Cerebrovascular Diseases

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

race

risk factors

(over 55), male gender, African American

 Modifiable

risk factors: see Chart 62-1

 Hypertension:

the primary risk factor

 Cardiovascular  Elevated

disease

cholesterol or elevated hematocrit

 Obesity  Diabetes  Oral

contraceptive use

Stroke “Brain

attack”

Sudden

loss of function resulting from a disruption of the blood supply to a part of the brain

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

 Types  Large

artery thrombosis

 Small

penetrating artery thrombosis

 Cardiogenic  Cryptogenic  Other

embolism

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

“Warning

of an impending stroke”

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

Thrombolytic

therapy

Criteria

for tissue plasminogen activator (tPA): see Chart 62-2

IV

dosage and administration

Patient Side

monitoring

effects: potential bleeding

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

HOB unless contraindicated

Maintain

airway and ventilation

Provide

continuous hemodynamic monitoring and neurologic assessment

See

the guidelines in Appendix B

Hemorrhagic Stroke  Caused

by bleeding into brain tissue, the ventricles, or subarachnoid space

 May

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

Hemorrhagic Stroke (cont.) Brain

metabolism is disrupted by exposure to blood

ICP

increases due to blood in the subarachnoid space

Compression

or secondary ischemia from reduced perfusion and vasoconstriction injures brain tissue

Manifestations Similar

to ischemic stroke

Severe

headache

Early

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

 Monitor

for potential complications including musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of increased ICP and meningeal irritation



After the stroke is complete  Focus

on patient function; self-care ability,

Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke  Impaired physical mobility

 Acute

pain

 Self-care

deficits

 Disturbed  Impaired  Urinary

sensory perception

swallowing

incontinence

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

Disturbed Impaired Risk

thought processes

verbal communication

for impaired skin integrity

Interrupted Sexual

family processes

dysfunction

Collaborative Problems/Potential Complications Decreased

cerebral blood flow

Inadequate Pneumonia

oxygen delivery to brain

Nursing Process—Planning Patient Recovery After an Ischemic Stroke

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

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

Provide Listen

support and encouragement

to the patient

   

Improving Mobility and Preventing Joint Deformities

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



Positioning to Prevent Shoulder Abduction

Prone Positioning to Help Prevent Hip Flexion

Improving Mobility and Preventing Joint Deformities

 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 

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

 Assess

and schedule voiding

 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)

Disturbed Anxiety

tissue perfusion

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

 Provide

nonstimulating, nonstressful environment: dim lighting, no reading, no TV, and no radio

 Prevent

constipation

 Restrict

visitors

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

Home Care and Teaching for the Patient Recovering From a Stroke

 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 (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