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Nursing Care of Patients with Cerebrovascular Disorders
Chapter 49 Nursing Care of Patients with Cerebrovascular Disorders
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Transient Ischemic Attack
Temporary Impairment of Cerebral Circulation Deprives Brain of Glucose and Oxygen Symptoms Resolve One-third of Patients have Stroke within 5 Years
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Cerebrovascular Accident (Stroke)
Pathophysiology Inadequate Blood Flow to Brain Infarction of Brain Tissue Permanent Damage if Not Reversed Neurological Deficits
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Etiology Ischemic Hemorrhagic Deficient Blood Supply Subarachnoid
Thrombotic Embolic Hemorrhagic Subarachnoid Intracerebral Please see figure 49.1, page 1110 of the text. Embolism and Thrombosis
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Risk Factors Modifiable Non-Modifiable Hypertension Smoking
Diabetes Mellitus Cardiovascular Disease Atrial Fibrillation Carotid Stenosis Tia Sickle Cell Anemia Dyslipidemia Non-Modifiable Age Gender Heredity Prior Stroke or Heart Attack
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Warning Signs CALL 911! Sudden Numbness or Weakness Sudden Confusion
Sudden Change in Vision Sudden Trouble Walking/Dizziness Sudden Severe Headache CALL 911!
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F.A.S.T. Face Arms Speech Time – Call 911
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Acute Signs and Symptoms
Depend on Area of Brain Affected One-Sided Weakness/Paralysis Dysphagia Sensory Loss Mental Status Changes Visual Disturbance Speech Disturbance
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Opposite Side Affected
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One-Sided Weakness
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Visual Disturbances
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Diagnosis CT Scan EKG CBC, Electrolytes, Glucose Metabolic Panel
PT, INR NIH Stroke Scale Carotid Doppler Cerebral Angiogram
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Therapeutic Interventions
Thrombolytic Therapy Airway Management Control of Hypertension, Fever, Glucose Seizure Prevention
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Thrombolytic Therapy Dissolves Clot Three Hour Time Window
May Reverse Symptoms TIME LOST IS BRAIN LOST!
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Post-Emergent Interventions
Treat Cause of Stroke Physical, Occupational, Speech Therapy Antiplatelet Agent Anticoagulant Agent Antihyperlipidemic Agent Antidysrhythmic Agent Maintain Patent Airway
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Stroke Prevention Control Smoking Cessation Aspirin or Warfarin
Weight Hypertension Cholesterol Smoking Cessation Aspirin or Warfarin Early Recognition and Treatment
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Surgical Intervention
Carotid Endarterectomy Balloon Angioplasty with Stent
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Long-Term Effects Impaired Motor Function Impaired Sensation Dysphagia
Aphasia Emotional Lability Impaired Judgment Unilateral Neglect
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Cerebral Aneurysm/ Subarachnoid Hemorrhage
Weakness in Artery Wall Subarachnoid Hemorrhage AV Malformation Head Trauma
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Arteriovenous Malformation
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Signs and Symptoms Severe Headache Photophobia Vomiting Disorientation
IICP Changes in LOC Seizures Nuchal Rigidity Pupil Changes Motor Dysfunction
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Diagnosis CT Scan Cerebral Angiogram
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Therapeutic Interventions
Craniotomy Clamp Wrap Remove
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Therapeutic Interventions (cont’d)
Nonsurgical Thrombose Aneurysm Monitoring Blood Pressure Control
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Complications Rebleed Hydrocephalus Vasospasm Others Similar to Stroke
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Ventriculoperitoneal Shunt
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Nursing Process: Assessment
LOC Restlessness Dizziness Vision Changes Pupil Changes Vital Signs Pain SpO2 Paresthesias Weakness Paralysis Seizures Respiratory Status Swallowing
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Nursing Diagnoses: Cerebrovascular Disorder
Ineffective Cerebral Tissue Perfusion Ineffective Airway Clearance Risk for Injury Impaired Physical Mobility Imbalanced Nutrition
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Nursing Diagnoses (cont’d)
Disturbed Sensory Perception Risk for Impaired Skin Integrity Incontinence Self-Care Deficit Impaired Verbal Communication
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Nursing Diagnoses (cont’d)
Acute or Chronic Confusion Risk for Falls Deficient Knowledge Risk for Caregiver Role Strain
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Ineffective Cerebral Tissue Perfusion
Monitor Neurological Status Vital Signs SpO2 Blood Glucose Coagulation Studies Medication Effects Report Changes Keep HOB up 20 to 30 Degrees Monitor Medication Effects
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Ineffective Airway Clearance
Monitor Lung Sounds, Cough, Respirations Position to Maintain Open Airway Encourage to Cough and Deep Breathe Suction PRN
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Risk for Injury Monitor Neuro Status and Report Changes
Monitor for Hemorrhage Administer Anticonvulsant as Ordered Implement Seizure Precautions Assist with Transfers and Ambulation
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Impaired Physical Mobility
Refer to PT, OT Consider Constraint Therapy Maintain Good Body Alignment Perform ROM Exercises Mobilize: Chair or Ambulate Turn q 2 Hours
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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
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Disturbed Sensory Perception
Assess for Sensory Deficits Teach Patient to Scan Environment Protect Skin
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Risk for Impaired Skin Integrity
Monitor Skin for Breakdown Keep Perineal Area Clean and Dry Use Barrier Cream PRN Turn Patient every 2 Hours Use Lift Sheet to Reposition Consider Pressure-Reducing Mattress
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Incontinence Monitor for Incontinence
Determine Usual Elimination Patterns Provide Assistance with Toileting Schedule Respond Quickly to Requests for Help
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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
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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
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Picture Board
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Acute or Chronic Confusion
Monitor Changes in Thought Processes Place Calendars, Clocks in Environment Reduce Stressors Maintain Patient’s Usual Routines Communicate Slowly and Clearly Involve Family
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Risk for Falls Perform Fall Risk Assessment
Instruct to Ask for Help to Get Up Keep Call Light Within Reach Provide Frequent Toileting Avoid Restraints
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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
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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
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