ALTERED PERCEPTION

RHEALEEN V. VICEDO, MAN, RN

Assistant Professor IV
CEREBROVASCULAR
DISORDERS
ISCHEMIC STROKE
A.k.a. Cerebrovascular
accident (CVA)

Sudden loss of function

resulting from disruption of
blood supply to a part of the
brain
ISCHEMIC STROKE
TYPES:
⚫ Large Artery Thrombotic Stroke

• Caused by atherosclerotic plaques

• Thrombus formation & occulusion
• Infarction (tissue necrosis)

⚫ Small Penetrating Artery Thrombosis

• One or more blood vessel
• Most common type
• Lacunar stroke
ISCHEMIC STROKE
TYPES:
⚫ Cardiogenic Embolic
• Associated with cardiac dysrhythmias (atrial fibrillation)
• Emboli originate from the heart & lodge on the cerebral
artery

⚫ Cryptogenic
• No known cause

⚫ Others
• E.g. Coagulopathies, dissection of the carotid artery
ISCHEMIC STROKE
PATHOPHYSIOLOGY
Ischemia
↓
Energy failure
↓ ↓
Acidosis ↔ Ion imbalance
↓ ↓ ↓
↑ Intracellular Calcium depolarization
↓ ↕
Cell membranes breakdown ↑ glutamate
& proteins breakdown; formation
of free radicals; ↓ protein production
↓
Cell injury and death
ISCHEMIC STROKE
⚫ Penumbra Region

▪ Area of low cerebral blood flow

▪ Exists around the area of infarction

ISCHEMIC STROKE
CLINICAL MANIFESTATIONS:

▪ Numbness or weakness of the face, arm, leg especially on

one side of the body
▪ Confusion / change in mental status
▪ Slurred speech / trouble understanding speech
▪ Difficulty walking, dizziness, loss of balance and coordination
ISCHEMIC STROKE
NEUROLOGIC DEFICITS:

▪ VISUALFIELD DEFICITS:
▪ Homonymous hemianopsia
▪ Loss of half of the visual field
▪ Affected side corresponds to the paralyzed side of the body

▪ Loss of Peripheral Vision

▪ Difficulty of seeing at night
▪ Unaware of objects / borders of objects

▪ Diplopia
▪ Double vision
ISCHEMIC STROKE
NEUROLOGIC DEFICITS:
▪ MOTOR DEFICITS:
▪ Hemiparesis
▪ Weakness of one side of the face, arm, leg

▪ Hemiplegia
▪ Paralysis of one side of the face, arm, leg
ISCHEMIC STROKE
NEUROLOGIC DEFICITS:

▪ MOTOR DEFICITS:
▪ Ataxia
▪ Unsteady gait

▪ Dysphagia
▪ Difficulty of swallowing

▪ Dysarthria
▪ Difficulty of forming words
ISCHEMIC STROKE
NEUROLOGIC DEFICITS:

▪ SENSORY DEFICITS:
▪ Paresthesias
▪ Numbness or tingling sensations
▪ “pins and needles” sensation
▪ Occurs on side opposite the lesion
ISCHEMIC STROKE
NEUROLOGIC DEFICITS:

▪ VERBAL DEFICITS:
▪ Dysphasia (impaired speech)
▪ Aphasia
▪ Inability
to express oneself or to understand language
▪ Expressive Aphasia: inability to form words
▪ Receptive Aphasia: unable to comprehend
▪ Global (Mixed) Aphasia
ISCHEMIC STROKE
NEUROLOGIC DEFICITS:

▪ COGNITIVE DEFICITS:
▪ Memory loss
▪ ↓ attention span
▪ Inability to concentrate
▪ Altered judgment
▪ Poor abstract reasoning
ISCHEMIC STROKE
NEUROLOGIC DEFICITS:

▪ EMOTIONAL DEFICITS:
▪ Loss of self control
▪ Depression
▪ Withdrawal
▪ Feelings of isolation
ISCHEMIC STROKE
ASSESSMENT:
▪ History
▪ Complete physical exam
▪ Neurologic exam
▪ Temporaryneurologic deficit (TIA or Transient
Ischemic Attack)
▪ Warning sign of impending stroke
ISCHEMIC STROKE
RISK FACTORS:
▪ Age(> 55 y/o)
▪ Gender (males)
▪ Race (African Americans)
▪ Hypertension
▪ DM
▪ Smoking
ISCHEMIC STROKE
PREVENTION:
▪ Healthy lifestyle:
▪ No smoking
▪ Maintaining desirable body weight
▪ Healthy diet
▪ Moderate alcohol consumption
▪ Regular exercise

▪ DASH Diet (Dietary Approaches to Stop Hypertension)

▪ ↑ fruits and vegetables
▪ Moderate in low fat-dairy products
▪ ↓animal protein consumption
ISCHEMIC STROKE
PHARMACOLOGIC INTERVENTION:
▪ Warfarin (Coumadin)
▪ Mgt. of atrial fibrillation

▪ Rivaroxaban (Xarelto) / Dabitagram (Pradaxa)

▪ Newer generation anticoagulants

▪ Aspirin
▪ Best option if anti-coagulants are contraindicated
ISCHEMIC STROKE
PHARMACOLOGIC INTERVENTION:
▪ Clopidogrel (Plavix)
▪ ↓ incidence of cerebral infarction in pts. Who have
experienced TIAs and stroke

▪ Simvastatin (Zocor)
▪ Reduce coronary events and stroke
ISCHEMIC STROKE
THROMBOLYTIC THERAPY:
▪ Thrombolytic Agents
▪ Dissolving the blood clot that blocks the blood flow to the brain

▪ Tissue Plasminogen Activator (t-PA)

▪ Works by binding to fibrin and converting plasminogen to
plasmin, w/c stimulates fibrinolysis

▪ Initiation w/in 3 hours to 6 hours

▪ ↓ in size of stroke
▪ Improvement in functional outcome
ISCHEMIC STROKE
THROMBOLYTIC THERAPY:
▪ Dose and Administration
▪ 0.9 mg/kg (max dose of 90mg)
▪ 10% of calculated dose IV bolus over 1 minute
▪ 90% IV over 1 hour via infusion pump

▪ SideEffects
▪ Bleeding
▪ 24-hour delay in placement of NGT, IFC, intra-arterial
pressure catheters
ISCHEMIC STROKE
THERAPY FOR PATIENTS NOT RECEIVING t-
PA:
▪ IV heparin or Low molecular weight heparin (Enoxaparin)

▪ Maintain Cerebral perfusion

▪ Reduce ICP (e.g. Osmotic diuretics)
▪ Maintain PaCO2 w/in 30-35 mmHg
ISCHEMIC STROKE
THERAPY FOR PATIENTS NOT RECEIVING
t-PA:
▪ Maintain Cerebral perfusion
▪ Supplemental oxygenation (O2sat <92%)
▪ Elevate head of bed (25 to 30 degrees)
▪ Intubation
▪ Hemodynamic monitoring
▪ Frequent neurologic assessments
ISCHEMIC STROKE
SURGICAL MANAGEMENT:
▪ Carotid Endarterectomy (CEA)

▪ Removal of an atherosclerotic plaque or thrombus from

the carotid artery

▪ Prevent stroke in patients with occlusive disease

ISCHEMIC STROKE
NURSING ASSESSMENT:
▪ Change in level of consciousness
▪ presence or absence of voluntary/ involuntary movement
▪ Eye opening
▪ Quality and rates of pulses and respiration
▪ Ability to speak
▪ I and O
▪ Presence of bleeding
▪ Maintenance of blood pressure
ISCHEMIC STROKE
NURSING DIAGNOSES:
▪ Impaired physical mobility
▪ Acute pain
▪ Self-care deficits
▪ Impaired swallowing
▪ Impaired urinary elimination
▪ Constipation
▪ Impaired verbal communication
▪ Risk for impaired skin integrity
ISCHEMIC STROKE
NURSING INTERVENTIONS:
▪ Improve mobility and prevent deformities
▪ Correct positioning
▪ Turning every 2 hrs
▪ Prevent contractures thru the use of splinting, pillows, towel rolls
▪ Passive exercise regularly
▪ Assist in ambulation

▪ Acute pain (shoulder)

▪ Use arm sling
▪ ROM
▪ Elevate affected arm

▪ Self-care deficits
▪ Carry out self-care activities on unaffected side
▪ Support and encourage
ISCHEMIC STROKE
NURSING INTERVENTIONS:
▪ Impaired swallowing
▪ Check gag reflex
▪ NGT insertion / feeding

▪ Impaired physical comfort r/t altered sensory reception

▪ Approach on the side where visual perception is intact
▪ Stand on the position that encourages pt. To move or turn to the
affected side

▪ Impaired urinary elimination

▪ Catheterization
ISCHEMIC STROKE
NURSING INTERVENTIONS:
▪ Constipation
▪ High fiber diet
▪ Adequate fluid intake (2 to 3L/day)

▪ Impaired verbal communication

▪ Speak clearly and slowly
▪ Provide a communication board

▪ Risk for impaired skin integrity

▪ Frequently assess skin w/ emphasis on bony areas and dependent parts
▪ Turning schedule q2
▪ Keep linen wrinkle free
▪ Keep skin clean and dry
HEMORRHAGIC STROKE
▪ caused by bleeding into the brain
tissue, ventricles or subarachnoid
space

▪ 80%are due to uncontrolled

hypertension

▪ Mortality rate: 50% at 30 days after

HEMORRHAGIC STROKE
PATHOPHYSIOLOGY
HPN/ Atherosclerosis/congenital defect/ head trauma/ degeneration
↓
Intracerebral hemorrhage/ Intracranial Aneurysm/ Arteriovenous
Malformations/ Subarachnoid Hemorrhage
↓
Brain exposure to blood
↓
↑ICP
↓
Compression and injury to brain tissues
↓
↓perfusion
↓
Cell injury and death
HEMORRHAGIC STROKE
CLINICAL MANIFESTATIONS:

▪ Severe Headache
▪ Vomiting
▪ Sudden change in level of consciousness (or loss
of consciousness)
▪ Focal seizure
▪ Nuchal rigidity and spine (meningeal irritation)
▪ Coma --→ death
HEMORRHAGIC STROKE

DIAGNOSTICS:

▪ CT Scan
▪ MRI
▪ Cerebral angiography (Aneurysms & AVMs)
▪ Lumbar Puncture (confirms subarachnoid
hemorrhage)
HEMORRHAGIC STROKE
COMPLICATIONS:

▪ Cerebral hypoxia and decreased blood flow

▪ Maintain BP, Cardiac output
▪ Adequate hydration (IV fluids)
▪ Seizure precautions and intervention
HEMORRHAGIC STROKE
COMPLICATIONS:

▪ Cerebral Vasospasm
▪ Narrowing of the lumen of the involved cranial blood vessel

▪ 7-10 days after initial hemorrhage

▪ When clot undergoes lysis, chance of rebleeding is

increased → ↑vascular resistance →impedes blood flow →
infarction
HEMORRHAGIC STROKE
COMPLICATIONS:
▪ Cerebral Vasospasm
▪ Intensifiedheadache, ↓LOC (confusion, disorientation, lethargy),
neurologic deficits

▪ **caused by ↑calcium influx into the cell

▪ Tx: nimodipine (Nimotop)– calcium channel blocker

▪ Triple-H Therapy:
▪ Hypervolemia
▪ Hypertension (induced)
▪ Hemodilution
HEMORRHAGIC STROKE
COMPLICATIONS:
▪ ↑ICP
▪ Disturbed circulation of CSF
▪ Administration of mannitol; stool softeners
▪ Elevate head of bed
▪ Sedation
▪ Hyperventilation
▪ IVF
HEMORRHAGIC STROKE
MEDICAL MANAGEMENT:
▪ Hypertension
▪ SBP may be lowered to prevent hematoma enlargement
▪ If BP is elevated, anti-hypertensives may be prescribed
▪ E.g. Nicardipine (Cardene), hydrlazine (Apresoline)
▪ Hemodynamic monitoring
▪ Drop in BP → ischemia
HEMORRHAGIC STROKE

MEDICAL MANAGEMENT:
▪ Bed rest with sedation
▪ Anti-embolism stockings
▪ Iced saline bolus for fever
HEMORRHAGIC STROKE
PHARMACOLOGIC MANAGEMENT:
▪ If bleeding is caused by anti-coagulation, Vitamin K is
administered or FFP

▪ Phenytoin (Dilantin) for seizure

▪ Low-molecular weight heparin (Enoxaparin)

▪ Acetaminophen (Tylenol)/ paracetamol for fever

HEMORRHAGIC STROKE
PHARMACOLOGIC MANAGEMENT:
▪ Analgesics

▪ Anti-hypertensives

▪ Osmotic diuretics
HEMORRHAGIC STROKE
SURGICAL MANAGEMENT:
▪ Craniotomy
▪ For evacuation of hemorrhage
HEMORRHAGIC STROKE
SURGICAL MANAGEMENT:
▪ Aneurysm ligation or clipping
HEMORRHAGIC STROKE
NURSING DIAGNOSES:
▪ Ineffective cerebral tissue perfusion

▪ Anxiety
HEMORRHAGIC STROKE

NURSING INTERVENTIONS:
▪ Optimizing Cerebral Tissue Perfusion
▪ Neurologic assessment
▪ Close monitoring of BP, LOC, pupillary responses,
motor function
▪ Respiratory status
HEMORRHAGIC STROKE
NURSING INTERVENTIONS:
▪ Implementing Aneurysm precautions

▪ provide nonstimulating environment

▪ Bed rest
▪ Quiet, non stressful environment
▪ Visitors are restricted
▪ Head of bed elevated to 15 to 30 degrees
HEMORRHAGIC STROKE
NURSING INTERVENTIONS:
▪ Implementing Aneurysm precautions

▪ Any activity that ↑BP and valsalva maneuver is avoided

▪ Exhale through the mouth when defecating/voiding
▪ X smoking
HEMORRHAGIC STROKE
NURSING INTERVENTIONS:
▪ Monitor & Manage Potential Complications:
▪ Seizure
▪ Hydrocephalus
▪ CSF circulation is blocked
▪ Sudden onset of stupor, coma
▪ Ventriculostomy drain / Ventriculoperitoneal shunt
▪ Hyponatremia (SIADH/ Cerebral Salt wasting Syndrome)
SEIZURE DISORDERS
SEIZURE DISORDERS
▪ Disorder of the CNS

▪ characterized by paroxysmal seizure w/ or w/o loss

of consciousness, abnormal motor activity,
alteration in sensation, perception and changes in
behavior

▪ Sudden excessive electrical discharges from

neurons
SEIZURE DISORDERS
PREDISPOSING FACTORS:
▪ Head injury
▪ CO2 poisoning
▪ Genetics
▪ Brain tumor
▪ Nutritional & metabolic deficiencies
▪ Sudden withdrawal of anticonvulsants
▪ Fever
▪ Febrile seizure: normal for < 5y/o
SEIZURE DISORDERS
GENERALIZED TYPES:

1. GRAND MAL (TONIC-CLONIC)

▪ w/ or w/o aura (warning sign, subjective)
▪ Epileptic cry
▪ Simultaneous contraction of diaphragm & chest muscles
▪ Loss of consciousness 3-5mins
▪ Tonic : direct symmetrical extension of extremities/
stretching
▪ Clonic: contraction
▪ Post-ictal sleep
SEIZURE DISORDERS
GENERALIZED TYPES:
2. PETIT MAL (ABSENCE SEIZURE)
▪ children
▪ Blank stare
▪ Loss of consciousness 5-10 seconds
▪ ↓ blinking of the eyes
▪ Twitching of the mouth
SEIZURE DISORDERS
GENERALIZED TYPES:

3. ATONIC SEIZURE
▪ a loss of muscle tone
▪ the person may fall limply,
like a ‘rag doll’
SEIZURE DISORDERS
PARTIAL / LOCAL TYPES:

1. JACKSONIAN SEIZURE
▪ Focal seizure
▪ Tingling and jerky movement of index finger &
thumb
▪ Spreads to shoulder and to other side of the body
SEIZURE DISORDERS
PARTIAL / LOCAL TYPES:
2. PSYCHOMOTOR SEIZURE
▪ Focal-motor seizure
▪ Automatism repetitive & non-purposive
behavior
▪ Clouding of consciousness (not in contact
w/ reality)
▪ Mild hallucinatory sensory expreience
SEIZURE DISORDERS
DIAGNOSTICS:
1. MRI / CT Scan
2. EEG
▪ Shampoo hair prior
▪ X caffeine in meal before
SEIZURE DISORDERS
NURSING MANAGEMENT: (DURING)
Document the ff:
▪ Circumstances before the seizure
▪ Aura (visual, auditory, olfactory)
▪ First thing the patient does
▪ Type of movement and areas involved
▪ Pupil size
▪ Incontinence of urine & stool
▪ Duration
▪ Unconsciousness
SEIZURE DISORDERS
NURSING MANAGEMENT: (DURING)
SEIZURE DISORDERS
NURSING MANAGEMENT: (DURING)
▪ Provide privacy
▪ Ensure safety
▪ Ease pt to the floor / raise side rails if in bed
▪ Loosen constrictive clothing
▪ Push aside any furniture than may injure pt
▪ If an aura precedes seizure, insert oral airway
▪ DO NOT ATTEMPT TO PRY OPEN JAWS THAT ARE
CLENCHED IN SPASM OR ATTEMPT TO INSERT ANYTHING
SEIZURE DISORDERS
NURSING MANAGEMENT: (AFTER)
▪ Ensure patent airway
▪ Position pt side-lying (facilitate drainage of secretions
& prevent aspiration)
▪ Suction secretions prn
▪ Raise and pad side rails
▪ Allow to sleep
▪ Reorient if awaken with confusion
EPILEPSY
▪ Group of syndromes characterized by unprovoked,
recurring seizures

TYPES:
▪ Primary: unknown
▪ Secondary: known;
▪ brain tumor, birth trauma, heredity, head injury, toxicity,
metabolic/ nutritional deficits
EPILEPSY
Neurons continue firing after a task is
finished (unwanted electrical discharges)
↓
Parts of the body may perform erratically
↓
Abnormal discharges occur repeatedly
↓
Epileptic syndrome
EPILEPSY
EPILEPSY in women:
▪ ↑ seizure frequency during menses
▪ r/t ↑ sex hormones w/c alter excitability
of neurons

▪ Effectiveness of contraceptives ↓ by
anticonvulsants

▪ Risk for congenital anomaly

EPILEPSY
EPILEPSY in old-age:

▪ ↑ incidence of new onset epilepsy

▪ CVA – leading cause
▪ Often have chronic health problems that may interfere
with anti-convulsant meds
▪ Degenerative processes
EPILEPSY
PHARMACOLOGIC THERAPY:

▪ medications control rather than cure

▪ medication levels monitored in the blood

▪ Long term anticonvulsants result to bone loss

(osteoporosis)
EPILEPSY
PHARMACOLOGIC THERAPY:
1. Diazepam (Valium)
▪ Active seizure

2. Carbamazepine (Tegretol)
▪ Most effective to prevent future seizure
▪ Toxicity: hepatitis

3. Phenobarbital (Luminal)
EPILEPSY
PHARMACOLOGIC THERAPY:
4. Phenytoin (Dilantin)
▪ Only administered on PNSS to prevent crystallization/
precipitate
▪ Given IV via sandwich method (5-10cc PNSS—dilantin—5-
10cc PNSS)
▪ Toxicity:
▪ Gingival Hyperplasia
▪ Hairy tongue
▪ Ataxia
▪ Nystagmus
EPILEPSY
SURGICAL MANAGEMENT:

1. Cortical Resection
▪ Removal of tumors, correction of vascular
anomalies

2. Vagal nerve Generator implant

▪ Cervical area
▪ Delivers electrical signals to the brain to control
seizure
EPILEPSY
NURSING DIAGNOSES:

1. Risk for injury

2. Fear
3. Ineffective individual coping
4. Deficient knowledge
EPILEPSY
NURSING INTERVENTION:

1. Seizure precautions
2. Educate client
3. Involve significant others
4. Coping strategies
EPILEPSY
STATUS EPILEPTICUS
▪ Acute prolonged seizure activity

▪ Series of generalized seizures w/o period of full

recovery

▪ Leads to venous congestion, hypoxia

▪ If left untreated may interfere w/ respiration

NEUROLOGIC TRAUMA
HEAD INJURIES
A broad classification that includes injury to the scalp,
skull or brain.

Also known as Traumatic Brain Injury (TBI)

TYPES OF BRAIN INJURIES
CONCUSSION
⚫ Temporary loss of neurologic function with no

apparent structural damage to the brain

⚫ May or may not produce a brief loss of

consciousness (> 15mins)

⚫ Mild TBI
TYPES OF BRAIN INJURIES
CONTUSION
⚫ Moderate to severe TBI

⚫ Brain is bruised and damaged in a specific area

⚫ Impact of brain against the skull

⚫ Loss of consciousness associated with stupor and

confusion
TYPES OF BRAIN INJURIES
SIGNS AND SYMPTOMS:

Signs and symptoms of increased ICP

CSF leakage from ears or nose (detected with halo sign)

Battle’s sign (hematoma at the mastoid process) in basilar

head trauma
TYPES OF BRAIN INJURIES
Diagnostic Test:

• Radiologic exam
• CT Scan or MRI
• Cerebral angiography
TYPES OF BRAIN INJURIES

Collaborative Management:
• Treatment of increased ICP
• Fluid and electrolyte management – through IVFs, Mannitol
• O2 therapy or may require mechanical ventilation
TYPES OF BRAIN INJURIES

Collaborative Management:
• Monitor drainage from ears or nose
• Monitor for signs and symptoms of meningitis, atelectasis,
pneumonia, UTI
• Assist in correcting the cause of brain injury
SPINAL CORD INJURY

• Damage to the spinal cord ranges from transient

concussion, contusion, laceration, compression,
to complete transection of the cord.
SPINAL CORD INJURY
Causes:

• Age
• Gender
• Alcohol or drug intoxication
• Falls
• Vehicular accident
SPINAL CORD INJURY
Signs and symptoms:
Note: manifestations depend of the type and level
of injury
• Paralysis
• Loss of reflexes
• Loss of sensory function
• Loss of motor function
• Autonomic dysfunction
SPINAL CORD INJURY
Signs and symptoms:

Cervical SCI:
⚫ ↑C4 – fatal

⚫ Quadriplegia

⚫ Respiratory muscle paralysis

⚫ Bowel / bladder retention

SPINAL CORD INJURY
Signs and symptoms:

Thoracic SCI:
⚫ Paraplegia

⚫ Poor control of upper trunk

⚫ Bowel / bladder retention

SPINAL CORD INJURY
Signs and symptoms:
Lumbar SCI:
⚫ Paraplegia (flaccid)
⚫ Bowel / bladder retention

Sacral SCI:
⚫ ↑S2: with erection, no ejaculation
⚫ S2 – S4: no erection, no ejaculation
⚫ Paraplegia
⚫ Bowel / bladder incontinence
SPINAL CORD INJURY
Diagnostic Test:

• Radiographic examination
• CT scan, MRI
• ECG
SPINAL CORD INJURY
Collaborative / Emergency Management

• Any direct trauma to the head, neck and back must be

considered to have SCI
• Respiratory function is the first priority especially in cervical
SCI
• O2 therapy
• Immobilized the patient on a spinal board with head and neck
in neutral position
SPINAL CORD INJURY
Collaborative / Emergency Management

• Cervical collar if cervical injury is suspected

• Do not attempt to realign body parts
• Traction (e.g. halo vest), cast
• Pharmacologic Treatment
⚫ Corticosteroids, e.g. methylprednisolone
• Surgery as indicated
INTRACRANIAL TUMORS
A localized intracranial lesion that occupies space within the
skull.

May be classified according to origin as:

• Gliomas – originating from brain tissues (50%)
• Meningiomas – originating from brain coverings
(meninges)
• Neuromas – originating from cranial nerve (acoustic
commonly)
• Hemangiomas – originating from abnormal blood vessel
build up
INTRACRANIAL TUMORS
May be classified according to location:

• Supratentorial tumor – cerebrum, anterior 2/3 of the

brain

• Infratentorial tumor – cerebellum, brain stem, and

posterior 1/3 of the brain
INTRACRANIAL TUMORS
Causes:

No definitive causes

Genetics (Mutation or deletion of tumor suppressor

genes)
INTRACRANIAL TUMORS
Signs and Symptoms:

• Personality disturbances
• Inappropriate affects
• Indifference of bodily functions
• Jacksonian seizure
• Olfactory, auditory, visual disturbances or hallucinations
• Loss of right –left discrimination
INTRACRANIAL TUMORS
Collaborative Management:
• Surgery
• Supratentorial Craniotomy
⚫ Semi-fowler’s position postop

• Infratentorial Craniotomy
⚫ Prone position, turn to sides, avoid supine position for the first 48
hours, avoid neck flexion

• Radiation Therapy
THANK YOU!