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The world as a whole has been facing different constant changes not only in the
environment but also in peopleǯs lives As changes occur, the more people become in
need to adopt with these changes, thus, and we expose ourselves to illness that could
even lead to unwanted events in our lives

Our nursing case presentation is about Cerebrovascular Accident discussing


Ãschemic stroke The content includes the patientǯs general data and physical
assessment, anatomy, physiology and pathophysiology, review of related literature,
laboratory and pharmacology

The highlight if the presentation deals with the nursing care presentation with
the nursing care plan of our patient revolving on his priority nursing problems, goals of
care, appropriate nursing intervention and its feedback evaluation

Our group is composed of 11 Nursing students We have chosen this case as a


help for studies to eliminating and prevent through health education the enlarging
occurrence of Cerebrovascular diseases like this

We greatly acknowledge the cooperation extended by the patient We also


appreciate the effort of Our Lady of Fatima University Medical Center staff and the
guidance provided to us by our Clinical Ãnstructor, Mrs Anna Liza Morales, and most
importantly, we thank our God Almighty for all the graces he bestowed on us

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Name: Estrellia, Remedios Salazar

Age: 54

Civil Status: F

Date of Birth: October 25 1956

Place of Birth: Valenzuela City

Nationality: Filipino

Religion: Roman Catholic

Address: 618 Caloong Ã, Valenzuela City

Date of Admission: December 6 2010

Date of Discharge: December 10 2010

Admitting Diagnosis: Cerebrovascular Accident

Physician-in-charge: Dra Rebecca W Deguyo, MD

Ê 
Ê  


HEADACHE

 

  
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One day prior to admission, patient complained of headache,

associated with nape pain and dizziness There was also a noted limitation of

motion of the neck area There was no associated vomiting, blurring of vision

and loss of consciousness No medications taken and no consult were done

Few hours prior to admission


above symptoms have persisted which

prompted patient to seek consult of his physicianǯs clinic Patient was advised to

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be admitted for further evaluation and management, hence the subsequent

admission


 
 

‰  HPN- DX 2002

-on maintenance medication

‰- DM

‰- Asthma

‰  Previous hospitalization 2007 FUMC

‰  CVO Bleed ȂCVD bleed vs infarct

  
 
 


‰- Smoker

‰- Alcoholic drinker

 
 


‰  HPN on both sides

‰  DM on mother side

‰  CA both sides

-Cervical CA, Breast CA

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ÃÃÃ c ÃÊ 

  



  
December 6 2010

     


Conscious, coherent, ambulatory, NÃCRD

  
 

Musculoskeletal disorder

R/to CVD re-intant

S/p CVD infarct

Left with sensory deficit

Right extremely

 
 

BP: 100/90

PR: 81

RR: 18

Temp: 36 8

! 

Warm, with good skin turgor and skin texture, moist

 

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PPC, AS

‰- CLAD

‰- TPC

!

‰  Limitation of the RAM of neck

Ê 

SCE,

‰- Retractor CBS

 


AP, NARR,

‰- murmurs

  


Flabby, nabs, soft

‰- tenderness

   

GME

‰- edema

‰- cyanosis

PEP

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Ê  
Convulsion, coherent for 3 spheres


Ê   
Can perform RAM

No nystagmus

à  t/c CVD bleed vs infarct

Ê 
 


Ã

N/A


ÃÃ

PERTL 2-3 mm


ÃÃÃ
Ã

Ãntact EDMs

 Ãntact bicorneal reflexes

ÃÃ
No facial symmetry

ÃÃÃ Can hear

Ã
 Can swallow


Can shrug shoulders

ÃÃ Tongue at the midline

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R L

5/5 5/5

5/5 5/5

 

R L

75 % 100 %



75 % 100 %

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ÃV c 

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# 

 
$"%" The Anatomy of the Brain

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The brain is protected by a bony covering called the cranium ‰which, along with
the bones of the face, makes up the skull Ãnside the cranium, the brain is
surrounded by the meninges The meninges are made up of 3 layers of tissue:

îc Pia mater Ȃ the layer closest to the surface of the brain


îc Arachnoid membrane Ȃ the middle layer of tissue
îc Dura mater Ȃ the outer-most layer


  
&




 

The largest part of the brain located in the front is called the cerebrum The
cerebrum is responsible for:

îc Movement
îc Body temperature
îc Touch
îc Vision
îc Hearing
îc Vudgment
îc Reasoning
îc Problem solving
îc Emotions
îc Learning

The cerebrum has 2 parts: the right cerebral hemisphere and the left cerebral
hemisphere They are connected at the bottom and have a deep groove running
between them Ãn general, the right cerebral hemisphere controls the left side of
the body, and the left cerebral hemisphere controls the right The right side is
involved with creativity and artistic abilities The left side is important for logic
and rational thinking

The hemispheres of the cerebrum are divided into lobes, or broad regions of the
brain Each lobe is responsible for a variety of bodily functions:

îc Frontal lobes are involved with personality, speech, and motor


development
îc Temporal lobes are responsible for memory, language and speech
functions
îc Parietal lobes are involved with sensation
îc Occipital lobes are the primary vision centers

The surface of the cerebrum appears wrinkled and is made up of deep grooves
‰called sulci and bumps or folds ‰called gyri The outer part of the cerebrum is
called gray matter and contains nerve cells The inner part is called white matter
and contains connections of nerves

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The brainstem is located in front of the cerebellum The brainstem is like the
hard-drive of a computer Ãt is the main control panel for the body that passes
messages back and forth between the brain and other parts of the body The
cerebrum, the cerebellum, and the spinal cord are all connected to the
brainstem The brainstem has three main parts, the midbrain, the pons, and the
medulla oblongata

The brainstem controls vital functions of the body, including:

îc Breathing
îc Consciousness
îc Cardiac function
îc Ãnvoluntary muscle movements
îc Swallowing
îc Movement of the eyes and mouth
îc Relaying sensory messages ‰pain, heat, noise, etc 
îc Hunger


   
&

!


 

Behind the cerebrum at the back of the head is the cerebellum Ãn Latin,
cerebellum means Dzlittle brain  However, the cerebellum contains more nerve
cells than both hemispheres combined The cerebellum is primarily a movement
control center, responsible for:

îc Voluntary muscle movements


îc Fine motor skills
îc Maintaining balance, posture, and equilibrium
îc Unlike the cerebrum, the left cerebellum controls the left side of the body,
and the right cerebellum controls the right side of the body

Unlike the cerebrum, the left cerebellum controls the left side of the body,
and the right cerebellum controls the right side of the body

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$"'"
The Motor, Sensory and Association Areas of the
Cerebral Cortex

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 " The brain is not a solid organ There are fluid-filled
cavities within the brain called ventricles The ventricles are important in
providing nourishment to the brain The ventricular system produces and
processes cerebrospinal fluid Ȃ a clear, watery substance that flows around the
brain and helps cushion and protect it

Ê 
  " The brain also contains 12 pairs of cranial nerves each
responsible for specific functions in the body:

îc Olfactory nerve Ȃ smell


îc Optic nerve Ȃ vision
îc Oculomotor Ȃ eye movements, eyelid opening
îc Trochlear Ȃ eye movements
îc Trigeminal Ȃ facial sensations, chewing
îc Abducens Ȃ eye movements
îc Facial Ȃ taste, facial expressions
îc Vestibulocochlear Ȃ hearing, balance
îc Glossopharyngeal Ȃ taste, swallowing
îc Vagus Ȃ swallowing, taste
îc Accessory Ȃ neck and shoulder muscles
îc Hypoglossal Ȃ tongue movement

  
 "
The pituitary gland is located in the center of the brain and is
about the size of a dime The pituitary gland, often referred to as the Dzmaster
gland, is responsible for a number of functions including producing hormones
for the thyroid and adrenal glands, as well as the hormones responsible for
normal growth and sexual maturation

#"c Ê  
Ê   

The cerebral circulation receives approximately 15% of the cardiac


output, or 750 ml per minute The brain does not store nutrients and has a high
metabolic demand that requires the high blood flow The brainǯs blood pathway
is unique because it flows against gravity; its arteries fill from below and the
veins drain from above Ãn contrast to other organs that may tolerate decrease in
blood flow because of their adequate collateral circulation, the brain lacks
additional collateral blood flow, which may result in irreversible tissue damage
when blood flow is occluded for even short periods of time

  "
Two internal carotid arteries and vertebral arteries and their extensive
system of branches provide the blood supply to the brain The internal carotids

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arise from the bifurcation of the common carotid and supply much of the
anterior circulation of the brain The vertebral arteries branch from the
subclavian arteries, flow back to and upward on either side of the cervical
vertebrae, enters the cranium through the foramen magnum The vertebral
arteries join to become the basilar artery at the level of the brain stem; the
basilar artery divides to form the two branches of the posterior cerebral arteries
The vertebrobasilar arteries supply most of the posterior circulation of the
brain


At the base of the brain surrounding the pituitary gland, a ring of arteries is
formed between the vertebral and internal carotid artery chains This ring is
called the circle of Willis and is formed from the branches of the internal carotid
artery, and anterior and middle cerebral arteries, and anterior and anterior and
posterior communicating arteries Functionally, the posterior portion of the
circulation and the anterior or carotid circulation usually remain separate The
arteries of the circle of Willis can provide collateral circulation if one or more of
the four vessels supplying to become occluded or are ligated

The arterial anastomoses along the circle of Willis are frequent sites of
aneurysms Theses can be formed when the pressure at a weakened arterial wall
causes the artery to balloon out Aneurysms may be congenital or the result of
degenerative changes in the vessel wall associated with atherosclerotic vascular
disease Ãf an artery with an aneurysm bursts or becomes occluded by
vasospasm, an embolus, or a thrombus, the neurons distal to the occlusion are
deprived f their blood supply and the cells die quickly The result is hemorrhagic
stroke ‰cerebrovascular accident or infarction The effects of the occlusion
depend on which vessels are involved and which areas of the brain these vessels
supply

  Venous drainage for the brain does not follow the arterial circulation as
in other body structures The veins reach the brainǯs surface, join larger veins,
then cross the subarachnoid space and empty into the dural sinuses, which are
vascular channels lying within the tough Dura mater The network of sinuses
carries venous outflow from the brain and empties into the internal jugular vein,
returning the blood to the heart Cerebral veins and sinuses 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

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$"(" The Arterial Blood Supply of the Brain, including the
Circle of Willis, as viewed from ventral surface

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Stroke could soon be the most common cause of death worldwide Stroke
is currently the second leading cause of death in the Western world, ranking
after heart disease and before cancer, and causes 10% of deaths worldwide
Geographic disparities in stroke incidence have been observed, including the
existence of a "stroke belt" in the southeastern United States, but causes of these
disparities have not been explained

The incidence of stroke increases exponentially from 30 years of age, and


etiology varies by age Advanced age is one of the most significant stroke risk
factors 95% of strokes occur in people age 45 and older, and two-thirds of
strokes occur in those over the age of 65 A person's risk of dying if he or she
does have a stroke also increases with age However, stroke can occur at any age,
including in childhood

Family members may have a genetic tendency for stroke or share a lifestyle
that contributes to stroke Higher levels of Von Willebrand factor are more
common amongst people who have had ischemic stroke for the first time The
results of this study found that the only significant genetic factor was the
person's blood type Having had a stroke in the past greatly increases one's risk
of future strokes

Men are 25% more likely to suffer strokes than women, yet 60% of deaths
from stroke occur in women Since women live longer, they are older on average
when they have their strokes and thus more often killed ‰NÃMH 2002 Some risk
factors for stroke apply only to women Primary among these are pregnancy,
childbirth, menopause and the treatment thereof ‰HRT

#"c Ê  
   

 
  

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 and symptoms:

-Numbness or weakness of the face, arm, or leg, especially on ne side


of the body;

-Confusion or change in mental status;

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-Trouble speaking or understand 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


)*%"
eurologic Deficits of Stroke: Manifestations and ursing
Implications

  
   
   
 
à 

 
  

  

ÿ  

Homonymous îc Unaware of the -Place objects within intact
hemianopsia ‰loss of persons or objects field of vision
half of the visual field on side of the -Approach the patient
visual loss from side of the intact field
îc Neglect of one side of vision
of the body -Ãnstruct/remind the
îc Difficulty judging patient to turn the head in
distances the direction of visual loss
to compensate for loss of
visual field
-Encourage the use of eye
glasses if available
-when teaching the
patient, do so within the
patientǯs intact visual field
Loss o peripheral îc Difficulty seeing at -Avoid night driving or
vision night other risky activities in the
îc Unaware of darkness
objects or the -Place objects in center of
borders of objects patientǯs intact visual field
-Encourage the use of a
cane or other object to
identify objects in the
periphery of visual field
Diplopia îc Double of vision -Explain to the patient the
location of an object when

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placing it near the patient
-Consistently place patient
care items in the same
location
ë
 

Hemiparesis îc Weakness of the -Place objects within the
face, arm, and leg patientǯs reach on the non
on the same side affected site
‰due to a lesion in
the opposite
hemisphere
Hemiplegia îc Paralysis of the -Encourage the patient to
face, arm, and leg provide range-of-motion
on the same side exercises to the affected
‰due to a lesion in site
the opposite -Provide immobilization as
hemisphere needed on the affected
site
_-Maintain body alignment
in functional position
-exercise unaffected limb
to increase mobility,
strength and use
Ataxia îc Staggering, -Support patient during
unsteady gait the initial ambulation
îc Unable to keep phase
feet together; -Provide supportive device
needs a broad for ambulation ‰walker,
base to stand cane
Ãnstruct the patient not to
walk without assistance or
supporting device
Dysarthria îc Difficulty in -Provide the patient with
forming words alternative methods of
communicating
-Allow the patient
sufficient time to respond
to verbal communication
-Support patient and
family to alleviate
frustration relate to
difficulty communicating
Dysphagia îc Difficulty -Test the patientǯs
swallowing pharyngeal reflexes before
offering food or fluids

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-Assist the patient with
meals
-Place food on the affected
site of the mouth
-Allow ample time to eat
u  

Paresthesia ‰occurs îc Numbness and -Ãnstruct the patient to
on the site opposite to tingling of avoid using this extremity
the lesion extremity as the dominant limb due
îc Difficulty with to altered sensation
proprioception -Provide range of motion
to affected areas and apply
corrective devices as
needed
ÿ

Expressive aphasia îc Unable to form -Encourage patient to
words that are repeat sounds of the
understandable; alphabet
may be able to
speak in single
word responses

Receptive aphasia îc Unable to -Speak slowly and clearly


comprehend the to assist the patient in
spoken word; can forming sounds
speak but may not
make sense
Global ‰mixed îc Combination of -Speak clearly and in
aphasia both receptive and simple sentences; use
expressive aphasia gestures or pictures when
able
-Establish alternative
means of communication
Ê 
 

îc Short and long -Reorient patient to time,
term memory loss place and situation
îc Decreased frequently
attention span -Use verbal and auditory
îc Ãmpaired ability to cues to orient patient
concentrate Provide familiar objects ‰
îc Poor abstract family photographs,
reasoning favorite objects
îc Altered judgment -Use no complicated
language
-Match visual tasks with a

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verbal cue; holding a
toothbrush, stimulate
brushing of teeth while
saying, Dzà would like you to
brush your teeth now 
-Minimize distracting
noises and views when
teaching the patient
-Repeat and reinforce
instructions frequently
G
 

îc Loss of self control -Support patient during
îc Emotional lability uncontrollable outbursts
îc Decreased -Discuss with the patient
tolerance to and family that the
stressful situations outbursts are due to the
îc Depression disease process
îc Withdrawal -Encourage the patient to
îc Fear, hostility, and participate in group
anger activity
îc Feelings of -Provide stimulation for
isolation the patient
-Control stressful
situations, if possible
-Provide a safe
environment
-Encourage patient to
express feelings and
frustrations related to
disease process

Ê"c 

   
  

Any patient with neurologic deficits needs a careful history and a


complete physical and neurologic examination Ãnitial assessment will focus on
airway patency, which may be compromised by loss of gag or cough reflexes and
altered respiratory pattern; cardiovascular status ‰including blood pressure,
cardiac rhythm and rate, carotid bruit, and gross neurologic losses

Stroke patients may present to the acute care facility at any point along a
continuum of neurologic involvement A system that uses the time course to
classify patients along this continuum may be used to guide treatment Strokes

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use the time course is commonly classified in the following manner: ‰1 transient
ischemic attack; ‰2 reversible ischemic neurologic disease; ‰3 stroke in
involution; and ‰4 compensated stroke

The initial diagnostic test for a stroke is a non contrast computed therapy
‰CT scan performed emergently to determine of the event is ischemic or
hemorrhagic ‰which determines treatment Further diagnostic work up for
ischemic stroke involves attempting to identify the source of thrombi or emboli
A 12-lead electrocardiogram and a carotid ultrasound are standard tests Other
studies may include Cerebral Angiography, transcranial flow studies,
transthoracic or transesophagel echocardiography, magnetic resonance imaging
of the brain and/or neck, xenon CT, and single photon emission CT

Remarkable advances in technology now make it possible to examine


how the brain looks, works and gets its blood supply These tests can outline the
affected part of the brain and help define the problem created by stroke Most of
these tests are safe, painless and can be done as an outpatient However, in many
cases these tests are ordered when a patient is hospitalized with a stroke A
doctor must decide on a case-by-case basis whether such tests will be useful, and
if so, which ones to use The following tests are described in this section:

ic Carotid phonoangiography
ii c Computerized axial tomographic scan ‰CT or CAT scan
iii c Digital subtraction angiography ‰DSA
iv c Doppler ultrasound test
vc Electroencephalogram ‰EEG
vi c Evoked response test
vii c Magnetic resonance imaging scanning ‰MRÃ
viii c Radionuclide angiography


 
 




 +

îc Ê  ,       ‰CT or CAT scan Ȅ Uses X-rays


to generate an image of the brain Doctors use CT to determine whether a
stroke has occurred and, if so, what kind ‰Ãschemic strokes are caused by
a clot that blocks an artery Hemorrhagic strokes result from a ruptured
blood vessel in the brain causing bleeding into brain tissue  CT scanning
takes from 5 to 10 minutes to complete ‰mostly less than 5 minutes The
test causes no discomfort
îc           ‰MRÃ Ȅ The stroke patient is
placed into the MRÃ scanner This scanner has a magnetic field in which
the head is subjected to bursts of energy of a known magnetic frequency
The response of the brain cells to these bursts of energy is detected as
signals that ultimately generate an image of the brain MRÃ can give very

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accurate images of the brain These are used to determine the presence,
location and size of aneurysms and arteriovenous malformations, which
are potential sources for hemorrhagic stroke This test is performed in 40
minutes to one hour, and causes no discomfort
îc      Ȅ Radioactive compounds are injected into
a vein in the arm; the bloodstream then carries them toward the head As
the radioactive compound circulates in the bloodstream, it constantly
emits bursts of radiation Once the radioactive compound reaches the
brain, these bursts of radiation are detected and used to form an image of
the brain This imaging procedure can show areas where the brain has
been deprived of blood flow and is damaged


 
-

 .
 
  +

îc      ‰EEG Ȅ Small metal disks ‰electrodes are


placed at strategic locations on a person's scalp The electrodes can detect
the electrical activity in the form of impulses that are then transcribed to
paper By observing such impulse characteristics as intensity ‰the size of
the impulse, duration ‰the width of the impulse, frequency ‰how often
impulses occur during a given time and location ‰what region of the
brain produces these impulses, an EEG can provide valuable information
about underlying problems in the brain Some people who have strokes
are prone to seizures, and this test will help doctors determine if seizures
are present and if treatment with medications is needed
îc !     Ȅ a diagnostic procedure that provides a
measurement of the brain's ability to process and react to different
sensory stimuli A doctor evokes a visual response by flashing a light or
checkerboard pattern in front of a patient For auditory evoked
responses, a doctor produces a sound in one of the patient's ears For
bodily evoked responses, one of the nerves in an arm or leg is electrically
stimulated The responses from these sensory stimuli can indicate
abnormal areas of the brain


 
-
 
 -+

îc       Ȅ Uses high-frequency sound waves to detect


blockages in the carotid artery A Doppler probe or instrument capable of
generating ultrasound waves is placed on the neck very near to the
carotid artery Ultrasound waves from the probe travel through the neck
and bounce off the moving blood cells The reflected sound wave, now
returning to the probe at a different frequency, is then detected by the
same probe The change in frequency of the sound waves relates to the
speed of the blood cells and thus the blood flow This test takes an hour or
more, and causes no discomfort
îc Ê    Ȅ a sensitive microphone is placed on the
neck, very close to the carotid artery, to record sounds Ordinarily, in a

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normal artery, blood flows in a smooth and controlled manner However,
the presence of blockages, such as those caused by atherosclerosis, causes
the blood flow to become turbulent This turbulent blood flow can create
a sound, called a bruit ‰BROO'e, which can be detected and registered by
the microphone The presence of a bruit may indicate a blockage in the
carotid artery and is cause for more tests
îc        ‰DSA Ȅ gives an image of the brain's
major blood vessels A thin plastic tube ‰a catheter is inserted into a
major artery of the leg and advanced through the body's major vessels
until it reaches the brain's blood vessels A contrast dye is injected
through the catheter and allowed to circulate in the bloodstream At that
point, an X-ray machine quickly takes a series of pictures of the head and
neck The images track the movement of the contrast dye as it moves
through the brain's blood vessels This imaging technique lets the doctor
identify and localize the source of a blocked blood vessel that caused the
stroke Some people may feel a warm sensation as the contrast medium is
injected into the blood vessels

Ãn patient with TÃA, a bruit ‰abnormal sound heard on auscultation


resulting from interference with normal blood flow may be heard over the
carotid artery There are diminished or absent of carotid pulsationsin the neck
Diagnostic tests for TÃA may include carotid phonoangiography; this involves
auscultation, direct visualization, and photographic recording of carotid bruits
Oculoplethysmography measures the pulsation of blood flow through the
ophthalmic artery Carotid angiography allows visualization of intracranial and
cervical vessels Digital subtraction angiography is used to define carotid artery
obstruction and provides information on patterns of cerebral blood flow

"c Ã
!


The National Ãnstitute of Health ‰NÃH stroke scale ‰NÃHSS is a


standardized method used by physicians and other health care professionals to
measure the level of impairment caused by a stroke The NÃH stroke scale serves
several purposes, but its main use in clinical medicine is during the assessment
of whether or not the degree of disability caused by a given stroke merits
treatment with tPA Another important use of the NÃHSS is in research, where it
allows for the objective comparison of efficacy across different stroke
treatments and rehabilitation interventions The NÃH stroke scale measures
several aspects of brain function, including consciousness, vision, sensation,
movement, speech, and language A certain number of points are given for each
impairment uncovered during a focused neurological examination A maximal
score of 42 represents the most severe and devastating stroke Current
guidelines as of 2008 allow strokes with scores greater than 4 points to be
treated with tPA

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)*'"
Summary of IH Stroke Scale

Ê 
   

# 
  

  

1a Level of Alert 0
Consciousness
‰alert, drowsy, etc  Drowsy 1

Stupotous 2

Coma 3

1b LOC questions Answers both correctly 0


‰month, age
Answers one correctly 1

incorrect 2

1c LOC commands Obeys both correctly 0


‰open, close eyes,
make fist, let go Obeys one correctly 1

Ãncorrect 2

2 Best Gaze ‰eyes Normal 0


open- patient
follows examiners Partial Gaze Plasy 1
fingers or face
Forced Deviation 2

3 visual ‰introduce No visual loss 0


visual stimulus/
threat to patientǯs Partial Hemianopia 1
visual field
quadrants Complete Hemianopia 2

Bilateral Hemianopia 3

4 Facial Palsy Normal 0

Minor 1

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Partial 2

Complete 3

5a Motor arm- Left No drift 0


‰elevate extremity
to 90ͼ and score Drift 1
drift movement
Canǯt resist gravity 2

No effort Against Gravity 3

No movement 4

Amputation joint fusion 9


‰explain

5b Motor arm- No drift 0


Right
Drift 1
‰elevate extremity
to 90ͼ and score Canǯt resist gravity 2
drift movement
No effort Against Gravity 3

No movement 4

Amputation joint fusion 9


‰explain

6a Motor leg-Left No drift 0


‰elevate extremity
to 30ͼ and score Drift 1
drift movement
Canǯt resist gravity 2

No effort Against Gravity 3

No movement 4

Amputation joint fusion 9


‰explain

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6b Motor leg-Right No drift 0
‰elevate extremity
to 30ͼ and score Drift 1
drift movement
Canǯt resist gravity 2

No effort Against Gravity 3

No movement 4

Amputation joint fusion 9


‰explain

7 Limb ataxia Absent 0


‰finger-to-nose and
heel-to-shin Present in One Limb 1
testing
Present in Two Limbs 2

8 Sensory ‰pin Normal 0


prick to face, arm,
trunk and leg- Partial Loss 1
compare side to
side Severe Loss 2

9 Best Language No Aphasia 0


‰name items,
describe a picture Mild to Moderate Aphasia 1
and read
sentences Severe Aphasia 2

Mute 3

10 Dysarthria Normal Articulation 0


‰evaluate speech
clarity by patient Mild to Moderate 1
repeating words  Dysarthria
2
Near to Unintelligible or
Worse 9

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Ãntubated or Other
Physical Barrier

11 Extinction and No Neglect 0


Ãnattention ‰use
information from Partial Neglect 1
LOC and motor
testing to identify Complete Neglect 2
neglect
________________________________________________________________________
à 
    
 

The level of stroke severity as measured by the NÃH stroke scale scoring system:

/ = no stroke

%*$ = minor stroke

)*%) = moderate stroke

%)*'/ = moderate/severe stroke

'%*$' = severe stroke

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VÃ c  Ã

Ãn an ischemic brain attack, there is disruption of the cerebral blood flow due
to obstruction of blood vessel This disruption in blood flow initiates a complex
series of cellular metabolic events referred to as the ischemic cascade
The ischemic cascade begins when cerebral blood flow falls less than 25
ml/100 g/min at this point, neurons can no longer maintain anaerobic
respiration The mitochondria must then switch to anaerobic respiration, which
generates large amounts of lactic acid, causing a change in pH level This switch
to the less efficient anaerobic respiration also renders the neuron incapable of
producing sufficient quantities of adenosine triphosphate ‰ATP to fuel the
depolarization process Thus membrane pumps that maintain electrolyte
balances begin to fail and the cells cease to function
Early in the cascade, an area of low cerebral blood flow, referred to as
penumbra region, exists around the area of infarction The  
 
is
ischemic brain tissue that can be salvaged with timely intervention The ischemic
cascade threatens cells in the penumbra because membrane depolarization of
the cell walls leads to an increase in intracellar calcium and the release of
glutamate The penumbra area can be revitalized with the administration of
tissue plaminogen activator ‰t-PA, and the influx of calcium can be limited with
the use of cacium channel blocker The influx of calcium and release of
glutamate, if continued, activate a number of damaging pathways that result in
the destruction of the cell membrane, the release of more calcium and glutamate,
vasoconstriction, and the generation of free radicals These processes enlarge
the area of infarction into the penumbra, extending the stroke

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0*% Pathophysiology of the Cerebrovacular Accident èrocess
contributing to ischemic brain iinjury. Courtesy of ational Stroke
Association, Englewood, Colorado

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# 
Ê

 
/0
'/%/

à  

  

   
117 g/L 123-152 g/ L Lower
  
0 36 0 37-0 42 % Slightly lower
#Ê

11 9 5 0-10 0 x 10 Higher
g/L
    
Ê
 
0 22 0 20-0 40 Normal
 
0 07 0 02-0 08 Normal
  
0 01 0 01-0 03 Normal
# 
0 01 0-0 02 Normal
 

0 69 0 40-0 60 Higher
#Ê
4 98 4 5-5 5x10/2 L Normal
Ê
73 88-96 Lower
Ê
23 5 27-33 pg Lower
ÊÊ
321 330-360 g/L Lower

14 3 12 7-22 7 % Normal
  

210 150-450x 10 Normal


g/L

9 47 4 5-7 5 Higher

3 17-39 1
Ê
2-4 mins
#
1-3 mins
   
05-1 5%
Ê


0-20 mm/hr

#"c   

Ê   
88 2mmol/L
 
135 mmol/L
 
4 3 mmol/L
Ê  
1 12 mmol/L
Ê 
92 mmol/L

Ê"c Ê  
Ê  

Ê  
5 0 mmol/L
   
0 32 mmol/L
  

Ê  
1 9 mmol/L

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Ê  
3 66 mmol/L

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1
'/%/

à 
Cortical cerebral atrophy

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Ê  
 
- 
   



  




   "

   
1
'/%/


   

-Scannogram shows mild reversal of the cervical lordesis most


likely due to muscular spasm

-Thecal sac is intact

-There is no evidence of canal stenosis

-Osteophytic formation is ruled at C5 and C6 vertebral bodies

-Visualized soft tissue planes within normal

-No other findings noted

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#

Osmitrol
 2

75 mg prn
Ê    
Diagnostic agent; osmotic diuretic, urinary irrigant
à 
îc Prevention and treatment of oliguric phase of
renal disease
îc Reduction of intracranial pressure and
treatment of cerebral edema; of elevated ÃOP
when the pressure cannot be lowered by
other means
îc Promotion of the urinary excretion of toxic
substances
îc Diagnostic use: measurement of GFR
îc Ãrrigant in transurethral prostatic resection or
other transurethral precedures
 
Elevates the osmolarity of the glomerular filtrate,
thereby hindering the reabsorption of water and
leading to a loss of water, sodium, chloride ‰used for
diagnosis of glumerular filtration rate; creates an
osmotic gradient in the eye between plasma and
oclular fluids, thereby reducing ÃOP; creates an
osmotic effect, leading to decreased swelling in
posttransurethral prostatic resection
!   


 
 !

 

ÃV 30-60 minutes 1 hour 6-8 hours


Ãrrigant Rapid Rapid Short
  
T 1/2 : 15-100 minutes
   
Crosses placenta; may enter breast milk
  
Urine


   

 :
ÃV infusion only; individualized concentration and rate of administration
Dosage is 50-200g/day Adjust dosage to maintain urine flow of 30-50 ml/hr
îc èrevention of oliguria: 50-100 g ÃV as a 5% -25% solution
îc Treatment of oliguria: 50-100 g ÃV of a 15%-25% solution
îc 6eduction of intracranial pressure and cerebral edema: 1 5-2g/kg ÃV as
a 15%-25% solution over 30-60 minutes Evidence of reduced
pressure should be seen in 15 minutes
îc 6eduction of IOè: infuse 1 5-2 g/kg as a 25% solution, 20% solution Or
15% solution over 30 minutes Ãf used preoperatively, use 60-90

c
c
minutes before surgery for maximal effect
îc Adjunctive therapy to promote dieresis in intoxications: maximum of
200 g ÃV of mannitol with other fluids and electrolytes
îc Measurement of glumerular filtration rate: dilute 100 ml of a 20%
solution with 108 ml of sodium chloride injection Ãnfuse this 280 ml of
702% solution ÃV at rate of 20 ml/ min collect urine with a catheter for
the specified time for measurement of mannitol in mg/min draw blood
at the start and at the end of the time for measurement of mannitol in
mg/ml plasma
îc Test dose of mannitol for patients with inadequate renal function: 0 2
g/kg ÃV ‰about 50 ml of 25% solution, 75 ml of a 20% solution in 3-5
minutes to produce urine flow of 30-50 ml/hour Ãf urine flow does not
increase, repeat dose Ãf no response to second dose, reevaluate patient
situation
îc {rologic irrigation: use prepared 5g/ 100ml distilled water solution;
irrigate as needed
  
 

Dosage for children younger than 12 yr not established


Ê   
Contraindicated with anuria due to severe renal
disease
  
Use cautiously with pulmonary congestion, active
intracranial bleeding ‰except during crainiotomy,
dehydration, renal disease, heart failure, pregnancy,
lactation
 
  


 

Ê 

Dizziness, headache, blurred vision,  ,, 
 

Ê  

Hypotension, hypertension, edema, HF,


thromboplebitis, tachycardia, chest pain
   
Urticaria, skin necrosis with infiltration
   
ausea, anorexia, dry mouth, thirst
   
Diuresis, urine retention
   
Fluid and electrolyte imbalances
  
Pulmonary congestion, rhinitis
 
Ê  

  
îc  
Pulmonary congestion, active intracranial bleeding,
dehydration, renal disease, heart failure, pregnancy,
lactation

îc  
Skin color, lesions, edema, hydration, orientation,
muscle strength , reflexes, pupils, pulses, BP,
perfusion; Respiratory pattern, adventitious sounds,
urinary output patterns, serum electrolytes,
urinalysis , renal function tests

c
c
à  
¦ : Do not give electrolyte free mannitol with blood Ãf blood must be
given, add at least 20 mEq of sodium chloride to each liter of mannitol
solution
îc Do not exposesolutions to low temperatures; crystallization may occur
Ãf crystals are seen, warm the bottle in a hot water bath, then cool to
body tempearature before administering
îc Make sure the infusion set contains a filter if giving concentrated
mannitol
îc Monitor serum electrolyte periodically with prolonged therapy
  
 
îc *ou may experience these side effects: Ãncreased urination; GÃ upset
‰eat frequent small meals; dry mouth ‰suck sugarless lozenges;
headache, blurred vision ‰use caution when moving for assistance
îc Report difficulty of breathing, pain in the ÃV site, chest pain

#"c  
  

#

Ultral, Ultral ER
 2

50 mg PO q 6h
Ê    
Analgesic ‰centrally acting
Opoid Analgesic
à 
îc relief of moderate to moderately severe pain
îc relief of moderate to severe chronic pain
in adults who need RTC Treatment for
extended periods ‰ER tablets
îc Unlabelled uses: Premature ejaculation;
restless leg syndrome

 
Binds to mu-opiod receptors and inhibits the
reuptake of norepinephrine and serotonin; causes
many effects similar to opoids- dizziness,
somnolence, nausea, constipation - but does not
have the respiratory depressant effects
!   


 
 !

Oral 1 hour 2 hours


  
Hepatic; t ½ : 6-7 hours
   
Crosses placenta; enters breast milk
  
Urine


   

 

îc èatients who require rapid analgesic effect: 50-100mg PO every 4-6 hr;
do not exceed 400 mg/day

c
c
îc èatients with moderate to moderately severe chronic pain: Ãnitiate at 25
mg /day in the morning, and titrate in 25-mg increments every 3 days
to reach 100 mg/day Then increase every 3 days to reach 200 mg/day
After titration, 50-100mg every 4-6 hours; do not exceed 400 mg/day
Alternatively, 100-mg ER tablet once daily, titrated by 100-mg
increments every 5 days; do not exceed 300 mg/day

  
 

Safety and efficacy not established

   
 

 
- 
  

 
  

Older than 75 years old: do not exceed 300 mg/day


èatients with cirrhosis: 50 mg every 12 hour ER tablets should not be used in
severe hepatic impairment
èatients with creatinine clearance less than 30ml/min: 50-100 mg PO every
12 hours Maximum 200 mg/day ER tablets should not be used in patients
with creatinine clearance less than 30 ml/min

Ê   


Contraindicated with allergy to tramadol, or opoids
or acute intoxication with alcohol opoids and
psychoactive drugs
  
Use cautiously with pregnancy, lactation; seizures;
concomitant use of CNS depressants, MAOÃs, SSRÃs,
TCAs; renal impairment; hepatic impairment
 
  


 

Ê 

Sedation, dizziness or vertigo, headache, confusion,
 
dreaming, sweating, anxiety, seizures
Ê  

Hypotension, tachycardia, bradycardia


   
Sweating, pruritus, rash, pallor, urticaria
   
ausea, vomiting, dry mouth, constipation,
flatulence
 
Potential abuse,  
  

à 

îc Devreased effectiveness with carbamazepine


îc Ãncreased risk of tramadol toxicity with MAOÃs or SSRÃs

 
Ê  

  

îc  
Hypersensitivity to tramadol; pregnancy; acute
intoxication with alcohol, opoids, psychotropic
drugs or other centrally acting analgesics; lactation;
seizures; concomitant use of CNS depressants or
MAOÃs; renal ore hepatic impairment; past or
present history of opoid addiction

c
c
îc  
Skin color, texture, lesions; orientation, reflexes,
bilateral grip strength, affect; Pulmonary
auscultation, BP; bowel sounds, normal output;
LFTs, renal function tests
à  

îc Control environment ‰temperature, lighting, if sweating or CNS effects


occur
¦arning: Limit use in patients with past or present history of
addiction to or dependence on opoids
  
 

îc *ou may experience these side effects: dizziness, sedation, drowsiness,


impaired visual acuity ‰avoid driving or performing tasks that require
alertness; nausea, loss of appetite, ‰lie quietly, eat frequent small
meals
îc Repot severe nausea, dizziness, severe constipation

Ê"c Ê  

#

Celebex
 2

100 mg PO bid
Ê    
Analgesic ‰nonopoid
NSAÃD
Specific COX-2 enzyme inhibitor
à 
îc acute and long term treatment of Signs and
symptoms of rheumatoid arthritis and
osteoarthritis
îc reduction of the number of colorectal polyps
in familial adenomatous polyposis ‰FAP
îc management acute pain
îc treatment of primary dysmenorrhea
îc relief of signs and symptoms of ankylosing
spondylitis
îc Relief of signs and symptoms of juvenile
rheumatoid arthritis
 
Analgesic and anti-inflammatory activities related to
inhibition of the COX-2 enzyme, which is activated Ã
inflammation to cause the signs and symptoms
associated with inflammation; does not affect the
COX-1 enzyme, which protects the lining of the GÃ
tract and has blood clotting and renal functions
!   


 
 !

Oral Slow 3 hours


  
Hepatic; t ½ : 11 hours

c
c
   
Crosses placenta; may enter breast milk
  
Bile, urine


   

 

Ãnitially, 100mg PO bid; may increase to 200 mg/day PO bid as needed


îc acute pain, dysmenorrheal: 400mg, then 200mg PO bid
îc ÔAè: 400mg PO bid
îc Anyklosing spondylitis: 200mg/day PO; after 6week,; if no effect,
suggest another therapy

  
 

0 kg or 25 kg or less: 50 mg capsule PO bid


More than 25 kg: 100 mg capsule PO bid"
Ê   
Contraindicated with allergies to sulfonamides,
celecoxib, NSAÃD's or aspirin; significant renal
impairment; pregnancy ‰third trimester, lactation

  
Use cautiously with impaired hearing, hepatic and
CV condition
 
  


 

Central Nervous Headache, dizziness, somnolence, insomnia, fatigue,


System tiredness, dizziness, tinnitus, ophthalmologic effects
Cardiovascular Ã
Ê

Dermatologic Rash, pruritis, sweating, dry mucous membranes,


stomatitis
Gastrointestinal Nausea, abdominal pain, dyspepsia, flatulence, GÃ
bleed
Hematologic Neutropenia, eosinophilia, leucopenia,
pancytopenia, thrombocytopenia, agranulocytosis,
granulocytopenia, aplastic anemia, decreased Hgb
or Hct, bone marrow depression, menorrhagia
Others Peripheral edema,  
   to
  
!

à 

îc Ãncreased risk of bleeding if taken concurrently with warfarin Monitor


patient closely and reduce warfarin dose as appropriate
îc Ãncreased lithium level and toxicity
îc Ãncreased risk of GÃ bleeding with long term use of alcohol, smoking

 
Ê  

  
îc  
Renal impairment, impaired hearing, allergies
hepatic and CV conditions, lactation and pregnancy

îc  
Skin color and lesions; orientation, reflexes,
ophthalmologic and audiometric evaluation,

c
c
peripheral sensation; Pulmonary edema,
Respiratory, adventitious sounds; liver evaluation;
CBC, LFTǯs, renal function tests; serum electrolytes
à  
# !
#
-  
Be aware that the patient maybe at increased risk for
CV events, GÃ Bleeding; monitor accordingly
îc Administer drug with food or after meals if GÃ upset occurs
îc Establish safety measures if CNS or visual disturbances occur
îc Arrange for periodic ophthalmologic examination during long term
therapy
  
Ãf overdose occurs, institute emergency procedures-gastric lavage,
induction of emesis, supportive therapy
îc Provide further comfort measures to reduce pain ‰e g positioning,
environmental control and t reduce inflammation ‰e g warmth,
positioning, and rest
Ê 
 
  
îc Take only the prescribed dosage, do not increase dosage
îc *ou may experience these side effects: Dizziness, drowsiness ‰avoid
driving or the use of dangerous machinery while taking this drug
îc Report sore throat, fever, rash, itching, swelling in ankles or fingers;
changes in vision

"c   
 

#

Benicar
 2

20 mg/ day PO as a once-daily dose
Ê    
Angiotensin ÃÃ receptor antagonist
Antihypertensive
à 
Treatment of hypertension, alone or in combination
with other hypertensives
 
Selectively blocks the binding Angiotensin ÃÃ to
specific tissue receptors found in the vascular
smooth muscle and adrenal gland; this action blocks
the vasoconstricting effect of the renin-angiotensin
system as well as the release of aldosterone leading
to decreased BP; may prevent the vessel remodeling
associated with the development of atherosclerosis
!   


 
 !

Oral Varies 1-2 hours


  
Hydrolyzed in GÃ tract; T 1/2 : 13hours
   
Crosses placenta; enters breast milk
  
Feces, urine


   

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c
 

20 mg/day as a once-daily dose; mat titrate to 40 mg/day if needed after 2


weeks

  
 

Safety and efficacy not established


Ê   
Contraindicated with hypersensitivity to any
component of drug, pregnancy ‰use during the
second or third trimester can cause injury or death
to the fetus
  
Use cautiously with renal impairment, hypovolemia,
salt depletion
 
  


 

Central Nervous Headache, dizziness, syncope, muscle weakness


System
Cardiovascular Hypotension, tachycardia
EENT Rash, inflammation, urticaria, pruritus, alopecia, dry
skin
Gastrointestinal Diarrhea, abdominal pain, nausea, constipation, dry
mouth, dental pain
Hematologic Ãncreased CPK, hyperglycemia, hypertriglycemia
Respiratory URÃ symptoms, bronchitis, cough, sinusitis, rhinitis,
pharyngitis
Others Back pain, flulike symptoms, fatigue, hematuria,
arthritis
 
Ê  

  
îc History Hypersensitivity to any component of the drug,
pregnancy, lactation, hepatic or renal impairment
hypovolemia, salt depletion

îc Physical Skin lesions, turgor; body temp; reflexes, affect; BP,


R, respiratory auscultation; LFTs, renal function
tests, serum electrolytes
à  

îc Administer without regard to meals


# !
#
  : ensure that patient is not pregnant before beginning
therapy Suggest the use of barrier birth control while using olmesartan; fetal
injury and deaths have been reported
îc Find an alternate method of feeding infant if given to a nursing mother
Depression of the renin-angiotensin system in infants is potentially
very dangerous
  : alert the surgeon and mark the patientǯs chart with notice that the
olmesartan is being taken The blockage of the renin-angiotensin system
following the surgery can produce problems Hypotension may be reversed

c
c
with volume expansion
îc Monitor patient closely in any situation that may lead to decreased in
BP secondary to reduction in fluid volume- excessive perspiration,
dehydration, vomiting, diarrhea; excessive hypotension can occur
Ê 
 
  
îc Take drug without regard of meals Do not stop taking this drug
without consulting your health care provider
îc Use barrier method of birth control while using this drug; if you
become pregnant or desire to become pregnant, consult your health
care provider
îc Take special precautions to maintain your fluid intake and safety
precautions in any situations that night cause a loss of fluid volume-
excessive perspiration, dehydration, vomiting, diarrhea; excessive
hypotension can occur
îc *ou may experience these side effects: Dizziness ‰avoid driving a car or
perform hazardous activitie0; headache ‰medications may be available
to help nausea, vomiting diarrhea ‰proper nutrition is important,
consult dietician o maintain nutrition; symptoms of the upper
respiratory tract and cough ‰do not self medicate, consult your health
care provider if this becomes uncomfortable
îc Report fever, chills, dizziness, pregnancy, and swelling

c
c

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