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SEMINAR

ON
ENCEPHALITIS

SUBMITTED TO, SUBMITTED BY, Mrs.


PRIYADARSHINI MADAM M.MADHAVI

ASSISTANT PROFESSOR MSC(N) 1 ST YEAR

MEDICAL SURGICAL NURSING, SVS COLLEGE OF NURSING

SVS COLLEGE OF NURSING, MAHABUBNAGAR, TELANGANA.


MAHABUBNAGAR, TELANGANA.
name of the student : Mrs.M.madhavi

class : MSC(N) 1ST YEAR

subject : Medical surgical nursing

topic : Encephalitis

time : 10 am

place : MSC(N) 1st year class room

duration : 3 hrs

method of teaching : lecture com discussion

a.v. aids : charts,flash cards,OHP

submitted to : Mrs. PRIYADARSHINI MADAM


ASSISTANT PROFESSOR

MEDICAL SURGICAL NURSING

SVS COLLEGE OF NURSING


General objectives:

By the end of seminar the students should be able to gain in depth


knowledge regarding encephalitis.

Specific objectives:

 define encephalitis.

 state the incidence of encephalitis.

 list out the classification of encephalitis.

 explain the etiological factors of encephalitis.

 explain the risk factors of encephalitis.

 explain the pathophysiology of encephalitis.

 explain the diagnostic investigations of encephalitis.

 explain the management of encephalitis.

 explain the complications of encephalitis.

 explain the prevention of encephalitis.

 explain the prognosis of encephalitis.


GLOSSERY

Encephalitis: is acute inflammation of the brain. this can be from infection,

metabolic disease, or autoimmune disease

inflammation: a localized reaction that produces redness, warmth, swelling, and

pain as a result of infection, irritation, or injury. inflammation can be external or

internal.

Antibody: also known as an immune globulin, is a large y-

shaped protein produced by b-cells and plasma cells that is used by the immune

system to identify bacteria, viruses, and damaged cells in our body and direct our

immune system to remove them.

Auto immune diseases: arise from an inappropriate immune response of the body

against and the body’s own healthy tissues (autoimmunity).

EEG: is an electroencephalograph used to record the brain’s spontaneous electrical

activity and can detect if a person is having seizures or abnormal brain activity..

.MRI : is a magnetic resonance imaging scan. it can show the brain inflammation

characteristic of encephalitis.

Steroids: are medications used to treat inflammation. one of the most common

prescribed oral steroid drugs is called prednisone and iv steroid is

methylprednisolone.
Teratoma: is a tumor comprised of tissue and/or organ components. teratomas are

normally benign, but it is believed that the teratomas (which sometimes contain

brain tissue) act as the “trigger” in an ae patient’s autoimmune response. surgical

removal of the teratomas in autoimmune encephalitis patients with one is the first

step in the recovery process.

Bacteria: a large group of unicellular microorganisms that lack a cell nucleus.

some bacteria are pathogenic and harmful to humans, some have no effect at all on

humans, and some are beneficial.

Virus: an infectious agent that is only capable of replicating itself inside the living

cells of other organisms

epidemic: the occurrence of more cases of a disease than would be expected in a

community or region during a given time period.


INTRODUCTION

encephalitis denotes inflammation or infection of the brain parenchyma.

because meningeal inflammation commonly accompanies encephalitis, many

authorities employ the term ‘meningo encephalitis’ when discussing encephalitis.

encephalitis has many distinct etiologies, including infections with parasites,

bacteria, fungi, and viruses, and the clinical manifestations of encephalitis can be

mimicked by several noninfectious conditions, including acute stroke, metabolic or

inflammatory disorders, and neoplasia.

this most common cause of encephalitis, viral infections. despite remarkable

advances in preventing many viral causes of encephalitis (such as polio, measles,

and mumps) virus encephalitis remains a major potential source of morbidity and

mortality among the world’s peoples.

DEFINITION

encephalitis is an inflammatory process involving the

brain parenchyma associated with clinical or laboratory evidence of neurologic

dysfunction.

“S.n. chungh”

encephalitis is an inflammation of the brain. it is caused either by an

infection invading the brain (infectious encephalitis) or through the immune

system attacking the brain in error (post-infectious or autoimmune encephalitis).


“Brunner and siddharth”

encephalitis, an acute inflammation of the brain, is a serious, and sometimes

fatal, disease.

“Lewis”

encephalitis is an acute inflammation of the brain. the majority of cases are

caused by either a viral infection or the immune system mistakenly attacking brain

tissue.

“Joy ce,m.black”

encephalitis is an uncommon but serious condition in which the brain

becomes inflamed (swollen).

“b.t.basavanthappa”

INCIDENCE

recurrent epidemics of encephalitis of unknown etiology have occurred in

the country. between 2008 and 2014, there have been more than 44,000 cases and

nearly 6000 deaths from encephalitis in india, particularly in uttar pradesh and

bihar. in 2016, there has been a rise in encephalitis, with over 125 children reported

to have died in one hospital in gorakhpur alone.


permanent sequelae after st. louis encephalitis are uncommon, except for

elderly individuals; the mortality rate is 2% in young adults and 20% in elderly

patients.

a large number of cases of newborns with microcephaly has been reported in

pregnant women infected by zika virus.

CLASSIFICATION OF ENCEPHALITIS

 primary encephalitis. this condition occurs when a virus or other agent

directly infects the brain. the infection may be concentrated in one area or

widespread. a primary infection may be a reactivation of a virus that had been

inactive after a previous illness.

 secondary encephalitis. this condition results from a faulty immune system

reaction to an infection elsewhere in the body. instead of attacking only the

cells causing the infection, the immune system also mistakenly attacks

healthy cells in the brain. also known as post-infection encephalitis,

secondary encephalitis often occurs two to three weeks after the initial

infection.

CAUSES

 herpes simplex virus (hsv). both hsv type 1 — associated with cold sores

and fever blisters around your mouth — and hsv type 2 — associated with
genital herpes — can cause encephalitis. encephalitis caused by hsv type 1 is

rare but can result in significant brain damage or death.

 other herpes viruses. these include the epstein-barr virus, which commonly

causes infectious mononucleosis, and the varicella-zoster virus, which

commonly causes chickenpox and shingles.

 enteroviruses. these viruses include the poliovirus and the coxsackievirus,

which usually cause an illness with flu-like symptoms, eye inflammation and

abdominal pain.

 mosquito-borne viruses. these viruses can cause infections such as west nile,

la crosse, st. louis, western equine and eastern equine encephalitis. symptoms

of an infection might appear within a few days to a couple of weeks after

exposure to a mosquito-borne virus.

 tick-borne viruses. the powassan virus is carried by ticks and causes

encephalitis in the midwestern united states. symptoms usually appear about a

week after a bite from an infected tick.

 rabies virus. infection with the rabies virus, which is usually transmitted by a

bite from an infected animal, causes a rapid progression to encephalitis once

symptoms begin. rabies is a rare cause of encephalitis in the united states.

 childhood infections. common childhood infections — such as measles

(rubeola), mumps and german measles (rubella) — used to be fairly common


causes of secondary encephalitis. these causes are now rare in the united

states due to the availability of vaccinations for these diseases.

bacterial and other[edit]

it can be caused by a bacterial infection, such as bacterial meningitis,[13] or may be

a complication of a current infectious disease syphilis(secondary encephalitis).[14]

certain parasitic or protozoal infestations, such as toxoplasmosis, malaria,

or primary amoebic meningoencephalitis, can also cause encephalitis in people

with compromised immune systems. lyme disease or bartonella henselae may also

cause encephalitis.[citation needed]

other bacterial pathogens, like mycoplasma and those causing rickettsial disease,

cause inflammation of the meninges and consequently encephalitis. a non-

infectious cause includes acute disseminated encephalitis which is demyelinated.[15]

RISK FACTORS

 age. some types of encephalitis are more common or more severe in certain

age groups. in general, young children and older adults are at greater risk of

most types of viral encephalitis.

 weakened immune system. people who have hiv/aids, take immune-

suppressing drugs or have another condition causing a weakened immune

system are at increased risk of encephalitis.


 geographical regions. mosquito- or tick-borne viruses are common in

particular geographical regions.

 season of the year. mosquito- and tick-borne diseases tend to be more

common in summer in many areas of the united states.

PATHOPHYSIOLOGY

virus enters the body throughh the bite of the insect vector (mosquitos)

after multiplication in r.e.system, viremia of varing duration ensures

virus transport to target organ(brain) via blood

virus proliferate and damage the neuronal tissue, there by elicits nervous

manifestations

CLINICAL MANIFISTATIONS

mild symptoms include:

 fever

 headache

 vomiting

 stiff neck

 lethargy (exhaustion)
severe symptoms include:

 fever of 103°f (39.4°c) or higher

 confusion

 drowsiness

 hallucinations

 slower movements

 coma

 seizures

 irritability

 sensitivity to light

 unconsciousness

MODES OF TRANSMISSION OF VIRUSES

viruses spread by different means, and some are more infectious than others.

some of the modes of viral transmission include:

 coughs or sneezes from an infected person that release airborne viruses,

which are then inhaled by others

 infected insects (such as mosquitoes or ticks) and animals, which can

transfer some viruses directly into the bloodstream via their bite

 eating contaminated food or drink

 the transfer of some viruses can occur through touching an infected person
 there is evidence to suggest that some cases of viral encephalitis are caused

by a dormant viral infection (such as herpes simplex virus) becoming active

again.

DIAGNOSIS

blood and urine tests that may be helpful include the following:

 complete blood count (cbc)

 serum electrolyte levels

 serum glucose level

 blood urea nitrogen (bun) and creatinine levels

 urine electrolyte levels

 urine or serum toxicology screening

lumbar puncture (lp): should be performed in all cases of suspected viral

encephalitis.

identify the infectious agent include the following:

 hsv cultures of suspicious lesions and a tzanck smear

 viral cultures of csf, including hsv

 blood cultures for bacterial pathogens

 complement fixation antibodies to identify arbovirus

 heterophile antibody and cold agglutinin testing for ebv

 serologic tests for toxoplasma


imaging modalities that may be helpful include the following:

 CT

 MRI

 EEG

CSF analysis is essential. parameters to be evaluated include the following:

 pressure

 cell counts

 microorganisms

 glucose

 protein

MANAGEMENT

Medical management

 fluids given into a vein to prevent dehydration

 oxygen given through a face mask to support the lungs – sometimes a

machine called a ventilator may be used to control breathing

 bed rest

 anti-inflammatory drugs such as acetaminophen (tylenol,others), ibuprofen

(advil, motrin others) and naproxen sodium (aleve) — to relieve headaches

and fever

pharmacological management
 antiviral medication – used if encephalitis is caused by the herpes simplex

or chickenpox viruses; it's usually given into a vein three times a day for two to

three weeks

 steroid injections – used if encephalitis is caused by a problem with the immune

system and sometimes in cases linked to the chickenpox virus; treatment is

usually for a few days

 immunoglobulin therapy – medication that helps control the immune system,

which may be needed if steroids don't help

 plasmapheresis – a procedure which removes the substances that are attacking

the brain from the blood, which may be needed if immunoglobulin therapy

doesn't help

 bacteria

bartonella bacilliformis: chloramphenicol, ciprofloxacin, doxycycline,

ampicillin, or trimethoprim-sulfamethoxazole is recommended.

 bartonella henselae: doxycycline or azithromycin, with or without rifampin, can

be considered .

 listeria monocytogenes: ampicillin plus gentamicin is recommended (a-iii);

trimethoprim-sulfamethoxazole is an alternative in the penicillin-allergic

patient.
 mycoplasma pneumoniae: antimicrobial therapy (azithromycin, doxycycline, or

a fluoroquinolone) can be considered .

 tropheryma whipplei: ceftriaxone, followed by either trimethoprim-

sulfamethoxazole or cefixime, is recommended .

 mycobacteria

 mycobacterium tuberculosis: 4-drug antituberculous therapy should be initiated

; adjunctive dexamethasone should be added in patients with meningitis.

 rickettsioses and ehrlichioses

 anaplasma phagocytophilum: doxycycline is recommended .

 ehrlichia chaffeensis: doxycycline is recommended.

 rickettsia rickettsii: doxycycline is recommended; chloramphenicol can be

considered an alternative in selected clinical scenarios, such as pregnancy .

 coxiella burnetii: doxycycline plus a fluoroquinolone plus rifampin is

recommended.

 spirochetes

 borrelia burgdorferi: ceftriaxone, cefotaxime, or penicillin g is recommended .

 treponema pallidum: penicillin g is recommended (a-ii); ceftriaxone is an

alternative .

 fungi
 coccidioides species: fluconazole is recommended alternatives are itraconazole,

voriconazole and amphotericin b (intravenous and intrathecal) .

 cryptococcus neoformans: initial treatment with amphotericin b deoxycholate

plus flucytosine or a lipid formulation of amphotericin b plus flucytosine is

recommended.

histoplasma capsulatum: liposomal amphotericin b followed by itraconazole is

recommended .

 protozoa

 acanthamoeba: trimethoprim-sulfamethoxazole plus rifampin plus

ketoconazole or fluconazole plus sulfadiazine plus pyrimethamine can be

considered.

 balamuthia mandrillaris: pentamidine, combined with a macrolide

(azithromycin or clarithromycin), fluconazole, sulfadiazine, flucytosine, and a

phenothiazine can be considered .

 trypanosoma brucei gambiense: eflornithine is recommended ; melarsoprol is

an alternative .

 trypanosoma brucei rhodesiense: melarsoprol is recommended

 helminths

 baylisascaris procyonis: albendazole plus diethycarbamazine can be considered

; adjunctive corticosteroids should also be considered.


 gnathostoma species: albendazole or ivermectin is recommended.

taenia solium: need for treatment should be individualized; albendazole and

corticosteroids are recommended ; praziquantel can be considered as an

alternative .

 postinfectious/postvaccination status

 acute disseminated encephalomyelitis: high-dose corticosteroids are

recommended ; alternatives include plasma exchange and intravenous

immunoglobulin .

SURGERY

surgery to remove abnormal growths (tumours) – done if encephalitis was

triggered by a tumour somewhere in the body

NURSING MANAGEMENT

 monitoring pupils and vital signs frequently for increased intracranial

pressure (icp; irregular pupils, widening pulse pressure, tachycardia,

irregular breathing hyperthermia).

 monitor the patient’s response to medications and observe for adverse

reactions.

 monitor neurologic status closely. watch for subtle changes, such as

behavior or personality changes, weakness, or cranial nerve involvement.

 monitor fluid intake and output to ensure adequate hydration.


 maintain quiet environment and provide care gently, to avoid excessive

stimulation and agitation, which may cause increase icp.

 maintain seizure precautions; pad side rails of bed and have airway and

suction equipment available at bedside.

 maintain standard precautions and additional isolation according to hospital

policy to prevent transmission.

 administer antipyretics and other cooling measures as indicated.

 provide fluid replacement through i.v. lines as needed.

 reorient patient frequently.

 provide supportive care if coma develops; may last several weeks.

 encourage significant others to interact with patient with even while in coma

and to participate in care to promote rehabilitation.

NURSING DIAGNOSIS

actual

 acute pain related to irritation encephalon as evidenced by verbalaization

 increased temperature related to infection as evidenced by warm touch of

skin

potential

 ineffective cerebral tissue perfusion related to inflammatory processes as

evidenced by hypotension
 imbalanced nutrition less than body requirements related to nausea, and

vomiting as evidenced by weakness

risk

 risk for injury related to seizures as evidenced by skin injuries

PSychological

 altered thought processes related to changes in the level of consciousness as

evidenced by asking more questions

 self esteem disturbance related to hospitalaization as evidenced by feeling

ofinferiority
ASSESSMENT NURSING GOAL INTERVENTIONS RATIONAL EXPECTED

DIAGNOSIS OUT COME

Acute pain Reduce the  Assess the condition To get the base Gradually
Acute pain related pain of the patient line data reduced pain
to irritation

encephalon as  Monitor vital signs To know the


evidenced by condition
verbalaization  Provide comfort
To reduce pain
position

 Administer To reduce pain


analgesics

 Provide
psychological To decrease fear
support
ASSESSMENT NURSING GOAL INTERVENTIONS RATIONAL EXPECTED

DIAGNOSIS OUT COME

. Ineffective . Ineffective To  Asses the level of Graduallly


To get the base
consciousness.
Cerebral Tissue Cerebral Tissue maintain line data maintained

Perfusion Perfusion related the normal normal tissue


 Monitor the vital To know the
to inflammatory tissue signs condition perfusion

processes as ev perfusion To improve


 Elevate head of bed
idenced by 300 (Keep the neck venous return

and head straight )


hypotension

 Teach about avoid To maintain the


the Valsalva normal tissue
manuever perfusion
(coughing,
sneezing)
ASSESMENT NURSING GOAL INTERVENTIONS RATONAL EXPECTED
DIAGNOSIS OUT COME

Imbalanced Imbalanced Gradually


To  Asses the patient To get the
Nutrition Less Than
Nutrition: Less condition. base line data Improved
Body improve
Than Body nutritional
Requirements related nutritional  Provide the To improve
Requirements to nausea, and recommended diet. nutritional status
status
vomiting as status
 Serve food in small
evidenced by
portions but To reduce
weakness
frequently. nausea

I
 Monitor body To know the
weight per day. condition
ASSESMENT NURSING GOAL INTERVENTIONS RATIONAL EXPECTED

DIAGNOSIS OUT COME

Risk for injury


Risk for To reduce  Observation level of To obtain Gradually
consciousness. data
injury related to reduced
seizures
seizures as  Check the status of To know the seizures
neurology every 1-2 condition
evidenced by skin
hours
injuries
 Maintain a calm and
To get
comfortable
comfort
environment.
To get
 Limit the number of plessure
visitors.

 Teach ROM
exercises To get
(passive, active) relaxation
ASSESMENT NURSING GOAL INTERVENTIONS RATONAL EXPECTED
DIAGNOSIS OUT COME
Altered thought  Observation level of
Altered thought To To obtain Gradually
processes
processes related to consciousness. data
improve improved
changes in the level of
 Check the status of To know the
thought thought
consciousness as
neurology every 1-2 condition
evidenced by asking process process
more qustions hours a

 Speak slowly and To


understand
clearly. about
condition
 Maintain a calm and To improve
thought
comfortable process

environment
COMPLICATIONS

memory problems, which affect 70% of people who have complications

 personality and behavioural changes, which occur in just under half of all

people

 aphasia - speech and language problems, which occur in around 1 in 3

people

 epilepsy, which occurs in 1 in 4 affected adults and 1 in 2 affected children

 changes in emotions, such as anxiety and anger; mood swings are also

common

 problems with attention, concentrating, planning and problem solving

 physical and motor difficulties

 low mood and a sense of feeling different

 fatigue (extreme tiredness)

PRIMARY PREVENTION

MMR vaccine

the most effective way to protect against encephalitis is to make sure that

you receive the MMR vaccine (for measles, mumps and rubella).
the first MMR vaccination should be given to all children at around 13 months of

age, with a booster dose given before they start school (between three and five

years old). between 5 and 10% of children are not fully immune after the first dose,

so the booster jab increases protection and results in less than 1% of children

remaining at risk.

other vaccinations

vaccinations are also available for japanese encephalitis and tick-borne

encephalitis, which are two types of encephalitis that are spread by insects (for

more information see encephalitis - causes).

in ireland, these types of encephalitis are virtually non-existent, but they are

widespread in certain parts of the world, such as some countries in europe, in africa

and asia. therefore it is a good idea to discuss vaccinations for these types of

encephalitis with your gp before travelling to these areas.

the health a-z topics about japanese encephalitis - vaccination and tick-borne

encephalitis - prevention for more information and advice about taking

precautionary measures against these types of encephalitis.

SECONDARY PREVENTION
certain measures are available for the prevention of a limited number of

agents (viral and bacterial) that can cause encephalitis.

 specific drugs: isoniazid for purified protein derivative positivity in tb and for post-

exposure prophylaxis.

 education and avoidance of risk-taking behavior (unprotected sexual acts):

prevention of hiv, syphilis.

 environmental control (sanitation, vector control and avoidance): nipah and hendra

virus, all the arboviruses, enteroviruses, typhoid.

 isolation should be considered for patients who are severely immunosuppressed

and those with rabies encephalitis, exanthematous encephalitis, or contagious viral

hemorrhagic fever. [47]

 as west nile virus encephalitis has been reported to occur after blood transfusion

and solid organ transplantation, sensitive screening laboratory tests are in

development, which may guide future preventive measures. [86]

PROGNOSIS

the prognosis is dependent on the virulence of the virus and the patient’s

health status. extremes of age (< 1 y or >55 y), immune-compromised status, and

preexisting neurologic conditions are associated with poorer outcomes.


untreated hse has a mortality of 50-75%, and virtually all untreated or late-

treatment survivors have long-term motor and mental disabilities.

the mortality in treated has averages 20%, and the neurologic outcome

correlates with the neurological disability present at the time of the first dose of

acyclovir or comparable antiviral agents. approximately 40% of survivors have

minor-to-major learning disabilities, memory impairment, neuropsychiatric

abnormalities, epilepsy, fine-motor-control deficits, and dysarthria.

supportive care

FOLLOW-UP THERAPY

if you experience complications of encephalitis, you might need additional

therapy, such as:

 physical therapy to improve strength, flexibility, balance, motor coordination

and mobility

 occupational therapy to develop everyday skills and to use adaptive products

that help with everyday activities

 speech therapy to relearn muscle control and coordination to produce speech


 psychotherapy to learn coping strategies and new behavioral skills to improve

mood disorders or address personality changes

SUMMARY

till now we discussed about encephalitis definition is encephalitis is an

inflammatory process involving the brain parenchyma associated with clinical or

laboratory evidence of neurologic dysfunction. incidence between 2008 and 2014,

there have been more than 44,000 cases and nearly 6000 deaths from encephalitis

in india. Classification is primary encephalitis, secondary encephalitis. risk factors

are age, weakend immune system, causes of encephalitis herpes simplex virus

(hsv). other herpes viruses, enteroviruses, mosquito-borne viruses,tick-borne

viruses, rabies virus,childhood infections bacteria , pathophysiology, symptoms

like fever, headache, vomiting, stiff neck.

 diagnosis complete blood count (cbc),serum electrolyte levels, serum glucose

level, blood urea nitrogen (bun) and creatinine levels, urine electrolyte

levels,management, complications, prevention, supportive care, follow up of

the encephalitis

CONCLUSION
by this seminar me and my peer group got in depth knowledge regarding

encephalitis and its management. and i hope that it will be beneficial for my further

studies.

BIBLIOGRAPHY:

 joyce.m.blac, text book of medical surgical nursing,8 th

edition,vol1,pg.no:720-724

 lewis,text book of medical surgical nursing,6th edition,vol-1,pg.no:302-305

 brunner& siddharth,text book of medical surgical nursing,13 th

edition,pg.no:502-505

 b.t.basavanthappa,text book of medical surgical nursing,4 th edition, pg

.no:602-605

 dr.prithi gupta,text book ,p.v.publications,pg.no:90-91


stroke

introduction

the brain is arguably the most complex of all the organs in your body. these three

pounds of tissue compose the major nerve center of the body, which coordinates all

of our bodily functions, including behavior, thought and emotions. because your

brain is a very hard-working organ, it requires constant supplies of oxygen and

nutrients from the blood to function effectively.


the heart pumps blood throughout the cerebral arteries ("cerebral" means "related

to the brain"), delivering blood to the brain. any significant interruption to this

supply of nutrients and oxygen will start killing brain cells. damage to brain cells

occurs almost immediately upon cessation or even significant restriction of blood

flow to the brain. minor damage to any part of the brain can have a serious adverse

effect on the rest of the body. significant damage to the brain can even result in

death.

one relatively common cause of brain damage and death is referred to as a stroke. a

stroke is similar to a heart attack, only in this case, blood flow to brain, rather than

the heart, is blocked. the term "stroke" comes from the once popular idea that

someone had received a "stroke of god's hand" and was therefore damaged. strokes

are also called cerebrovascular accidents (cva's; "cerebrum" is latin for brain, while

"vascular" refers to the blood vessels) or "brain attacks" to emphasize the need to

call 911 and get immediate medical attention when they occur.

definitions
the damaging or killing of brain cells starved of oxygen as a result of the blood

supply to part of the brain being cut off. types of stroke include ischaemic stroke

caused by blood clots to the brain or haemorrhagic stroke caused by bleeding

into/of the brain.

stroke: the sudden death of brain cells due to lack of oxygen, caused by blockage

of blood flow or rupture of an artery to the brain. sudden loss of speech, weakness,

or paralysis of one side of the body can be symptoms.

stroke occurs when part of the brain loses its blood supply and stops working. this

causes the part of the body that the injured brain controls to stop working.

stroke occurs when there is ischemia(in adequate blood flow)to a part of brain or

hemmarrhage into brain that results in death of brain cells.

lewis

a stroke also is called a cerebrovascular accident, cva, or "brain attack."

incidence

tudy reported nearly 5.87 million stroke deaths globally in 2010, as compared to

4.66 million in 19902,3. this indicated a 26 per cent increase in global stroke deaths
during the past two decades. with the rising proportion of mortality, stroke still

remains the second leading cause of death worldwide2,3.

a global systematic review of population-based stroke studies has documented that

the incidence rate of stroke in lmics has increased from 56/100,000 person-years

during 1970-1979 to 117/100,000 person-years during the period 2000-20085. this

study has also reported a decrease in the stroke incidence from 163 per 100,000

person-years in 1970-1979 to 94 per 100,000 person-years during 2000-2008 in

high-income countries (hics)5 indicating approximately 42 per cent decrease in

stroke incidence in hics and more than double increase in stroke incidence in lmics,

during the past four decades5.

hemorrhagic strok

a hemorrhagic stroke is bleeding (hemorrhage) that suddenly interferes with the

brain's function. this bleeding can occur either within the brain or between the

brain and the skull. hemorrhagic strokes account for about 20% of all strokes, and

are divided into categories depending on the site and cause of the bleeding:

here are two main types of hemorrhagic stroke:


a hemorrhagic stroke occurs when a weakened blood vessel bursts, leaking blood

into the brain.

 intracerebral hemorrhage: the bleeding occurs inside of the brain. this is the most

common type of hemorrhagic stroke.

 subarachnoid hemorrhage: the bleeding occurs between the brain and the

membranes that cover it.

both types of hemorrhagic stroke have the conventional stroke risk factors.

causes are:

 high blood pressure

 injury

 bleeding disorders

 cocaine use

 abnormal blood vessels (avms)

 aneurysm (a weak area in a blood vessel that breaks open)

in addition, the risk factors fontracerebral hemorrhage include:

 hypertension - the most common cause.


 cerebral cavernous malfunctions - when blood vessels do not form correctly in the

brain.

 arteriovenous malformations (avms) - a genetic condition where blood vessels

form incorrectly, leading to an abnormally tangled web.

avms typically occur in the brain and spine. if they occur in the brain, the vessels

can break, leading to bleeding into the brain. this disorder is rare.

risk factors for subarachnoid hemorrhage are most often:

 avms

 bleeding disorders

 head injury and trauma

 blood-thinning medication

 a bulge in the wall of a blood vessel called a cerebral aneurysm

an aneurysm can increase in size, causing the artery wall to weaken. if an

aneurysm bursts, uncontrolled bleeding may occur.

pathophisiology
n intracerebral hemorrhage, bleeding occurs directly into the brain parenchyma. the

usual mechanism is thought to be leakage from small intracerebral arteries

damaged by chronic hypertension. other mechanisms include bleeding diatheses,

iatrogenic anticoagulation, cerebral amyloidosis, and cocaine abuse.

intracerebral hemorrhage has a predilection for certain sites in the brain, including

the thalamus, putamen, cerebellum, and brainstem. in addition to the area of the

brain injured by the hemorrhage, the surrounding brain can be damaged by

pressure produced by the mass effect of the hematoma. a general increase in

intracranial pressure may occur.

 symptoms

symptoms of a hemorrhagic stroke vary, depending on the cause:

 intracerebral hemorrhage — symptoms almost always occur when the person is

awake. symptoms tend to appear without warning, but they can develop gradually.

symptoms worsen over a period of 30 to 90 minutes. symptoms can include:

o sudden weakness

o paralysis or numbness in any part of the body

o inability to speak

o inability to control eye movements correctly


o vomiting

o difficulty walking

o irregular breathing

o stupor

o coma

 subarachnoid hemorrhage — when caused by a ruptured aneurysm, symptoms can

include:

o a very severe headache that starts suddenly (some people describe it like a

"thunderclap.")

o loss of consciousness

o nausea and vomiting

o inability to look at bright light

o stiff neck

o dizziness

o confusion

o seizure

o loss of consciousness

 blood tests. you may have several blood tests, which tell your care team how

fast your blood clots, whether your blood sugar is abnormally high or low,

whether critical blood chemicals are out of balance, or whether you may
have an infection. managing your blood's clotting time and levels of sugar

and other key chemicals will be part of your stroke care.

 computerized tomography (ct) scan. a ct scan uses a series of x-rays to create

a detailed image of your brain. a ct scan can show a hemorrhage, tumor,

stroke and other conditions. doctors may inject a dye into your bloodstream

to view your blood vessels in your neck and brain in greater detail

(computerized tomography angiography). there are different types of ct

scans that your doctor may use depending on your situation.

 magnetic resonance imaging (mri). an mri uses powerful radio waves and

magnets to create a detailed view of your brain. an mri can detect brain

tissue damaged by an ischemic stroke and brain hemorrhages. your doctor

may inject a dye into a blood vessel to view the arteries and veins and

highlight blood flow (magnetic resonance angiography, or magnetic

resonance venography).

 carotid ultrasound. in this test, sound waves create detailed images of the

inside of the carotid arteries in your neck. this test shows buildup of fatty

deposits (plaques) and blood flow in your carotid arteries.

 cerebral angiogram. in this test, your doctor inserts a thin, flexible tube

(catheter) through a small incision, usually in your groin, and guides it


through your major arteries and into your carotid or vertebral artery. then

your doctor injects a dye into your blood vessels to make them visible under

x-ray imaging. this procedure gives a detailed view of arteries in your brain

and neck.

 echocardiogram. an echocardiogram uses sound waves to create detailed

images of your heart. an echocardiogram can find a source of clots in your

heart that may have traveled from your heart to your brain and caused your

stroke.

you may have a transesophageal echocardiogram. in this test, your doctor

inserts a flexible tube with a small device (transducer) attached into your

throat and down into the tube that connects the back of your mouth to your

stomach (esophagus). because your esophagus is directly behind your heart, a

transesophageal echocardiogram can create clear, detailed ultrasound images

of your heart and any blood clots.

treatment

hemorrhagic stroke
emergency treatment of hemorrhagic stroke focuses on controlling your bleeding

and reducing pressure in your brain. you might also need surgery to help reduce

future risk.

emergency measures. if you take warfarin (coumadin, jantoven) or anti-platelet

drugs such as clopidogrel (plavix) to prevent blood clots, you may be given drugs

or transfusions of blood products to counteract the blood thinners' effects. you may

also be given drugs to lower pressure in your brain (intracranial pressure), lower

your blood pressure, prevent vasospasm or prevent seizures.

once the bleeding in your brain stops, treatment usually involves supportive

medical care while your body absorbs the blood. healing is similar to what happens

while a bad bruise goes away. if the area of bleeding is large, your doctor may

perform surgery to remove the blood and relieve pressure on your brain.

surgical blood vessel repair. surgery may be used to repair blood vessel

abnormalities associated with hemorrhagic strokes. your doctor may recommend

one of these procedures after a stroke or if an aneurysm or arteriovenous

malformation (avm) or other type of vascular malformation caused your

hemorrhagic stroke:
 surgical clipping. a surgeon places a tiny clamp at the base of the aneurysm, to

stop blood flow to it. this clamp can keep the aneurysm from bursting, or it

can prevent re-bleeding of an aneurysm that has recently hemorrhaged.

 coiling (endovascular embolization). a surgeon inserts a catheter into an artery

in your groin and guides it to your brain using x-ray imaging. tiny detachable

coils are guided into the aneurysm (aneurysm coiling). the coils fill the

aneurysm, which blocks blood flow into the aneurysm and causes the blood to

clot.

 surgical avm removal. surgeons may remove a smaller avm if it's located in an

accessible area of your brain, to eliminate the risk of rupture and lower the

risk of hemorrhagic stroke. however, it's not always possible to remove an

avm if its removal would cause too large a reduction in brain function, or if

it's large or located deep within your brain.

 stereotactic radiosurgery. using multiple beams of highly focused radiation,

stereotactic radiosurgery is an advanced minimally invasive treatment used to

repair vascular malformations.


complications

in addition to other medical problems, a stroke can cause temporary or permanent

disability. this depends on how long blood flow to the brain was interrupted and

which part of the brain was affected.

possible complications include:

 blood clots

 difficulty swallowing or talking

 pneumonia

 loss of bladder control

 memory loss or thinking difficulties

 pain

 emotional problems

 brain swelling

 seizures

 depression
prevention

hemorrhagic strokes can be prevented in some cases. according to the centers for

disease control and prevention (cdc), 1 in 4 strokes each year are recurrent.

understanding the risk factors and preventive measures are crucial. those people at

higher risk include smokers and those with one or more of the following:

 high blood pressure or high cholesterol

 diabetes

 being overweight

 a family history of stroke

 heart disease or disorder

women and african americans are at an increased risk of stroke. according to the

national stroke association, african americans have twice the risk mostly because

they are more prone than others to high blood pressure, diabetes, and obesity.

preventive measures include practicing a heart-healthy lifestyle, which includes:

 exercising

 avoiding tobacco products


 staying within a healthy weight

 making heart-healthy eating choices

 managing stress properly

people should always seek medical care as soon as any of the symptoms of a

hemorrhagic stroke are suspected.

ischemic stroke

 types of ischemic stroke?

 ischemic (“is-skeem-ic”) stroke occurs when an artery to the brain is

blocked. the brain depends on its arteries to bring fresh blood from the heart

and lungs. the blood carries oxygen and nutrients to the brain, and takes

away carbon dioxide and cellular waste. if an artery is blocked, the brain

cells (neurons) cannot make enough energy and will eventually stop working

types

an interruption of blood supply to the brain causes all ischemic strokes. however,

ischemic strokes can start in different areas of the body and may occur due to

various types of blockage:


 embolic stroke: this occurs when a blood clot, piece of plaque, or another object

forms in a different part of the body and travels to the brain's blood vessels.

 thrombotic stroke: this type of stroke occurs when a thrombus or clot forms inside

a blood vessel in the brain.

learn about other types of stroke here.

 .

causes

ischemic stroke is the most common type, and early intervention is vital.

an ischemic stroke occurs due to atherosclerosis, which causes fatty deposits and a

buildup of cholesterol plaque in the blood vessels.

when too much plaque collects in one spot, it can block the blood flow to vital

organs.

a blood clot may stick to a plaque buildup while passing through the blood vessels,

which also creates a blockage.


the neck contains carotid arteries, which are blood vessels that supply blood to the

brain. if plaque blocks a carotid artery (carotid artery disease), a stroke might

occur.

atherosclerosis is largely symptomless. therefore, many people do not know they

have atherosclerosis until they have a stroke or experience the other effects of

blocked arteries near different organs, such as a heart attack.

risk factors

the major risk factors for an ischemic stroke and carotid artery disease are the

same.

they include:

 high blood pressure: this is the primary cause of stroke.

 diabetes: people with diabetes are four times more likely to have carotid artery

disease.

 atherosclerosis or carotid artery disease: having either of these conditions or a

family history of these conditions can increase the risk of stroke.


 atrial fibrillation (afib): approximately 15% of strokes occur in people who have

afib.

 cholesterol levels: high levels of "bad" low-density lipoprotein (ldl) cholesterol or

low levels of "good" high-density lipoprotein (hdl) cholesterol can contribute to

plaque buildup in the arteries.

 a sedentary lifestyle: a lack of physical activity can lead to high blood pressure,

high cholesterol, and being overweight. these increase the risk of arterial plaque

buildup.

 being overweight or obese.

 an unhealthful diet: consuming too many saturated or trans fats and foods high in

cholesterol, sodium, and sugar can lead to diabetes, plaque buildup, high blood

pressure, and high cholesterol.

 being over 55 years of age: the risk of stroke increases in people aged over 55

years and increases with each additional decade of life.

symptoms

strokes can be life-threatening, so it is important to seek medical care immediately

if symptoms appear.
ischemic stroke symptoms often affect one side of the body and develop quickly.

face drooping: people may notice one side of the face drooping or feeling numb.

another person can check for this symptom by asking the person to smile or stick

out their tongue.

if their smile is uneven, or their tongue moves to one side of the mouth instead of

the middle, this could be a warning sign for ischemic stroke.

arm weakness: being unable to lift one arm or feeling weakness or numbness in

one arm may suggest that an ischemic stroke is occurring.

speech problems: these might include being unable to speak or repeat a sentence

clearly.

time to call 9-1-1: contact emergency services immediately on noting the other

indicators of ischemic stroke.

beyond f.a.s.t., a stroke may also cause the following symptoms to develop

suddenly:

 difficulty walking

 dizziness
 falling without an identifiable cause

 a sudden inability to understand speech

 confusion

 rapidly developing vision problems

 a severe headache without an apparent cause

treatment

to treat an ischemic stroke, doctors must quickly restore blood flow to your brain.

emergency treatment with medications. therapy with clot-busting drugs must start

within 4.5 hours if they are given into the vein — and the sooner, the better. quick

treatment not only improves your chances of survival but also may reduce

complications. you may be given:

 intravenous injection of tissue plasminogen activator (tpa). this injection of

recombinant tissue plasminogen activator (tpa), also called alteplase, is

considered the gold standard treatment for ischemic stroke. an injection of tpa

is usually given through a vein in the arm. this potent clot-busting drug ideally

is given within three hours. in some instances, tpa can be given up to 4.5 hours

after stroke symptoms begin.


this drug restores blood flow by dissolving the blood clot causing your stroke,

and it may help people who have had strokes recover more fully. your doctor

will consider certain risks, such as potential bleeding in the brain, to determine

if tpa is appropriate for you.

emergency endovascular procedures. doctors sometimes treat ischemic strokes

with procedures performed directly inside the blocked blood vessel. these

procedures must be performed as soon as possible, depending on features of the

blood clot:

 medications delivered directly to the brain. doctors may insert a long, thin

tube (catheter) through an artery in your groin and thread it to your brain to

deliver tpa directly into the area where the stroke is occurring. this is called

intra-arterial thrombolysis. the time window for this treatment is somewhat

longer than for intravenous tpa, but is still limited.

 removing the clot with a stent retriever. doctors may use a catheter to

maneuver a device into the blocked blood vessel in your brain and trap and

remove the clot. this procedure is particularly beneficial for people with large

clots that can't be completely dissolved with tpa, though this procedure is

often performed in combination with intravenous tpa.


several large and recent studies suggest that, depending on the location of the clot

and other factors, endovascular therapy might be the most effective treatment.

endovascular therapy has been shown to significantly improve outcomes and

reduce long-term disability after ischemic stroke.

other procedures. to decrease your risk of having another stroke or transient

ischemic attack, your doctor may recommend a procedure to open up an artery

that's narrowed by plaque. doctors sometimes recommend the following

procedures to prevent a stroke. options will vary depending on your situation:

 carotid endarterectomy. in a carotid endarterectomy, a surgeon removes

plaques from arteries that run along each side of your neck to your brain

(carotid arteries). in this procedure, your surgeon makes an incision along the

front of your neck, opens your carotid artery and removes plaque that blocks

the carotid artery.

your surgeon then repairs the artery with stitches or a patch made from a vein

or artificial material (graft). the procedure may reduce your risk of ischemic

stroke. however, a carotid endarterectomy also involves risks, especially for

people with heart disease or other medical conditions.


 angioplasty and stents. in an angioplasty, a surgeon usually accesses your

carotid arteries through an artery in your groin. here, your surgeon can gently

and safely navigate to the carotid arteries in your neck. a balloon is then

inflated to expand the narrowed artery. then a stent can be inserted to support

the opened artery.

 nursing management

 monitor vital signs at least every 15 minutes. it's critical that patients who

experienced an ischemic stroke avoid hypotension because they already have

reduced oxygen-rich blood flow to the brain. if tpa is initiated, vital signs

should be monitored before initiation and every 5 minutes for the first 15

minutes after administration, then every 15 minutes thereafter.13

 nurses managing a patient with a diagnosis of hemorrhagic stroke should

avoid hypertensive states because this can result in an expansion of

intracranial bleeding, which will result in increased intracranial hypertension

and predispose the patient to further neurologic injury.15

 support of airway, breathing, and circulation as a primary goal. these

patients may need ventilator support for respiratory depression or respiratory

fatigue secondary to the neurologic injury.


 neurologic assessments should be performed hourly or as needed to closely

monitor for neurologic decline

• nursing diagnosis

actual

ineffective tissue perfusion related to decreased cerebral blood flow as evidenced

by decreased glassgow coma scale

ineffective air way clearance related to increase secretions as evidenced by

diminished breath sounds

potential

impaired physical mobility, related to neurologic deficits as evidenced by limited

ability to perform gross and fine motor skills

impaired urinary elimination related to impaired impulse to void as evidenced by

incontinence ofurine

risk

risk for impaired skin integrity, related to inability to change position as evidenced

byskin infection

psychological
• impaired verbal communication, related to cerebral injury as evidenced by

inability to speak

 low self esteem related to altered body image as evidenced by refusal to

touch

prevention

even people with risk factors or a history of stroke can take steps to improve

cardiovascular health and reduce the risk of ischemic stroke.

the following measures can help prevent a stroke and improve overall health:

 having regular check-ups: high blood pressure and cholesterol do not have visible

symptoms. regular health tests are the only way to know if these are present.

blood tests and health checkups can help detect these problems early and allow for

timely treatment.

 getting regular exercise: an active lifestyle reduces the risk of diabetes, high blood

pressure, high cholesterol, and other conditions that increase the risk of ischemic

stroke.
 following a heart-healthy diet: a diet should be low in "bad" fats, such as saturated

and trans fats. people should also limit their sodium intake. eating more fruits,

vegetables, whole grains, healthful fats, and lean proteins can help them preserve

cardiovascular health.

 managing body weight: if a person is overweight or has obesity, reaching a

healthy body weightcan bring down their risk for stroke.

 avoiding first-hand or secondary smoking: smoking and inhaling smoke from

others can cause damage to blood vessels and increase the risk of stroke-related

health problems.

 being aware of family history: always discuss a family history of stroke or tia with

a doctor.

 taking daily aspirin: a doctor may recommend that a person who has an especially

high risk of a heart attack or stroke and a low risk of bleeding take a daily aspirin.

guidelines no longer recommend the widespread use of aspirin for this purpose,

due to the high risk of bleeding.

 getting enough sleep and managing stress: getting 7–8 hours of sleep and taking

steps to reduce stress, such as relaxation techniques, may help to prevent stroke

and improve overall health and well-being.



ASSESSMENT NURSING GOAL INTERVENTIONS RATIONAL EXPECTED
DIAGNOSIS OUT COME
Ineffective Ineffective tissue Improve To obtain base Gradually
perfusion related to  Asses the patient
line data improved
tissue perfusion decreased cerebral cerebral condition
blood flow as To asses the cerebral
evidenced by perfusion  Monitor neurological
changes perfusion
decreased status
glassgow coma
scale  Administer
To increase
vasopressin ,calcium
tissue
channel blockers’,
perfusion
anti coagulant
medication,
 Avoid neck flexion
or extreme hip / knee
flexion
To avoid
obstruction of
blood floe
ASSESSMENT NURSING GOAL INTERVENTIONS RATIONAL EXPECTED
DIAGNOSIS OUT COME
Ineffective air Ineffective air way To maintain  Assess the patient To get base gradually
clearance related to
condition line data maintained
way clearance increase secretions clear air way
as evidenced by  Monitor vital signs clear air way
diminished breath
sounds  Encourage to use To know
incentive spirometry condition

 Remove secretions by To open


encouraging collapsed

coughing alvieoli

 Instrut patient to To maintain

inhale deeply ,bend clear air way

forward slightly , and


perform three or four
huffs To expel
secretions
ASSESSMENT NURSING GOAL INTERVENTIONS RATIONAL EXPECTED
DIAGNOSIS OUT COME
Impaired Impaired physical To increase To get base Gradually
mobility, related to  Asses the patient
line data increased
physical mobility neurologic deficits muscle condion
as evidenced by muscle
limited ability to streangth  Determine patients
To assess level streangth and
perform gross and readiness to engage in
fine motor skills and ability of participation ability to move
activity
to move  Apply splints to
To increase
achive the stability of
muscle
proximal joints
streangth
 Encourage the patient
to practice exercise
To increase
independently
muscle
 Provide restfull
streangth
environment to
patient after exercises

To facilitate
recuparation
ASSESSMENT NURSING GOAL INTERVENTIONS RATIONAL EXPECTED
DIAGNOSIS OUT COME

 Asses the patient


Risk for impaired To get base Gradually
Risk for impaired skin integrity, To impro ve condion
line data impro ve skin
related to inability  Frequently changing
skin integrity skin
to change position integrity
as evidenced Positions
integrity To impro ve
byskin infection
 Teach about
skin integrity
importence of
To impro ve
changing positions
skin integrity
 Perform hygienic
measures like regular
To prevent
bath
skin infections
 Provide
psychological support
To reduce fear
ASSESSMENT NURSING GOAL INTERVENTIONS RATIONAL EXPECTED
DIAGNOSIS OUT COME
Impaired verbal Impaired verbal To improve To get base gradually
communication,  Asses the patient
line data
communication related to cerebral Verbal condition improved
injury as evidenced
by inability to communicati  Listen alternatively Verbal
To improve
speak and convay the
on communication
patient thoughts Verbal
techniques  Provide positive techniques
communication
reinforcement
techniques
 use simple words and
to build self
sentences
esteem
 Provide verbal
to avoid
prompts
overwhelming
patient with
verbal stimulai
summery

 stroke: the sudden death of brain cells due to lack of oxygen, caused by blockage

of blood flow or rupture of an artery to the brain.types are ischemic

stroke,hemmorhagic stroke .incidence causes are high blood

pressure,injury,bleeding disorders,cocaine use,abnormal blood vessels

(avms),aneurysm (a weak area in a blood vessel that breaks open).risk factors like

diabetes,carotid artery disease,atherosclerosis ,pathophysiology,diagnosis are

blood test ,ct,mri.management ,complications ,prevention.

conclusion

by this seminar me and my peer group got in depth knowledge regarding stroke

and its management. and i hope that it will be beneficial for my further studies.