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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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PreventionNonmodifiable risk factors

Age (over 55), male gender, African-American race

Modifiable risk factorsHypertension is the primary risk factor Cardiovascular diseaseElevated cholesterol or elevated hematocritObesityDiabetes Oral contraceptive useSmoking 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

TypesLarge artery thrombosisSmall artery thrombosisCardiogenic embolismOther

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Pathophysiology

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Manifestations of Ischemic StrokeSymptoms 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 statusTrouble speaking or understanding speechDifficulty in walking, dizziness, or loss of balance or

coordinationSudden, severe headachePerceptual disturbancesloss 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) 7

Terms:HemiplegiaHemiparesisDysarthria (Difficulty in forming words)Aphasia: expressive aphasia, receptive

aphasiaHemianopsia: blindness of half of the field of

vision in one or both eyesApraxia: 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 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

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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 endarterectomyAnticoagulant therapy Antiplatelet therapy: aspirin, Antihypertensive medications

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Medical Management—Acute Phase of Stroke

Prompt diagnosis and treatmentAssessment of strokeThrombolytic therapy

IV dosage and administrationPatient monitoringSide effects—potential bleeding

Elevate HOB unless contraindicated Maintain airway and ventilationContinuous hemodynamic monitoring and

neurologic assessment13

Hemorrhagic StrokeCaused 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. 14

ManifestationsSimilar to ischemic strokeSevere headacheEarly and sudden changes in LOCVomiting

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Medical Management

Prevention: control of hypertensionDiagnosis: CT scan, cerebral angiography,

lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage

Care is primarily supportiveBed rest with sedation OxygenTreatment 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 completeFocus 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—DiagnosesImpaired physical mobilityAcute painSelf-care deficitsDisturbed sensory perceptionImpaired swallowingUrinary incontinenceDisturbed thought processesImpaired verbal communicationRisk for impaired skin integrityInterrupted family processesSexual dysfunction

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Collaborative Problems/Potential Complications

Decreased cerebral blood flowInadequate oxygen delivery to brainPneumonia

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Nursing Process: The Patient Recovering from an Ischemic Stroke—PlanningMajor goals may include:

Improved mobility Avoidance of shoulder painAchievement of self-care Relief of sensory and perceptual deprivation Prevention of aspirationContinence of bowel and bladderImproved thought processesAchieving a form of communicationMaintaining skin integrity Restored family functioning Improved sexual function Absence of complications

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InterventionsFocus on the whole personProvide interventions to prevent

complications and to promote rehabilitationProvide support and encouragementListen to the patient

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Improving Mobility and Preventing Joint DeformitiesTurn and position in correct alignment every 2

hoursUse of splintsPassive or active ROM 4–5 times dayPositioning of hands and fingersPrevention of flexion contractures Prevention of shoulder abductionDo not lift by flaccid shoulderMeasures to prevent and treat shoulder

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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 dayEncourage patient to exercise unaffected sideEstablish regular exercise routineQuadriceps setting and gluteal exercisesAssist patient out of bed as soon as possible-

assess and help patient achieve balance, move slowly

Ambulation training

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InterventionsEnhancing self-care

Set realistic goals with the patientEncourage personal hygieneAssure that patient does not neglect the

affected sideUse of assistive devices and modification of

clothing Support and encouragementStrategies to enhance communicationEncourage patient to turn head, look to side

with visual field loss

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InterventionsNutrition

Consult with speech therapy or nutritional services

Have patient sit upright, preferably OOB, to eatChin tuck or swallowing methodUse of thickened liquids or pureed (مهروس) diet

Bowel and bladder controlAssessment of voiding and scheduled voidingMeasures to prevent constipation—fiber, fluid,

toileting scheduleBowel and bladder retraining

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Nursing Process: The Patient with a Hemorrhagic Stroke—AssessmentComplete and ongoing neurologic assessment

—use neurologic flow chartMonitor respiratory status and oxygenationMonitoring of ICPPatients with intracerebral or subarachnoid

hemorrhage should be monitored in the ICU Monitor for potential complicationsMonitor fluid balance and laboratory dataAll changes must be reported

immediately

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Nursing Process: The Patient with a Hemorrhagic Stroke—Diagnoses

Ineffective tissue perfusion (cerebral)Disturbed sensory perceptionAnxiety

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Collaborative Problems/Potential ComplicationsVasospasmSeizuresHydrocephalusRebleedingHyponatremia

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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 restElevate HOB 30° to promote venous drainage

or flat to increase cerebral perfusionAvoid 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 hygieneNonstimulating, nonstressful environment; dim

lighting, no reading, no TV, no radioPrevent constipationVisitors are restricted

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Interventions

Relieving sensory deprivation and anxietyKeep sensory stimulation to a minimum for

aneurysm precautionsRealty orientationPatient and family teachingSupport and reassuranceSeizure precautionsStrategies to regain and promote self-care

and rehabilitation

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Home Care and Teaching for the Patient Recovering from a StrokePrevention of subsequent strokes, health promotion,

and follow-up carePrevention of and signs and symptoms of complications Medication teachingSafety measuresAdaptive strategies and use of assistive devices for

ADLsNutrition—diet, swallowing techniques, tube feeding

administrationElimination—bowel and bladder programs, catheter

useExercise and activities, recreation and diversionSocialization, support groups, and community

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