Management of Patients Management of Patients with Cerebrovascular with Cerebrovascular

DisordersDisorders

Cerebrovascular DisordersCerebrovascular Disorders

$53.6 Functional abnormality of the CNS that $53.6 Functional abnormality of the CNS that occurs when the blood supply is disrupted occurs when the blood supply is disrupted

Stroke is the primary cerebrovascular disorder Stroke is the primary cerebrovascular disorder and the third leading cause of death in the U.S.and the third leading cause of death in the U.S.

Stroke is the leading cause of serious long-term Stroke is the leading cause of serious long-term disability in the U.S.disability in the U.S.

Direct and indirect costs of stroke are billionDirect and indirect costs of stroke are billion

PreventionPrevention

Nonmodifiable risk factorsNonmodifiable risk factors Age (over 55), male gender, African American Age (over 55), male gender, African American

racerace

Modifiable risk factors: see Chart 62-1Modifiable risk factors: see Chart 62-1 Hypertension: the primary risk factor Hypertension: the primary risk factor

Cardiovascular diseaseCardiovascular disease

Elevated cholesterol or elevated hematocritElevated cholesterol or elevated hematocrit

ObesityObesity

Diabetes Diabetes

Oral contraceptive useOral contraceptive use

Smoking and drug and alcohol abuseSmoking and drug and alcohol abuse

StrokeStroke““Brain attack”Brain attack”

Sudden loss of function resulting Sudden loss of function resulting from a disruption of the blood from a disruption of the blood supply to a part of the brainsupply to a part of the brain

Types of stroke: see Table 62-1Types of stroke: see Table 62-1

Ischemic (80% to 85%) Ischemic (80% to 85%)

Hemorrhagic (15% to 20%)Hemorrhagic (15% to 20%)

Ischemic StrokeIschemic Stroke Disruption of the blood supply due to an Disruption of the blood supply due to an

obstruction, usually a thrombus or obstruction, usually a thrombus or embolism, that causes infarction of brain embolism, that causes infarction of brain tissuetissue

TypesTypesLarge artery thrombosisLarge artery thrombosis

Small penetrating artery thrombosisSmall penetrating artery thrombosis

Cardiogenic embolismCardiogenic embolism

CryptogenicCryptogenic

OtherOther

PathophysiologyPathophysiology

Manifestations of Ischemic Manifestations of Ischemic StrokeStroke

Symptoms depend upon the location and size of Symptoms depend upon the location and size of the affected area the affected area

Numbness or weakness of face, arm, or leg, Numbness or weakness of face, arm, or leg, especially on one side especially on one side

Confusion or change in mental statusConfusion or change in mental status

Trouble speaking or understanding speechTrouble speaking or understanding speech

Difficulty in walking, dizziness, or loss of balance Difficulty in walking, dizziness, or loss of balance or coordinationor coordination

Sudden, severe headacheSudden, severe headache

Perceptual disturbancesPerceptual disturbances

See Tables 62-2See Tables 62-2 andand 62-362-3

Types of ParalysisTypes of Paralysis

Abnormal Visual FieldsAbnormal Visual Fields

Cerebrovascular TermsCerebrovascular Terms

HemiplegiaHemiplegia

Hemiparesis Hemiparesis

DysarthriaDysarthria

Aphasia: expressive aphasia, Aphasia: expressive aphasia, receptive aphasiareceptive aphasia

HemianopsiaHemianopsia

Transient Ischemic Attack Transient Ischemic Attack (TIA)(TIA)

Temporary neurologic deficit Temporary neurologic deficit resulting from a temporary resulting from a temporary impairment of blood flowimpairment of blood flow

““Warning of an impending stroke”Warning of an impending stroke”

Diagnostic work-up is required to Diagnostic work-up is required to treat and prevent irreversible treat and prevent irreversible deficitsdeficits

Carotid EndarterectomyCarotid Endarterectomy

Carotid EndarterectomyCarotid Endarterectomy

Preventive Treatment and Preventive Treatment and Secondary PreventionSecondary Prevention

Health maintenance measures including a Health maintenance measures including a healthy diet, exercise, and the prevention healthy diet, exercise, and the prevention and treatment of periodontal diseaseand treatment of periodontal disease

Carotid endarterectomyCarotid endarterectomy Anticoagulant therapy Anticoagulant therapy Antiplatelet therapy: aspirin, dipyridamole Antiplatelet therapy: aspirin, dipyridamole

(Persantine), clopidogrel (Plavix), and (Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid)ticlopidine (Ticlid)

StatinsStatins Antihypertensive medicationsAntihypertensive medications

Medical Management DuringMedical Management DuringAcute Phase of StrokeAcute Phase of Stroke

Prompt diagnosis and treatmentPrompt diagnosis and treatment

Assessment of stroke: NIHSS Assessment of stroke: NIHSS assessment toolassessment tool

Thrombolytic therapyThrombolytic therapyCriteria for tissue plasminogen Criteria for tissue plasminogen

activator activator ((tPA): see Chart 62-2tPA): see Chart 62-2

IV dosage and administrationIV dosage and administration

Patient monitoringPatient monitoring

Side effects: potential bleedingSide effects: potential bleeding

Medical Management DuringMedical Management DuringAcute Phase of Stroke (cont.)Acute Phase of Stroke (cont.)

Elevate HOB unless contraindicated Elevate HOB unless contraindicated

Maintain airway and ventilationMaintain airway and ventilation

Provide continuous hemodynamic Provide continuous hemodynamic monitoring and neurologic monitoring and neurologic assessmentassessment

See the guidelines in Appendix BSee the guidelines in Appendix B

Hemorrhagic StrokeHemorrhagic Stroke

Caused by bleeding into brain tissue, the Caused by bleeding into brain tissue, the ventricles, or subarachnoid space ventricles, or subarachnoid space

May be due to spontaneous rupture of May be due to spontaneous rupture of small vessels primarily related to small vessels primarily related to hypertension; subarachnoid hemorrhage hypertension; subarachnoid hemorrhage due to a ruptured aneurysm; or due to a ruptured aneurysm; or intracerebral hemorrhage related to intracerebral hemorrhage related to amyloid angiopathy, arterial venous amyloid angiopathy, arterial venous malformations (AVMs), intracranial malformations (AVMs), intracranial aneurysms, or medications such as aneurysms, or medications such as anticoagulantsanticoagulants

Hemorrhagic Stroke (cont.)Hemorrhagic Stroke (cont.)

Brain metabolism is disrupted by Brain metabolism is disrupted by exposure to bloodexposure to blood

ICP increases due to blood in the ICP increases due to blood in the subarachnoid spacesubarachnoid space

Compression or secondary ischemia Compression or secondary ischemia from reduced perfusion and from reduced perfusion and vasoconstriction injures brain tissuevasoconstriction injures brain tissue

ManifestationsManifestations

Similar to ischemic strokeSimilar to ischemic stroke

Severe headacheSevere headache

Early and sudden changes in LOCEarly and sudden changes in LOC

VomitingVomiting

Medical ManagementMedical Management

Prevention: control of hypertensionPrevention: control of hypertension

Diagnosis: CT scan, cerebral angiography, and Diagnosis: CT scan, cerebral angiography, and lumbar puncture if CT is negative and ICP is not lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhageelevated to confirm subarachnoid hemorrhage

Care is primarily supportiveCare is primarily supportive

Bed rest with sedation Bed rest with sedation

OxygenOxygen

Treatment of vasospasm, increased ICP, Treatment of vasospasm, increased ICP, hypertension, potential seizures, and hypertension, potential seizures, and prevention of further bleedingprevention of further bleeding

Intracranial AneurysmsIntracranial Aneurysms

Nursing Process—Assessing the Nursing Process—Assessing the Patient Recovering From an Patient Recovering From an

Ischemic StrokeIschemic Stroke Acute phase Acute phase

Ongoing/frequent monitoring of all systems Ongoing/frequent monitoring of all systems including vital signs and neurologic assessment: including vital signs and neurologic assessment: LOC and motor, speech, and eye symptomsLOC and motor, speech, and eye symptoms

Monitor for potential complications including Monitor for potential complications including musculoskeletal problems, swallowing difficulties, musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of respiratory problems, and signs and symptoms of increased ICP and meningeal irritationincreased ICP and meningeal irritation

After the stroke is completeAfter the stroke is complete

Focus on patient function; self-care ability, coping, Focus on patient function; self-care ability, coping, and teaching needs to facilitate rehabilitationand teaching needs to facilitate rehabilitation

Nursing Process—Diagnosis of Nursing Process—Diagnosis of the Patient Recovering From an the Patient Recovering From an

Ischemic StrokeIschemic Stroke Impaired physical mobilityImpaired physical mobility

Acute painAcute pain

Self-care deficitsSelf-care deficits

Disturbed sensory perceptionDisturbed sensory perception

Impaired swallowingImpaired swallowing

Urinary incontinenceUrinary incontinence

Nursing Process—Diagnosis of Nursing Process—Diagnosis of the Patient Recovering From an the Patient Recovering From an

Ischemic Stroke (cont.)Ischemic Stroke (cont.)Disturbed thought processesDisturbed thought processes

Impaired verbal communicationImpaired verbal communication

Risk for impaired skin integrityRisk for impaired skin integrity

Interrupted family processesInterrupted family processes

Sexual dysfunctionSexual dysfunction

Collaborative Problems/Potential Collaborative Problems/Potential ComplicationsComplications

Decreased cerebral blood flowDecreased cerebral blood flow

Inadequate oxygen delivery to brainInadequate oxygen delivery to brain

PneumoniaPneumonia

Nursing Process—Planning Nursing Process—Planning Patient Recovery After an Patient Recovery After an

Ischemic StrokeIschemic StrokeMajor goals include: Major goals include:

Improved mobility Improved mobility Avoidance of shoulder painAvoidance of shoulder painAchievement of self-care Achievement of self-care Relief of sensory and perceptual Relief of sensory and perceptual

deprivation deprivation Prevention of aspirationPrevention of aspirationContinence of bowel and bladderContinence of bowel and bladder

Nursing Process—Planning Nursing Process—Planning Patient Recovery After an Patient Recovery After an

Ischemic Stroke (cont.)Ischemic Stroke (cont.)Major goals include (cont):Major goals include (cont):

Improved thought processesImproved thought processesAchievement of a form of Achievement of a form of

communicationcommunicationMaintenance of skin integrity Maintenance of skin integrity Restoration of family functioning Restoration of family functioning Improved sexual function Improved sexual function Absence of complicationsAbsence of complications

InterventionsInterventions

Focus on the whole personFocus on the whole person

Provide interventions to prevent Provide interventions to prevent complications and to promote complications and to promote rehabilitationrehabilitation

Provide support and encouragementProvide support and encouragement

Listen to the patientListen to the patient

Improving Mobility and Improving Mobility and Preventing Preventing

Joint DeformitiesJoint Deformities Turn and position the patient in correct alignment Turn and position the patient in correct alignment

every 2 hoursevery 2 hours Use splintsUse splints Practice passive or active ROM 4 to 5 times dayPractice passive or active ROM 4 to 5 times day Position hands and fingersPosition hands and fingers Prevent flexion contractures Prevent flexion contractures Prevent shoulder abductionPrevent shoulder abduction Do not lift by flaccid shoulderDo not lift by flaccid shoulder

Implement measures to prevent and treat Implement measures to prevent and treat shoulder problems shoulder problems

Positioning to Prevent Shoulder Positioning to Prevent Shoulder AbductionAbduction

Prone Positioning to Help Prone Positioning to Help Prevent Prevent

Hip FlexionHip Flexion

Improving Mobility and Improving Mobility and Preventing Preventing

Joint DeformitiesJoint Deformities Perform passive or active ROM 4 to 5 times Perform passive or active ROM 4 to 5 times

dayday Encourage patient to exercise unaffected Encourage patient to exercise unaffected

sideside Establish regular exercise routineEstablish regular exercise routine Use quadriceps setting and gluteal exercisesUse quadriceps setting and gluteal exercises Assist patient out of bed as soon as possible: Assist patient out of bed as soon as possible:

assess and help patient achieve balance and assess and help patient achieve balance and move slowlymove slowly

Implement ambulation trainingImplement ambulation training

InterventionsInterventions

Enhance self-careEnhance self-care Set realistic goals with the patientSet realistic goals with the patient Encourage personal hygieneEncourage personal hygiene Ensure that patient does not neglect the affected sideEnsure that patient does not neglect the affected side Use assistive devices and modification of clothing Use assistive devices and modification of clothing

Provide support and encouragementProvide support and encouragement

Implement strategies to enhance communication: Implement strategies to enhance communication: see Chart 62-4see Chart 62-4

Encourage the patient with visual field loss to Encourage the patient with visual field loss to turn his head and look to sideturn his head and look to side

Interventions (cont.)Interventions (cont.)

Nutrition Nutrition Consult with speech therapist or nutritionistConsult with speech therapist or nutritionistHave patient sit upright to eat, preferably OOBHave patient sit upright to eat, preferably OOBUse chin tuck or swallowing methodUse chin tuck or swallowing methodFeed thickened liquids or pureed dietFeed thickened liquids or pureed diet

Bowel and bladder controlBowel and bladder controlAssess and schedule voidingAssess and schedule voiding Implement measures to prevent constipation: Implement measures to prevent constipation:

fiber, fluid, and toileting schedulefiber, fluid, and toileting scheduleProvide bowel and bladder retrainingProvide bowel and bladder retraining

Nursing Process—Assessment of Nursing Process—Assessment of the Patient With a Hemorrhagic the Patient With a Hemorrhagic

Stroke/Cerebral AneurysmStroke/Cerebral Aneurysm Complete an ongoing neurologic assessment: use Complete an ongoing neurologic assessment: use

neurologic flow chartneurologic flow chart

Monitor respiratory status and oxygenationMonitor respiratory status and oxygenation

Monitor ICPMonitor ICP

Monitor patients with intracerebral or Monitor patients with intracerebral or subarachnoid hemorrhage in the ICUsubarachnoid hemorrhage in the ICU

Monitor for potential complicationsMonitor for potential complications

Monitor fluid balance and laboratory dataMonitor fluid balance and laboratory data

Reported all changes immediatelyReported all changes immediately

Nursing Process—Diagnosis of Nursing Process—Diagnosis of the Patient With a Hemorrhagic the Patient With a Hemorrhagic

Stroke/Stroke/Cerebral AneurysmCerebral Aneurysm

Ineffective tissue perfusion Ineffective tissue perfusion (cerebral)(cerebral)

Disturbed sensory perceptionDisturbed sensory perception

AnxietyAnxiety

Collaborative Problems/Potential Collaborative Problems/Potential ComplicationsComplications

VasospasmVasospasm

SeizuresSeizures

Hydrocephalus Hydrocephalus

RebleedingRebleeding

HyponatremiaHyponatremia

Nursing Process—Planning Care Nursing Process—Planning Care of the Patient With a of the Patient With a

Hemorrhagic Stroke/Cerebral Hemorrhagic Stroke/Cerebral AneurysmAneurysm

Goals may include: Goals may include: Improved cerebral tissue perfusion Improved cerebral tissue perfusion Relief of sensory and perceptual Relief of sensory and perceptual

deprivation deprivation Relief of anxiety Relief of anxiety Absence of complicationsAbsence of complications

Aneurysm PrecautionsAneurysm Precautions

Absolute bed restAbsolute bed rest

Elevate HOB 30° to promote venous drainage or Elevate HOB 30° to promote venous drainage or keep the bed flat to increase cerebral perfusionkeep the bed flat to increase cerebral perfusion

Avoid all activity that may increase ICP or BP; Avoid all activity that may increase ICP or BP; implement Valsalva maneuver, acute flexion, implement Valsalva maneuver, acute flexion, and rotation of the neck or headand rotation of the neck or head

Exhale through mouth when voiding or Exhale through mouth when voiding or defecating to decrease straindefecating to decrease strain

Aneurysm Precautions (cont.)Aneurysm Precautions (cont.)

Nurse provides all personal care and Nurse provides all personal care and hygienehygiene

Provide nonstimulating, nonstressful Provide nonstimulating, nonstressful environment: dim lighting, no reading, environment: dim lighting, no reading, no TV, and no radiono TV, and no radio

Prevent constipationPrevent constipation

Restrict visitorsRestrict visitors

InterventionsInterventions

Relieve sensory deprivation and anxietyRelieve sensory deprivation and anxiety Keep sensory stimulation to a minimum for Keep sensory stimulation to a minimum for

aneurysm precautionsaneurysm precautions Implement reality orientationImplement reality orientation Provide patient and family teachingProvide patient and family teaching Provide support and reassuranceProvide support and reassurance Implement seizure precautionsImplement seizure precautions Implement strategies to regain and Implement strategies to regain and

promote self-care and rehabilitationpromote self-care and rehabilitation

Home Care and Teaching for the Home Care and Teaching for the Patient Recovering From a Patient Recovering From a

StrokeStroke Prevention of subsequent strokes, health Prevention of subsequent strokes, health

promotion, and implementation of follow-promotion, and implementation of follow-up careup care

Prevention of and signs and symptoms of Prevention of and signs and symptoms of complications complications

Medication teachingMedication teaching Safety measuresSafety measures Adaptive strategies and use of assistive Adaptive strategies and use of assistive

devices for ADLsdevices for ADLs

Home Care and Teaching for the Home Care and Teaching for the Patient Recovering From a Patient Recovering From a

Stroke (cont.)Stroke (cont.) Nutrition: diet, swallowing techniques, Nutrition: diet, swallowing techniques,

and tube feeding administrationand tube feeding administration Elimination: bowel and bladder programs Elimination: bowel and bladder programs

and catheter useand catheter use Exercise and activities: recreation and Exercise and activities: recreation and

diversiondiversion Socialization, support groups, and Socialization, support groups, and

community resourcescommunity resources See Chart 62-6See Chart 62-6