Chapter 62 Management of Patients with Cerebrovascular Disorders - PowerPoint PPT Presentation

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Chapter 62 Management of Patients with Cerebrovascular Disorders

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Home Care and Teaching for the Patient Recovering from a Stroke Prevention of subsequent strokes, health promotion, and follow-up care Prevention of and signs and ... – PowerPoint PPT presentation

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Title: Chapter 62 Management of Patients with Cerebrovascular Disorders


1
Chapter 62 Management of Patients with
Cerebrovascular Disorders
2
Cerebrovascular Disorders
  • 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.

3
Prevention
  • Nonmodifiable risk factors
  • Age (over 55), male gender, African-American race
  • Modifiable risk factors
  • Hypertension is the primary risk factor
  • Cardiovascular disease
  • Elevated cholesterol or elevated hematocrit
  • Obesity
  • Diabetes
  • Oral contraceptive use
  • Smoking and drug and alcohol abuse

4
Stroke
  • Brain attack
  • Sudden loss of function resulting from a
    disruption of the blood supply to a part of the
    brain
  • Types of stroke
  • Ischemic (8085)
  • Hemorrhagic (1520)

5
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 artery thrombosis
  • Cardiogenic embolism
  • Other

6
Pathophysiology
7
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
  • loss of half of the visual field, Loss of
    peripheral vision, diplopia.
  • Cognitive Deficits (Short- and long-term memory
    loss, Decreased attention span, Impaired ability
    to concentrate
  • Emotional Deficits (Depression, Withdrawal, Fear,
    hostility, and anger, Feelings of isolation)

8
Terms
  • Hemiplegia
  • Hemiparesis
  • Dysarthria (Difficulty in forming words)
  • Aphasia expressive aphasia, receptive aphasia
  • Hemianopsia blindness of half of the field of
    vision in one or both eyes
  • Apraxia inability to perform previously learned
    purposeful motor acts on a voluntary basis

9
Comparison of Left and Right Hemispheric Strokes
Left Hemispheric Stroke Right Hemispheric Stroke
Paralysis or weakness on right side of body Paralysis or weakness on left side of body
Right visual field deficit Left visual field deficit
Aphasia (expressive, receptive, or global) Spatial-perceptual deficitsIncreased distractibility
Altered intellectual ability Impulsive behavior and poor judgment
Slow, cautious behavior Lack of awareness of deficits
10
Transient Ischemic Attack (TIA)
  • Temporary neurologic deficit resulting from a
    temporary impairment of blood flow
  • Warning of an impending stroke
  • Classic symptom is fleeting blindness in one eye.
  • Diagnostic workup is required to treat and
    prevent irreversible deficits

11
Carotid Endarterectomy
12
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,
  • Antihypertensive medications

13
Medical ManagementAcute Phase of Stroke
  • Prompt diagnosis and treatment
  • Assessment of stroke
  • Thrombolytic therapy
  • IV dosage and administration
  • Patient monitoring
  • Side effectspotential bleeding
  • Elevate HOB unless contraindicated
  • Maintain airway and ventilation
  • Continuous hemodynamic monitoring and neurologic
    assessment

14
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
    angiopathy, arterial venous malformations,
    intracranial aneurysms, or medications such as
    anticoagulants.
  • 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 causes injury to
    brain tissue.

15
Manifestations
  • Similar to ischemic stroke
  • Severe headache
  • Early and sudden changes in LOC
  • Vomiting

16
Medical Management
  • Prevention control of hypertension
  • Diagnosis CT scan, cerebral angiography, 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

17
Nursing Process The Patient Recovering from an
Ischemic StrokeAssessment
  • Acute phase
  • Ongoing/frequent monitoring of all systems
    including vital signs and neurologic
    assessmentLOC, motor symptoms, speech, 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,
    coping, and teaching needs to facilitate
    rehabilitation

18
Nursing Process The Patient Recovering from an
Ischemic StrokeDiagnoses
  • Impaired physical mobility
  • Acute pain
  • Self-care deficits
  • Disturbed sensory perception
  • Impaired swallowing
  • Urinary incontinence
  • Disturbed thought processes
  • Impaired verbal communication
  • Risk for impaired skin integrity
  • Interrupted family processes
  • Sexual dysfunction

19
Collaborative Problems/Potential Complications
  • Decreased cerebral blood flow
  • Inadequate oxygen delivery to brain
  • Pneumonia

20
Nursing Process The Patient Recovering from an
Ischemic StrokePlanning
  • Major goals may 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
  • Improved thought processes
  • Achieving a form of communication
  • Maintaining skin integrity
  • Restored family functioning
  • Improved sexual function
  • Absence of complications

21
Interventions
  • Focus on the whole person
  • Provide interventions to prevent complications
    and to promote rehabilitation
  • Provide support and encouragement
  • Listen to the patient

22
Improving Mobility and Preventing Joint
Deformities
  • Turn and position in correct alignment every 2
    hours
  • Use of splints
  • Passive or active ROM 45 times day
  • Positioning of hands and fingers
  • Prevention of flexion contractures
  • Prevention of shoulder abduction
  • Do not lift by flaccid shoulder
  • Measures to prevent and treat shoulder proclaims

23
Positioning to Prevent Shoulder Abduction
24
Prone Positioning to Help Prevent Hip Flexion
25
Improving Mobility and Preventing Joint
Deformities
  • Passive or active ROM 45 times day
  • Encourage patient to exercise unaffected side
  • Establish regular exercise routine
  • Quadriceps setting and gluteal exercises
  • Assist patient out of bed as soon as possible-
    assess and help patient achieve balance, move
    slowly
  • Ambulation training

26
Interventions
  • Enhancing self-care
  • Set realistic goals with the patient
  • Encourage personal hygiene
  • Assure that patient does not neglect the affected
    side
  • Use of assistive devices and modification of
    clothing
  • Support and encouragement
  • Strategies to enhance communication
  • Encourage patient to turn head, look to side with
    visual field loss

27
Interventions
  • Nutrition
  • Consult with speech therapy or nutritional
    services
  • Have patient sit upright, preferably OOB, to eat
  • Chin tuck or swallowing method
  • Use of thickened liquids or pureed (?????) diet
  • Bowel and bladder control
  • Assessment of voiding and scheduled voiding
  • Measures to prevent constipationfiber, fluid,
    toileting schedule
  • Bowel and bladder retraining

28
Nursing Process The Patient with a Hemorrhagic
StrokeAssessment
  • Complete and ongoing neurologic assessmentuse
    neurologic flow chart
  • Monitor respiratory status and oxygenation
  • Monitoring of ICP
  • Patients with intracerebral or subarachnoid
    hemorrhage should be monitored in the ICU
  • Monitor for potential complications
  • Monitor fluid balance and laboratory data
  • All changes must be reported immediately

29
Nursing Process The Patient with a Hemorrhagic
StrokeDiagnoses
  • Ineffective tissue perfusion (cerebral)
  • Disturbed sensory perception
  • Anxiety

30
Collaborative Problems/Potential Complications
  • Vasospasm
  • Seizures
  • Hydrocephalus
  • Rebleeding
  • Hyponatremia

31
Nursing Process The Patient with a Hemorrhagic
StrokePlanning
  • Goals may include
  • Improved cerebral tissue perfusion
  • Relief of sensory and perceptual deprivation
  • Relief of anxiety
  • The absence of complications

32
Aneurysm Precautions
  • Absolute bed rest
  • Elevate HOB 30 to promote venous drainage or
    flat to increase cerebral perfusion
  • Avoid all activity that may increase ICP or BP
    Valsalva maneuver, acute flexion or rotation of
    neck or head
  • Exhale through mouth when voiding or defecating
    to decrease strain
  • Nurse provides all personal care and hygiene
  • Nonstimulating, nonstressful environment dim
    lighting, no reading, no TV, no radio
  • Prevent constipation
  • Visitors are restricted

33
Interventions
  • Relieving sensory deprivation and anxiety
  • Keep sensory stimulation to a minimum for
    aneurysm precautions
  • Realty orientation
  • Patient and family teaching
  • Support and reassurance
  • Seizure precautions
  • Strategies to regain and promote self-care and
    rehabilitation

34
Home Care and Teaching for the Patient
Recovering from a Stroke
  • Prevention of subsequent strokes, health
    promotion, and follow-up care
  • Prevention of and signs and symptoms of
    complications
  • Medication teaching
  • Safety measures
  • Adaptive strategies and use of assistive devices
    for ADLs
  • Nutritiondiet, swallowing techniques, tube
    feeding administration
  • Eliminationbowel and bladder programs, catheter
    use
  • Exercise and activities, recreation and diversion
  • Socialization, support groups, and community
    resources
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