Transcript Chapter 62 Management of Patients With Cerebrovascular Disorders

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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.
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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
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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 (80–85%)
 Hemorrhagic (15–20%)
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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
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Pathophysiology
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Manifestations of Ischemic Stroke
 Symptoms depend upon the location and size of the affected
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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)
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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
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Comparison of Left and Right Hemispheric Strokes
Left Hemispheric Stroke
Right Hemispheric Stroke
Paralysis or weakness on right Paralysis or weakness on left
side of body
side of body
Right visual field deficit
Left visual field deficit
Aphasia (expressive, receptive, Spatial-perceptual deficits
or global)
Increased distractibility
Altered intellectual ability
Slow, cautious behavior
Impulsive behavior and poor
judgment
Lack of awareness of deficits
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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
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Carotid Endarterectomy
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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
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Medical Management—Acute Phase of Stroke
 Prompt diagnosis and treatment
 Assessment of stroke
 Thrombolytic therapy
 IV dosage and administration
 Patient monitoring
 Side effects—potential bleeding
 Elevate HOB unless contraindicated
 Maintain airway and ventilation
 Continuous hemodynamic monitoring and neurologic
assessment
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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.
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Manifestations
 Similar to ischemic stroke
 Severe headache
 Early and sudden changes in LOC
 Vomiting
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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
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Nursing Process: The Patient Recovering from
an Ischemic Stroke—Assessment
 Acute phase
 Ongoing/frequent monitoring of all systems including vital
signs and neurologic assessment—LOC, 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
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Nursing Process: The Patient Recovering from
an Ischemic Stroke—Diagnoses
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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
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Collaborative Problems/Potential
Complications
 Decreased cerebral blood flow
 Inadequate oxygen delivery to brain
 Pneumonia
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Nursing Process: The Patient Recovering from
an Ischemic Stroke—Planning
 Major goals may include:
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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
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Interventions
 Focus on the whole person
 Provide interventions to prevent complications and to
promote rehabilitation
 Provide support and encouragement
 Listen to the patient
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Improving Mobility and Preventing
Joint Deformities
 Turn and position in correct alignment every 2 hours
 Use of splints
 Passive or active ROM 4–5 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
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Positioning to Prevent Shoulder
Abduction
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Prone Positioning to Help Prevent
Hip Flexion
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Improving Mobility and Preventing Joint
Deformities
 Passive or active ROM 4–5 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
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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
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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 (‫ )مهروس‬diet
 Bowel and bladder control
 Assessment of voiding and scheduled voiding
 Measures to prevent constipation—fiber, fluid, toileting
schedule
 Bowel and bladder retraining
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Nursing Process: The Patient with a
Hemorrhagic Stroke—Assessment
 Complete and ongoing neurologic assessment—use
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
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Nursing Process: The Patient with a
Hemorrhagic Stroke—Diagnoses
 Ineffective tissue perfusion (cerebral)
 Disturbed sensory perception
 Anxiety
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Collaborative Problems/Potential
Complications
 Vasospasm
 Seizures
 Hydrocephalus
 Rebleeding
 Hyponatremia
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Nursing Process: The Patient with a
Hemorrhagic Stroke—Planning
 Goals may include:
 Improved cerebral tissue perfusion
 Relief of sensory and perceptual deprivation
 Relief of anxiety
 The absence of complications
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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
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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
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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 symptoms of complications
 Medication teaching
 Safety measures
 Adaptive strategies and use of assistive devices for ADLs
 Nutrition—diet, swallowing techniques, tube feeding
administration
 Elimination—bowel and bladder programs, catheter use
 Exercise and activities, recreation and diversion
 Socialization, support groups, and community resources
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