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Chapter 62 Management of Patients with Cerebrovascular Disorders . 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.

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cerebrovascular disorders
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.
prevention
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
stroke
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%)
ischemic stroke
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
manifestations of ischemic stroke
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)
terms
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
transient ischemic attack tia
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
preventive treatment and secondary prevention
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
medical management acute phase of stroke
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
hemorrhagic stroke
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.
manifestations
Manifestations
  • Similar to ischemic stroke
  • Severe headache
  • Early and sudden changes in LOC
  • Vomiting
medical management
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
nursing process the patient recovering from an ischemic stroke assessment
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
nursing process the patient recovering from an ischemic stroke diagnoses
Nursing Process: The Patient Recovering from an Ischemic Stroke—Diagnoses
  • 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
collaborative problems potential complications
Collaborative Problems/Potential Complications
  • Decreased cerebral blood flow
  • Inadequate oxygen delivery to brain
  • Pneumonia
nursing process the patient recovering from an ischemic stroke planning
Nursing Process: The Patient Recovering from an Ischemic Stroke—Planning
  • 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
interventions
Interventions
  • Focus on the whole person
  • Provide interventions to prevent complications and to promote rehabilitation
  • Provide support and encouragement
  • Listen to the patient
improving mobility and preventing joint deformities
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
improving mobility and preventing joint deformities1
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
interventions1
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
interventions2
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 (مهروس) diet
  • Bowel and bladder control
    • Assessment of voiding and scheduled voiding
    • Measures to prevent constipation—fiber, fluid, toileting schedule
    • Bowel and bladder retraining
nursing process the patient with a hemorrhagic stroke assessment
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
nursing process the patient with a hemorrhagic stroke diagnoses
Nursing Process: The Patient with a Hemorrhagic Stroke—Diagnoses
  • Ineffective tissue perfusion (cerebral)
  • Disturbed sensory perception
  • Anxiety
collaborative problems potential complications1
Collaborative Problems/Potential Complications
  • Vasospasm
  • Seizures
  • Hydrocephalus
  • Rebleeding
  • Hyponatremia
nursing process the patient with a hemorrhagic stroke planning
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
aneurysm precautions
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
interventions3
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
home care and teaching for the patient recovering from a stroke
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