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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 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


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
 Disruptionof 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 embolism
 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

“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 monitoring
Side 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.)
Brainmetabolism is disrupted by
exposure to blood

ICPincreases 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 sensory perception

 Impaired swallowing

 Urinary incontinence
Nursing Process—Diagnosis of
the Patient Recovering From an
Ischemic Stroke (cont.)
Disturbed thought processes

Impaired verbal communication

Risk for impaired skin integrity

Interrupted family processes

Sexual dysfunction
Collaborative Problems/Potential
Complications
Decreased cerebral blood flow

Inadequate oxygen delivery to brain

Pneumonia
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 support and encouragement

Listen 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 with speech therapist or nutritionist
 Have 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 tissue perfusion
(cerebral)

Disturbed sensory perception

Anxiety
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.)
 Nurseprovides all personal care and
hygiene

 Providenonstimulating, 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 follow-
up 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