Acute Biologic Crisis

SCENARIO
Susan is a 67-year-old female brought to the emergency
room by a friend. Her health history is as follows:
Right-sided CVA with left hemiparesis, arthritis, and
hypertension.

Her friend speaks for her, since Susan has aphasia and her
friend reports general decline in her overall health over the
past few weeks.

Susan is a vegetarian and believes in the power of prayer and
crystal to heal body imbalances. She has incontinent bladder
and bowel. Susan is diagnosed with dehydration, UTI, and
pressure ulcer.

HEALTH HISTORY

Right-sided CVA with left hemiparesis
Arthritis
Hypertension

CEREBROVASCULAR ACCIDENT
CVA is the medical term for what is commonly termed stroke.

It refers to the injury to the brain that occurs when flow of
blood to brain tissue is interrupted by a clogged or ruptured
artery, causing brain tissue to die because of lack of nutrients
and oxygen.

The severity associated with cerebrovascular accident can
best be demonstrated by the following facts: CVA is the
leading cause of adult disability in the world. Two thirds of
strokes appear among 65 year old and above. Stroke affects
more men than women and most of the cases are among
African American.


The most commonly affected blood
vessels are:
Middle Cerebral Artery Internal Carotid Artery
Transient Ischemic Attacks (TIAs) refers to transient cerebral ischemia with
temporary episodes of neurological dysfunction.
TYPES OF STROKE
Ischemic strokes occur as a result of an obstruction
within a blood vessel supplying blood to the brain.
The underlying condition for this type of obstruction
is the development of fatty deposits lining the vessel
walls. This condition is called atherosclerosis.
It results from a weakened vessel that ruptures and
bleeds into the surrounding brain. The blood
accumulates and compresses the surrounding brain
tissue.
PATIENTS W/ UNCONTROLLED HYPERTENSION, CEREBRAL ATHEROSCLEROSIS


BUILDING UP OF PLAQUE, LIPID DEPOSITS


THROMBUS EMBOLUS


DECREASED CEREBRAL OXYGEN SUPPLY


DECREASED CERBRAL PERFUSION


NEUROLOGICAL DYSFUNCTION
I
S
C
H
E
M
I
C


S
T
R
O
K
E

PATIENTS W/ UNCONTROLLED HYPERTENSION,
CEREBRAL ATHEROSCLEROSIS

DUE TO DEGENERATIVE CHANGES OF THE
ARTERIAL WALLS

CAUSES RUPTURE OF INTRACEREBRAL BLOOD
VESSELS

INTRACEREBRAL HEMORRHAGE

INTRACEREBRAL ANEURYSMS

Hemorrhagic stroke
PREDISPOSING FACTORS
Modifiable

Smoking
Hypertension
Obesity
Hyperlipidemia
Drug addiction
Excessive alcohol consumption
High dose Estrogen Oral
Contraceptives
Diabetes Mellitus
Atrial fibrillation
Type A personality
Sedentary lifestyle

Nonmodifiable
Age
Family history of CVA
Family history of DM
Sex (Male)
Race
CLINICAL MANIFESTATIONS

Signs and symptoms of increased ICP
Restlessness
Nausea & vomiting
Diplopia
Altered LOC
V/S changes : Pulse Pressure, PR RR, Temp
Pupillary changes
Papilledema
Brainstem function impairment
Health Deficits

SPECIFIC DEFICITS
Hemiparesis/Hemiplegia
Aphasia
Apraxia
Homonymous
Hemianopsia
Agnosia
Dysarthia
Kinesthesia

Incontinence
Shoulder pain
Horners syndrome
Unilateral neglect
Dysphagia
Ataxia

COMPARISON OF LEFT AND RIGHT CVA
Left CVA Right CVA
oRight hemiplegia oLeft hemiplegia
oLeft visual field effect oRight visual field effect
oAphasia: expressive, receptive, global oSpatial-perceptual field defect
oAltered intellectual activity oIncreased distractibilty
oSlow, cautious behavior oImpulsive behavior, poor judgment,
lack of awareness deficit
DIAGNOSTICS
Confirmation of stroke is based on symptoms, a history of risk factors, and the
results of diagnostic tests.
Computed tomography scan shows evidence of hemorrhagic stroke
immediately but may not show evidence of thrombotic infarction for 48 to
72 hours.
Magnetic resonance imaging may help identify ischemic or infarcted areas
and cerebral swelling.
Ophthalmoscopy may show signs of hypertension and atherosclerotic
changes in retinal arteries.
Angiography outlines blood vessels and pinpoints atherosclerotic plaques,
vessel occlusion, or the rupture site.
EEG helps to localize the damaged area.

Other baseline laboratory studies include urinalysis, coagulation studies,
complete blood cell count, serum osmolality, and electrolyte, glucose,
triglyceride, creatinine, and blood urea nitrogen levels.
TREATMENT
Medications useful in treating stroke include:

Alteplase (recombinant tissue plasminogen activator),
effective in emergency treatment of embolic stroke.
Long-term use of aspirin or ticlopidine, used as
antiplatelet agents to prevent recurrent stroke
Anticoagulants (heparin, warfarin), which may be
required to treat crescendo TIAs not responsive to
antiplatelet drugs
Antihypertensives, antiarrhythmics, and antidiabetics,
which may be used to treat risk factors associated with
recurrent stroke.

Surgery may also be performed to improve cerebral circulation
for patients with thrombotic or embolic stroke includes:


Endarterectomy (the removal of atherosclerotic
plaque from the inner arterial wall).

Microvascular bypass (the surgical anastomosis of
an extracranial vessel to an intracranial vessel).
SPECIAL CONSIDERATIONS
Early supportive therapy
Frequently assess neurologic status, using the National Institutes of Health
(NIH) Stroke Scale to determine deficits. (See Using the NIH Stroke
Scale, pages 828 and 829.)
If the patient has been treated with alteplase, monitor him for signs of
hemorrhage.
Monitor blood pressure frequently; give labetalol for severe hypertension.

CLINICAL TIP: Remember that because autoregulation is disrupted in patients
with stroke, its necessary to maintain perfusion higher than the usual
blood pressure.
Use acetaminophen and hypothermia blankets to control fever.
Maintain a patent airway and oxygenation status; intubate and ventilate
the patient as needed.
Monitor blood glucose levels.
Monitor electrocardiogram results, and treat arrhythmias as early as
possible.
If the patient develops a headache, administer an analgesic.

PREVENTIVE PROMOTIVE CURATIVE REHABILITATIVE

Provide
preventive care
through health-
education-
activities based
on identified
learning needs.

Identify
patients with
risk factors.

Involve in
HEP regarding
lifestyle
modification.

Promote nutrition.

Promote activity.

Promote
elimination.

Promote
communication.

Provide emotional
support.


Special considerations
above.
Watch for signs and
symptoms of pulmonary
emboli.
Watch for signs of other
complications.
Offer the urinal or bedpan
every 2 hours.
Ensure adequate nutrition.
Prevent aspiration.
Position the patient and
align his extremities correctly
to prevent external rotation.
Provide range-of-motion
exercises throughout the day.




Maintain communication with
the patient.
Provide psychological support.
Establish rapport with the
patient.
If necessary, teach the patient
to comb his hair, dress, and wash.
Speech therapy
Reinforce teaching, involve the
patients family in all aspects of
rehabilitation.
Discharge teachings.
Emphasize the importance of
regular follow-up visits.
If aspirin has been prescribed
to minimize the risk of embolic
stroke, tell the patient to watch
for GI bleeding related to ulcer
formation. Make sure the patient
realizes that he cant substitute
acetaminophen for aspirin.

NURSING RESPONSIBILITIES
ADMITTING DIAGNOSIS
Dehydration, UTI, and Pressure Ulcer

Nursing Diagnosis:

FLUID VOLUME DEFICIT
IMPAIRED URINARY ELIMINATION
IMPAIRED SKIN INTEGRITY