CRITICAL CARE NURSING

Unit IV - Care of the Patient with Cerebrovascular Accident

Subarachnoid Hemorrhage (S A H)
STROKE  Most commonly a rupture of an aneurysm; releases blood
directly into the subarachnoid space
Introduction  Blood spreads rapidly within the C S F, immediately
Cerebral Vascular Accident increasing I C P.
 Classic symptom is a sudden, severe headache.
Stroke  If bleeding continues, deep coma or death may result.
 Also referred to as
o Cerebral vascular accident (C V A) Ischemic Stroke
o Brain attack Thrombotic Stroke
 Decrease in blood flow and oxygen to brain cells with the
subsequent loss of neurological functioning  Pathologic process promotes thrombus formation in a
cerebral artery.
 Causes infarction and stroke due to decreased blood flow
Causes of stroke are:  Atherosclerosis is the most common cause of occlusion.
 Ischemic Embolic Stroke
o Disruption of blood flow to part of the brain due to a  Caused by particles that arise from another part of the body
thrombus or embolus  Result in blockage of arterial blood flow to a particular area
o Account for 80% of strokes of the brain
 Hemorrhagic  Onset of symptoms is abrupt and maximal
o Loss of blood flow due to rupture of cerebral vessels
o Account for 20% of strokes Systemic Hypoperfusion
 Extent of damage to the brain cells varies according to:  General circulatory problem that can occur in the brain and
o Length of time blood flow is disrupted possibly other organs
o Area of the brain affected  Decreased perfusion can be due to:
o Size of the area involved o Cardiac arrest
 Fifth leading cause of death o Arrhythmia
 Complications resulting in morbidity and mortality are very o Pulmonary embolism
common. o Pericardial effusion
o Often include recurrent stroke o Bleeding

Risk Factors Manifestations

 Classic signs and symptoms include:
High blood pressure o Sudden confusion
 Most important controllable risk factor o Sudden difficulty understanding or speaking
Age o Sudden loss of vision out of one eye
o Sudden severe headache
 Strongest uncontrollable risk factors
o Sudden weakness of the face, arm, or leg, especially
Atrial fibrillation (A F) affecting one side of the body
 Most common dysrhythmia associated with ischemic stroke  Usually specific to the area of the brain that has been
 Increased total cholesterol and decreased high-density affected
lipoprotein can increase the risk of an ischemic stroke. o Middle cerebral artery (M C A) occlusions
o Anterior cerebral artery occlusions
Other modifiable risk factors for stroke o Posterior cerebral artery occlusions
include: o Vertebrobasilar artery occlusion
 High-fat diet
 Excessive alcohol intake Patient History and Assessment
 Drug abuse  Time is of the essence
o Strokes caused by drug abuse are often seen in a  Focused history and neurological exam with diagnostic
younger population. tests
 Single most important point is the time the patient was last
Pathophysiology seen well.
 National Institutes of Health (N I H) Stroke Scale should be
 Pathophysiologic changes begin seconds after a reduction performed by a certified healthcare provider as soon as a
in blood flow and oxygen supply. stroke is suspected.
 When brain cells are damaged, function of the body parts o Examines visual, motor, sensory, cerebellar, inattention,
they control is impaired or lost. language, and level of consciousness (L O C)
o Paralysis functioning
o Speech and sensory problems
o Memory and reasoning deficits
o Coma Diagnostic Criteria
o Possibly death  Non-contrast brain CT or brain MRI
Hemorrhagic Stroke  Serum glucose
 Intracerebral Hemorrhage (ICH)  Prothrombin time
 Usually derived from bleeding of small arteries or arterioles  Electrocardiogram (E C G)
directly into the brain forming a localized hematoma  Complete blood count (C B C)
 Progressive development of neurological symptoms  Cardiac enzymes and troponin
 Most common causes are:  Electrolytes, urea nitrogen, creatinine
o Hypertension  Partial thromboplastin time (P T T)
o Illicit drug use  Oxygen saturation
o Vascular malformations
o Bleeding diathesis
 Neuroimaging
 Imaging studies are necessary.
o Rule out hemorrhage as a cause of the presenting
symptoms
o Differentiate ischemic stroke from hemorrhage
o Determine vascular distribution of the ischemic lesion.
 Computerized Tomography
 Magnetic Resonance Imagery
 Magnetic Resonance Angiography
Computed Tomography Angiography
 Considered “gold standard” for detecting:
o Cerebral aneurysms
o Arteriovenous malformations (A V Ms)
o Arteriovenous fistulae (A V Fs)
 Carotid Ultrasound
 Transcranial Doppler
 Transthoracic and Transesophageal Echocardiography
Emergent Care
 Immediate goals of collaborative management for the
patient with a stroke include:
o Minimizing brain injury
o Preventing medical complications
 Treatment is ideally initiated in the pre-hospital area with
rapid recognition of stroke symptoms and immediate
transport to a stroke center.
 In the ED clinical identification, testing, and treatment is
immediately initiated.
Nursing Actions
 Airway and Breathing Management
 Cardiac Monitoring
o Stroke can cause arrhythmias when the sympathetic
response results in demand-induced myocardial
ischemia.
 Monitoring for Hyperthermia
o Fever may promote further brain injury in patients with
an acute stroke.
 Blood Pressure Management
o Will vary depending on the type of stroke.
Ischemic Stroke
 Elevated B P may be necessary to maintain brain
perfusion.
 Rapidly lowering B P could cause neurological
deterioration.
Hemorrhagic Stroke
o There is not sufficient evidence to support a specific
therapy for hypertension in the patient with a S A H.
 Determining Diagnosis
o In most cases, a patient history, physical examination
with N I H stroke scale, and noncontrast C T scan are
adequate.
o Differential diagnosis is necessary to rule out conditions
that mimic stroke.
Collaborative Care after Diagnosis Is
Determined
 Goal of acute stroke management is rapid and efficient
care.
 Determine if the patient is suffering an ischemic stroke and
is a candidate for thrombolytic therapy
 If the patient is eligible, therapy should be administered
within 1 hour from the patient’s presentation to the E D.
 NINDS (National Institute of Neurological Disorders and
Stroke) has recommended the following time benchmarks
for the potential thrombolysis candidate:
o Door to doctor in 10 minutes
o Access to neurologic expertise in 15 minutes
o Door to C T scan completion in 25 minutes
o Door to C T scan interpretation in 45 minutes.
o Door to treatment in 60 minutes.
o Admission to monitored bed in 3 hours.
Ischemic Stroke
 Revascularization is the most critical aspect of treatment.
 May be possible to utilize a thrombolytic to reestablish blood
flow through the involved cerebral artery.
 Thrombolysis
 rt-PA (recombinant tissue-type plasminogen activator)
enzyme used to restore blood flow.
 Dissolves the clot in the cerebral artery, restores blood flow,
and improves neurological functioning
Invasive and Surgical Management
 Thrombolysis
o Alteplase may be administered directly to the site of
obstruction.
 Embolectomy
o Restores blood flow in stroke patients, by removing the
clot
 Carotid endarterectomy
 Angioplasty
 Carotid stenting
 Multi-modal reperfusion therapy (MMRT)
Hemorrhagic Stroke
 In the U.S., about 20% of all strokes are hemorrhagic.
 Two primary types of hemorrhagic strokes:
o Intracerebral Hemorrhages (I C H)
o Subarachnoid Hemorrhages (S A H)
Intracerebral Hemorrhage (I C H)
 Of the hemorrhagic strokes, up to 41% may be I C H.
 Cared for in I C U
o Patients experience frequent increases in I C P.
 Immediate complications include:
o Cerebral hypoxia
o Decreased cerebral blood flow
o Increased risk of further bleeding
 Hydrocephalusis a common complication. o Hemodilution
 Therapy is limited.  Only way to increase blood flow to cerebral tissue during
vasospasm, is to increase BP.

Subarachnoid Hemorrhage (S A H)
Hydrocephalus
 Most common cause is rupture of an aneurysm or an A V
M.  Develops when blood in the subarachnoid space obliterates
 Major contributing factors the arachnoidal villi
o Prolonged hemodynamic stress  Prevents absorption of C S F, or blood within the ventricles
o Local arterial degeneration at vessels bifurcations blocks the foramen of Monro, preventing drainage of C S F
 Presence of an aneurysm is not known until the aneurysm
ruptures.
Nursing Care for the Stroke Patient
The Hunt and Hess scale  Ongoing neurological assessments and seizure
Grade 0 precautions are necessary components.
 Unruptured aneurysm  Carefully assess neurological status because cerebral
edema usually peaks within 3 to 5 days post-stroke.
Grade 1  Patients need to be thoroughly monitored for a decline in
 Asymptomatic or minimal headache and slight nuchal neurological status during the first week post-stroke.
rigidity o Identify and treat hemorrhagic conversion and diminish
Grade 1A its neurological effects.
 No acute meningeal or brain reaction but with fixed Screening for Dysphagia
neurological deficit  Dysphagia
Grade 2  Difficulty swallowing
 Moderate-to-severe headache, nuchal rigidity, no  Very common post stroke
neurological deficit other than cranial nerve palsy  Major risk factor for developing aspiration pneumonia
Grade 3  Can occur when there is damage to the brain
 Increased risk of aspirating saliva or food, which may result
 Drowsiness, confusion, or mild focal deficit
in pneumonia
Grade 4
Prior to swallow screening, the nurse should:
 Stupor, moderate-to-severe hemiparesis, possible early
decerebrate rigidity, and vegetative disturbances  Evaluate lung sounds.
 Obtain the patient’s most recent vital signs, including
Grade 5 temperature.
 Deep coma, decerebrate rigidity, and moribund appearance  Evaluate the ability of the patient to follow directions.
neurological deficit  If the patient demonstrates any of the following problems,
at any time during the assessment, cease the evaluation,
keep the patient N P O, and ask the M D for a speech
Collaborative Care therapy order for a swallowing evaluation:
 In the past, most patients were treated with craniotomy and o Coughing before, during, or after swallowing
surgical clipping of the aneurysm. o Gurgly/wet vocal quality or any voice changes
 Less invasive procedures include endovascular o Need to swallow two or more times to clear
embolization. o Excessive length of time to move food to the back of the
o Detachable coils of platinum wire are passed through throat to swallow
the catheter and released into the aneurysm. o Pocketing of food
o Most common coils used are platinum Guglielmi o Excessive secretions
detachable coils.
Screening for Dysphagia
Two common complications following
Swallowing evaluations
treatment  Videofluoroscopy
 Vasospasm o Allows for accurate visualization of the swallowing
 Hydrocephalus sequence
 Barium swallow
Vasospasm o May identify the presence of an aspiration and subtler
 Most feared complication anatomic abnormalities
 Accounts for about 20% of patients with severe disability or  Test analysis identifies abnormal movement of fluid/food
death. o Pooling
o Aspiration
 Defined as an angiographic narrowing of cerebral blood
vessel(s); can lead to delayed ischemia Enhancing Comfort
 Most likely to occur in patients with a Fisher grade 3, and a  Areas that may need to be addressed are pain,
high grade on the Hunt and Hess scale incontinence, and constipation.
Providing Nutrition
Fisher grade  Undernourished stroke survivors have a higher mortality
 Describes the amount of blood seen on a noncontrast head rate, more likely to develop complications
CT Monitoring Lab Values for Alterations in Blood
 Useful for identifying the likelihood the patient will develop
vasospasm Glucose
1. No blood detected.  All patients should be monitored for hyperglycemia and
2. Diffuse or vertical layers less than 1 mm thick. hypoglycemia.
3. Localized clot or vertical layer greater than or equal to 1  Hyperglycemia may intensify brain injury by increasing
mm. tissue acidosis and increasing blood-brain barrier
4. Intracerebral or intraventricular clot with diffuse or no S permeability.
A H.
Facilitating Communication
 Patient may experience expressive or receptive aphasia, be
Aggressively Managed Vasospasm unable to retrieve words.
 Triple-H therapy (H H H)  Music therapy may be recommended.
o Hypertension
o Hypervolemia Fostering Patient-Centered Care
 Provide resources.  Common acute and subacute complications include:
 Arrange for appropriate referrals. o Pulmonary embolism
o Urinary tract infection
Maintaining Safety o Aspiration pneumonia
 Falls are one of most common incidents after an acute o Decubitus ulcers
stroke.
Monitor for Urinary Tract Complications
Prevention and Management of  U T I is a common complication during the first 3 months
Complications post-stroke.
 Approximately half of the deaths after stroke are due to Monitor for Altered Tissue Perfusion
complications.  Deep vein thrombosis is a common complication in acute
 Common acute and subacute complications include: stroke and a precursor of a pulmonary embolus (P E)
o Cerebral edema
o Hemorrhagic conversion of an ischemic infarct Recovery
o Progression of penumbra to infarction  Recovery time and plans of care are specific to each
o Seizures individual.
o Deep vein thrombosis  Early aggressive rehabilitation therapies maximize
Prevention and Management of functional recovery.

Complications