiratory system Mr. Ramegowda says that, I have cough but sputum is not comming

Cardio-vascular system Mr. Ramegowda says that, I dont have chest pain

Peripheral pulses are palpable Auacultation: S1 and S2 heard. No abnormal heart sounds Gastro intestinal system Mr. Ramegowda says that, I am having swallowing Inspection difficulty Well nourished and well built Maintaining good oral hygiene but dental caries present on left molar Lips are dry No loss of teeth No gum bleeding Normal in size and shape, of abdomen no scar present NGT present Auscultation Bowel sounds present at the rate of 10 /min Palpation: Absence of hepatosplenomegaly No lesions Percussion: Dullness heard Lymphatic system No lymph nodes are enlarged Mr. Ramegowda says that, I dont have enlargement in my neck Renal system Urine colour is amber yellow, Mr. Ramegowda says that, I am passing urine he is on urinary catheter through pipe , Intake/Output = 2000/1700= +300ml Albumin nil Sugar - nil Pus nil

Musculo skeletal system Mr. Ramegowda says that, I cant walk

Inspection: he is not able to walk, because his right side is paralysed. No odema, Patient is able to move the left limbs Palpation: Muscle size is symmetrical in both sides rigidity or spasticity present on right limbs ROM is possible on all joints in the left side 6

Muscle strength: RT Upper limb: Lower limb Nervous system Mr. Ramegowda says that, I cant hold the objects 2/5 2/5 LT 5//5 5/5

MSE - GCS= E4M5V6 - Appearance and behaviour: groomed, worried and anxious - Oriented to time, place and person Speech: slurring of speech resentr - Judgment and abstract thinking : present - Calculation is able to perform - General information; he is having good knowledge in agriculture. Cranial Nerves Olfactory nerve(CN I): He is able to smell coffee powder with each nostrils. Optic (CN II): 1) vision: 20/20 2) visual acuity: patient is able to identify the picture on the wall 3) visual field : possible in each side Occulomotor, Trochlear, Abducens(CN III, IV, VI): 1) Pupils are equally reacting to light 2) EOEM are present in both eyes. Trigeminal Nerve (CN V): While clenching the teeth, patient has normal strength. Sensation on frontal, Maxillary and mandibular area is normal Facial Nerve (CN VII) : Smiles normally. Identifies taste of sugar and salt in the anterior 2/3rd of the tongue. Vestibulo-Cochlear Nerve (CN VIII):., 7

Webers test =positive Rinnies test= positive Glosso pharyngeal and Vagus(x): Patient is having difficulty in swallowing food Spinal accessory: is not able to elicit on right side of the body Hypoglossal nerve: Protrudes and move tongues normally Assessment of sensation Sensation to the cold, pain, hot and vibration is not present on right side - Position sence, graphesthesia and steriognos is not - Present on right side. Assessment of motor function Muscle tone- rigidity on right side Muscle size is less in right side of the body Muscle strength: RT LT Upper limb: 2/5 5//5 5/5

Lower limb 2/5 Reflexes Superficial reflexes Corneal-normal Abdominal-normal Plantar-normal Deep tendon reflexes Lt Biceps2+ Triceps2+ 2+ 2+ Bracheo-RadialisPatellar-

Rt 1+ 1+

1+ 1+

Achilis1+ 2+ Assessment of cerebellar function : - Finger to Nose test: not able to elicit on right side - Pronation-Supination test: is not able to elicit - Gait- Not able to test - Finger to finger test: not able to elicit on right side patting test, Rebound test, and Dexterity test is not able to elicit Integumentary system Mr. Ramegowda says that, I have fever Inspection Body temperature is 1020F Hairs are equally distributed. Nails are normal shape No lesions on body Palpation Body is warm Skin turgor is reduced

Rest and sleep Mr. Ramegowda says that, I am sleeping properly at night time after taking tablet Psycho social aspect No drooping of eyelids Mr. Ramegowda says that, I have good relationship with other family members Mr Ramegowda is having good relationship with family members and health team members

Name of the test Blood Hb% TLC ESR RBS Blood Urea S. Creatinine S.Phosphorous Total Protien Globulin A/G Ratio Total Bilirubin Alkaline Phosphatase SGOT SGPT Creatinine Kinase Sodium Potassium Urine Albumin Sugar Pus

CLINICAL DATA Patients value Normal value 12 mg/dl 10400cells/Cumm 10mm/hr 90 mg/dl 38mg/dl 1mg/dl 4mg/dl 6.gm/dl 1gm/dl 1.8g/dl 0.8mg/dl 128u/l 32u/l 28u/l 329u/l 136meq/l 4.meq/l Nil Nil Nil 132 mg/dl 4000 -11000cells/Cumm 0- 10mm/hr 70-150 mg/dl 20-40mg/dl 0.8-1.4mg/dl 2.5-5mg/dl 6-8g/dl 2-3g/dl 1.2-2.5 0.1-1mg/dl 37-147u/l 0-40u/l 0-40u/l 250-400u/l 135-145meq/l 3.5-4.5meq/l Nil Nil Nil

Evaluation Normal leucocytosis Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

SPECIAL INVESTIGATIONS Apart from the above investigation patient under gone special investigations like 1. 2. 3. 4. 5. CT Scan: hypodense lesion on left side of the brain Chest X ray: With in normal limit MRI: frontal infraction ultra sound : normal ECG: With in normal limit

10

11

PLAN OF TRAETMENT NAME OF THE DRUG INJ M-20 (Mannitol) DOSE 100ml ROUTE IV FREQUENCY ACTION Tid It is an osmotic diuretic that increases the osmotic pressure of the glomerular filtrate and thus inhibiting tubular reabsorption of the water and elecTrolytes. It elevates plasma osmolalty, resulting in enhanced water flow to extra celIular fluid. SIDEEFFECTS NURSES RESPONSIBILITY CNS: seizures, head ache, - Warm bottle to prevent Fever crystallization CVS:Edema, - Give 60-90 minutes thrombophlebitis, HTN, properly Tachy cardia, Heart failure - Monitor vital signs and ENT: Blurred vision CVP, I/O hourly, serum GI: Thirst, dry mouth sodium and potassium and GU:Urine retension for signs of dehydration and electrolyte imbalance. - Give frequent mouth care to relieve thirst - Dont give electrolyte free mannitol solutions with blood. If blood is given simultaneously, add atleast 20 meq of sodium to avoid pseudo agglutination CNS: Vertigo, Malaise and Use cautioly in patient with head ache hepatic dysfunction EENT: Blurerred Vision Assess patient for Hepatic:Jaundice abdominal pain Others: Itching and Instruct the patient to take blurring in the incision site without regard to meals because absorption is not

INJ Rantac (Rannitidine)

2ml

IV

TID

Completively of histamine receptor sites decreasing secretion.

inhibits action on the H2 at of parietal cells, gastric acid

12

affected by food. Urge patient to avoid cigarette smoking because it will increase gastric secretions

INJ. C-tax (Ceftriaxon)

1gm

IV

Bd

A third generation cephalosporin that inhibits cell wall synthesis and promoting osmotic instability, usually bactericidal.

CNS: Fever, Head ache, Dizziness CVS: Phlebitis GU: Genital Pruritis Heamatologic: Eosinophilia, Thrombocytosis Skin: Pain, induration

Use cautiously in patients hypersensitive to Pencillin And to pregnant and lactating Woman Obtain specimen for culture and sensitivity Monitor PT and INR in patient with poor Vitamin K synthesis Tell patient to report adverse reaction promptly

Tab. Amlo at

50mg

NGT

tid Beta blockers and ca2+ channel blockers. Antihypertensive. Atenolol is a cardioselective beta blocker. CNS: Ataxia, slurred speech, dizziness, insomnia, nervousness, twitching, head ache, mental confusion CVS: Periarteritis nodosa GI: Gingival hyperplasia

(amlodepine atenolol)

and

- Use cautiously in patients with hepatic dysfunction, hypotension, Myocardial insufficiency, DM and elderly - reduce if alt level is increases - Stop drug if rashes

13

Heamatologic: Thrombocytopenia, agranulocytosis and pancytopenia Skin: Pupuric dermatitis

appears - Monitor drug level in blood - Monitor CBC and calcium level in every 6 months - Teach the patient about side effect and tell to report if any. - Advise to avoid Alcohol - Advise for good oral hygiene and regular dental examination to prevent excess gum deposition. - Caution patient that drug may colour urine pink, red or recdish brown. - Use cautiously in patients with hepatic dysfunction, hypotension, Myocardial insufficiency, DM and elderly - Give with meals to prevent GI irritation - Stop drug if rashes appears - - Monitor CBC

Tab. pacimol (paracetamol)

500mg

NGT

sos

It is an antipyretic and Blood dyscariasis. Nausea, anagelsics in nature in action vomiting, allergeic with weak anti inflammatry reactions, hepatic necrosis action which may due to inhibition of PG

14

- Teach the patient about side effect and tell to report if any. - Advise to avoid Alcohol -..

SPECIAL TREATMENT: 1. IVF on flow 40 ml/hr 2. Physiotherapy 3. Nasogasrtic tube feeding 4. O2onflow 5.)Nebulization

15

16

CEREBRUM The brain is divided into mainly 3 parts , cerebrum, brain stem and cerebellum. Cerebrum is composed of both right and left hemispheres. Both hemispheres can be further divided into four major lobes. 1. frontal lobe 2. parietal lobe 3. temporal lobe 4. occipital lobe Gray matter is the outer covering of the cerebrum. Each lobes have different functions. The basal ganglia, thalamus, hypothalamus and limbic system are also located in the cerebrum. The basal ganglia are a group of paired structure located central to cerebrum and mid brian. It helps in execution and completion of involuntary movements. Thalamus lies directly above the brain tem. it is mainly sensory canter. Hypothalamus lies below the thalamus and it regulates Mans. In the inner surface of the cerebrum, limbic system present. It concerned with emotion, feeding behaviour, and sexual response. Circle of Willis The circle of Villis which is located in the base of the skull, is devided in to anterior (carotid portion) and posterior (Vertebro basilar portion) circulation. The components of the each portion involve: Middle cerebral arteries, the anterior cerebral arteries and the anterior communicating artery which connects the two anterior cerebral arteries Two posterior cerebral areteries, two posterior communicating arteries connect the middle cerebral arteries with the posterior cerebral arteries, thus uniting the internal carotid system with the vertebral-basilar system The circle of Willis encloses a very small area that is little more than one square inch in diameter or approximately 6 cm2. Functionally the carotid circulation and the posterior circulation usually remain separate. Venous Drainage Unlike venous drainage in other parts of the body, which closely follows the arterial pattern, the cerebral venous drainage is chiefly managed by vascular channels created by the two dural sinuses. There are no valves in he dural sinuses

17

18

19

NURSING CARE PLAN Nursing diagnosis: 1. Ineffective airway clearance related to accumulation of secretions. 2. Ineffective tissue perfusion (cerebral) related to infracted areas in the cerebrum. 3. Hyperthermia related to cerebral infection 4. acute pain (frontal area) related to vasospasam 5. Impaired physical mobility related to weakness of limbs. 6. Impaired verbal communication related to dysfunction of speech center. 7. Impaired family process related to hospitalized sick family member. 8. anxiety related to hospitalization 9. knowledge deficit related to disease process 10. Risk for seizures related to neuronal irritation 11. Risk for fluid electrolyte imbalance related to mannitol therapy 12. Risk for impaired skin integrity (bedsore) related to prolonged bed rest 13. Risk for UTI related to presence of urinary catheter.

20

21

Assessment

Nursing diagnosis Subjective data Ineffective Mr. Ramegowda says that, airway I have cough, but sputum clearance is not able to split out related to accumulation of secretions Objective data Thick secretions Crackles on auscultation Yellow discoloration of secretions Thorasic expansion is 2cm

Objective Patient maintains a patent airway as evidenced by absence of thick secretions

Interventions with rationale

Implementation

Evaluation Patient is having thin secretions.

- Provide lateral position with head Provided lateral position end elevation- helps to drain the secretions and prevents aspiration -- Provide Nebulization- Helps to soften the secretions - Provide chest PhysiotherapyMobilize the secretions and promote expectoration - Promote Posturl drainage- Mobilize the secretions - maintain fluid intake- Hydration helps to dilute the secretions - change the position every 2nd hourly do the suctioning helps to remove the secretions. Administer medications as per physicians order helps to reduce the secretions. Provided nebulization Provided chest physiotherapy

---------Promoted fluid intake Changed the position every 2nd hourly Done the suctioning

Subjective data Mr. Ramegowda says that, I have fever Objective data

Hyperthermia Patient related to maintains cerebral normal body

Give tapid sponge, reduces Given tapid sponge, Patient, temperature by conduction method. temperature is Maintain adequate hydration Maintained adequate reduced into to prevent dehydration. hydration 990F

22

Body is warm Body temperature is 102oF Lips are dry Skin turgor is reduced. TLC= 10400cell/cumm

infection

temperature as evidenced Normal body temperature 98.60F

Give cold compress, reduces body temperature by conduction Given cold compress Administer medications as per physicians order Administered medications Loosen the clothings Tab. Pacimol 500mg , for comfort Loosened the clothings Maintain intake and output chart, shows dehydration Maintained intake and output chart

Objective data: Patient have CVA CT Scan: hypodense lesion on left side of the brain

Risk for The client - Implement seizure precautions: seizures remains side rails up and padded- Prevent related to free from injury due to seizures neuronal seizures as - Assess keenly for the occurrence of irritation evidenced seizures- Helps to prevent injury by absence - Administer Dilantin 50mg tidof signs of Maintain the stability of neural seizures membrane and prevent seizures - Take all measure to prevent ICPProvide comfortable position with head end elevated to 300-Reduces the risk for seizures - Restrict all activities which will lead to increase in ICP-like neck flexion, cluster of activities Reduction of ICP will reduce the

Implemented precautions

seizure Patient is not have any signs of seizures. Assessed for the occurrence of seizures Administered Dilantin 50 mg.

the

Took the measures to prevent ICP

Restricted the activities that will lead to seizures

23

chance for seizures Objective data: Patient have CVA CT Scan: hypodense lesion on left side of the brain patient is receiving mannitol therapy Risk for fluid electrolyte disturbance related to mannitol therapy Patient maintain normal fluid and electrolytes as evidenced by absence of signs of dehydration -Monitor for intake and out put-helps to identify fluid imbalance - Assess serum sodium and Pottasium-Helps in early diagnosis of electrolyte imbalance - Assess for signs of dehydration, hypokalemia and hypo natremiaHelps to prevent complications - Closely monitor for ECG changesArrythmias can be predisposed by fluid electrolyte imbalance Maintain intake out put chart shows the dehydration Change the position frequently every 2nd hourly, prevents bedsore Give pressure point care to increase blood supply. Provide back care every 2nd hourly to increase blood supply. Check the signs of bedsore periodically, shows early signs of bedsore Provide comfort devices like pillows and waterbed , takes pressure Monitored for intake and out Patient is not put having signs of fluid electrolyte Assessed serum electrolytes imbalance

Assessed for signs of dehydration, hypokalemia and hypo natyremia Monitored for ECG changes Maintained intake output chart Changed the position There is no nd frequently every 2 hourly signs of bedsore Given pressure point care present Provided back care every Checked the signs of bedsore periodically, Provided comfort devices like pillows and waterbed

Objective data: Patient have CVA CT Scan: hypodense lesion on left side of the brain Rt. Side of the body hemiplegia Muscle strength 2/5 in right side DTR: Weak

Risk for impaired skin integrity (bedsore) related to prolonged bed rest

Patient will maintain normal skin integrity as evidenced by absence of bedsore.

24

25

INTAKE AND OUT PUT Date 18/3/09 19/3/09 20/3/09 Intake 1950ml 2100ml 2450ml Output 2100ml 2150ml 2550ml Balance -150ml +50ml -100ml

NUTRITIONAL REQUIREMENT: As per dieticians advice patient is receiving 2220kcal. The menu plan given by the dietician is:

Time 6.30am 9.30am 12.30pm 3.30pm 6.30pm 9.30pm 12.30am

Diet Rava ganji cooked with milk Vegetable soup Rava ganji cooked with milk Milk Rava ganji cooked with milk Dhal soup Milk

Quantity 200ml 250ml 300ml 100ml 250ml 150ml 200ml

Health education needs Health education on Hygiene: importance of personal hygiene Exercises : ROM exercises Prevention of bedsore: back care, use of comfort devices Relaxation techniques Nutrition and hydration: high calorie and high protein Compliance to the treatment regimen and Follow up complications and management Rehabilitation - Promote compliance to the treatment regimen

26

Promote exercises Health education Follow up

RECENT TRENDS 1. .Upper limb and lower limb neurotic devices are available to rehabilitate the motor impairement in the CVA patient. This is known as robot assisted therapy. But practicability is less for this devices. 2. The incidence of pulmonic complications are more among the CVA patients as compared with other systemic complications.

APPLICATION OF THEORY Lidiya Halls Care, core and cure theory is applied in this case study.

This model provides base for nursing care. It consists of interlocking circle the core, cure and care. Core circle: refers to the patient, it includes nursing care that resolves around a nurses therapeutic use of self. It involves developing an interpersonal relationship with a patient, which allows the patient to express feelings about disease condition. Care circle: refers to the patients body. It includes nursing care given. Cure circle: refers to the pathological condition or the disease. It is a collaborative process and nurses advocate role is coming under this.

Cure: Inj Mannitol, T. Dilantin and T. Rantac and Inj Ceftriaxone and T. Dolo were the medications. Closely monitor for complications. Patient improved. 27

Core: Mr. Ramegowda 55yrsold man came with cough, fever and breathing difficulty. diagnosed as CVA. Weakness of limb present. Nasogastric tube feeding, fever present, headache.

Care: - Pain management - Take measures to maintain patent airway - chest physiotherapy - Administered medications as prescribed - Monitor for complications Monitor I/O chart ROM exercise,

Cure: Inj Mannitol, and T. Rantac and Inj Ceftriaxone and T. Dolo were the medications. Closely monitor for complications Rehabilitation Physiotherapy.

PROGRESS NOTES Date 18/3/09 Problems of the client Care given Evaluation fever, headache, cough not Head end elevation at His temperature is reduced into able to move his right side 1000F 30 degree limbs urinary catheter. Changed the position nasogasrtic tube feeding every 2nd hourly Given back care every 2nd hourly Checked the vital signs Maintained I/O chart Administered medication Suctioning done Send the lab investigation Checked the neurological status

28

Provided the cold compress Massaged the head

19/3/09

fever, headache, cough not able to move his right side limbs urinary catheter. nasogasrtic tube feeding

Suctioning done 0 Checked the His temperature is 101 F neurological status Checked the vital signs Changed the position every 2nd hourly Head end elevation at 30 degree Kept head in neutral position Provided back care Pressure point care given Elevated the foot end Provided comfortable devices like pillows Nebulization given ROM exercise performed tapid sponge and cold compress Checked the vital His temperature is 99.6 0F signs Changed the position every 2nd hourly Head end elevation at 30 degree Kept head in neutral position Suctioning done Checked the neurological status Checked the vital

20/3/09

fever, headache, cough not able to move his right side limbs urinary catheter. nasogasrtic tube feeding

29

signs Kept head in neutral position Provided back care Pressure point care given Elevated the foot end Provided comfortable devices like pillows Nebulization given provided tapid sponge and cold compress ROM exercise performed

PATIENT EVALUATION : After giving 3 days care to the patient, patients condition improved. Hyperthermia is reduced, rigidity on joints reduced, and cooperates while doing exercises SELF EVALUATION : After taking this patient I understood how to give care to patients with CVA and rehabilitation of CVA patients. I studied regarding the meaning pathophysiology and clinical features and rehabilitation aspects of CVA. Bibliography Text book 1. Joanne v hicky, the clinical practice of neurological and neuro surgical Nursing, 5 th edition, Lippincott,2003 p.438-432 2. Sandra M Netlina. The Lippincott manual of nursing practice.7 th edition. Philadelphia:Lippincott;1996. p.669-674 3. Lewis Heitkemper Dirksen. Medical surgical nursing, Assessment and management of clinical problem.6th edition. Missouri: Mosby;2004. p.1556-1559 4. Suzannae .c.Smeltzer,Brenda. G Bare. Medical Surgical nursing, 9th edition. Philadelphia: Lippincott ;2000 p.768-770 Website www. Pubmed.com www. Google.com

INDEX
SL No CONTENT PAGE No

30

1 2 3 4 5 6 7 8 9 10

Nursing History Physical examination Related anatomy and Physiology Disease condition Rehabilitation Nursing care plan Recent trends Application of theory Patient evaluation Bibliography

CVA REHABILITATION

31

Introduction A stroke is the rapidly developing loss of brain function(s) due to a disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood supply) caused by thrombosis or embolism or due to a hemorrhage. In the past, stroke was referred to as cerebrovascular accident or CVA, but the term "stroke" is now preferred. Definition The traditional definition of stroke, devised by the World Health Organization in the 1970s,[4] is a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours".The traditional definition of stroke, devised by the World Health Organization in the 1970s. A "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours". Classification

Ischemic stroke :In an ischemic stroke, blood supply to part of the brain is decreased,
leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen: thrombosis (obstruction of a blood vessel by a blood clot forming locally), embolism (idem due to an embolus from elsewhere in the body, see below), [1] systemic hypoperfusion (general decrease in blood supply, e.g. in shock)[6] and venous thrombosis.[

Hemorrhagic stroke: Intracranial hemorrhage is the accumulation of blood anywhere

within the skull vault. A distinction is made between intra-axial hemorrhage (blood inside the brain) and extra-axial hemorrhage (blood inside the skull but outside the brain). Intra-axial hemorrhage is due to intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular system). Signs and symptomsSigns and symptoms If the area of the brain affected contains one of the three prominent Central nervous system pathwaysthe spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include:

hemiplegia and muscle weakness of the face numbness reduction in sensory or vibratory sensation

In addition to the above CNS pathways, the brainstem also consists of the 12 cranial nerves. A stroke affecting the brain stem therefore can produce symptoms relating to deficits in these cranial nerves:

altered smell, taste, hearing, or vision (total or partial) drooping of eyelid (ptosis) and weakness of ocular muscles decreased reflexes: gag, swallow, pupil reactivity to light decreased sensation and muscle weakness of the face

32

balance problems and nystagmus altered breathing and heart rate weakness in sternocleidomastoid muscle with inability to turn head to one side weakness in tongue (inability to protrude and/or move from side to side)

If the cerebral cortex is involved, the CNS pathways can again be affected, but also can produce the following symptoms:

aphasia (inability to speak or understand language from involvement of Broca's or Wernicke's area) apraxia (altered voluntary movements) visual field defect memory deficits (involvement of temporal lobe) hemineglect (involvement of parietal lobe) disorganized thinking, confusion, hypersexual gestures (with involvement of frontal lobe) anosognosia (persistent denial of the existence of a, usually stroke-related, deficit)

If the cerebellum is involved, the patient may have the following:

trouble walking altered movement coordination vertigo and or disequilibrium

Pathophysiology Ischemic stroke occurs due to a loss of blood supply to part of the brain, initiating the ischemic cascade. Brain tissue ceases to function if deprived of oxygen for more than 60 to 90 seconds and after a few hours will suffer irreversible injury possibly leading to death of the tissue, i.e., infarction. Atherosclerosis may disrupt the blood supply by narrowing the lumen of blood vessels leading to a reduction of blood flow, by causing the formation of blood clots within the vessel, or by releasing showers of small emboli through the disintegration of atherosclerotic plaques. Embolic infarction occurs when emboli formed elsewhere in the circulatory system, typically in the heart as a consequence of atrial fibrillation, or in the carotid arteries. These break off, enter the cerebral circulation, then lodge in and occlude brain blood vessels. Due to collateral circulation, within the region of brain tissue affected by ischemia there is a spectrum of severity. Thus, part of the tissue may immediately die while other parts may only be injured and could potentially recover. The ischemia area where tissue might recover is referred to as the ischemic penumbra (medicine). As oxygen or glucose becomes depleted in ischemic brain tissue, the production of high energy phosphate compounds such as adenosine triphosphate (ATP) fails, leading to failure of

33

energy-dependent processes (such as ion pumping) necessary for tissue cell survival. This sets off a series of interrelated events that result in cellular injury and death. A major cause of neuronal injury is release of the excitatory neurotransmitter glutamate. The concentration of glutamate outside the cells of the nervous system is normally kept low by so-called uptake carriers, which are powered by the concentration gradients of ions (mainly Na+) across the cell membrane. However, stroke cuts off the supply of oxygen and glucose which powers the ion pumps maintaining these gradients. As a result the transmembrane ion gradients run down, and glutamate transporters reverse their direction, releasing glutamate into the extracellular space. Glutamate acts on receptors in nerve cells (especially NMDA receptors), producing an influx of calcium which activates enzymes that digest the cells' proteins, lipids and nuclear material. Calcium influx can also lead to the failure of mitochondria, which can lead further toward energy depletion and may trigger cell death due to apoptosis.

Care and rehabilitation

Stroke rehabilitation is the process by which patients with disabling strokes undergo treatment to help them return to normal life as much as possible by regaining and relearning the skills of everyday living. It also aims to help the survivor understand and adapt to difficulties, prevent secondary complications and educate family members to play a supporting role. A rehabilitation team is usually multidisciplinary as it involves staff with different skills working together to help the patient. These include nursing staff, physiotherapy, occupational therapy, speech and language therapy, and usually a physician trained in rehabilitation medicine. Some teams may also include psychologists, social workers, and pharmacists since at least one third of the patients manifest post stroke depression. Validated instruments such as the Barthel scale may be used to assess the likelihood of a stroke patient being able to manage at home with or without support subsequent to discharge from hospital. Good nursing care is fundamental in maintaining skin care, feeding, hydration, positioning, and monitoring vital signs such as temperature, pulse, and blood pressure. Stroke rehabilitation begins almost immediately. For most stroke patients, physical therapy (PT) and occupational therapy (OT) are the cornerstones of the rehabilitation process, but in many countries Neurocognitive Rehabilitation is used, too. Often, assistive technology such as a wheelchair, walkers, canes, and orthosis may be beneficial. PT and OT have overlapping areas of working but their main attention fields are; PT involves re-learning functions as transferring, walking and other gross motor functions. OT focusses on exercises and training to help relearn everyday activities known as the Activities of daily living (ADLs) such as eating, drinking, dressing, bathing, cooking, reading and writing, and toileting. Speech and language therapy is appropriate for

34

patients with problems understanding speech or written words, problems forming speech and problems with swallowing. Patients may have particular problems, such as complete or partial inability to swallow, which can cause swallowed material to pass into the lungs and cause aspiration pneumonia. The condition may improve with time, but in the interim, a nasogastric tube may be inserted, enabling liquid food to be given directly into the stomach. Stroke rehabilitation should be started as immediately as possible and can last anywhere from a few days to over a year. Most return of function is seen in the first few days and weeks, and then improvement falls off with the "window" considered officially by U.S. state rehabilitation units and others to be closed after six months, with little chance of further improvement. However, patients have been known to continue to improve for years, regaining and strengthening abilities like writing, walking, running, and talking. Daily rehabilitation exercises should continue to be part of the stroke patient's routine. Complete recovery is unusual but not impossible and most patients will improve to some extent : a correct diet and exercise are known to help the brain to selfrecover. Goals Demonstrate self care skills Exhibit problem solving skill Establish a communication system maintain nutritional and hydration status Musculoskeletal function: sitting up in the bed transfer from bed to chair(sit on bed , stand place a strong hand on the far wheel chair arm and sit down constraint induced movement therapy. use the weakend extremity by avoiding the movement of strong extremity. use of supportive devices eg. cane ,walker limb ROM physiotherapy Nutritional therapy: PEG is dysphagia persists speech therapiat and dietician and occupational therapist use unaffected extremity to eat removing unnecessary items from tray effective dietary programme adequate hydration Bowel function high fiber diet fluid intake 3-4lit/day bowel programme 30min after breakfast

35

 stool softeners and dulcolax suppository Bladder function assessment of bladder distension offering bed pan encourage usual position for urination fluid intake catheterization Communication. speech therapist consultation visual cues magic slate communication board short sentences use patient listening Sexual dysfunction: counselling health education optional positioning of partners open communication with partners

36