Title: Chapter 62 Management of Patients with Cerebrovascular Disorders
1Chapter 62 Management of Patients with
Cerebrovascular Disorders
2Cerebrovascular 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.
3Prevention
- 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
4Stroke
- 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)
5Ischemic 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
6Pathophysiology
7Manifestations 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)
8Terms
- 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
9Comparison 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
10Transient 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
11Carotid Endarterectomy
12Preventive 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
13Medical 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
14Hemorrhagic 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.
15Manifestations
- Similar to ischemic stroke
- Severe headache
- Early and sudden changes in LOC
- Vomiting
16Medical 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
17Nursing 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
18Nursing 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
19Collaborative Problems/Potential Complications
- Decreased cerebral blood flow
- Inadequate oxygen delivery to brain
- Pneumonia
20Nursing 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
21Interventions
- Focus on the whole person
- Provide interventions to prevent complications
and to promote rehabilitation - Provide support and encouragement
- Listen to the patient
22Improving 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
23Positioning to Prevent Shoulder Abduction
24Prone Positioning to Help Prevent Hip Flexion
25Improving 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
26Interventions
- 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
27Interventions
- 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
28Nursing 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
29Nursing Process The Patient with a Hemorrhagic
StrokeDiagnoses
- Ineffective tissue perfusion (cerebral)
- Disturbed sensory perception
- Anxiety
30Collaborative Problems/Potential Complications
- Vasospasm
- Seizures
- Hydrocephalus
- Rebleeding
- Hyponatremia
31Nursing 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
32Aneurysm 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
33Interventions
- 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
34Home 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