Nursing Care of Patients with Cerebrovascular Disorders The Nervous System Nursing Care of Patients with Cerebrovascular Disorders

Transient Ischemic Attack Temporary impairment of cerebral circulation, deprives brain of glucose and oxygen, may last mins to hrs, resolve/24 24-29% have Stroke within 5 Years May be a forewarning for CVA S/S: depends on area of brain affected, visual/speech difficulty, weakness/paralysis

Cerebrovascular Accident (Stroke) Pathophysiology Inadequate blood flow to brain, destroys brain tissue, permanent damage if not reversed Ischemic- death of brain tissue Thrombotic- circulation or Embolic-obstruction Hemorrhagic- rupture of a vessel, bleeding into the brain

Risk Factors Modifiable Non-Modifiable Hypertension Smoking Diabetes Mellitus Atherosclerosis Atrial Fibrillation Obesity Hypercholesterolemia TIA Alcohol, Drugs Non-Modifiable Age Gender Prior Stroke or Heart Attack Heredity

Warning Signs CALL 911! Sudden Numbness or Weakness Sudden Confusion Sudden Change in Vision Sudden Trouble Walking / Dizziness Sudden Severe Headache CALL 911!

Acute Signs & Symptoms Depend on Area of Brain Affected Change in LOC, numbness, weakness Visual/ language disturbance One-Sided Weakness / Paralysis Dysphagia HA, N/V, resp compromise

Opposite Side Affected

Visual Disturbances

Cincinnati Pre-Hospital Stroke Scale Have Patient Smile Have Patient Hold Arms out Straight and Close Eyes Ask Patient to Repeat a Phrase CT, MRI, Angiogram, NIH stroke scale, PT, PTT, electrolytes, CBC

Therapeutic Interventions Thrombolytic Therapy Must be given within 3 hours to be effective to reverse stroke s/s TIME IS BRAIN! Treat cause of stroke Airway Management Control of Hypertension Seizure Prevention Anticoagulants and antiplatelets

Surgical Intervention Carotid Endarterectomy- carotid artery is opened and plaque removed Balloon Angioplasty

Long Term Effects Impaired Motor Function Impaired Sensation Aphasia Emotional Lability Impaired Judgment Unilateral Neglect Homonymous Hemianopsia

Cerebral Aneurysm/Subarachnoid Hemorrhage Weakness in Artery Wall, result of trauma, disease, or congential Subarachnoid Hemorrhage AV Malformation Head Trauma

Arteriovenous Malformation

S/S of Hemorrhage Severe Headache Photophobia Vomiting Disorientation IICP Dx: CT scan, cerebral angiogram Changes in LOC Seizures Nuchal Rigidity Pupil Changes Motor Dysfunction

Therapeutic Interventions Craniotomy Clamp Wrap Remove

Therapeutic Interventions cont’d Nonsurgical Thrombose Aneurysm Monitoring Blood Pressure Control

Complications Rebleed Hydrocephalus Vasospasm Others Similar to Stroke

Ventriculoperitoneal Shunt

Nursing Process: Assessment LOC Restlessness Dizziness Vision Changes Pupils Vital Signs Pain SaO2 Paresthesias Weakness Paralysis Seizures Respiratory Status Swallowing

Nursing Diagnoses: Cerebrovascular Disorder Ineffective Cerebral Tissue Perfusion Ineffective Airway Clearance Risk for Injury Impaired Physical Mobility Imbalanced Nutrition Disturbed Sensory perception Risk for Impaired Skin integrity

Nursing Diagnoses Cont’d Incontinence Self-Care Deficit Impaired Verbal Communication Disturbed Thought Processes Deficit Knowledge Risk for Caregiver Role Strain

Ineffective Cerebral Tissue Perfusion Monitor Neurological Status Monitor Vital Signs Monitor Coagulation Studies Monitor Medication Effects Report Changes

Ineffective Airway Clearance Monitor Lung Sounds, Cough, Respirations Position to Maintain Open Airway Encourage to Cough and Deep Breathe Suction PRN

Risk for Injury Monitor Neuro Status and Report Changes Administer Anticonvulsant as Ordered Implement Seizure Precautions Offer Toileting on Schedule

Impaired Physical Mobility Refer to PT, OT Maintain Good Body Alignment Perform ROM Exercises Mobilize – Chair or Ambulate Turn q 2 Hours

Imbalanced Nutrition Keep NPO Until Swallowing Evaluated Perform Dysphagia Screen Try Sip of Water Request ST Swallowing Evaluation Implement Aspiration Precautions Consider Tube Feeding if Necessary

Disturbed Sensory Perception Assess for Sensory Deficits Teach Patient to Scan Environment Protect Skin

Risk for Impaired Skin Integrity Monitor Skin for Breakdown Keep Perineal Area Clean and Dry Use Barrier Cream PRN Turn Patient q2 Hours Use Lift Sheet to Reposition Consider Pressure-Reducing Mattress

Incontinence Monitor for Incontinence Determine Usual Elimination Patterns Provide Assistance with Toileting Schedule Respond Quickly to Requests for Help

Self Care Deficit Assess Ability to Perform ADLs Encourage Independence Place Objects in Reach Provide Assistive Devices Assist to Learn Use of Non-Dominant Side Involve and Educate Family

Impaired Verbal Communication Assess Verbal Ability Consult Speech Pathologist Answer Call Light in Person Listen Patiently Provide Communication Aids Keep Communication Appropriate Don’t Assume Patient Does Not Understand

Picture Board

Disturbed Thought Processes Monitor Changes in Thought Processes Place Calendars, Clocks in Environment Reduce Stressors Maintain Patient’s Usual Routines Communicate Slowly and Clearly Involve Family

Deficient Knowledge Explain What Happened to Patient Explain Tests and Procedures Orient Patient and Family to Setting Provide Instruction for Care at Home Evaluate Need for Home Nursing

Risk for Caregiver Role Strain Assess Impact of Patient’s Needs on Caregiver Assist Caregiver to Identify Resources Consult Social Worker or Case Manager Consider Skilled Nursing Facility PRN