NOW LOADING . . . . . .

OUTLINE

Cerebrovascular accident also called as Stroke“Brain attack” a True Emergencyoccurs when a blood clot blocks an artery or a blood vessel breaks, interrupting blood flow to an area of the brain. Leading to cell injury and cell death

• Attacks millions of people worldwide every year

• Higher incidence and death rates among African-Americans, Hispanics, Native-American, Asian Americans

• In the Phil – 2nd Leading cause of Death & Leading cause of chronic disability

• ‘30-30-30’ situation  • Mortality: women > men• 2/3 people >65

Non Modifiable• Age• Gender• Race• Heredity• Prior Stroke/Heart Attack

Modifiable• HTN• Smoking• Diabetes mellitus • Asymptomatic carotid

stenosis• Heart disease, atrial

fibrillation • Sickle cell disease

• Hyperlipidemia • Oral contraceptives• Poor Diet• Physical inactivity• Hypercoagulability • Heavy alcohol

consumption • Obesity

‘MASTER CONTROL UNIT’-coordinates and controls all activities of the body

CNSBrain - complex computer

Spinal Cord- large cable- integrator

PNSCranial Nerves 12Spinal Nerves 31

Structure

Cerebral hemispheres form the largest part of the human brain situated above most other brain structures. covered with a cortical layer with a

convoluted topography.Underneath the cerebrum lies the brainstem

Cerebrum large, main, superior

component of the brain. Cerebrum is ones

conscious brain. It is separated into two

hemispheres and each hemisphere into five lobes.

That means there are 2 of each lobe (one in each hemisphere) in the brain. Below are the lobes and what they are associated with.

Frontal Lobe Associated with

reasoning, planning, parts of speech, voluntary motor function of skeletal muscles, emotions, memory and problem solving, personality and inhibitions

Parietal Lobe Associated with

movement, orientation, recognition, and perception of stimuli.

Awareness in space and spatial relations and of body shape

Occipital Lobe

Associated with visual processing/ interpretation.

Temporal Lobe Associated with

perception and recognition of auditory stimuli, storage and recall of memories, language, comprehension, smell

Cerebellum At the rear of the

brain, beneath the cerebrum and behind the brainstem, is the cerebellum.

associated with regulation and coordination of movement, posture, and balance

Brain Stem

Resembling a stalk on which the cerebrum is attached.

This structure is responsible for basic vital life functions such as breathing, heartbeat, and blood pressure. 

Pons

Relay messages from the cerebrum to the cerebellum and spinal cord

Medulla Oblangata

Located above spinal cord. It regulates vital functions, such as heartbeat and breathing. The Medulla Oblongata is responsible for the 6 Crazy Dwarfs:1.Coughing2.Sneezing3.Vomiting4. Salivating5. Swallowing6. Gaging

Cranial Bones

Provides a rigid support and protection for the brain

Connective Tissue (Meninges)

Blood supply by arteries

Blood is supplied to the brain by two major pairs of arteries Internal carotid arteriesVertebral arteries

Blood supply by arteries

Carotid arteries branch to supply most of the Frontal, parietal, and temporal lobesBasal gangliaPart of the diencephalon

○ Thalamus○ Hypothalamus

Blood supply by arteries

Vertebral arteries join to form the basilar artery, which supply theMiddle and lower temporal lobesOccipital lobesCerebellum BrainstemPart of the diencephalon

Vascular wall becomes fragile and thickens

Leaking of blood from the fragile blood vessel

Lysed or moved thrombus from the vessels

CEREBRAL HEMORRHAGE

Obstruction of blood vessels / Vascular occlusion

Blood seeps into the ventricles

Obstruction of CSF passageway

CEREBRAL HYPOPERFUSSION

Cerebral ISCHEMIA

Accumulation of CSF in the ventricles

Ventricles dilated to the point of obstruction

Increased ICP

Secondary Hydrocephalus

Anaerobic metabolism

of Mitochondria

Increased Lactic Acid

METABOLIC ACIDOSIS

Initiation of ISCHEMIC CASCADE

Decreased ATP

Failed energy dependent

process

Release of Glutamate

Influx of Calcium

Unrelieved obstruction

Production of oxygen free radicals and other oxygen

reactive species

Irreversible brain damage

CEREBRAL EDEMA

Compression of brain tissue

Middle Cerebral Artery

Frontal, Parietal, Temporal Lobes,

Basal Ganglia

Contralateral hemiperesis or hemiplegia, unilateral neglect, altered LOC, homonymous

hemianposia, visual changes, dyslexia, dysgraphia, aphasia, agnosia, memory deficits,

vomiting

Anterior Cerebral Artery

Frontal Lobe

Contralateral hemiperesis (foot and leg > arm), foot drop, disturbances in gait, contralateral hemisensory alteration, expressive aphasia,

confusion, amnesia, flat affect, apathy, apraxia, shortened span of attention, incontinence,

Posterior Cerebral Artery

Occipital and Temporal Lobe

Internal Carotid Artery

Branches to opthalmic, PCA, ACA, MCA and

anterior choriodal

Mild contralateral hemiperesis,intention tremors, diffused sensory loss, pupillary

dysfinction, loss of conjugate gaze, nystagmus, loss of depth perception, cortical blindness, homonymous hemianopsia, dyslexia, visual

hallucinations, memory deficitsContralateral hemiperesis with facial assymetry, contralateral sensory alterations, homonymous hemianposia, ipsilateral periods of blindness, aphasia if dominant sphere is affected, mild

Horner’s syndrome, carotid bruits

Vertibrobasillar Artery

Cerebellum and Brainstem

Anteroinferior CerebellarCerbellum

Posteroinferior CerebellarCerebellum

Alternating motor weakness, ataxic gait, dysmetria, contralateral hemisensory

impairment, double vision, homonymous hemianposia, nystagmus, conjugate gaze,

disorientation, hearing loss, tinnitus, vertigo, coma

Ipsilateral ataxia, facial paralysis, ipsilateral loss of sensation in face, sensation changges in trunks and limbs, nystagmus, tinnitus and

hearing loss

Paralysis of larynx and soft palate, ataxia, ipsilateral loss of sensation in face, nystagmus, dysarthia, hiccups, vertigo, coughing, nausea

and vomiting

U – utal (stuttering) T - tabingi ang mukha o tindig (uneven facial expression)

A - angal nang angal ng sakit ng ulo (rants of headache)

K - kumilos at komunsulta agad! (act and consult a doctor)

Goals For Management Of StrokePresented by: Ms. Rhea Carla Erica Balog,

R.N.

Goals for Management of Patients With Suspected Stroke Algorithm.

Copyright © American Heart Association

Identify signs and symptoms of possible stroke

Activate Emergency Response

Critical EMS Assessment and ActionsSupport ABCs; give oxygen if neededPerform prehospital stroke assessmentEstablish time of symptom onset (last normal)Triage to stroke centerAlert hospitalCheck glucose if possible

Immediate General Assessment and StabilizationAssess ABCs and VSProvide oxygen if hypoxemicObtain IV access and perform laboratory

assessmentsCheck glucose, treat if indicatedPerform neurologic screening assessmentActivate stroke teamOrder emergent CT or MRI of brainObtain 12 lead ECG

Immediate Neurologic Assessment by Stroke Team or designeeReview patient historyEstablish time of symptom onset (or last

known normal)Perform neurologic examination

DOES CT SCAN SHOW HEMORRHAGE?NO HEMORHHAGE:Probable Acute Ischemic Stroke: consider

fibrinolytic therapy:Check for fibrinolytic exclusionsRepeat neurologic exams: are deficits rapidly

improving to normal?

Patient remains candidate for fibrinolytic therapyIf candidate: Review risks/benefits with patient and family. If

acceptable:Give rtPANo anticoagulants or anti platelet treatment for

24 hours

Begin post rtPA stroke pathwayAggresively monitor: BP per protocolFor neurologic deteriorationEmergent admission to stroke unit or ICU

IF NOT A CANDIDATE FOR FIBRINOLYTIC THERAPY:Administer aspirin

Begin stroke or hemorrhage pathwayAdmit to stroke unit or ICU

DOES CT SCAN SHOW HEMORRHAGEIF HEMORHHAGE:Consult neurologist or neurosurgeon:

consider transfer if not available

Begin stroke or hemorrhage pathwayAdmit to stroke unit or ICU

CAROTID ULTRASOUNDCAROTID ULTRASOUND

measures the cholesterol levels — both the bad (low-density lipoprotein, or LDL) and the good (high-density lipoprotein, or HDL). High cholesterol is a major risk factor for stroke and may indicate that you are at greater risk of having a stroke.

measures the cholesterol levels — both the bad (low-density lipoprotein, or LDL) and the good (high-density lipoprotein, or HDL). High cholesterol is a major risk factor for stroke and may indicate that you are at greater risk of having a stroke.

including prothrombin time (PT), partial thromboplastin time (PTT), and international normalized ratio (INR), check the speed at which the blood clots. Abnormal bleeding is a potential cause of hemorrhagic strokeabnormal clotting is a potential cause of ischemic stroke.

Blood chemistry testsHomocysteine level tests

the level of the amino acid homocysteine in the blood, which is thought to contribute to increased stroke risk and atherosclerosis, a known risk factor for stroke.

Contra Indications: Hypersensitivity, severe pulmonary congestion, progressive renal disease or dysfunction.

Adverse Reactions: CNS: seizures, dizziness, headache. CV: hypotension, tachycardia, chest pain. EENT: blurred vision, rhinitis. GI: thirst, dry mouth, nausea, vomiting,

diarrhea. GU: urine retention Metabolic: fluid and electrolyte imbalance,

dehydration.

Nursing Considerations: Monitor vital signs, and fluid intake and

output. Check weight, renal function, serum and urine sodium and potassium daily.

Patient Teachings: Tell patient he may feel thirsty or have a

dry mouth. Instruct patient to promptly report adverse

reactions and discomfort at I.V site.

Classification: CNS Stimulants

Indications: CVD in acute and recovery phase, symptoms and signs of cerebral insufficiency, dizziness, memory loss, poor concentration and recent cranial trauma.

Contra Indication: Parasympathetic hypertonia

Adverse Reaction: GI disorders

Nursing Considerations: Assess patient before giving the

medication, Monitor vital signs.

Classification: Nootropics and Neurotonics

Indication: Cerebral Circulatory insufficiency and chronic manifestations of CVA.

Contra Indication: Cerebral Hemorrhage and ESRD.

Adverse Reaction: Hyperkinesia, weight gain, astheria, nervousness, agitation, irritability, anxiety or sleep disturbance, fatigue or drowsiness, GI disturbances

Nursing Consideration: Observe the patients for  possible untoward reactions

Adverse Reactions: CNS: dizziness, fainting, headache,

malaise, fatigue. CV: tachycardia, hypotension. GI: Abdominal pain, anorexia, dry

mouth, nausea and vomiting. Respiratory: dyspnea, dry cough.

Nursing Considerations: Monitor patients vital signs

especially blood pressure and cardiac rate,

Drug is linked with the most frequent occurrence of cough.

Classification: Antihyperlipidaemic Agents

Indication: Reduction of the risk of CHD death, major vascular and coronary events, stroke, hospitalization for angina pectoris and developing propheral macrovascular complications.

Contra Indications: Hypersensitivity to drug. And in those with active liver disease or conditions that cause unexplained persistent elevations of serum transaminase levels. Pregnancy and breast-feeding women.

Adverse Reactions: CNS: headache GI: Abdominal pain Hepatic: elevated liver enzyme

levels. Respiratory: URTI

Nursing Considerations: Use cautiously in patients who

consume substantial quantities of alcohol or have a history of liver disease.Instruct patient to take drug with evening meal.

Classification: Laxatives

Indication: Constipation, stool softeners.

Contra Indication: Contra indicated in patients on a low galactose diet.

Adverse Reactions: GI: abdominal cramps, diarrhea,

gaseous distention, flatulence, nausea and vomiting.

Nursing Considerations: Use cautiously in patients with

diabetes mellitus. To minimize sweet taste, dilute

with water or fruit juice or give with food.

Inform patient about adverse reactions and notify the nurse.

 is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury and stroke.

Craniotomy is any bony opening that is cut into the skull. A section of skull, called a bone flap, is removed to access the brain underneath. There are many types of craniotomies, which are named according to the area of skull to be removed .

Insert an intracranial pressure (ICP) monitor

remove a small sample of abnormal tissue (needle biopsy)

drain a blood clot (stereotactic hematoma aspiration)

insert an endoscope to remove small tumors and clip aneurysms

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONOBJECTIVE:HemiplegiaAltered mental statusRestlessnessChanges in pupillary reactionDifficulty in swallowing

Ineffective Cerebral Tissue Perfusion May be related to Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vaso spasm, cerebral edema Possibly evidenced by Altered level of consciousness; memory loss Changes in motor/sensory responses; restlessness Sensory, language, intellectual, and emotional deficits Changes in vital signs

Maintain usual/improved level of consciousness, cognition, and motor/sensory function. Demonstrate stable vital signs and absence of signs of increased ICP. Display no further deterioration/recurrence of deficits

Determine factors related to individual situation/cause for coma/decreased cerebral perfusion and potential for increased ICP.

Influences choice of interventions. Deterioration in neurological signs/symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity requiring patient be transferred to critical care area for monitoring of ICP, other therapies. If the stroke is evolving, patient can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence

Maintain/increase strength and function of affected or compensatory body part. Maintain optimal position of function as evidenced by absence of contractures, footdrop. Demonstrate techniques/behaviors that enable resumption of activities. Maintain skin integrity.

1. Ineffective Cerebral Tissue Perfusion — Stroke (CVA)

Monitor/document neurological status frequently and compare with baseline.

Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression/resolution of CNS damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA.Fluctuations in pressure may occur because of cerebral pressure/injury in vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse). Increased ICP may occur because of tissue edema or clot formation. Subclavian artery blockage may be revealed by difference in pressure readings between arms.Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (e.g., stroke after MI or from valve dysfunction).Irregularities can suggest location of cerebral insult/increasing ICP and need for further intervention, including possible respiratory support.

•Evaluate pupils, noting size, shape, equality, light reactivity. 

Assess higher functions, includingg speech, if patient is alert

• Position with head slightly elevated and in neutral position. 

Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brainstem is intact. Pupil size/equality is determined by balance between parasympathetic and sympathetic enervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves.

Changes in cognition and speech content are an indicator of location/degree of cerebral involvement and may indicate deterioration/increased ICP. Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation/perfusion.

• Maintain bedrest; provide quiet environment; restrict visitors/activities as indicated. Provide rest periods between care activities, limit duration of procedures.

• Prevent straining at stool, holding breath

• Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity. 

• Administer supplemental oxygen as indicated. 

Continual stimulation/activity can increase ICP. Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage. 

Valsalva maneuver increases ICP and potentiates risk of rebleeding. Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may reflect increased ICP/cerebral injury, requiring further evaluation and intervention.  

Reduces hypoxemia, which can cause cerebral vasodilation and increase pressure/edema formation.

  

2. Impaired Physical Mobility

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVERight hemiplegiaLimited ROMDifficulty turningSlowed movementGait changes

Impaired Physical Mobility may be R/T Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic paralysis possibly evidenced by Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength/control

Maintain/increase strength and function of affected or compensatory body part.

Maintain optimal position of function as evidenced by absence of contractures, footdrop.

Demonstrate techniques/behaviors that enable resumption of activities. Maintain skin integrity.

Assess functional ability/extent of impairment initially and on a regular basis. Classify according to 0–4 scale.Change positions at least every 2 hr (supine, sidelying) and possibly more often if placed on affected side.Position in prone position once or twice a day if patient can tolerate.Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head

Identifiesstrengths/deficiencies and may provide information regarding recovery. Assists in choice of interventions, because different techniques are

used for flaccid and spastic paralysis.Reduces risk of tissue ischemia/injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/decubitus ulcerHelps maintain functional hip

extension; however, may increase anxiety, especially about ability to breathe.Prevents contractures/footdrop and facilitates use when/if function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side.

Patient shall have participated in the Activities necessary for him/herPatient shall have improved/ increased strength and function of affected body part

•Maintain leg in neutral position with a trochanter roll;•Observe affected side for color, edema, or other signs of compromised circulation.•Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary.•Provide egg-crate mattress, water bed, flotation device, or specialized beds (e.g., kinetic), as indicated.

Prevents external hip rotation.Edematous tissue is more easily traumatized and heals more slowly.Pressure points over bony prominences are most at risk for decreased perfusion/ischemia. Circulatory stimulation and padding help prevent skin breakdown and decubitus development.Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown/decubitus formation. Specialized beds help with positioning,enhance circulation, and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia. 

3.Impaired verbal communication

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE:w/slurred speechdisorienteddifficulty expressing thoughs verballyDifficulty in comprehending or maintaining usual communication patternInability or difficulty in use of facial or body expressions

Impaired verbal communication maybe related to Impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle tone/control; generalized weakness/fatiguePossibly evidenced by Impaired articulation; does not/cannot speak (dysarthria) Inability to modulate speech, find and name words, identify objects; inability to comprehend written/spoken language Inability to produce written communication

to Establish method of communication in which needs can be expressed.

Assess type/degree of dysfunction: e.g., patient does not seem to understand words or has trouble speaking or making self understood.

Listen for errors in conversation and provide feedback

Provide special call bell if necessary.

Provide alternative methods of communication, visual clues gestures, pictures, “needs” list,

Helps determine area and degree of brain involvement and difficulty patient has with any or all steps of the communication process.

Patient may lose ability to monitor verbal output and be unaware that communication is not sensible. Feedback helps patient realize why caregivers are not understanding/responding appropriately and provides opportunity to clarify content/meaning.

Call bell that is activated by minimal pressure is useful when patient is unable to use regular call system.

Provides for communication of needs/desires based on individual situation/underlying deficit.

. Establish method of communication in which needs can be expressed. Use resources appropriately.

Anticipate and provide for patient’s needs.

Talk directly to patient, speaking slowly and distinctly. Use yes/no questions to begin with, progressing in complexity as patient responds.

Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Talk without pressing for a response.

Helpful in decreasing frustration when dependent on others and unable to

communication desires.

Reduces confusion/anxiety at having to process and respond to large amount of information at one time

Patient is not necessarily hearing impaired, and raising voice may irritate or anger patient. Forcing responses can result in frustration

Respect patient’s preinjury capabilities; avoid “speaking down” to patient or making patronizing remarks.

Enables patient to feel esteemed, because intellectual abilities often remain intac

ASSESSMENT

NURSING DIAGNOSIS

PLANNING INTERVENTION EVALUATION

 Objective:     Pt is physically immobile and unable to get out of bed.     An area on the pt’s buttocks was reddened and warm to touch. 

Risk for impaired skin integrity R/TImmobility

Short Term: After 8hrs. of nursing interventions, the patient will not develop any further skin breakdown. 

 1. Reposition the pt at least once every two hours.     Rationale:“Positioning interventions reduce pressure and shearing force to the skin.” (Potter & Perry, 2009, p. 1305)

Goal met. Patient’s skin has no signs of worsening or advanced impairment and skin integrity has not been further compromised.   

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION EVALUATION

 Pt is incontinent of her bowels, which leads to moisture on her skin. 

 2. Keep the skin clean and dry     Rationale:“Moisture softens the skin and causes a break in the skin integrity.”(Potter & Perry, 2009, p. 1302)

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION

EVALUATION

 3. Monitor skin condition at least once a day for color or texture changes, dermatological conditions, or lesions.”     Rationale: “Systematic inspection can identify impending problems early.” (Ackley & Ladwig, 2008, p. 754)  

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION EVALUATION

Long Term:Patient will verbalize the measures needed to promote good skin integrity by discharge.

1. Educate pt on the importance of proper dieting and food intake.     Rationale: “… Nutrition is fundamental to normal cellular integrity and tissue repair.” (Potter and Perry, 2008, p. 1310)

Hypothetically, once the patient was oriented, she would be taught the needed measures to promote good skin integrity and she would verbalize her understanding.

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION

EVALUATION

 2. Educate the pt on the importance of keeping the skin clean and dry.     Rationale:“Moisture softens the skin and causes a break in the skin integrity.”(Potter & Perry, 2009, p. 1302)          

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION

EVALUATION

Objective: Disoriented to time, place and person

Disturbed Sensory Perception R/T Neurological Impairment

Short Term: After 8hrs. of nursing interventions, the patient will be able to demonstrate behavior to overcome deficits.

1. Orient patient to time, place and persons frequently. Rationale: Orientation minimizes anxiety and promotes cognitive function.

Goal Met: The patient cooperates with nursing care.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING INTERVENTION EVALUATION

Long Term:Regain usual level of consciousness and perceptual functioning

2. Provide a consistent physical environment and a daily routine. Rationale:“Routine eliminates the element of surprise, overstimulation, and further confusion.” 3. Provide access to familiar objects when possible.

 Goal met: patient was oriented to time, place and significant other.

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION EVALUATION

Rationale:“Familiarity helps reduce confusion.” 4. Provide for adequate rest, sleep, and daytime naps. Rationale:“Reduces overstimulation and fatigue which can be contributing factors to confusion.”

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION EVALUATION

5. Use calm and unhurried approach when interacting. Rationale:“Promotes communication that enhances person’s sense of dignity.

6. Speak to the client in a slow, distinct manner with appropriate volume.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION EVALUATION

Rationale:“The client who has difficulty of hearing will be better to lip read and comprehends speech.” 7. Use simple words and short sentences as appropriate.  Rationale:“Using simple terms facilitates understanding and minimize anxiety.  

 

REMEMBER!Maintain a patent airway to promote

adequate oxygenationAdminister oxygen therapy with possible

intubation and mechanical ventilation to ensure adequate tissue perfusion

Monitor O2 Sat ABG levels as orderedPlace patient on cardiac monitor and WOF

arrhythmias: Correct cardiovascular abnormalities, such as atrial fibrillation, that may be contributing factors

Administer dexamethasone to reduce cerebral edemaMaintain bed rest to minimize metabolic requirementsProvide I.V. fluids to support blood pressure and maintain

volumeAdminister anticoagulants and antiplatelet drugs for

thrombotic conditions after hemorrhage has been ruled outAdminister sedatives, such as Phenobarbital, to decrease

metabolic requirementsAssess the patient’s neurologic status; observe for CVA

progression and level of consciousness (LOC) change as evidenced by decreasing numerical score on the GLASGOW COMA SCALE at every hour or more frequently

If cerebral edema if suspected, maintain ICP sufficient for adequate cerebral perfusion but not low enough to avoid

BRAIN HERNATION. Elevate head of bed 2o to 30 degreesTurn patient oftenUse antiembolic stockingsProvide ROM exercisesProvide meticulous eye and oral careSet up simple method of communicating –aphasic ptsConsider surgical procedures to correct circulatory

impairment, prevent repeated hemorrhage, or relieve cerebral pressure

Provide psychological support