Symptoms of Addison's disease

To contact us Click HERE


Addison's disease symptoms sometimes develop slowly, usually over many months, and should include:

• Muscle weakness and fatigue
• Weight loss and decreased appetite
• Darkening of your skin (hyperpigmentation)
• Low blood pressure, even fainting
• Salt craving
• Low blood sugar (hypoglycemia)
• Nausea, diarrhea or vomiting
• Muscle or joint pains
• Irritability
• Depression

Acute adrenal failure (addisonian crisis)
Sometimes, however, the signs and symptoms of Addison's disease could seem suddenly. In acute adrenal failure (addisonian crisis), the signs and symptoms might also include:

• Pain in your lower back, abdomen or legs
• Severe vomiting and diarrhea, resulting in dehydration
• Low blood pressure
• Loss of consciousness
• High potassium (hyperkalemia)

When to see a doctor
See your doctor if you've got signs and symptoms that commonly occur in folks with Addison's disease, such as:

• Darkening areas of skin (hyperpigmentation)
• Severe fatigue
• Unintentional weight loss
• Gastrointestinal issues, like nausea, vomiting and abdominal pain
• Dizziness or fainting
• Salt cravings
• Muscle or joint pains

Your doctor will verify whether or not Addison's disease or another medical condition could also be inflicting these issues.

Causes of Addison's disease

To contact us Click HERE


Addison's disease results when your adrenal glands are broken, manufacturing insufficient amounts of the hormone cortisol and infrequently aldosterone similarly. These glands are located simply higher than your kidneys. As a part of your endocrine system, they turn out hormones that offer directions to nearly each organ and tissue in your body.

Your adrenal glands are composed of 2 sections. the inside (medulla) produces adrenaline-like hormones. The outer layer (cortex) produces a bunch of hormones referred to as corticosteroids, that embrace glucocorticoids, mineralocorticoids and male sex hormones (androgens).

Some of the hormones the cortex produces are essential forever — the glucocorticoids and therefore the mineralocorticoids.

• Glucocorticoids. These hormones, that embrace cortisol, influence your body's ability to convert food fuels into energy, play a task in your immune system's inflammatory response and facilitate your body answer stress.
• Mineralocorticoids. These hormones, that embrace aldosterone, maintain your body's balance of sodium and potassium to stay your blood pressure traditional.
• Androgens. These male sex hormones are made in little amounts by the adrenal glands in each men and ladies. They cause sexual development in men and influence muscle mass, libido and a way of well-being in men and ladies.

Primary adrenal insufficiency
Addison's disease happens when the cortex is broken and does not turn out its hormones in adequate quantities. Doctors confer with the condition involving harm to the adrenal glands as primary adrenal insufficiency.

The failure of your adrenal glands to provide adrenocortical hormones is most typically the results of the body attacking itself (autoimmune disease). For unknown reasons, your immune system views the adrenal cortex as foreign, one thing to attack and destroy.
 Other causes of adrenal gland failure might include:

• Tuberculosis
• different infections of the adrenal glands
• unfold of cancer to the adrenal glands
• Bleeding into the adrenal glands

Secondary adrenal insufficiency
Adrenal insufficiency may occur if your pituitary gland is diseased. The pituitary gland makes a hormone referred to as adrenocorticotropic hormone (ACTH),

that stimulates the adrenal cortex to provide its hormones. Inadequate production of ACTH will cause insufficient production of hormones normally made by your adrenal glands, albeit your adrenal glands are not broken. Doctors decision this condition secondary adrenal insufficiency.

Another additional common reason behind secondary adrenal insufficiency happens when folks that take corticosteroids for treatment of chronic conditions, like asthma or arthritis, abruptly stop taking the corticosteroids.

Addisonian crisis
If you've got untreated Addison's disease, an addisonian crisis could also be provoked by physical stress, like an injury, infection or illness.

Treatment of Addison's disease

To contact us Click HERE


All treatment for Addison's disease involves hormone replacement therapy to correct the amount of steroid hormones your body is not manufacturing. Some choices for treatment include:

• Oral corticosteroids. Your doctor might prescribe fludrocortisones (Florinef) to replaces aldosterone. Hydrocortisone (Cortef), prednisone or cortisone acetate is also used to switch cortisol.
• Corticosteroid injections. If you are unwell with vomiting and cannot retain oral medications, injections are an choice.
• Androgen replacement therapy. To treat androgen deficiency in ladies, dehydroepiandrosterone will be prescribed. Some studies recommend that this therapy might improve overall sense of well-being, libido and sexual satisfaction.

An ample intake of sodium is usually recommended, particularly throughout significant exercise, when the weather is hot, or if you've got gastrointestinal upsets, like diarrhea. Your doctor also will recommend a short lived increase in your dosage if you are facing a stressful state of affairs, like an operation, an infection or a minor illness.

Addisonian crisis
An addisonian crisis could be a life-threatening state of affairs that leads to low blood pressure, low blood levels of sugar and high blood levels of potassium. this case needs immediate medical care. Treatment usually includes intravenous injections of:

• Hydrocortisone
• Saline resolution
• Sugar (dextrose)

Adenomyosis Disease

To contact us Click HERE


Adenomyosis (ad-uh-no-my-O-sis) is acondition in which endometrial tissue, that normally lines the uterus, is present within and grows into the muscular walls of the uterus. this is possibly to happen late in your childbearing years and when you have had youngsters.

Adenomyosis is not the same as endometriosis — a condition within which the uterine lining becomes implanted outside the uterus — though ladies with adenomyosis usually even have endometriosis. The reason behind adenomyosis remains unknown, however the disease generally disappears when menopause. for girls who experience severe discomfort from adenomyosis, there are treatments that may facilitate, however hysterectomy is that the onlycure.

Although adenomyosis may be quite painful, the condition is mostly harmless.

Symptoms of Adenomyosis

To contact us Click HERE


In some women, adenomyosis is "silent" — inflicting no signs or symptoms — or only mildly not comfortable. but other women with adenomyosis may experience:

• Serious or prolonged menstrual bleeding
• Severe cramping or sharp, knife-like pelvic pain throughout menstruation (dysmenorrhea)
• Menstrual cramps that last throughout your period and worsen as you become old
• Pain throughout intercourse
• Bleeding between periods
• Passing blood clots throughout your period

Your uterus may be increased to double or triple its normal size. though you may not understand if your uterus is enlarged, you will notice that your lower abdomen seems larger or feels tender.

When to check a doctor
If you experience any signs or symptoms of adenomyosis, like prolonged, serious bleeding throughout your periods or severe cramping, to the extent that they interfere with regular activities, make an appointment  to check your doctor.

Causes of Adenomyosis

To contact us Click HERE


The reason behind adenomyosis is not known. knowledgeable theories a few potential cause include:

• Invasive tissue growth. Some specialists believe that adenomyosis results from the direct invasion of endometrial cells from the surface of the uterus into the muscle that forms the uterine walls. Uterine incisions created throughout an operation like a cesarean section (C-section) promotes the direct invasion of the endometrial cells into the walls of the uterus.
• Developmental origins. Other specialists speculate that adenomyosis originates within the uterine muscle from endometrial tissue deposited there when the uterus was 1st forming within the feminine fetus.
• Uterine inflammation related with childbirth. Still another theory suggests a link between adenomyosis and childbirth. An inflammation of the uterine lining throughout the postpartum period may cause a break in the normal boundary of the cells that line the uterus.

Regardless of how adenomyosis develops, its growth depends on the circulating estrogen in an exceedingly woman's body. When estrogen production decreases at menopause, adenomyosis goes away.

DEMENTIA

To contact us Click HERE
DEFINITION

The term dementia refers to the loss of memory reasoning,judgement,and language to such an extent that it interferes with everyday life.The changes may occur gradually or quickly and how they come about is the key to determine whether the condition causing dementia is temporary

Dementia is a syndrom e characterized by dysfunction or loss of memory,orientation,attention,language and judgementand reasoning and changes in the behaviour,ultimately these changes will result in the alteration in the individuals ability to work,social and family responsibilities and activities of daily living

CAUSES OF DEMENTIA

• Neurodegenerative disorders-Alzeimers disease,frontal lobe dementia,Frontal temperoral dementia(Eg:Pick s disease),Down syndrome,Amylotropic lateral sclerosis,Parkinson s disease,Huntingtons disease.
• Vascular diseases-Vascular multi infarct dementia,cardiac diseases producing emboli or decreased perfusion,Subarachnoid hemorrhage,chronic subdural hematoma.
• Toxic or metabolic disease-Alcoholism,Thiamine(Vitamin B1)deficiency,Cobalmin (Vitamin B12)deficiency,folate deficiency,hyperthyroidism,hypothyroidism,
• Hypoglycaemia,hypercalcemia.
• Immunological diseases or infections-Multiple sclerosis,chronic fatigue syndrome,AIDS,meningitis,encephalitis.
• Systemic diseases-Dialysis dementia,hepatic encephalopathy,
• Trauma-Head injury
• Cancer-Brain tumor,metastatic tumor
• Ventricular disorders-Hydrocephalus
• Seizure disorders-Epilepsy
• DrugsDiuretics,digoxin,anticholinergics,Narcotics,hypnotics,antihypertensives,antiparkinsonian drugs,antihistamines.
• Genetic factors are linked with Alzeimer s disease.Atleast five chromosomes(1,12,14,19,21) are involved in the familial AD including the amyloid precursor gene,the presenelin 1 gene,the presenelin 2 gene,the presenelin 1 gene and the presenelin 2 gene,apolipoprotein E gene.

Situations affecting behavior may include:

• Moving to a new residence or nursing home
• Changes in the environment or caregiver arrangements
• Misperceived threats
• Admission to a hospital
• Being asked to bathe or change clothes
• Fear and fatigue resulting from trying to make sense out of an increasingly confusing world

Potential solutions
Monitor personal comfort. Check for pain, hunger, thirst, constipation, full bladder, fatigue, infections and skin irritation. Maintain a comfortable room temperature.
Avoid being confrontational or arguing about facts; instead, respond to the feeling behind what is being expressed. For example, if a person expresses a wish to go visit a parent who died years ago, don't point out that the parent is dead. Instead, say, "Your mother is a wonderful person. I would like to see her too."
Redirect the person's attention. Try to remain flexible, patient and supportive.
Create a calm environment. Avoid noise, glare, insecure space, and too much background distraction, including television.
Simplify the environment, tasks and solutions.
Allow adequate rest between stimulating events.
Provide a security object or privacy.
Equip doors and gates with safety locks.
Remove guns.

RISK FACTORS

• Age
• Family history
• Genetics (heredity)
• Head injury
• Heart-head connection
• General healthy aging

TYPES OF DEMENTIA

• Alzeimers dementia-It is the most common dementia in people above 65 years of age and older.Dementia is intellectual deterioration severe enough to interfere with the occupation of the client as well as the social performance.It involves progressive decline of two or more areas of cognition,usually memory and language,calculation and personality.Alzeimers disease constitutes about half of all dementias.
• Multi infarct dementia-It is the second common cause of dementia.It causes irreversible dementia.Blood clots blocks small blood vessels in the brain and and destroys the brain tissue.Multi infarct dementia occurs in people over 50 years of age
• Lewy body dementia-It is similar to alzeimers disease but will progress more rapidly.Abnormal brain cells called cortical lewi bodies occurs throughout the brain and can cause manifestations
• Picks disease-It is also a form of dementia but varies from Alzeimers disease.At first both these diseases produces abnormalities in the brain,Pick sdisease is associated with the formation of Pick bodies.These are rounded bodies,microscopic structures found in the affected cells.Neurones will swell and forms balloon shape.Neither of these changes occurs in Alzeimers disease and and the pathology of Alzeimers disease is(formation of plaques and tangles )is not seen in Pick s disease.Picks disease is confined to the front part of the brain,particularly the frontal and anterior temporal lobes

Clinical manifestations are classified as mild moderate and severe

EARLY(MILD)

• Forgetfullness beyond what is seen in the normal person.
• Short term memory impairment especially for new learning.
• Difficulty in recognizing what numbers mean.
• Loss of initiative and interest.
• Decreased judgement.
• Geographic disorientation

MIDDLE(MODERATE)

• Forgetfullness beyond what is seen in the normal person.
• Short term memory impairment especially for new learning.
• Difficulty in recognizing what numbers mean.
• Loss of initiative and interest.
• Decreased judgement.
• Geographic disorientation

LATE(SEVERE)

• Impaired ability recognize close family members or friends.
• Agitation
• Wandering
• Getting lost
• Loss of remote memory
• Confusion
• Impaired comprehension.
• Forgets how to do simple tasks
• Apraxia
• Receptive aphasia
• Expressive aphasia
• Insomnia
• Delusions,Illusions,hallucinations
• Behavioural problems

DIAGNOSTIC EVALUATIONS
WHEN THE PERSON NEEDS TREATMENT

• Consult a doctor when you have concerns about memory loss, thinking skills and behavior changes in yourself or a loved one. For people with dementia and their families, an early diagnosis has many advantages:
• Time to make choices that maximize quality of life
• Lessened anxieties about unknown problems
• A better chance of benefiting from treatment
• More time to plan for the future
• It is also important for a physician to determine the cause of memory loss or other symptoms. Some dementia-like symptoms can be reversed if they are caused by treatable conditions, such as depression, drug interaction, thyroid problems, excess use of alcohol or certain vitamin deficiencies.

DIAGNOSIS

• The diagnosis is based on the cause of the disease whether it is reversible or irreversible
• An important first step is the thorough medical ,neurological history of the patient.
• Screening for cobalmin(Vitamin B12)deficiency and hypothyroidism is performed.
• Mental status examination is done for the patient
• Cognitive testing is focussed on the evaluation of memory,ability to calculate,language etc..
• When the depression is severe poor memory ,attension and concentration impairment occurs
• If the dementia is due to vascular cause cognitive impairment will be there and presence of vascular lesions will be there in neuro imaging techniques
• CT Scan and MRI is usually done
• SPECT is done and PET to rule out the degenerative changes in the brain

MINI MENTAL STAUS EXAMINATION
TREATMENT FOR BEHAVIOURAL OR PSYCHIATRIC PROBLEMS
For many individuals, Alzheimer's disease affects the way they feel and act in addition to its impact on memory and other thought processes. As with cognitive symptoms, the chief underlying cause is progressive destruction of brain cells. In different stages of Alzheimer's, people may experience:

• Physical or verbal outbursts
• General emotional distress
• Restlessness, pacing, shredding paper or tissues and yelling
• Hallucinations (seeing, hearing or feeling things that are not really there)
• Delusions (firmly held belief in things that are not real)

Many diagnosed individuals and their families find these symptoms the most challenging and distressing effects of the disease..
There are two approaches to managing behavioral symptoms: using medications specifically to control the symptoms or non-drug strategies. Non-drug approaches should always be tried first.

Non-drug approaches
Steps to developing successful non-drug treatments include:

• Recognizing that the person is not just "acting mean or ornery," but is having further symptoms of the disease
• Understanding the cause and how the symptom may relate to the experience of the person with Alzheimer's
• Changing the person's environment to resolve challenges and obstacles to comfort, security and ease of mind

Everyone who develops behavioral symptoms should receive a thorough medical examination, especially if symptoms appear suddenly. Even though the chief cause of behavioral symptoms is the effect of Alzheimer's disease on the brain, an exam may reveal treatable conditions that are contributing to the behavior.
Treatable conditions may include:Drug side effects. Many people with Alzheimer's take prescription medications for other health problems. Drug side effects or interactions between drugs can sometimes affect behavior.

• Physical discomfort. As the disease gets worse as it progresses to Alzheimer's have more and more difficulty communicating about their experience. As a result, symptoms of common illnesses may sometimes go undetected. Pain from infections of the urinary tract, ear or sinuses may lead to restlessness or agitation. Discomfort from a full bladder, constipation, or feeling too hot or too cold may also be expressed through behavior.
• Uncorrected problems with hearing or vision. These can contribute to confusion and frustration and foster a sense of isolation.
• Factors in the environment may also trigger behaviors. Events or changes in a person's surroundings may contribute to a sense of uneasiness, or increase fear or confusion.

Medications for behavioral symptoms

• If non-drug approaches fail after they have been applied consistently, introducing medications may be appropriate when individuals have severe symptoms or have the potential to harm themselves or others. Medications can be effective in some situations, but they must be used carefully and are most effective when combined with non-drug approaches.
• Medications should target specific symptoms so their effects can be monitored. In general, it is best to start with a low dose of a single drug. Effective treatment of one core symptom may sometimes help relieve other symptoms. For example, some antidepressants may also help people sleep better. Individuals taking medications for behavioral symptoms must be closely monitored. People with dementia are susceptible to serious side effects, including stroke and an increased risk of death from antipsychotic medications. Sometimes medications can cause an increase in the symptom being treated. Without careful evaluation, some medical providers will increase rather than decrease the dose, putting the person at greater risk. Risk and potential benefits of a drug should be carefully analyzed for any individual.
• When considering use of medications, it is important to understand that no drugs are specifically approved by the U.S. Food and Drug Administration (FDA) to treat behavioral and psychiatric dementia symptoms..
• The decision to use an antipsychotic drug needs to be considered with extreme caution. A recent analysis shows that atypical antipsychotics are associated with an increased risk of stroke and death in older adults with dementia. The FDA has asked manufacturers to include a “black box” warning about the risks and a reminder that they are not approved to treat dementia symptoms. The warning states: “Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo.”
• The analysis states that while risperidone and olanzapine are useful in reducing aggression and risperidone reduces psychosis, both drugs are associated with severe side effects. Despite some efficacy, these drugs should not be used routinely with dementia patients, unless the person is in severe distress or there is a marked risk of harm.

Risks and potential benefits of a drug should be carefully analyzed for any individual. Examples of medications commonly used to treat behavioral and psychiatric symptoms of Alzheimer's disease, listed in alphabetical order, include the following:

Antidepressant medications for low mood and irritability:

Anxiolytics for anxiety, restlessness, verbally disruptive behavior and resistance:

Antipsychotic medications for hallucinations, delusions, aggression, agitation, hostility and uncooperativeness:

Research evidence as well as governmental warnings and guidance regarding the use of antipsychotics indicate that individuals with dementia should only use these medications when:

1) Their behavioral symptoms are due to mania or psychosis
2) The symptoms present a danger to the resident or others
3) The resident is experiencing inconsolable or persistent distress, a significant decline in function or substantial difficulty receiving needed care

Antipsychotic medications should not be used to sedate or restrain persons with dementia. The minimum dosage should be used for the minimum amount of time possible. Adverse side effects require careful monitoring.

Although antipsychotics are the most frequently used medications for agitation, some physicians may prescribe a seizure medication/mood stabilizer, such as:

NURSING MANAGEMENT OF THE CLIENT
ASSESSMENT

• A complete history has to be taken to assess for the causes.Data can be obtained from the client,family and the co-workers
• Secondary sources are usually used because the client is unaware of the thought process and usually minimizes it.
• Ask questions regarding the activities of daily living,increasing forgetfulness and changes in personality.
• Assess the past medical history for any history head injury or surgery,recent falls,head ache and family history.
• A mini mental sttus examination helps in ongoing assessment.
• As the condition progresses the client may become paranoid,uses abusive language and becomes suspicious of others
• Assess the strengths and weaknesses of the family members and the ability to provide care for the patient and financial concerns.

NURSING DIAGNOSIS
Impaired verbal communication related to neuronal degeneration

• In the initial stage the clients verbal capacities will be intact,as the time progresses the capacities of the client will deteriorate.
• The nurse must be adaptable toprepare for the communicative level of the client.
• Always speak firmly and slowly in a low pitch voice.
• The tone of the voice should be calm and reassuring.
• When the language is impaired new techniques should be adopted to communicate with the client.
• Understand the non verbal communication of the client.Clients with AD often will avert the eyes,look down,and increase motor activity ,waving their arms and shaking their fists,raising their volumeand pitch or tightening the facial muscles.Interventions can include the following:

ü Decreasing the environmental stimuli.
ü Approaching the client calmly and reassurance
ü Gently distracting the client.
ü Making sure that all verbal and nonverbal communication cues are concordant.
ü The client should be removed from the stressful environment and reassurance should be given.
ü Calm non threatening environment should be given to the client.
ü Elicit listening behaviour by reaching out and touching,holding a hand,putting an arm around the wrist,or some way maintaining physical contact with the patient.Dementia patients can perceive non verbal cues of others and can cause agitation if a negative non verbal cue is observed
ü Promote activities of interest ,exercises and oppurtunities to wander in safe environment reduces the stress and strain in the patient

• Behavioural indicators of discomfort includes noisy breathing,negative vocalization,a sad facial expression and frowning

Disturbed thought process related to neuronal degeneration

• Apply constant intervention to reduce the fear and anxiety
• Reorient the client by providing calendar or clock.
• Be aware of the past experiences of the client and share it meaningful.
• Repetition is necessary.

 
Risk for injury related to impaired judgement,forgetfulness and motor impairments

• Teach the clients family members how to eliminate the safety hazards,which includes mainlyloose rugs,hot water,inadequate lighting and unlocked doors.
• Ensure that the client will not roam unnecessarily without being unnoticed.
• The patient must wear an identification badge in case if they are lost
• Windows and the doors must be locked and secured.Dangerous items should be kept away from the client and assistance should be given on cooking..
• The clients driving ability should be evaluated at regular intervals.

 
Self care deficit related to loss of memory and motor impairments

• Ask the client to do as much as activities as possible provided that it is safer for the client to do.
• Help the client in maintaining the autonomy.
• Develop the clients self respect and confidence.
• Give the client ample time to complete a task
• Constantly encourage and guide the client

 
Urge urinary incontinence related to neuronal damage

• Schedule the voiding and defecation timings of the client in the initial stage.
• Understand the non verbal signs of the client to urinate and to defecate(restlessness,grasping the genital area,picking at the clothing etc..
• Clear signs indicating the position of the bathrooms should be there because the patiet may forget the location of the bathroom.
• Fluid after the dinner time should be avoided.
• The bowel and the bladder pattern should be maintained.
• External urinary drainage devices are given in the night
• Extra absorbabale washable underwear, and bedpads can be given to the client.

Technorati Tags: non verbal cues,communication,dementia patients,nursing diagnosis,facial muscles,non verbal communication,noisy breathing,facial expression,vocalization,stimuli,fists,agitation

CEREBRO VASCULAR DISORDERS (STROKE)

To contact us Click HERE

Cerebro vascular disorders is an umbrella term that refers to the functional abnormality of the central nervous system that occurs when the normal blood supply to tha brain is distrupted.It is a leading disease which causes death and even life time disability in people.

DEFINITION

Stroke occurs when there is ischemia(distrupted blood supply)To a aprt of the brain or hemorrhage into the brain that results in the death of the brain cells.Functions such as movements,sensations or emotions that are controlled by the particular part is affected

  INCIDENCE

African Americans have a higher incidence of stroke and higher death rates due to stroke when compared to whites.It is the third leading cause of death beyond cancer and heart disease

TYPESStroke is divided into two major categories:

• Ischemic Stroke-It occurs due to vascular occlusion and severe hypoperfusion.
• Hemorrhagic stroke-It occurs due to extravasation of blood into the brain and subarachnoid space.

ISCHEMIC STROKEAn ischemic stroke or cerebrovascular accident or brain attack is the sudden loss of functioning resulting from the distruption of the blood supply to a part of the brain.Early treatment with thrombolytic therapy for ischemic stroke results in fewer symptoms and less loss of function.Thrombolytic therapy has a treatment window only 3 hours after the onset of stroke.
TYPES OF ISCHEMIC STROKE

• Large artery thrombolytic stroke-It is caused by atherosclerotic plaques in the large blood vesselsof the brain.Thrombus formation and occlusion at the site of the atherosclerosis results in ischemia and infarction(deprivation of blood supply)

 

• Small penetrating artery thrombolytic stroke-This affects one or more blood vessels and and are the most common types of ischemic stroke.Small artey thrombolytic stroke are also called lacunar stroke because of the cavity that is created after the death of the infracted brain tissue.

• Cardiogenic stroke-It is associated with cardiac dysrrythmias usually atrial fibrillation.Emboli orginates from the heart and circulate to the cerebral vasculature,most commonly the middle cerebral artery is affected.Embolic strokes can be prevented by starting anti coagulation therapy in patients with atrial fibrillation.
• Cryptogenic Stroke-It doesn’t have any specific cause,it may be due to drug use,coagulopathies,migraine,and spontaneous dissection of the carotid artery.

PATHOPHYSIOLOGY steps

• Due to etiological factors
• Distruption of the cerebral blood flow due to obstruction of cerebral blood vessel
• Cellular metabolic events called ischemic cascade develops(ischemic cascade begins when the cerebral blood flow is decreased to less than 25 ml per minute)
• Mitochondria performs anaerobic respiration which generates large amount of lactic acid causing change in the Ph level
• Neuron becomes incapable of producing sufficient amount of ATP(Adenosine triphosphate) to fuel the depolarization
• The cells will stop functioning(Early in the cascade ,an area of low cerebral blood flow exists around the area of infarction,this area is called penumbra.
• Depolarization of the cellwall leads to increase in the intracellular calcium and release of glutamate
• More amount of calcium and glutamate occurs
• Vasoconstriction occurs in the cerebral artery
• Destruction of the cell membrane occurs
• This process results in the enlargement of the area of infarction

CLINICAL MANIFESTATIONS

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

Visual field deficits

Homonymous hemianopsia(loss of half of the visual field)

• Clinical manifestations-The person will be unaware of the persons or objects on the side of the visual loss,neglect of one side of the body,difficulty in judging the distances
• Nursing Implications-Place the objects within the intact field of vision.Approach the patient from the side of intact field of vision,encourage the use of eye glasses if available

Loss of peripheral vision

• Clinical manifestations-Difficulty in seeing at night,unaware of the objects and the borders of the objects
• Nursing Implications-Place the objects atethe centre of the patients visual field,Encourage the use of cane or or any other object to identify objects in the periphery of the visual field,Driving ability should be evaluated.

Diplopia(Double vision)

• Clinical manifestations- Double vision
• Nursing Implications-Explain the location of the object when placing at near to the patient,place the objects in the same position

 

Motor deficits

Hemiparesis-

• Clinical manifestations-Weakness of the face arm and leg on the same side due to lesion on the opposite side.
• Nursing Implications-Place objects on the non affected site within the patients reach,instruct the patient to exercise and increase the strength of the unaffected side.

Hemiplegia-

• Clinical manifestations Paralysis of the face arm and leg on the same side(due to lesion in the opposite hemisphere)
• Nursing Implications-Encourage the patient for range of motion exercises on the affected side,provide immobilization as needed to the affected side

Ataxia

• Clinical manifestations-Staggering unsteady gait,inability to keep the feets together,needs a broad base to stand
• Nursing Implications-Support the patient during initial ambulation phase.,provide supportive walking device to the patient.(cane stick,walker etc...)

Dysarthria

• Clinical manifestations-Difficulty in forming words
• Nursing Implications-Provide the patient with alternative methods of communication,allow the patient sufficient time to respond to verbal communication,support the patient and the family to relieve frustration

Dysphagia

• Clinical manifestations-Difficulty in swallowing
• Nursing Implications-Test the patients pharyngeal reflexex before offering food or fluids,assist the patient with the meals.,place food on the unaffected side of the mouth,allow ample time to eat.

SENSORY DEFICITS

• Parasthesia-It occurs on the side opposite to the lesion
• Clinical manifestations-Numbness and tingling of the extremity,
• Nursing Implications-Instruct the patient that sensation can be altered,provide range of motion in the affected area and apply corrective devices as needed

Verbal deficits

• Expressive aphasia-Unable to form words that are understandable.
• Nursing Implications-Encourage the patient to repeat the words of the alphabet,explore the students alternative ways of communication,

Cognitive deficits

• Clinical manifestations-Short and long term memory loss,decreased attention span,impaired ability to concentrate,altered judgement.
• Nursing Implications-Reorient patient to time,place and person,provide familiar objects(family photographs,favourite photographs,use of uncomplicated language,minimize distracting noises while teaching the patient,repeat and reinforce instructions frequently

Emotional deficits

• Clinical manifestations-Loss of self control,emotional instability,decreased tolerance to stressful situations,depression,withdrawal,fear hostility and anger,feelings of isolation
• Nursing Implications-Support the patient during uncontrollable outbursts,educate the patient that the outbursts are due to the disease condition,encourage the patient to participate in group activity,control stressful situations,provide a safe environment.

RISK FACTORS

• Hypertension
• Atrial fibrillation
• Hyperlipedemia
• Diabetes insipidus
• Smoking
• Asymptomatic carotid stenosis
• Obesity
• Excessive alcohol consumption

ASSESSMENTS AND DIAGNOSTIC FINDINGSHistory collection and physical examinationNeurological examination

• Initial assessment focuses on the patency of airway,respiratory status ,cardiovascular status,(including blood pressure,cardiac rhythm and rate etc..)
• Monitor for transcient ischemic attack.It is manifested by sudden loss of motor,sensory or visual function.The symptoms results from temporary ischemia(impairment of blood flow) to a specific region in the brain.Transcient ischemic attack is a warning sign of stroke.
• CT Scan has to be performed to determine whether the stroke is ischemic or hemorrhagic.
• ECG
• Cerebral Angiography
• Doppler flow studies
• Transthoracic and transesophageal echocardiography
• MRI of the brain,neck or both.
• SPECT Scan

PREVENTION

• Stroke risk screening helps to identify the people at risk
• Educate the community and the people regarding the prevention of stroke
• Recent research has found that low dose heparin will lower the risk of stroke
• Identify the high risk groups which includes certain non modifiable risk factors like age ,gender,sex,ethnicity etc..
• Modifiable risk factors are hypertension,atrial fibrillation,hyperlipedemia,obesity,smoking and diabetes.Other modifiable risk factors are endocarditis,prosthetic heart valves,periodontal diseases etc..
• Patients with moderate to severe carotid stenosis is treated with carotid endarterectomy.
• In patients with atrial fibrillation administration of Warfarin will prevent the clot formation.

MEDICAL MANAGEMENTTHROMBOLYTIC THERAPY(ELIGIBILTY CRITERIA FOR t PA ADMINISTRATION

• Age 18 years or older
• Clinical diagnosis of ischemic stroke
• Time of onset of stroke known and is 3 hours or less.
• Systolic blood pressure<185 mmhg diastolic <110 mmhg
• No seizure at the onset of stroke
• Not taking Warfarin(Coumadin)
• Not receiving heparin during the past 48 hours
• No prior intracranial hemorrhage,neoplasm,artereovenous malformation or aneurysm
• No major surgical procedure within 14 days..
• No stroke,serious head injury or intracranial surgery within 3 months
• No gastrointestinal or urinary bleeding within 21 days.
• Patients who has experienced TIA or stroke should take medical management for secondary prevention
• Atrial fibrillation patients are treated with dose adjusted Warfarin sodium(Coumadin) unless contraindicated
• If Warfarin is contraindicated then aspirin is the next choice.
• Platelet inhibiting medications(Eg:Aspirin,Clopidogrel)reduces the risk of cerebral infarction.
• 3-hydroxy-2-methyl-glutaryl coenzyme A reductase inhibitors reduces stroke(Statin medications)Eg:Simvastatin
• Antihypertensives

THROMBOLYTIC THERAPY

• Thrombolytic agents are used to treat ischemic stroke by dissolving the blood clot that blocks blood to the brain.
• Rapid diagnosis of the stroke and initiation of thrombolytic therapy(within 3 hours )reduces the risk because revascularization of the necrotic tissue(which develops after 3 hours)increases the risk of cerebral edema and hemorrhage.

DOSAGE AND ADMINISTRATION

• Patient is weighed to determine the dosage of medication.Dosage for tpA is 0.9mg/kg. .10% of the calculated dose is administered as an IV bolus over minute.The remaining dose(90%)is administeres over 1 hour via infusion pump
• Patient is admitted in intensive care unit and continuously monitored
• Neurological assessment has to be done continuously.
• Vital signs should be assessed evey 15 minutes,for first 2 hours ,every 30 minutes for the next 6 hours,then every hour until 24 hours of initiating the treatment.
• Blood pressure should be monitored with systolic less than 180mmhg and diastolic less than 105mmhg.

SIDE EFFECTS

Bleeding is the most common side effect(observe closely for any bleeding in the IV insertion site endotracheal tube ,urine,stool,emesis other secretions etc...

THERAPIES FOR PATIENTS NOT RECEIVING t PA

• Anticoagulant administration (IV heparin or low molecular
• Increased ICP increases the complications ,so measures has to be followed to reduce intracranial pressure so mannitol is usually administered.

OTHER TREATMENTS

• Elevation of the head end of the bed to promote venous drainage and to reduce iCP
• Endotracheal intubation to establish patent airway
• Continuous hemodynamic monitoring
• Neurological assessment to rule out complications

SURGICAL MANAGEMENT

CAROTID ENDARTERECTOMY-It is the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.This surgery is indicated in patients with mild strokeand symptoms of mild TIA
SELECTED COMPLICATIONS OF THE SURGERY AND MEASURES UNDERTAKEN

INCISION HEMATOMA

• Clinical features-It occurs in 5.5%of the patients.Large or rapidly expanding hematomas requires immediate treatmentIf the airway is obstructed by the hematoma the incision may be opened at the bedside
• Nursing Interventions-Monitor neck discomfort and wound expansion.Report swelling,subjective feelings of pressure in the neck,difficulty in breathing

HYPERTENSION

• Clinical features-Poorly controlled hypertension increases the risk of postoperative complications, including hematoma and hyper perfusion syndrome. There is an increased incidence of neurological impairment and death due to intracerebral hemorrhage.May be related to surgically induced abnormalities of the carotid baroreceptor sensitivity.
• Nursing Interventions-Risk is highest in first 48hours after the surgery. Check BP frequently and report deviations from baseline.Observe for and report new onset of neurological deficits.

POSTOPEREATIVE HYPOTENSION

• Clinical features-Occurs in approximately 5% of the patients.It is treated with fluids and loe dose phenylephrine infusion.Usually resolves in 24 to 48 hours.Patients with hypotension should have serial ECG to rule out myocardial infarction.
• Nursing Interventions-Monitor blood pressure and observe for signs and symptoms of hypotension.

INTRACEREBRAL HEMORRHAGE

• Clinical features-Increased risk with advanced age,hypertension,presence of high grade stenosis,poor collateral flow,and slow flow in the region of the middle cerebral artery
• Nursing Interventions-Monitor the neurological status and report any changes in the mental staus or neurological functioning immediately

NURSING PROCESS

The patient recovering from Ischemic stroke
The acute phase of ischemic stroke may last 1-3 days but ongoing monitoring of all the bodysystems is required as long as the patient requires care.After the stroke is complete management focuses on the initiation of rehabilitation of deficits

ASSESSMENTThe following things has to be taken into consideration

• Change in the level of consciousness or responsiveness as evidenced by movement,resistance to changes in position,response to stimulation and orientation to time place and person
• Presence or absence of voluntary or involuntary movements of the extremities
• Stiffness or flaccidity of the neck
• Eye opening,comparative size of the pupils and papillary reaction to light.
• Colour of the face and extremities and also temperature.
• Quality of the rate of pulse and respiration,arterial blood gas values,body temperature and arterial pressure.
• Ability to speak.
• Volume of fluids ingested or administered,volume of urine excreted within 24 hours.
• Presenceof bleeding
• Maintanance of blood pressure within the desired limits
• After the acute phase the nurse assess for mental status(memory,attention span,perception ,orientation etc..)
• Ongoing assessment should include any deterioration in the performance of ADL

NURSING DIGNOSISImpaired physical mobility related to hemiparesis,loss of balance and coordination,spasticity and brain injury

• Correct positioning is required to prevent contractures
• Measures are taken to relieve pressure
• Assist in maintaining good body alignment
• Since flexor muscles are stronger than extensor muscles,a posterior splint applied at the night will prevent flexion and maintain correct position during night.

Acute pain (painful shoulder)related to hemiplegia and diffuse

• A pillow is placed under the axilla when there is limited external rotation,this keeps the arm away from the chest
• A pillow is placed under the arm and arm is placed in a neutral (slightly flexed)position,the distal joints are placed higher than the proximal joints(elbow is placed higher than the shoulder and the wrist higher than the elbow.This prevents edema and resultant joint fibrosis.
• Medications are helpful in maintain post stroke pain.Amytryptilline hydrochloride is used ,but it has got cognitive problems and it will induce sleep.
• Antiseizure mediaction Lamotrigine is effective in managing post stroke pain,it is an alternative for patients who cannot tolerate amytryptilline

Self care deficit(bathing,grooming,toilettingdressing and feeding)related to stroke sequalae

• Assess the level of selfcare ability of the client.
• The patient is encouraged to perform the regular activities such as combing the hair,brushing the teeth,shaving with electric razor,eventhough the patient will feel awkward in the beginning he can achieve performing the activities by repetitive actions.The nurse must be sure that the patient is not neglecting the affected side.
• Assistive devices will make up some patients deficits
• The family members are instructed to bring a cloth that is larger than the usual size of the patient.Clothing with front and side fastners are more easier.The clothing is placed in the affected side of the patient.The clothes are arranged in the order to be worn.A mirror is placed in the front,so that the patient will get an awareness regarding what he is putting
• Support and encouragement are provided for preventing the patient from becoming over fatigued

Disturbed sensory perception related to altered sensory reception,transmissionand integration

• Assess the sensory perception level of the patient.
• Patients with decreased field of vision should be approached on the side where visual perception is intact
• All visual stimuli(clock,calendar,television)should be placed on this side.
• The patient should maintain eye to eye contact with the patient and encourage the patient to concentrate on the affected side.
• The nurse should encourage the patient to visualize the things in the room
• Providing artificial glasses in the room and providing eye glasses helps to increase the vision
• The patient with homonymous hemiapnosia (loss of half of the visual field)will be able to see only the half of the visual field ie only half of the food in the tray will be visible and only half of the room will be visible.This condition is called amorphosynthesis.The nurse should remind the patient regarding the sffected side of the body.
• The nurse should remind the patient regarding the extremities on the affected side

Imbalanced nutrition less than body requirement realted to dysphagia

• Assess the nutritional status of the client
• Patient should be observed for paroxysms of coughing,dribbling of food,or pooling of the food on the side of the mouth,food retained for long periods of time in the mouth or nasal regurgitation while swallowing liquids.Swallowing difficulties will place the patient at risk of aspiration,pneumonia,malnutrition and dehydration.
• A speech therapist should evaluate the patients gag reflex and swallowing reflex.
• Advice the patient to take small amounts of food and teach the patient which all foods are easy to swallow.
• The patient can be instructed to start a thick pureed or liquid diet because it is easier to swallow mainly in the initial stage.The diet can be advanced as the swallowing ability increases
• Enteral tubes can be nasogastric or nasoenteric to prevent aspiration.
• Nurses responsibility includes elevating the head end atleast 30 degrees to prevent aspiration of the food.
• The position of the tube should be checked frequently to prevent the risk of aspiration.

Total urinary incontinence related to flaccid bladder,detrussor instability,confusion or difficulty in communication

• Assess the voiding pattern of the patient and a urinal or bed pan is offered
• In the initial stage frequent urinary catheterization is carried out
• If the patient has constipation high fibre rich diet is given.,and increase the fluid intake of the client (2-3L per day)
• The diet should be provided at a regular time to enhance toileting.

Disturbed thought process related to brain damage confusion or inability to follow instructions

• Assess the cognitive,behavioural and emotional deficits,a considerable degree of function can be regained as all the parts of the brain are not equally affected
• After assessment that delineates the patients deficits,a neuropsychiatrist,physician,nurse and other professionals initiates a training programme using visual imagery,reality orientation to compensate the losses.
• The nurses role is supportive.The nurse reviews the reviews the result of neuropsychological testing and reports the progress.

Impaired verbal communication realted to brain damage

• Assess the communication capacity of the client
• The speech therapist assists the communication needs of the stroke patient and suggests the overall method of communication.The inability to speak i Creases the frustration.So psychological support should be given to the patient .
• If the patient cannot talk encourage the patient to write and communicate.
• When talking to the patient it is important to draw the attention of the patient,speak slowly and draw the attention of the patient.
• Encourage the use of gestures.

Risk for impaired skin integrity related to hemiparesis,hemiplegia or decreased mobility

• Assess the level of skin integrity of the patient.
• Give more importance to the bony prominences.
• A regular turning schedule has to be practised(Turn the patient every 2 nd hourly)
• The patients skin should be kept clean and dry, gentle massage of the healthy(non reddened skin)and adequate nutrition and other factors to maintain the normal skin integrity

HEMORRAHGIC STROKE

• Hemorrhagic stroke accounts for 15-20% of the cerebrovascular disorders and are primarily caused by intracranial or subarachnoid hemorrhage.Hemorrhagic stroke is caused by bleeding into the brain tissue,ventricles or subarachnoid space.

ETIOLOGY

• Primary intracerebral hemorrhage from a spontaneous rupyure of small vessels accounts for approximately 80%of the hemorrhagic strokes and is caused by uncontrolled hypertension.
• Subarachnoid hemorrhage results from ruptured intracranial aneurysm(a weakening in the arterial wall)
• Intracerebral hemorrhage is caused by cerebral amyloid angiopathy which involves damage caused by deposit of beta amyloid protein in the small and medium sized blood vessels of the brain
• Secondary intracerebral hemorrhage is associated with arterivenous malformations,intracranial aneurysms,intracranial neoplasms or certain medications(anticoagulants,amphetamines)

PATHOPHYSIOLOGY

• Due to primary hemorrahge,aneurysm,pressing of AVM on the nearby cranial nerves or due to the rupture of AVM,reduced perfusion pressure and vasospasm
• The intracranial pressure increases
• The brain will be exposed to blood from the sudden entry of blood into the subarachnoid space
• The normal brain metabolism is distrupted
• The brain tissue will be compressed and injured

INTRACEREBRAL HEMORRHAGE

• Intracerebral hemorrhage or bleeding into the barin substance is common in patients with hypertension and cerebral atherosclerosis resulting in the rupture of the blood vessel.An intracerebral hemorrhage can also result from certain type of arterial pathology,brain tumors and due to the use of certain mediactions(anticoagualnts,ampheatmines)
• Bleeding usually occurs in the cerebral lobes,basal gangli ,thalamus,pones etc..Occassionally the bleeding ruptures the lateral ventricles and and causes intraventricular hemorrhage which is usually fatal.

INTRACRANIAL (CEREBRAL )ANEURYSM

• An intracranial aneurysm occurs from the dilatation of the walls of the cerebral artery that develops as a result of the weakening of the arterial wall.The cause of aneurysm is not known.An aneurysm may be due to atherosclerosis which results in the defect in the vessel wallwhich causes subsequent weakness of the wall,congenital defect of the vessel wall,hypertensive vascular disease,head trauma or advancing age
• Any artery within the brain can be a site of cerebral aneurysm,but the lesions occurs at the bifurcations of the large arteries of the Circle of Willis.The cerebral arteries most commonly affected are internal carotid artery(ICA),anterior cerebral artery(ACA),anterior communicating artery(ACOA),posterior communicating artery(PCOA),posterior cerebral artery(PCA),middle cerebral artery(MCA)

ARTERIOVENOUS MALFORMATIONS

It is caused by abnormal embryonal development that results in the tangling of the arteriesand veins in the brain that lacks a capillary bed.The absence of capillary bed leads to dilatation of the arteries and the veins and eventually rupture.AVM is a common cause of hemorrhagic stroke among younger people.

SUBARACHNOID HEMORRHAGE

• A subarachnoid hemorrhage(hemorrhge into the subarachnoid space occurs as a result of AVM,intracranial aneurysm,trauma or hypertension.The most common cause is the leaking aneurysm in the area of Circle of Willisand a congenital aVM of the brain

CLINICAL MANIFESTATIONS

• Neurological deficits(motor,sensory,cognitive and other functions)
• Conscious patients reports severe headache
• Vomiting
• Sudden change in the level of consciousness
• Focal seizures due to frequent brain stem involvement

Patients with intracranial aneurysm or AVM

• Sudden severe headache and loss of consciousness for a variable period of time
• Nuchal rigidity(pain and rigidity at the back of the neck nd spine due to meningeal irritation
• Visual disturbances(visual loss,ptosis,diplopia)
• Tinnitus,dizziness,hemiparesis.
• If severe bleeding occurs it results in severe cerebral damage,coma and death.

ASSESSMENT AND DIAGNOSTIC FINDINGS

• History collection and physical examination
• CT Scan and MRI to determine the size and location of the hematoma and presence and absence of ventricular blood and presence of hydrocephalus
• CT Scan and Cerebral angiography for the diagnosis of intracranial aneurysm or AVM.
• Lumbar puncture is done if there is no evidence of increased ICP.Lumbar puncture in presence of increased ICP will cause herniation and bleeding

PREVENTION

• Primary prevention is the best approach which includes managing hypertension and identifying the risk factors of the disease.
• Control of hypertension in people older than 55 years of age controls hypertension.
• Additional risk factors are age,male gender,excessive alcohol intake etc..
• Public awareness regarding association between phenylpropanolamine(PPA an ingredient found in appetite suppressants as well as cold and cough agents)and hemorrhagic stroke

COMPLICATIONS

• Cerebral hypoxia and decreased cerebral blood flow.
• Vasospasm
• Increased ICP
• Systemic hypertension

MEDICAL MANAGEMENT

• The goals of medical management is to allow the brain to recover from the initial insult,to prevent and minimize the risk of rebleeding and to prevent and to treat complications.
• Ongoing clinical trials are going on to see whether use of recombinant activator factor 7 can reduce bleeding after intracerebral hemorrhage.
• Management is supportive which consists of bedrest with sedation to prevent agitation and stress,management of vasospasm and surgical and medical treatment to prevent rebleeding.
• Analgesics(codeine,acetaminophen)is prescribed to relieve head and neck pain
• Patient is fitted with compression devices to prevent deep vein thrombosis

SURGICAL MANAGEMENT

• If the diameter of the hematoma exceeds more than 3cmsand the glascowcoma score decreases surgical evacuation is recommended for patients with cerebellar hemorrahge.Surgical evacuation is done by craniotomy.Then patient with intracranial aneurysm is prepared for surgery as soon as the condition is stable.The goal of the surgery is to prevent further bleeding.This objective is accomplished by isolating the aneurysm from the circulation or by strengthening the arterial wall.An aneurysm may be excluded from the cerebral circulation by means of a ligature or a clip across the neck
• Other less invasive intravascular treatments includes
• Endovascular treatment-Occlusion of the parent artery
• Aneurysm coiling-Obstruction of the aneurysm site with a coil.

Post operative complications

Psychological symptoms(disorientation,amnesia,Korsakoff s syndrome, personality changes),intraoperative embolization,post operative internal artery occlusion, fluid and electrolyte disturbance and gastrointestinal bleeding

NURSING PROCESSASSESSMENT-A complete neurological assessment is performed which includes the following:

• Altered level of consciousness
• Sluggish papillary reaction.
• Motor and sensory dysfunction
• Cranial nerve deficits(intraocular eye movements, facial droop, presence of ptosis)
• Speech difficulties and visual disturbance
• The patients should be monitored in the intensive care units
• Neurological findings should be recorded and reported
• Any changes in the patients condition requires thorough documentation, changes should be reported immediately

NURSING DIAGNOSISIneffective tissue perfusion(cerebral) related to bleeding or vasospasm

• The patient is continuously monitored for neurological deterioration resulting fromrecurrent bleeding,increasing ICP or vasospasm.
• The blood pressure,pulse,level of consciousness(indicator of cerebral perfusion),papillary response and motor function is checked hourly.
• Respiratory status is monitored because a reduction in the oxygen in the areas of the brain results in impaired autoregulation resulting in cerebral infarction
• Any changes should be monitored immediately.
• Cerebral aneurysm precautions are implemented in patients with aneurysm.The patient should be placed in a quiet,nonstimulating environment,to prevent increase in ICP and further bleeding.,because activity ,painand anxiety increases the blood pressure that can result in bleeding.
• Visitors except the family members are restricted
• The head is elevated to about 15-30 degrees to decrease ICP and to promote venous drainage.
• Any activity which causes a sudden increase in the blood pressure should be avoided.This includes straining,forceful sneezing,acute flexion or rotation of the head and the neck which compromises the jugular veins.and cigarette smoking
• Any activity which requires exertion is contraindicated.
• The patient is instructed to exhale through the mouth during voiding and defecation.
• No enemas are prescribed but stool softners and laxatives are given
• Dim light is given because photophobia is common
• Coffee and tea unless decaffeinated are usually avoided.
• Thigh high elastic compression stockings are given to reduce the incidence of DVT.
• The nurse helps in the self care activities of the client and helps to prevent any exertion
• External stimulation should be minimum including no television,no radio and no reading.
• Visitors are restricted and a sign indicating restriction should be placed on the door,the patient and the family members should be aware regarding this
• Disturbed sensory perception related to medically imposed restrictions(aneurysm precautions)
• Anxiety related to medically imposed restrictions(aneurysm precautions)
• Sensory precautions should be kept on minimum for patient on aneurysm precautions
• For the patients who are alert awake and oriented an explanation of the restrictions reduces the sense of isolation
• Keep the patient well informed regarding the plan of care and reassure and provide psychological support to the patient.

COMPARISON BETWEEN THE MAJOR TYPES OF STROKE

ITEM	ISCHEMIC	HEMORRHAGIC
CAUSES	LARGE ARTERY THROMBOSIS SMALL PENETRATING ARTERY THROMBOSIS CADIOGENIC EMBOLIC CRYPTOGENIC OTHER	INTRACEREBRAL HEMORRHAGE SUBARACHNOID HEMORRHAGE CEREBRAL ANEURYSM AVM
SYMPTOMS	NUMBNESS OR WEAKNESS OF THE FACE ,ARM OR LEG,ESPECIALLY ON ONE SIDE OF THE BODY	EXPLODING HEADACHE,DECREASED LEVEL OF CONSCIOUSNESS

CONCLUSIONCerebro vascular disorders refers to the functional abnormality of the central nervous system that occurs when the normal blood supply to tha brain is distrupted.If the patients are not taken care it may lead to life time complication sin the client.Technorati Tags: CAROTID ENDARTERECTOMY,HEMORRAHGIC STROKE,INTRACEREBRAL HEMORRHAGE,ARTERIOVENOUS MALFORMATIONS,SUBARACHNOID HEMORRHAGE,nursing process,management,diagnosis

DEGENERATIVE DISC DISEASE

To contact us Click HERE

Low back pain is a significant public health disorder. Acute low back pain lasts for less than 3 months or longer. Most back pains are due to disc disease.

 

CLINICAL MANIFESTATION

Pain occurs in the involved part of the spinal cord.ie..Cervical, thoracic or lumbar. The clinical manifestations depends on the location, rate of development (acute or chronic)and the effect on the surrounding structures.

PATHOPHYSIOLOGY

1. The intervertebral disc is a cartilaginous plate that forms a cushion between the vertebral bodies. This tough fibrous material is incorporated in a capsule. A ball like cushion in the centre of the disc is called nucleus pulposus.
2. In herniation of the intervertebral disc (ruptured disk) the nucleus of the disc protrudes into the annulus (fibrous ring around the disk)with subsequent nerve compression.
3. Protrusion or rupture of the nucleus pulposus usually is preceded with degenerative changes that occur with aging.
4. Loss of protein polysaccharides in the disc decreases the water content of the nucleus pulposus.
5. Radiating cracks develops in the annulus weakens resistance to the nucleus herniation.
6. With the degeneration the capsule pushes back into the spinal canal.
7. This sequence produces pain due to radiculopathy(pressure in the area of disturbance of the involved nerve endings.

ASSESSMENT AND DIAGNOSTIC FINDINGS

• A Thorough health history and physical examination
• CT Scan and MRI
• Neurological examination
• Electromyelography

MEDICAL MANAGEMENT

Herniation of the cervical and lumbar disc occurs commonly and are managed with bed rest and medication

SURGICAL MANAGEMENT

Surgical management is usually done if there is progressive neurologic deficit, muscle weakness or atrophy, loss of sensory and motor function, loss of sphincter control and continuing pain or sciatica(leg pain resulting from sciatic nerve involvement)The goal is to reduce the pressure on the nerve root to prevent pain. The following surgeries are usually performed.

• Disectomy-Removal of the herniated or extruded fragments of the intervertebral disc.
• Laminectomy-Removal of the bone between the spinal process and the facet pedicle junction to expose the neural elements in the spinal canal, this allows the surgeon to inspect the spinal canal, identify and remove the pathological tissue, and relieve the compression of the spinal cord and the nerve roots.
• Hemilaminectomy-Removal of the part of the lamina and part of the posterior arch of the vertebra.
• Partial laminectomy or Laminotomy-Creation of a hole in the lamina of the vertebra.
• Dissectomy with Fusion-A bone graft(from the iliac crest or the bone bank)is used to fuse the vertebral spinous process.
• Foraminotomy-Removal of the intervertebral foramen to increase the space for exit of the spinal nerve, resulting in reduced pain, compression and edema.

HERNIATION OF THE CERVICAL INTERVERTEBRAL DISC

The cervical spine is subjected to stressors that result from disc degeneration(due to aging, occupational stress)and spondylosis(degenerative changes occurring in a disc and other supportive structures)Cervical disc degeneration can lead to lesions that can cause damage to the spinal cord and its roots cervical disc degeneration usually occurs at C5-C6 and C6-C7interspaces.

CLINICAL MANIFESTATIONS

• Pain and stiffness in the neck and the top of the shoulders and the region of the scapula.Sometimes the pain is interpreted as signs of heart problem and bursitis.
• Pain in the upper extremities and the head accompanied by parasthesia.(Tingling or a pins or needle sensation.Cervical MRI confirms the diagnosis.

MEDICAL MANAGEMENT

The goal of the medical management is to rest and immobilize the cervical spine to give the soft tissues time to heal. And to reduce the inflammation in the subcutaneous tissues and the affected nerve roots in the spinal cord.

• Bedrest is recommended and the patient s head should be supported.
• The cervical spine can be immobilized by a cervical collar,cervical traction and a brace.The collar increases the vertebral separation and thus relieves the pressure on the nerve roots.
• The head should be elevated and counter traction should be given.If the skin becomes irritated the halter can be padded.A male patient should be told not to shave because beard offers a natural form of padding.

PHARMACOLOGICAL THERAPY

• Analgesics,NSAID,propoxyphene(Darvon),Oxycodone(Tylox)orHydrocodone(Vicodin)is given to relieve the pain.
• Sedatives are administered to relieve anxiety associated with cervical disc disease.
• Muscle relaxants(Cyclobenzaprine,Methocarbamol,Metaxalone)
• Corticosteroids are prescribed to relieve inflammation.Hot moist compresses(for 10-20 minutes)is applied to the back of the neckseveral times daily to increase the blood flow.

SURGICAL MANAGEMENT

A cervical dissectomy with or without fusion is performed to relieve the symptoms.An anterior or a posterior approach may be used.Potential complications associated with anterior approach are carotid or vertebral artery injuryrecurrent laryngeal nerve irritation,esophageal perforation and airway obstruction. Complications of posterior approach are damage of the nerve root of the spinal cord due to retraction or contusion.Micro surgery ,such as endoscopic micro dissectomy is performed in certain patients with their magnifying effect.

NURSING PROCESS

THE PATIENT UNDERGOING CERVICAL DISSECTOMY

• Assessment-The patient is asked regarding the past injuries to the neck (whiplash) because unresolved trauma can cause persistent discomfort, pain and tenderness, and symptoms of arthritis in the injured joint of the cervical spine. Assessment includes determining the onset, location and radiation of the pain and assessing for parasthesias,limited movement ,and
  • diminished function of the neck,shoulders,and upper extremities.The patient should be educated about the surgical management. Strategies of pain management should be informed.
  
  
  

  NURSING DIAGNOSIS

  • Acute pain related to surgical procedure.
  • Impaired physical mobility related to post operative surgical regimen.
  • Deficient knowledge about the post operative course and home care management.
  Complications-Hematoma at a surgical site, resulting in cord compression and neurological deficit. Reccurent or persistent pain after the surgery.
  
  

  NURSING INTERVENTIONS

  Relieving pain and discomfort-

  • The patient must be kept flat in the bed for 12-24hours.
  • If the patient has pain monitor the donor site for hematoma formation, administering the prescribed analgesic agent, positioning the patient and reassuring the patient that the pain will be relieved. If the patient experiences a sudden pain extrusion of the graft may have occurred which requires reoperation. A sudden increase in the pain should be reported to the surgeon
  • The patient may experience sore throat, hoarseness and dysphagia due to temporary edema.This symptoms are relieved by throat lozenges, voice rest and humidification. A pureed diet can be given if the patient has dysphagia.
   
  

  Improving mobility

  • Postoperatively a cervical collar is worn resulting in limited neck movement. The patient is instructed to turn the body rather than the neck while turning from side to side. The patient s neck should be kept in neutral position.
  • The patient is assisted during position changes to make sure that the head, shoulders and thorax are kept aligned. While keeping the patient in sitting position the nurse supports the patient s neck and shoulders.
  
  

  Monitoring and managing potential complications

  • The patient is evaluated for bleeding and hematoma formation by assessing for excessive pressure in the neck or severe pain in the incision area. The dressing is checked for serosanguinous drainage, which suggests a dural leak. A complaint of headache requires careful evaluation.
  • Neurological checks are made for swallowing deficits and upper and lower extremity weakness because cord compression may produce rapid or delayed onset of paralysis.
  • The patient should be monitored thoroughly for signs of respiratory difficulty, because retractors used during the surgery may injure the laryngeal nerve resulting in hoarseness and inability to clear the cough effectively.
  • The blood pressure and pulse are monitored to evaluate the cardiovascular status.
  • Severe pain which is not relieved by anaesthesia should be reported to the physician. A change in the neurological status should be reported to the physician because hematoma formation can result in permanent sensory and motor deficits.
  • Promoting home and community based care.

  Teaching patients self care

  • The patient and the family members should be educated regarding the care.
  • If a cervical collar is worn care has to be given. Instruct the client to limit the body movements with tasks that require greater body movement.
  • The patient is instructed about the signs of complications and regarding pain management
  • The nurse should assist in activities of daily living.
  • A discharge teaching plan has to be maintained. Topics include proper body mechanics, maintenance of optimal body weight, proper exercise techniques and modification in activity. The patient is instructed to see the physician at regular intervals and to document for complications.
  
  

  EVALUATION AND EXPECTED PATIENT OUTCOMES

  • Reports decrease severity in the frequency of pain.
  • Is knowledgeable about the post operative complications, and home care management
  • Reports absence of complications.

Technorati Tags: home care management,pureed diet,upper extremities,deficient knowledge,nursing interventions,neck shoulders,analgesic agent,nursing diagnosis,head shoulders,throat hoarseness,cervical collar,physical mobility,neurological deficit,cord compression,excessive pressure,persistent pain,position changes,neutral position,24hours,surgical management

BRAIN ABSCESS

To contact us Click HERE

DEFINITION

A brain abscess is a collection of infectious material within the tissue of the brain.Bacteria is the most common causative organisms.The most common predisposing factors for abscess among immunocompetant people are ottitis media and sinusitis.

 

ETIOLOGY

• Ottitis media and sinusitis.
• Intracranial surgery ,penetrating injury or tongue piercing.
• Wound or intra abdominal infection.
• Ottitis media, sinusitis,mastoiditis,dental infections and systemic infections.

 

CLINICAL MANIFESTATIONS

• Head ache usually worse in the morning
• Fever,vomiting and focal neurological deficits.(weakness and decreasing vision reflects the area which is involved)
• Increased ICP and decreased level of consciousness

 

PATHOPHYSIOLOGY

The mechanisms to the entry of the micro organisms are as follows:

• Direct extension-Infections stemming from the sinus,middle ear or mastoid may gain access into the venous drainage of the brain via valveless emissary veins and drain into this region. Because of the antibiotic therapy for this infections incidence rate due to this type of spread has been decreased to a greater extent
• Haematogenous spread-This includes the spread via blood
• Following penetrating head injury or neurosurgery-Most cases can also occur as a result of penetrating head injury or trauma.

 

ASSESSMENT AND DIAGNOSTIC FINDINGS

• History collection and physical examination
• MRI and CT scan demonstrates a ring around the hypodense area.
• Aspiration of the abscess guided by CT scan or mRI helps to identify the organism
• Blood cultures if the origin of the abscess is from a distant sourse
• Chest X-ray to rule out predisposing lung infections
• CT Scan to evaluate the bony structure of the ear and the sinus

 

MEDICAL MANAGEMENT

• The goal of the treatment is to drain the abscess and to provide antibiotic therapy for the infection detected.
• Large IV doses of antibiotics are given to penetrate the blood brain barrier and to reach the site of infection.
• The choice of the antibiotic depends on the causative organism being identified by culture.
• Corticosteroids are prescribed to reduce the inflammatory cerebral edema.
• Antiseizure medications(Phenytoin and phenobarbitone )is prescribed to prevent or to reduce seizure.

 

NURSING MANAGEMENT

• Nursing care focuses on the assessment of neurological status,administering the medication,assessing the response to the treatment and providing supportive care.
• Blood laboratory test results especiallyblood glucose and serum potassium levels has to be monitored and corticosteroids are prescribed.
• Administration of insulin or electrolyte replacement is required to return this values to the normal state.
• The level of consciousness and the physical status has to be monitored constantly
• Observe for neurological deficits like hemiparesis,seizures,visual deficits etc..

Technorati Tags: head injury,focal neurological deficits,brain abscess,emissary veins,morning fever,venous drainage,intracranial surgery,diagnostic findings,dental infections,penetrating injury,nursing diagnosis

BRAIN TUMORS

To contact us Click HERE

 

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place. Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

INCIDENCE

The annual rate of newly diagnosed brain tumors is 17000,with an estimate of 13100 deaths The brain is a frequent site of metastasis.Brain tumors rank as fourth cause for death of people between the age group of 35 to 54 years.Whites have a higher risk of malignant tumors compared with blacks.Meningiomas are the common brain tumors in Africa

TYPES

Brain tumors can be classified as:

• Primary-Arising from the tissues within the brain
• Secondary-It results from metastasis from a malignbant neoplasm that originates in some other parts of the body

Types of brain tumor depending on the tissue of origin

• Astrocytomas-These are called gliomas.It arises from star shaped cells called glial cells.It accounts for about 65% of the primary brain tumors.These tumors can range from low grade to moderate grade malignancy. In adults, astrocytomas most often arise in the cerebrum. In children, they occur in the brain stem, the cerebrum, and the cerebellum. A grade III astrocytoma is sometimes called an anaplastic astrocytoma. A grade IV astrocytoma is usually called a glioblastoma multiforme.
• Glioblastoma Multiforme-It arises from the primitive stem cells(glioblast).They are highly malignant and invasive, among the most devastating of primary brain tumors
• Oligodendroglioma-Tissue origin is Oligodendrocytes.It is characterized by benign encapsulation and calcification
• Ependymoma-It arises in the ependyaml epithelium.It ranges from benign to malignant,most are benign and encapsulated..
• Acoustic neuroma-(Schwannoma)-Cells arises from the myelin sheath around the nerves,commonly affects cranial nerve 8.They grows on both sides of the brain,usually benign or low grade malignancy
• Pituitory Adenoma-It arises in the pituitary gland.It is usually benign
• Hemangioblastoma-It arises from the blood vessels of the brain.It is rare and benign and the surgery is curative.
• Primary central nervous system lymphoma-It arises fromthe lymphocytes.It arises in in transplant recepients and acquired immunodeficiency syndrome(AIDS)patients.
• Metastatic tumors-It occurs in the lungs,breast,kidney,thyroid,prostate.It is malignant

Some types of brain tumors do not begin in glial cells. The most common of these are:

• Medulloblastoma - This tumor usually arises in the cerebellum. It is the most common brain tumor in children. It is sometimes called a primitive neuroectodermal tumor.
• Meningioma - This tumor arises in the meninges. It usually grows slowly.
• Schwannoma - A tumor that arises from a Schwann cell. These cells line the nerve that controls balance and hearing. This nerve is in the inner ear. The tumor is also called an acoustic neuroma. It occurs most often in adults.
• Craniopharyngioma - The tumor grows at the base of the brain, near the pituitary gland. This type of tumor most often occurs in children.
• Germ cell tumor of the brain - The tumor arises from a germ cell. Most germ cell tumors that arise in the brain occur in people younger than 30. The most common type of germ cell tumor of the brain is a germinoma.
• Pineal region tumor - This rare brain tumor arises in or near the pineal gland. The pineal gland is located between the cerebrum and the cerebellum.

Brain tumors can also be classified as

• Benign brain tumors do not contain cancer cells. Usually, benign tumors can be removed, and they seldom grow back.The border or edge of a benign brain tumor can be clearly seen. Cells from benign tumors do not invade tissues around them or spread to other parts of the body. However, benign tumors can press on sensitive areas of the brain and cause serious health problems. Unlike benign tumors in most other parts of the body, benign brain tumors are sometimes life threatening.
• Malignant brain tumors Very rarely, a benign brain tumor may become malignant containing cancer cells. Malignant brain tumors are generally more serious and often life threatening. They are likely to grow rapidly and crowd or invade the surrounding healthy brain tissue.Very rarely, cancer cells may break away from a malignant brain tumor and spread to other parts of the brain, to the spinal cord, or even to other parts of the body. The spread of cancer is called metastasis

BRAIN TUMOR LOCATIONS AND PRESENTING MANIFESTATIONS

• FRONTAL LOBE TUMORS –Unilateral hemiplegia,seizures,memory deficit,personality and judgement changes,visual disturbances.
• PARIETAL LOBE-Speech disturbance( If the tumor is in the dominant hemisphere inability to write,unilateral neglect
• OCCIPITAL LOBE-Blindness and seizures.
• SUBCORTICAL-Hemiplegia,other symptoms may depend on the area of infiltration
• MENINGEAL TUMORS-Symptoms are associated with compression of the brain
• METASTATIC TUMORS-Headache,nausea or vomiting because of increased ICP

CLINICAL MANIFESTATIONS

• Headaches (usually worse in the morning)
• Nausea or vomiting
• Changes in speech, vision, or hearing
• Problems balancing or walking
• Changes in mood, personality, or ability to concentrate
• Problems with memory
• Muscle jerking or twitching (seizures or convulsions)
• Numbness or tingling in the arms or legs

DIAGNOSTIC EVALUATION

• Physical examination - The doctor checks general signs of health.
• Neurologic examination - The doctor checks for alertness, muscle strength, coordination, reflexes, and response to pain. The doctor also examines the eyes to look for swelling caused by a tumor pressing on the nerve that connects the eye and brain.
• CT scan - An x-ray machine linked to a computer takes a series of detailed pictures of the head. The patient may receive an injection of a special dye so the brain shows up clearly in the pictures. The pictures can show tumors in the brain.
• MRI - A powerful magnet linked to a computer makes detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed. Sometimes a special dye is injected to help show differences in the tissues of the brain. The pictures can show a tumor or other problem in the brain.
• Angiogram - Dye injected into the bloodstream flows into the blood vessels in the brain to make them show up on an x-ray. If a tumor is present, the doctor may be able to see it on the x-ray.
• Skull x-ray - Some types of brain tumors cause calcium deposits in the brain or changes in the bones of the skull. With an x-ray, the doctor can check for these changes.
• Spinal tap - The doctor may remove a sample of cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). This procedure is performed with local anesthesia. The doctor uses a long, thin needle to remove fluid from the spinal column. A spinal tap takes about 30 minutes. The patient must lie flat for several hours afterward to keep from getting a headache. A laboratory checks the fluid for cancer cells or other signs of problems.
• Myelogram - This is an x-ray of the spine. A spinal tap is performed to inject a special dye into the cerebrospinal fluid. The patient is tilted to allow the dye to mix with the fluid. This test helps the doctor detect a tumor in the spinal cord.
• Biopsy - The removal of tissue to look for tumor cells is called a biopsy. A pathologist looks at the cells under a microscope to check for abnormal cells. A biopsy can show cancer, tissue changes that may lead to cancer, and other conditions. A biopsy is the only sure way to diagnose a brain tumor.

COMPLICATIONS

• If the tumor mass occludes the ventricles or occludes the outlet,ventricular enlargement (hydrocephalus)can occur
• The client should be continuously assessed for signs of altered level of consciousness,restlessness,blurred vision,vomiting without nausea and signs of infected shunts if shunts are placed to relieve the increased ICP. Such as high fever,persistent head ache etc..

TREATMENT

Treatment goals are aimed at identifying the tumor type and location,removing or decreasing the tumor massand preventing and managing increased ICP.

SURGICAL THERAPY

• Stereotactic surgical techniques are used with high frequency to perform a biopsy and to remove small tumors.
• Meningiomas and oligodendromyomas are completely removed where as invasive gliomas and medulloblastomas can be partially removed.Computer guided stereotactic biopsy ,ultrasound,functional MRI and cortical mapping is used to locate the brain tumors

RADIATION THERAPY AND RADIOSURGERY

• Radiation therapy is usually used in followup care.Radiation seeds can be implanted into the brain.Cerebral edema and rapidly increasing ICP can be a complication of radiation therapy.,they can be managed with high doses of corticosteroidsEg Dexamethasone,prednisolone.Stereotactic radiosurgery is a method of delivering high concentration of of radiation

CHEMOTHERAPY

• A group of chemotherapeutic agents called nitrosureas are administered.Eg:Carmustine,lomustine
• Chemotherapy laden biodegradable lesions Eg:Gliadel waferis implanted
• Methotrexate and Procrbazine
• Radiation can be delivered by Ommaya reservoir and intrathecal administration.
• Temozolomide is the first chemotherapeutic drug which crosses the blood brain barrier.
• Local hypothermia and biotherapy

NURSING MANAGEMENT

NURSING ASSESSMENT

• The initial data should contain the information about the present status of the client.
• Areas to be assessed includes LOC, state of consciousness, motor abilities,sensory perception integrated function including bowel and bladder function,balance and coordination and coping ability of the client.
• Watching the patient doing ADL and conversing to the patient is a method of assessment.
• The patient should be allowed to ventilate the feelings.
• Questions concerning medical history,intellectual abilities,educational level and history of nervous system infections and trauma should be collected.

NURSING DIAGNOSIS

Self care deficit related to loss of impairment of motor and sensory functionand decreased cognitive abilities

• Assess the level of cognitive function to obtain a baseline data
• Encourage the patient as wellas the family members to keep the patient as independant as possible
• Provide assistance with the self care activities
• The patient is encouraged to plan for each day to make the atmost of each day because the patient lives in uncertainity.
• An individualized exercise programme to maintain strength,endurance and range of motion

Altered nutrition less than body requirement related to cachexiadue to treatment and tumor effects,decreased nutritional intake and Malabsorption

• Assess the nutritional status of the client to obtain a baseline data.
• Symptoms like nausea,vomiting,breathlessness and pain should be managed.
• The nurse should teach the family members how to position the patient during feeding.
• The patient should be provided adequate rest to reduce the fatigue.
• The patient should be clean,comfortable and free of pain when on meals
• The environment should be attractive as possible.Avoid offensive sights,sounds and odours.
• Provide fluids and provide oppurtunities for socialization.
• Dietary suppliments provided should be rich in calories if it is advisable for the patient.
• If the patient cannot tolerate orally paranteral nutrition should be initiated.

Anxiety related to anticipation of death,uncertainity,change in appearance and altered lifestyle

• Assess the level of anxiety to obtain a baseline data.
• Explain about the disease condition and the treatment measures undertaken
• Encourage the family members and the friends to be with the patient
• Provide psychological support and provide oppurtunities to ventilate the feelings
• Open communication is encouraged
• If the patients emotional response is very intense additional help is taken from a clergy,social worker or a mental health professional.

Potential for altered family process related to anticipatory grief and the burdens imposed by the care of the person with terminal illness

• The family must be reassured that their loved one is receiving the maximum care.
• When the patient is not able to carry out the basic needs the family members should provide support
• Psychological support should

Technorati Tags: nervous system infections,nursing diagnosis,state of consciousness,breathlessness,cognitive abilities,initial data,cognitive function,educational level,nursing management