1. Chapter 62 Management of Patients With Cerebrovascular Disorders

2. 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.
Direct and indirect costs of stroke are $53.6 billion

3. Prevention Nonmodifiable risk factors
Age (over 55), male gender, African American race
Modifiable risk factors: see Chart 62-1
Hypertension: the primary risk factor
Cardiovascular disease
Elevated cholesterol or elevated hematocrit
Obesity
Diabetes
Oral contraceptive use
Smoking and drug and alcohol abuse

4. Stroke
“Brain attack”
Sudden loss of function resulting from a disruption of the blood supply to a part of the brain
Types of stroke: see Table 62-1
Ischemic (80% to 85%)
Hemorrhagic (15% to 20%)

5. 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 penetrating artery thrombosis
Cardiogenic embolism
Cryptogenic
Other

6. Pathophysiology

7. 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
See Tables 62-2 and 62-3

8. Cerebrovascular Terms
Hemiplegia
Hemiparesis
Dysarthria
Aphasia: expressive aphasia, receptive aphasia
Hemianopsia

9. Transient Ischemic Attack (TIA)
Temporary neurologic deficit resulting from a temporary impairment of blood flow
“Warning of an impending stroke”
Diagnostic work-up is required to treat and prevent irreversible deficits

10. Carotid Endarterectomy

11. 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, dipyridamole (Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid)
Statins
Antihypertensive medications

12. Medical Management During Acute Phase of Stroke
Prompt diagnosis and treatment
Assessment of stroke: NIHSS assessment tool
Thrombolytic therapy
Criteria for tissue plasminogen activator (tPA): see Chart 62-2
IV dosage and administration
Patient monitoring
Side effects: potential bleeding

13. Medical Management During Acute Phase of Stroke (cont.)
Elevate HOB unless contraindicated
Maintain airway and ventilation
Provide continuous hemodynamic monitoring and neurologic assessment
See the guidelines in Appendix B

14. 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 amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants

15. Hemorrhagic Stroke (cont.)
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 injures brain tissue

16. Manifestations Similar to ischemic stroke Severe headache
Early and sudden changes in LOC
Vomiting

17. Medical Management Prevention: control of hypertension
Diagnosis: CT scan, cerebral angiography, and 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

18. Intracranial Aneurysms

19. Nursing Process—Assessing the Patient Recovering From an Ischemic Stroke
Acute phase
Ongoing/frequent monitoring of all systems including vital signs and neurologic assessment: LOC and motor, speech, and 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

20. Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke
Impaired physical mobility
Acute pain
Self-care deficits
Disturbed sensory perception
Impaired swallowing
Urinary incontinence

21. Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke (cont.)
Disturbed thought processes
Impaired verbal communication
Risk for impaired skin integrity
Interrupted family processes
Sexual dysfunction

22. Collaborative Problems/Potential Complications
Decreased cerebral blood flow
Inadequate oxygen delivery to brain
Pneumonia

23. Nursing Process—Planning Patient Recovery After an Ischemic Stroke
Major goals 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

24. Nursing Process—Planning Patient Recovery After an Ischemic Stroke (cont.)
Major goals include (cont):
Improved thought processes
Achievement of a form of communication
Maintenance of skin integrity
Restoration of family functioning
Improved sexual function
Absence of complications

25. Interventions Focus on the whole person
Provide interventions to prevent complications and to promote rehabilitation
Provide support and encouragement
Listen to the patient

26. Improving Mobility and Preventing Joint Deformities
Turn and position the patient in correct alignment every 2 hours
Use splints
Practice passive or active ROM 4 to 5 times day
Position hands and fingers
Prevent flexion contractures
Prevent shoulder abduction
Do not lift by flaccid shoulder
Implement measures to prevent and treat shoulder problems

27. Positioning to Prevent Shoulder Abduction

28. Prone Positioning to Help Prevent Hip Flexion

29. Improving Mobility and Preventing Joint Deformities
Perform passive or active ROM 4 to 5 times day
Encourage patient to exercise unaffected side
Establish regular exercise routine
Use quadriceps setting and gluteal exercises
Assist patient out of bed as soon as possible: assess and help patient achieve balance and move slowly
Implement ambulation training

30. Interventions Enhance self-care Set realistic goals with the patient
Encourage personal hygiene
Ensure that patient does not neglect the affected side
Use assistive devices and modification of clothing
Provide support and encouragement
Implement strategies to enhance communication: see Chart 62-4
Encourage the patient with visual field loss to turn his head and look to side

31. Interventions (cont.) Nutrition
Consult with speech therapist or nutritionist
Have patient sit upright to eat, preferably OOB
Use chin tuck or swallowing method
Feed thickened liquids or pureed diet
Bowel and bladder control
Assess and schedule voiding
Implement measures to prevent constipation: fiber, fluid, and toileting schedule
Provide bowel and bladder retraining

32. Nursing Process—Assessment of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm
Complete an ongoing neurologic assessment: use neurologic flow chart
Monitor respiratory status and oxygenation
Monitor ICP
Monitor patients with intracerebral or subarachnoid hemorrhage in the ICU
Monitor for potential complications
Monitor fluid balance and laboratory data
Reported all changes immediately

33. Nursing Process—Diagnosis of the Patient With a Hemorrhagic Stroke/ Cerebral Aneurysm
Ineffective tissue perfusion (cerebral)
Disturbed sensory perception
Anxiety

34. Collaborative Problems/Potential Complications
Vasospasm
Seizures
Hydrocephalus
Rebleeding
Hyponatremia

35. Nursing Process—Planning Care of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm
Goals may include:
Improved cerebral tissue perfusion
Relief of sensory and perceptual deprivation
Relief of anxiety
Absence of complications

36. Aneurysm Precautions Absolute bed rest
Elevate HOB 30° to promote venous drainage or keep the bed flat to increase cerebral perfusion
Avoid all activity that may increase ICP or BP; implement Valsalva maneuver, acute flexion, and rotation of the neck or head
Exhale through mouth when voiding or defecating to decrease strain

37. Aneurysm Precautions (cont.)
Nurse provides all personal care and hygiene
Provide nonstimulating, nonstressful environment: dim lighting, no reading, no TV, and no radio
Prevent constipation
Restrict visitors

38. Interventions Relieve sensory deprivation and anxiety
Keep sensory stimulation to a minimum for aneurysm precautions
Implement reality orientation
Provide patient and family teaching
Provide support and reassurance
Implement seizure precautions
Implement strategies to regain and promote self-care and rehabilitation

39. Home Care and Teaching for the Patient Recovering From a Stroke
Prevention of subsequent strokes, health promotion, and implementation of follow-up care
Prevention of and signs and symptoms of complications
Medication teaching
Safety measures
Adaptive strategies and use of assistive devices for ADLs

40. Home Care and Teaching for the Patient Recovering From a Stroke (cont
Nutrition: diet, swallowing techniques, and tube feeding administration
Elimination: bowel and bladder programs and catheter use
Exercise and activities: recreation and diversion
Socialization, support groups, and community resources
See Chart 62-6