BY Dr. Maha Subih

1. BYDr. MahaSubih Management of Cerebrovascular disorders (Stroke)

2. Stroke An acute neurologic deficit persisting for more than 24 hours and caused by interruption of blood flow to the brain. Consequently, O2 supply is decreased and causing brain cell death (infarction). Other names: • Cerebrovascular accident • Brain attack

3. Risk Factors of Stroke

4. Risk Factors of Stroke • Stroke is the primary cerebrovascular disorder. • Non-modifiable risk factors • Age (over 55), male gender, 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

5. Stroke Warning Signs • If blood flow to brain is totally interrupted • Neurologic metabolism is altered in 30 seconds • Metabolism stops in 2 minutes • Cellular death occurs in 5 minutes • If adequate blood flow restored early (<3 hours) → less brain damage and less neurologic function lost. • According to the American Stroke Association the warning signs of stroke are sudden:

7. Brain (CT) without contrast is the most important initial diagnostic study • tissue plasminogen activator (tPA) is used to reestablish blood flow through a blocked artery in patients with acute onset of ischemic stroke symptoms

8. Types of Stroke

9. Types of Stroke • Ischemic strokesDisruption of the blood supply due to an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue • 85% of all strokes are ischemic strokes • Types • Large artery thrombosis • Small penetrating artery thrombosis • Cardiogenic embolism (arrhythmias: A. fib-valvular diseases) • Cryptogenic: No specific cause • Other

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11. Hemorrhagic Stroke • Caused by bleeding into brain tissue, the ventricles, or subarachnoid space. • Spontaneous rupture of small vessels related to hypertension • subarachnoid hemorrhage due to a ruptured aneurysm • intracerebral hemorrhage related to amyloid angiopathy (deposition of fibrous protein), arterial venous malformations (AVM), aneurysms, or medications such as anticoagulants. • ICP increases. • injury to brain tissue.

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14. Intracerebral hemorrhage (White areas indicate hyperdensity = blood) Large left frontal intracerebral hemorrhage. Intraventricular bleeding

15. Subarachnoid hemorrhage Acute subarachnoid hemorrhage Diffuse areas of white (hyperdense) images

16. Transient Ischemic Attack (TIA) • Temporary neurologic deficit resulting from a temporary impairment of blood flow • “Warning of an impending stroke” • Diagnostic workup is required to treat and prevent irreversible deficits

17. Preventive Treatment • Health maintenance measures: healthy diet, exercise, and treatment of underlying disease • Carotid endarterectomy • Anticoagulant therapy • Antiplatelet therapy: aspirin, Ticlid) • Antihypertensive medications

18. Clinical Manifestations • Motor activity • Communication • Affect • Intellectual function • Spatial-perceptual alterations (hemianopsia (loss of half of the visual field) • Elimination • Personality • Sensation • Headache

19. Clinical ManifestationsMotor Function • Most obvious effect of stroke: Hemiplegia (paralysis) or Hemiparesis (weakness) • Include impairment • In the early stage : flaccid paralysis and loss of or decrease in the DTR reappear (usually by 48 hours) • spasticity (abnormal increase in muscle tone) of the extremities on the affected side.

20. Clinical ManifestationsMotor Function • Characteristic motor deficits - Akinesia = Loss of skilled voluntary movement - Impairment of integration of movements • Alterations in muscle tone • Alterations in reflexes = hyporeflexia, hyperreflexia • An initial period of flaccidity for days to weeks related to nerve damage • Spasticity of the muscles related to interruption of upper motor neuron influence

21. Clinical ManifestationsCommunication • Lt. dominant hemisphere is dominant for language skills which involves expression and comprehension. • Stroke damage Lt. hemisphere: Aphasia is a total loss of comprehension and use of language

22. Clinical ManifestationsCommunication • Global Aphasia: lost comm. + lost receptive function • Receptive Aphasia: sound and speech not understood (stroke affecting wernicke’s area) • Expressive Aphasia= difficulty in speaking/writing (Brocas’ area)

23. when you hear a word, the signal is processed first in brain’s auditory cortex, which sends it on to the Wernicke’s area. Wernicke’s area associates the structure of the signal with the representation of a word stored in the memory, enabling you to retrieve the meaning of the word. to pronounce, the information must be transmitted to the Broca’s area, which plans the pronunciation process. Lastly, this information is routed to the motor cortex, which controls the muscles that are used to pronounce the word.

24. Clinical ManifestationsCommunication • Dysphasia: difficulty related to the comprehension or use of language due to partial disruption • Dysarthria: Disturbance in muscular control of speech may involve pronunciation, verbalization, and phonation • Apraxia =inability to perform a previously learned action

25. Clinical ManifestationsAffect • Difficulty controlling emotions • Emotional responses may be exaggerated or unpredictable • Depression • frustrated by mobility and communication problems

26. Clinical ManifestationsIntellectual Function • Both memory and judgment may be impaired • A left-brain stroke is more likely to result in memory problems related to language.

27. Clinical Manifestations

28. Clinical ManifestationsSpatial-Perceptual Alterations • Most commonly on right sided stroke, however, may occur with left-brain stroke • may be divided into four categories • Incorrect perception of self and illness • Wrong perception of self in space • Inability to recognize an object by sight, touch, or hearing • Inability to carry out learned sequential movements on command • hemianopsia

29. Clinical ManifestationsElimination • Most problems with urinary and bowel elimination occur initially and are temporary • the prognosis for normal bladder function is resumed.

30. Diagnostic Studies • CT • MRI • Transcranial Doppler: measure the velocity of blood flow through the brain's blood vessels • Cerebral Angiography • Carotid angiography

31. Medical Management—Acute Phase of Stroke • Platelet-inhibiting medications. If cause is A. fib → Warfarin or if contraindicated Aspirin • Statins • Antihypertensive medications as (ACE) inhibitors and thiazide diuretics • Thrombolytic therapy (chart 62-2) • Elevate head of the bed unless contraindicated • Maintain airway and ventilation(M.V) • Continuous monitoring

33. Medical Management • Assessment of stroke: NIHSS assessment tool (National Institutes of Health Stroke Scale) (Table 62-4). Score 0-42 • Control of hypertension, ICP, potential seizures, and prevention of further cerebral bleeding • Supportive Care • Bed rest with sedation • Oxygen • carotid endarterectomy or Carotid stenting

35. Collaborative Problems/Potential Complications • Ischemic • Decreased cerebral blood flow • Inadequate oxygen delivery to brain • Pneumonia • Vasospasm • Hemorrhagic • Seizures • Rebleeding • Hyponatremia

36. Nursing Process: AssessmentAcute phase • Change in level of consciousness • Presence or absence of voluntary or involuntary movements of the extremities; muscle tone…etc • Stiffness or flaccidity of the neck • Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position • Color of the face and extremities • Quality and rates of pulse and respiration; ABGs, temperature • Ability to speak • Intake & out pot each 24 hours • Presence of bleeding

37. Nursing Process: Assessment • After the stroke is complete • Focus on patient function; self-care ability, coping, and teaching needs to facilitate rehabilitation

38. Nursing Diagnosis • Ineffective tissue (cerebral) perfusion • Impaired physical mobility • Acute shoulder 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 • Anxiety

39. Figure 5: Quadriceps setting. While sitting in a chair, straighten your leg and hold. Repeat 5 to 10 times. Do the exercises with both knees, up to 3 times each day. Interventions: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 • Prevention of flexion contractures

40. Figure 5: Quadriceps setting. While sitting in a chair, straighten your leg and hold. Repeat 5 to 10 times. Do the exercises with both knees, up to 3 times each day. Improving Mobility and Preventing Joint Deformities • Prevent and treat shoulder pain; Prevent shoulder adduction • Do not lift by flaccid shoulder • Establish regular exercise routine; Encourage patient to exercise unaffected side • Quadriceps setting • Ambulation training: move slowly, Assist patient out of bed as soon as possible- assess to achieve balance.

41. Positioning to Prevent Shoulder Adduction Prone Positioning to Help Prevent Hip Flexion

42. Interventions • Enhancing self-care • Encourage personal hygiene alone using unaffected side • Assure that patient does not neglect the affected side • Use of assistive devices and modification of clothing • The clothing is placed on the affected side • Using a large mirror while dressing • Support and encouragement • Strategies to enhance communication • Encourage patient to turn head, look to side with visual field loss

43. Managing Sensory-Perceptual Difficulties • Patients with a decreased field of vision should be approached on the side where visual perception is intact. • turn the head in the direction of the defective visual field to compensate for this loss. • The nurse should make eye contact and draw his or her attention to the affected side by encouraging the patient to move the head.

44. Interventions • Nutrition • Consult with speech therapy or nutritional services • Have patient sit upright to eat • Chin tuck or swallowing method • Use of thickened liquids or smashed diet • If the patient cannot resume oral intake, NGT is placed for feedings and medication administration.

45. Nursing responsibilities in feeding • elevating the head of the bed at least 30 degrees to prevent aspiration, • checking the position of the tube before feeding, • ensuring that the cuff of the tracheostomy tube (if in place) is inflated, • and giving the tube feeding slowly. • For long-term feedings, a gastrostomy tube is preferred.

46. Interventions • Bowel and bladder control • Assessment of voiding and scheduled voiding • intermittent catheterization • urinal or bedpan is offered on this pattern or schedule. • Measures to prevent constipation—fiber, fluid, toileting schedule • Bowel and bladder retraining

47. Improving Communication • Avoid complete the thoughts or sentences of the patient. • A written copy of the daily schedule, a folder of personal information (address, names of relatives), and an audiotaped list help improve the patient’s memory and concentration. • When talking with the patient, gain the patient’s attention, speak slowly, and keep the language of instruction consistent. • time is allowed for the patient to process what has been said. • The use of gestures may enhance comprehension. • In working with the patient with aphasia, the nurse must remember to talk to the patient during care activities.

48. Home Care and Teaching for the Patient Recovering from a Stroke Prevent subsequent strokes, health promotion, and follow-up care, Prevent 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