Management of Patients with Cerebrovascular Disorders

Cerebrovascular Disorders

$53.6 Functional abnormality of the CNS that occurs when the blood supply is disrupted Stroke is the primary cerebrovascular disorder and the third leading cause of death in the U.S. Stroke is the leading cause of serious long-term disability in the U.S. Direct and indirect costs of stroke are billion

Prevention
 Nonmodifiable
 Age

risk factors

race

(over 55), male gender, African American

 Modifiable

risk factors: see Chart 62-1
the primary risk factor disease

 Hypertension:

 Cardiovascular  Elevated  Obesity  Diabetes  Oral

cholesterol or elevated hematocrit

contraceptive use

Stroke
“Brain

attack”

Sudden

loss of function resulting from a disruption of the blood supply to a part of the brain of stroke: see Table 62-1
(80% to 85%) (15% to 20%)

Types

Ischemic

Hemorrhagic

Ischemic Stroke
 Disruption

of the blood supply due to an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue
 Large  Small

 Types

artery thrombosis penetrating artery thrombosis embolism

 Cardiogenic  Cryptogenic  Other

Pathophysiology

Manifestations of Ischemic Stroke

Symptoms depend upon the location and size of the affected area Numbness or weakness of face, arm, or leg, especially on one side Confusion or change in mental status Trouble speaking or understanding speech Difficulty in walking, dizziness, or loss of balance or coordination Sudden, severe headache Perceptual disturbances See Tables 62-2 and 62-3

  

  

Types of Paralysis

Abnormal Visual Fields

Cerebrovascular Terms
Hemiplegia Hemiparesis Dysarthria Aphasia:

expressive aphasia, receptive aphasia

Hemianopsia

Transient Ischemic Attack (TIA)
Temporary

neurologic deficit resulting from a temporary impairment of blood flow of an impending stroke”

“Warning

Diagnostic

work-up is required to treat and prevent irreversible deficits

Carotid Endarterectomy

Carotid Endarterectomy

Preventive Treatment and Secondary Prevention
 Health

maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease  Carotid endarterectomy  Anticoagulant therapy  Antiplatelet therapy: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid)  Statins  Antihypertensive medications

Medical Management During Acute Phase of Stroke
Prompt

diagnosis and treatment

Assessment

of stroke: NIHSS assessment tool therapy
Criteria IV

Thrombolytic

for tissue plasminogen activator (tPA): see Chart 62-2 dosage and administration monitoring effects: potential bleeding

Patient Side

Medical Management During Acute Phase of Stroke (cont.)
Elevate

HOB unless contraindicated airway and ventilation

Maintain Provide

continuous hemodynamic monitoring and neurologic assessment the guidelines in Appendix B

See

Hemorrhagic Stroke
 Caused

by bleeding into brain tissue, the ventricles, or subarachnoid space be due to spontaneous rupture of small vessels primarily related to hypertension; subarachnoid hemorrhage due to a ruptured aneurysm; or intracerebral hemorrhage related to amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants

 May

Hemorrhagic Stroke (cont.)
Brain

metabolism is disrupted by exposure to blood increases due to blood in the subarachnoid space or secondary ischemia from reduced perfusion and vasoconstriction injures brain tissue

ICP

Compression

Manifestations
Similar Severe Early

to ischemic stroke headache

and sudden changes in LOC

Vomiting

Medical Management
 

Prevention: control of hypertension Diagnosis: CT scan, cerebral angiography, and lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage Care is primarily supportive Bed rest with sedation Oxygen Treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding

   

Intracranial Aneurysms

Nursing Process—Assessing the Patient Recovering From an Ischemic Stroke 
Acute phase
 Ongoing/frequent

monitoring of all systems including vital signs and neurologic assessment: LOC and motor, speech, and eye symptoms for potential complications including musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of increased ICP and meningeal irritation on patient function; self-care ability,

 Monitor

After the stroke is complete
 Focus

Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke 
Impaired physical mobility pain deficits sensory perception
 Acute

 Self-care

 Disturbed  Impaired  Urinary

swallowing

incontinence

Disturbed Impaired Risk

Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke (cont.)
thought processes verbal communication

for impaired skin integrity family processes

Interrupted Sexual

dysfunction

Collaborative Problems/Potential Complications
Decreased

cerebral blood flow oxygen delivery to brain

Inadequate Pneumonia

Major

Nursing Process—Planning Patient Recovery After an Ischemic Stroke
goals include:

Improved

mobility Avoidance of shoulder pain Achievement of self-care Relief of sensory and perceptual deprivation Prevention of aspiration Continence of bowel and bladder

Nursing Process—Planning Patient Recovery After an Ischemic Stroke (cont.)
Major

goals include (cont):

Improved

thought processes Achievement of a form of communication Maintenance of skin integrity Restoration of family functioning Improved sexual function Absence of complications

Interventions
Focus

on the whole person

Provide

interventions to prevent complications and to promote rehabilitation support and encouragement

Provide Listen

to the patient

       

Turn and position the patient in correct alignment every 2 hours Use splints Practice passive or active ROM 4 to 5 times day Position hands and fingers Prevent flexion contractures Prevent shoulder abduction Do not lift by flaccid shoulder Implement measures to prevent and treat shoulder problems

Improving Mobility and Preventing Joint Deformities

Positioning to Prevent Shoulder Abduction

Prone Positioning to Help Prevent Hip Flexion

 Perform

passive or active ROM 4 to 5 times day  Encourage patient to exercise unaffected side  Establish regular exercise routine  Use quadriceps setting and gluteal exercises  Assist patient out of bed as soon as possible: assess and help patient achieve balance and move slowly

Improving Mobility and Preventing Joint Deformities

Interventions

Enhance self-care
   

Set realistic goals with the patient Encourage personal hygiene Ensure that patient does not neglect the affected side Use assistive devices and modification of clothing

 

Provide support and encouragement Implement strategies to enhance communication: see Chart 62-4 Encourage the patient with visual field loss to turn his head and look to side

Interventions (cont.)
 Nutrition
 Consult  Have

with speech therapist or nutritionist

patient sit upright to eat, preferably

OOB  Use chin tuck or swallowing method  Feed thickened liquids or pureed diet
 Bowel

and bladder control
and schedule voiding

 Assess

 Implement

measures to prevent constipation: fiber, fluid, and toileting schedule  Provide bowel and bladder retraining

Nursing Process—Assessment of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm
Complete an ongoing neurologic assessment: use neurologic flow chart Monitor respiratory status and oxygenation Monitor ICP Monitor patients with intracerebral or subarachnoid hemorrhage in the ICU Monitor for potential complications Monitor fluid balance and laboratory data Reported all changes immediately

  

  

Nursing Process—Diagnosis of the Patient With a Hemorrhagic Stroke/ Cerebral Aneurysm
Ineffective

(cerebral)

tissue perfusion

Disturbed Anxiety

sensory perception

Collaborative Problems/Potential Complications
Vasospasm Seizures Hydrocephalus Rebleeding Hyponatremia

Nursing Process—Planning Care of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm
Goals

may include:

Improved

cerebral tissue perfusion Relief of sensory and perceptual deprivation Relief of anxiety Absence of complications

Aneurysm Precautions
 

Absolute bed rest Elevate HOB 30° to promote venous drainage or keep the bed flat to increase cerebral perfusion Avoid all activity that may increase ICP or BP; implement Valsalva maneuver, acute flexion, and rotation of the neck or head Exhale through mouth when voiding or defecating to decrease strain

Aneurysm Precautions (cont.)
 Nurse

provides all personal care and hygiene nonstimulating, nonstressful environment: dim lighting, no reading, no TV, and no radio constipation visitors

 Provide

 Prevent  Restrict

Interventions
 Relieve

sensory deprivation and anxiety  Keep sensory stimulation to a minimum for aneurysm precautions  Implement reality orientation  Provide patient and family teaching  Provide support and reassurance  Implement seizure precautions  Implement strategies to regain and promote self-care and rehabilitation

 Prevention

of subsequent strokes, health promotion, and implementation of followup care  Prevention of and signs and symptoms of complications  Medication teaching  Safety measures  Adaptive strategies and use of assistive devices for ADLs

Home Care and Teaching for the Patient Recovering From a Stroke

Home Care and Teaching for the Patient Recovering From a Stroke (cont.)
 Nutrition:

diet, swallowing techniques, and tube feeding administration  Elimination: bowel and bladder programs and catheter use  Exercise and activities: recreation and diversion  Socialization, support groups, and community resources  See Chart 62-6

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