Chapter 62 Management of Patients With Cerebrovascular Disorders

1. Chapter 62Management 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. • Direct and indirect costs of stroke are $53.6 billion

3. 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 • 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: see Table 62-1 • Ischemic (80% to 85%) • Hemorrhagic (15% to 20%)

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 penetrating artery thrombosis • Cardiogenic embolism • Cryptogenic • 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 • See Tables 62-2and62-3

8. Cerebrovascular Terms • Hemiplegia • Hemiparesis • Dysarthria • Aphasia: expressive aphasia, receptive aphasia • Hemianopsia

9. 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

10. Carotid Endarterectomy

11. 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

12. Medical Management DuringAcute 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

13. Medical Management DuringAcute 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

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 amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants

15. 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

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

17. 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

18. Intracranial Aneurysms

19. 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, coping, and teaching needs to facilitate rehabilitation

20. 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

21. 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

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

23. 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

24. 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

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

26. 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

27. Positioning to Prevent Shoulder Abduction

28. Prone Positioning to Help Prevent Hip Flexion

29. 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 • Implement ambulation training

30. 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

31. 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

32. 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

33. Nursing Process—Diagnosis of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm • Ineffective tissue perfusion (cerebral) • Disturbed sensory perception • Anxiety

34. Collaborative Problems/Potential Complications • Vasospasm • Seizures • Hydrocephalus • Rebleeding • Hyponatremia

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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