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1. 2. Management of Patients with Cerebrovascular Disorders Cerebrovascular Disorders $53.6 Functional abnormality of the CNS that occurs when the blood supply is
in the U.S.
Stroke is the primary cerebrovascular disorder and the third leading cause of death
Stroke is the leading cause of serious long-term disability in the U.S. Direct and indirect costs of stroke are billion Prevention Nonmodifiable risk factors
Age (over 55), male gender, African American race Modifiable risk factors: see Chart 62-1 Hypertension: the primary risk factor Cardiovascular disease Elevated cholesterol or elevated hematocrit Obesity Diabetes Oral contraceptive use Smoking and drug and alcohol abuse
“ Brain attack” Sudden loss of function resulting from a disruption of the blood supply to a part of
Types of stroke: see Table 62-1 Ischemic (80% to 85%) Hemorrhagic (15% to 20%) Ischemic Stroke Disruption of the blood supply due to an obstruction, usually a thrombus or
embolism, that causes infarction of brain tissue
arm. Types Large artery thrombosis Small penetrating artery thrombosis Cardiogenic embolism Cryptogenic Other Pathophysiology Manifestations of Ischemic Stroke Symptoms depend upon the location and size of the affected area Numbness or weakness of face. Types of Paralysis Abnormal Visual Fields o o o o o o o o 10.o 6. receptive aphasia Hemianopsia 11. especially on one side Confusion or change in mental status Trouble speaking or understanding speech Difficulty in walking. 7. dizziness. 9. or leg. or loss of balance or coordination Sudden. Carotid Endarterectomy . Transient Ischemic Attack (TIA) o o o Temporary neurologic deficit resulting from a temporary impairment of blood flow “ Warning of an impending stroke” Diagnostic work-up is required to treat and prevent irreversible deficits 12. Cerebrovascular Terms o o o o o Hemiplegia Hemiparesis Dysarthria Aphasia: expressive aphasia. severe headache Perceptual disturbances See Tables 62-2 and 62-3 8.
Preventive Treatment and Secondary Prevention o o o o o o Health maintenance measures including a healthy diet. the ventricles. arterial venous malformations (AVMs). or intracerebral hemorrhage related to amyloid angiopathy.) o Brain metabolism is disrupted by exposure to blood .13. dipyridamole (Persantine). clopidogrel (Plavix). or subarachnoid space May be due to spontaneous rupture of small vessels primarily related to hypertension. and ticlopidine (Ticlid) Statins Antihypertensive medications 15. Medical Management During Acute Phase of Stroke (cont. intracranial aneurysms. Hemorrhagic Stroke (cont. and the prevention and treatment of periodontal disease Carotid endarterectomy Anticoagulant therapy Antiplatelet therapy: aspirin. Hemorrhagic Stroke o o Caused by bleeding into brain tissue. subarachnoid hemorrhage due to a ruptured aneurysm. or medications such as anticoagulants 18. Carotid Endarterectomy 14. Medical Management During Acute Phase of Stroke o o o Prompt diagnosis and treatment Assessment of stroke: NIHSS assessment tool Thrombolytic therapy Criteria for tissue plasminogen activator ( tPA): see Chart 62-2 IV dosage and administration Patient monitoring Side effects: potential bleeding 16.) o o o o Elevate HOB unless contraindicated Maintain airway and ventilation Provide continuous hemodynamic monitoring and neurologic assessment See the guidelines in Appendix B 17. exercise.
and prevention of further bleeding 21. coping.o o ICP increases due to blood in the subarachnoid space Compression or secondary ischemia from reduced perfusion and vasoconstriction injures brain tissue 19. speech. swallowing difficulties. potential seizures. Manifestations o o o o Similar to ischemic stroke Severe headache Early and sudden changes in LOC Vomiting 20. and signs and symptoms of increased ICP and meningeal irritation o After the stroke is complete Focus on patient function. and eye symptoms Monitor for potential complications including musculoskeletal problems. Nursing Process—Assessing the Patient Recovering From an Ischemic Stroke o Acute phase Ongoing/frequent monitoring of all systems including vital signs and neurologic assessment: LOC and motor. 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. cerebral angiography. Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke o o o Impaired physical mobility Acute pain Self-care deficits . self-care ability. hypertension. and teaching needs to facilitate rehabilitation 23. respiratory problems. Medical Management o o o o o o Prevention: control of hypertension Diagnosis: CT scan. increased ICP. Intracranial Aneurysms 22.
) o 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 .) o o o o o Disturbed thought processes Impaired verbal communication Risk for impaired skin integrity Interrupted family processes Sexual dysfunction 25. Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke (cont. Nursing Process—Planning Patient Recovery After an Ischemic Stroke o Major 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 27. Collaborative Problems/Potential Complications o o o Decreased cerebral blood flow Inadequate oxygen delivery to brain Pneumonia 26.o o o Disturbed sensory perception Impaired swallowing Urinary incontinence 24. Nursing Process—Planning Patient Recovery After an Ischemic Stroke (cont.
Interventions o 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 .28. Improving Mobility and Preventing Joint Deformities o o o o o o o o 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 30. Interventions o o o o Focus on the whole person Provide interventions to prevent complications and to promote rehabilitation Provide support and encouragement Listen to the patient 29. Improving Mobility and Preventing Joint Deformities o o o o o o 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 Implement ambulation training 33. Positioning to Prevent Shoulder Abduction 31. Prone Positioning to Help Prevent Hip Flexion 32.
Collaborative Problems/Potential Complications o o o Vasospasm Seizures Hydrocephalus . Interventions (cont. fluid. Nursing Process—Diagnosis of the Patient With a Hemorrhagic Stroke/ Cerebral Aneurysm o o o Ineffective tissue perfusion (cerebral) Disturbed sensory perception Anxiety 37.) o o schedule Nutrition Consult with speech therapist or nutritionist Have patient sit upright to eat. and toileting Provide bowel and bladder retraining 35. preferably OOB Use chin tuck or swallowing method Feed thickened liquids or pureed diet Bowel and bladder control Assess and schedule voiding Implement measures to prevent constipation: fiber. Nursing Process—Assessment of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm o o o o o o o 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 36.o o o 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 34.
Aneurysm Precautions o o o o 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. acute flexion. no reading. Nursing Process—Planning Care of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm o Goals may include: Improved cerebral tissue perfusion Relief of sensory and perceptual deprivation Relief of anxiety Absence of complications 39.) o o and no radio Nurse provides all personal care and hygiene Provide nonstimulating. and rotation of the neck or head Exhale through mouth when voiding or defecating to decrease strain 40. Aneurysm Precautions (cont. o o Prevent constipation Restrict visitors 41. no TV.o o Rebleeding Hyponatremia 38. nonstressful environment: dim lighting. Interventions o o o o o o o 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 42. Home Care and Teaching for the Patient Recovering From a Stroke . implement Valsalva maneuver.
health promotion. and tube feeding administration Elimination : bowel and bladder programs and catheter use Exercise and activities : recreation and diversion Socialization. swallowing techniques. and implementation of follow- o o o o Prevention of and signs and symptoms of complications Medication teaching Safety measures Adaptive strategies and use of assistive devices for ADLs 43.) o o o o o Nutrition: diet. support groups. Home Care and Teaching for the Patient Recovering From a Stroke (cont.o up care Prevention of subsequent strokes. and community resources See Chart 62-6 .
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