Ns. Alfian, M.

Kep
 Describe the incidence and social impact of cerebrovascular
disorders.
 Identify the risk factors for cerebrovascular disorders and related
measures for prevention.
 Compare the various types of cerebrovascular disorders: their
causes, clinical manifestations, and medical management.
 Relate the principles of nursing management to the care of a
patient in the acute stage of an ischemic stroke.
 Use the nursing process as a framework for care of a patient
recovering from an ischemic stroke.
 Use the nursing process as a framework for care of a patient with a
cerebral aneurysm.
 Identify essential elements for family teaching and preparation for
home care of the stroke patient.
 Your patient had symptoms of an ischemic
stroke approximately 2 hours ago and is
undergoing a confirmatory CT scan in 30
minutes. You know t-PA must be
administered within 3 hours of the symptoms
 What actions would you take?
 What is your rationale for these actions?
 Your patient has expressive aphasia following
an ischemic stroke.
 How would you explain this phenomenon to
the patient and family?
 Describe appropriate techniques for
communicating with a patient with this type
of aphasia.
 Your patient is admitted with hemorrhagic
stroke and exhibits homonymous
hemianopsia
 How would you explain this phenomenon to the
patient and family?
 How would you modify your care for this patient?
 Describe ways that the patient and family may
work together to compensate for this problem
 A 50-year-old patient is expected to be
discharged to home today following a 5-day
stay for an ischemic stroke. He tells you that
he lives alone in a small apartment and knows
none of his neighbors. He has some residual
right-sided weakness.
 What teaching would be indicated to prevent
another stroke?
 What resources may be needed to enable him to
go home as scheduled?
 “Cerebrovascular disorders” is an umbrella
term that refers to any functional
abnormality of the central nervous system
(CNS) that occurs when the normal blood
supply to the brain is disrupted.
 Stroke is the primary cerebrovascular
disorder in the United States and in the
world.
 Strokes can be divided into two major
categories:
 ischemic (85%), in which vascular occlusion and
significant hypoperfusion occur
 hemorrhagic (15%), in which there is
extravasation of blood into the brain

(American Heart Association, 2000).

CLASSIFICATION CAUSES

Ischemic Large artery

thrombosis

Hemorrhagic Small penetrating

artery thrombosis
 Hypertension (controlling hypertension, the major risk factor, is the key to
preventing stroke)
 Cardiovascular disease (cerebral emboli may originate in the heart)
• Atrial fibrillation
• Coronary artery disease
• Heart failure
• Left ventricular hypertrophy
• Myocardial infarction (especially anterior)
• Rheumatic heart disease
 High cholesterol levels
 Obesity
 Elevated hematocrit (increases the risk of cerebral infarction)
 Diabetes mellitus (associated with accelerated atherogenesis)
 Oral contraceptive use (increases risk, especially with coexisting
 hypertension, smoking, and high estrogen levels)
 Smoking
 Drug abuse (especially cocaine)
 Excessive alcohol consumption
Hock, 1999; Summers et al., 2000.
 An ischemic stroke, cerebrovascular accident
(CVA), or what is now being termed “brain
attack” is a sudden loss of function resulting
from disruption of the blood supply to a part
of the brain.
 Strokes using the time course are commonly
classified in the following manner:
 (1) transient ischemic attack (TIA);
 (2) reversible ischemic neurologic deficit;
 (3) stroke in evolution; and
 (4) completed stroke
(Hock, 1999)
 The ischemic cascade begins when cerebral blood
flow falls to less than 25 mL/100 g/min.
 At this point, neurons can no longer maintain aerobic
respiration.
 The mitochondria must then switch to anaerobic
respiration, which generates large amounts of lactic
acid, causing a change in the pH level.
 This switch to the less efficient anaerobic respiration
also renders the neuron incapable of producing
sufficient quantities of adenosine triphosphate (ATP)
to fuel the depolarization processes.
 Thus, the membrane pumps that maintain electrolyte
balances begin to fail and the cells cease to function.
 Early in the cascade, an area of low cerebral blood flow, referred to
as the penumbra region, exists around the area of infarction.
 The penumbra region is ischemic brain tissue that can be
salvaged with timely intervention.
 The ischemic cascade threatens cells in the penumbra because
membrane depolarization of the cell wall leads to an increase in
intracellular calcium and the release of glutamate (Hock, 1999).
 The penumbra area can be revitalized by administration of tissue
plasminogen activator (t-PA), and the influx of calcium can be
limited with the use of calcium channel blockers.
 The influx of calcium and the release of glutamate, if continued,
activate a number of damaging pathways that result in the
destruction of the cell membrane, the release of more calcium and
glutamate, vasoconstriction, and the generation of free radicals.
 These processes enlarge the area of infarction into the penumbra,
extending the stroke.
 Each step in the ischemic cascade represents an
opportunity for intervention to limit the extent of
secondary brain damage caused by a stroke.
 Medications that protect the brain from secondary
injury are called neuroprotectants (Reed, 2000).
 A number of clinical trials are focusing on calcium
channel antagonists that block the calcium influx,
glutamate antagonists, antioxidants, and other
neuroprotectant strategies that will help prevent
secondary complications

(NINDS, 1999; Reed, 2000).

 An ischemic stroke can cause a wide variety of neurologic
deficits, depending on
 the location of the lesion (which vessels are obstructed),
 the size of the area of inadequate perfusion,
 the amount of collateral (secondary or accessory) blood flow

 The patient may present with any of the following signs or

symptoms:
 Numbness or weakness of the face, arm, or leg, especially on one
side of the body
 Confusion or change in mental status
 Trouble speaking or understanding speech
 Visual disturbances
 Difficulty walking, dizziness, or loss of balance or coordination
 Sudden severe headache
 A stroke is a lesion of the upper motor neurons and results in loss
of voluntary control over motor movements. Because the upper
motor neurons decussate (cross), a disturbance of voluntary motor
control on one side of the body may reflect damage to the upper
motor neurons on the opposite side of the brain.
 The most common motor dysfunction
 Hemiplegia (paralysis of one side of the body) due to a lesion of the
opposite side of the brain.
 Hemiparesis, or weakness of one side of the body, is another sign.
 In the early stage of stroke, the initial clinical features may be
flaccid paralysis and loss of or decrease in the deep tendon
reflexes.
 When these deep reflexes reappear (usually by 48 hours),
increased tone is observed along with spasticity (abnormal
increase in muscle tone) of the extremities on the affected side
 Other brain functions affected by stroke are language
and communication. In fact, stroke is the most
common cause of aphasia.
 The following are dysfunctions of language and
communication:
 Dysarthria (difficulty in speaking), caused by paralysis of
the muscles responsible for producing speech
 Dysphasia or aphasia (defective speech or loss of speech),
which can be expressive aphasia, receptive aphasia, or
global (mixed) aphasia
 Apraxia (inability to perform a previously learned action),
as may be seen when a patient picks up a fork and
attempts to comb his hair with it
 Perception is the ability to interpret sensation. Stroke can
result in visual-perceptual dysfunctions, disturbances in
visual-spatial relations, and sensory loss.
 Visual-perceptual dysfunctions are due to disturbances of
the primary sensory pathways between the eye and visual
cortex. Homonymous hemianopsia (loss of half of the
visual field) may occur from stroke and may be temporary
or permanent. The affected side of vision corresponds to
the paralyzed side of the body.
 Disturbances in visual-spatial relations (perceiving the
relation of two or more objects in spatial areas) are
frequently seen in patients with right hemispheric
damage.
 The sensory losses from stroke may take the
form of slight impairment of touch or may be
more severe, with loss of proprioception
(ability to perceive the position and motion of
body parts) as well as difficulty in interpreting
visual, tactile, and auditory stimuli.
 THROMBOLYTIC THERAPY
 Enhancing Prompt Diagnosis
 Dosage and Administration
 Side Effects
 Age 18 years or older
 Clinical diagnosis of stroke with NIH stroke scale
score under 22 Time of onset of stroke known
and is 3 hours or less
 BP systolic ≤ 185; diastolic ≤ 110
 Not a minor stroke or rapidly resolving stroke
 No seizure at onset of stroke
 Not taking warfarin (Coumadin)
 Prothrombin time ≤ 15 seconds or INR ≤ 1.7
 Not receiving heparin during the past 48 hours
with elevated partial thromboplastin time
 Platelet count ≥ 100,000
 Blood glucose level between 50 and 400 mg/dL
 No acute myocardial infarction
 No prior intracranial hemorrhage, neoplasm,
arteriovenous malformation, or aneurysm
 No major surgical procedures within 14 days
 No stroke or serious head injury within 3 months
 No gastrointestinal or urinary bleeding within
last 21 days Not lactating or postpartum within
last 30 days
 The acute phase of an ischemic stroke may last 1 to 3
days, but ongoing monitoring of all body systems is
essential as long as the patient requires care.
 The patient who has had a stroke is at risk for multiple
complications, including deconditioning and other
musculoskeletal problems, swallowing difficulties,
bowel and bladder dysfunction, inability to perform
self-care, and skin break- down.
 After the stroke is complete, management focuses on
the prompt initiation of rehabilitation for any deficits.
 During the acute phase, a neurologic flow sheet
is maintained to provide data about the
following important measures of the patient’s
clinical status:
 Change in the level of consciousness or
responsiveness as evidenced by movement,
resistance to changes of position, and response to
stimulation; orientation to time, place, and person
 Presence or absence of voluntary or involuntary
movements of the extremities; muscle tone; body
posture; and position of the head
 Stiffness or flaccidity of the neck
 Eye opening, comparative size of pupils and pupillary
reactions to light, and ocular position
 Color of the face and extremities; temperature and
moisture of the skin
 Quality and rates of pulse and respiration; arterial
blood gas values as indicated, body temperature, and
arterial pressure
 Ability to speak
 Volume of fluids ingested or administered; volume of
urine excreted each 24 hours
 Presence of bleeding
 Maintenance of blood pressure within the desired
parameters
 Based on the assessment data, the major nursing diagnoses for a patient with a
stroke may include:
 Impaired physical mobility related to hemiparesis, loss of balance and coordination,
spasticity, and brain injury
 Acute pain (painful shoulder) related to hemiplegia and disuse
 Self-care deficits (hygiene, toileting, grooming, and feeding) related to stroke sequelae
 Disturbed sensory perception related to altered sensory reception, transmission, and/or
integration
 Impaired swallowing
 Incontinence related to flaccid bladder, detrusor instability,
 confusion, or difficulty in communicating
 Disturbed thought processes related to brain damage, con-
 fusion, or inability to follow instructions
 Impaired verbal communication related to brain damage
 Risk for impaired skin integrity related to hemiparesis/
 hemiplegia, or decreased mobility
 Interrupted family processes related to catastrophic illness
 and caregiving burdens
 Sexual dysfunction related to neurologic deficits or fear of failure
Potential complications include:
Decreased cerebral blood flow due to
increased ICP
Inadequate oxygen delivery to the brain
Pneumonia
 Nursing care has a significant impact on the patient’s
recovery.
 Often many body systems are impaired as a result of
the stroke, and conscientious care and timely
interventions can prevent debilitating complications.
 During and after the acute phase, nursing
interventions focus on the whole person.
 In addition to providing physical care, nurses can
encourage and foster recovery by listening to patients
and asking questions to elicit the meaning of the
stroke experience
(Eaves, 2000; Pilkington, 1999).
 IMPROVING MOBILITY AND PREVENTING
JOINT DEFORMITIES
 Preventing Shoulder Adduction
 Positioning the Hand and Fingers
 Changing Positions
 Establishing an Exercise Program
 Preparing for Ambulation
 PREVENTING SHOULDER PAIN
 ENHANCING SELF-CARE
 MANAGING SENSORY-PERCEPTUAL
DIFFICULTIES
 MANAGING DYSPHAGIA
 Managing Tube Feedings
 ATTAINING BOWEL AND BLADDER
CONTROL
 IMPROVING THOUGHT PROCESSES
 IMPROVING COMMUNICATION
 MAINTAINING SKIN INTEGRITY
 IMPROVING FAMILY COPING
 HELPING THE PATIENT COPE
WITH SEXUAL DYSFUNCTION
 PROMOTING HOME AND COMMUNITY-
BASED CARE
 Teaching Patients Self-Care
 Continuing Care
 A hemiplegic patient has unilateral paralysis (paralysis on one
side).
 When control of the voluntary muscles is lost, the strong flexor
muscles exert control over the extensors.
 The arm tends to adduct (adductor muscles are stronger than
abductors) and to rotate internally.
 The elbow and the wrist tend to flex, the affected leg tends to
rotate externally at the hip joint and flex at the knee, and the foot
at the ankle joint supinates and tends toward plantar flexion.
 Correct positioning is important to prevent contractures;
measures are used to relieve pressure, assist in maintaining good
body alignment, and prevent compressive neuropathies,
especially of the ulnar and peroneal nerves.
 Because flexor muscles are stronger than extensor muscles, a
posterior splint applied at night to the affected extremity may
prevent flexion and maintain correct positioning during sleep.
 Hemorrhagic strokes account for 15% of
cerebrovascular disorders and are primarily
caused by an intracranial or subarachnoid
hemorrhage.
 Each year in the United States there are
approximately 50,000 intracerebral
hemorrhages and 25,000 cases of subarachnoid
hemorrhage from ruptured intracranial
aneurysm
(Pfohman & Criddle, 2001; Qureshi et al., 2001).
 Hemorrhagic strokes are caused by bleeding into the
brain tis- sue, the ventricles, or the subarachnoid
space.
 Primary intracerebral hemorrhage from a
spontaneous rupture of small vessels accounts for
approximately 80% of hemorrhagic strokes and is
primarily caused by uncontrolled hypertension
(Qureshi et al., 2001).
 Secondary intracerebral hemorrhage is associated
with arteriovenous malformations (AVMs),
intracranial aneurysms, or certain medications (eg,
anticoagulants and amphetamines)
(Qureshi et al., 2001).
 The pathophysiology of hemorrhagic stroke depends on
the cause and type of cerebrovascular disorder.
 Symptoms are produced when an aneurysm or AVM
enlarges and presses on nearby cranial nerves or brain
tissue or, more dramatically, when an aneurysm or AVM
ruptures, causing subarachnoid hemorrhage (hemorrhage
into the cranial subarachnoid space).
 Normal brain metabolism is disrupted by the brain being
exposed to blood; by an increase in ICP resulting from the
sudden entry of blood into the subarachnoid space, which
compresses and injures brain tissue; or by secondary
ischemia of the brain resulting from the reduced perfusion
pressure and vasospasm that frequently accompany
subarachnoid hemorrhage.
 Hemorrhagic Stroke
 INTRACEREBRAL HEMORRHAGE
 INTRACRANIAL (CEREBRAL) ANEURYSM
 ARTERIOVENOUS MALFORMATIONS
 SUBARACHNOID HEMORRHAGE
 The patient with a hemorrhagic stroke can
present with a wide variety of neurologic
deficits, similar to the patient with ischemic
stroke.
 A comprehensive assessment will reveal the
extent of the neurologic deficits.
 Many of the same motor, sensory, cranial
nerve, cognitive, and other functions that are
disrupted following ischemic stroke are
altered following a hemorrhagic stroke.
 In addition to the neurologic deficits that are similar
to ischemic stroke, the patient with an intracranial
aneurysm or AVM can have some unique clinical
manifestations.
 Rupture of an aneurysm or AVM usually produces a
sudden, unusually severe headache and often loss of
consciousness for a variable period.
 There may be pain and rigidity of the back of the neck
(nuchal rigidity) and spine due to meningeal irritation.
Visual disturbances (visual loss, diplopia, ptosis) occur
when the aneurysm is adjacent to the oculomotor
nerve.
 Tinnitus, dizziness, and hemiparesis may also occur.
 Cerebral Hypoxia and Decreased Blood Flow
 Vasospasm
 Increased ICP
 Systemic Hypertension
 Many patients with a primary intracerebral
hemorrhage are not treated surgically.
However, surgical evacuation is strongly
recommended for the patient with a
cerebellar hemorrhage if the diameter
exceeds 3 cm and the Glasgow Coma Scale
score is below 14
Assessment
A complete neurologic assessment is performed
initially and should include evaluation for the following:
Altered level of consciousness
Sluggish pupillary reaction
Motor and sensory dysfunction
Cranial nerve deficits (extraocular eye movements,
facial
droop, presence of ptosis)
Speech difficulties and visual disturbance
Headache and nuchal rigidity or other neurologic
deficits
Based on the assessment data, the patient’s
major nursing diagnoses may include the
following:
Ineffective cerebral tissue perfusion related to
bleeding
Disturbed sensory perception related to
medically imposed restrictions (aneurysm
precautions)
Anxiety related to illness and/or medically
imposed restrictions (aneurysm precautions)
Based on the assessment data, potential
complications that may develop include the
following:
• Vasospasm
• Seizures
• Hydrocephalus
• Rebleeding
 OPTIMIZING CEREBRAL TISSUE PERFUSION
 Implementing Aneurysm Precautions
 MONITORING AND MANAGING POTENTIAL
COMPLICATIONS
 Vasospasm
 Seizures
 Hydrocephalus
 Rebleeding