Chapter 62 Management of Patients With Cerebrovascular Disorders

1. Chapter 62Management of Patients With Cerebrovascular Disorders

2. Cerebrovascular Disorders • Functional abnormality of the CNS that occurs when the blood supply is disrupted • Occurs when there is ischemia to part of the brain or hemorrage to part of the brain that results in death of brain cells • 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.

3. Stroke • “Brain attack”; cerebrovascular accident (CVA) • Sudden loss of function resulting from a disruption of the blood supply to a part of the brain • Types of stroke: see Table 58-1 • Ischemic (80% to 85%) • Hemorrhagic (15% to 20%)

4. Fig 58-3

5. Ischemic Stroke • Disruption of the blood supply due to an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue • Types • Thrombotic stroke (d/t thrombus formation and occlusion at atherosclerotic plaque site) • Lacunar stroke (small penetrating artery thrombosis) • Emboblic stroke (embolus lodges in and occludes a cerebral artery - esp. cardiogenic) • Other may be due to illicit drugs, coagulopathies, dissection of carotid or vertebral arteries

6. Prevention of Ischemic Stroke • 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 • Obesity • Diabetes • Oral contraceptive use • Smoking and drug and alcohol abuse • Sedentary lifestyle

7. Pathophysiology

8. Manifestations of Ischemic Stroke • Symptoms depend upon the location and size of the affected area, amount of collateral circulation • 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 • Headache • Perceptual, visual disturbances

9. Fig 58-5

10. Manifestations of Ischemic Stroke • Clinical manifestations may be broadly grouped: • Motor loss • Communication loss • Affect • Perceptual disturbances • Sensory loss • Cognitive impairment

11. Cerebrovascular Terms • Hemiplegia (paralysis of one side of body) • Hemiparesis (weakness on one side of body) • Dysarthria (difficulty speaking) • Aphasia( loss of speech) • expressive aphasia • receptive aphasia • Apraxia (inability to perform prelearned action) • Hemianopsia (loss of half of visual field)

12. Cerebrovascular Terms • Agnosia (deficit in ability to recognize previously familiar objects) • Left hemispheric stroke • RIGHT sided weakness and/or visual field defects • Right hemispheric stroke • LEFT sided weakness and/or visual field deficits

13. 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 • Symptoms resolve within 24 hours

14. Ischemic stroke • Diagnosis • Initial test for stroke is noncontrast CT to r/o hemorrhagic stroke • May also help to localize the lesion • Further workup for ischemic stroke will include attempt to identify source of thrombi or emboli • May include ECG, carotid U/S, cardiac echo, MRI. angiography • See table 58-3

15. Preventive Treatment and Secondary Prevention • Management of modifiable risk factors • Health maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease • Anticoagulant therapy • Antiplatelet therapy: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), ticlopidine (ticlid) • Statins • Antihypertensive medications • Carotid endoarterectomy and stenting

16. Carotid Endarterectomy

17. Medical Management DuringAcute Phase of Stroke • Prompt diagnosis and treatment • Antiplatelet • Statin • ACE inhibitor (thrombotic) • If cardioembolic: heparin/warfarin • Thrombolytic therapy • Criteria for tissue plasminogen activator (tPA): see Chart 62-2 • Must be administered within 3 hours of symptom onset • Dosage based on wight • Side effects: potential bleeding!

18. Medical Management DuringAcute Phase of Stroke (cont.) • Elevate HOB unless contraindicated • Maintain airway and ventilation • Provide continuous hemodynamic monitoring and neurologic assessment • Monitor for complications of therapy • Antihypertensive therapy often held unless BP is very high; correct hypotension

19. Medical Management DuringAcute Phase of Stroke (cont.) • Surgical options • Aneurysms and hemorrhage • May require clot evacuation • Aneurysm clipping or coiling • Ischemic stroke • Percutaneous procedure to “retrieve” the clot

20. The Nursing Process-Ischemic Stroke • Assessment • Focused neurologic assesment, both baseline and ongoing, especially in the acute phase • LOC, orientation, eye opening, pupil assessment, speech, motor activity, GCS • Description of present illness • Risk factors • Sensory/perception • Swallowing • Activity tolerance • Vital signs • Bowel/bladder function • Functional impairment of ADLS

21. The Nursing Process-Ischemic Stroke • Nursing Diagnosis • Impaired physical mobility • Impaired swallowing • Ineffective tissue perfusion • Ineffective airway clearance • Self-care deficit • Distrubed sensory perception • Disturbed thought processes • Impaired verbal communication • Unilateral neglect • See Nursing Care Plans - 58-1

22. The Nursing Process-Ischemic Stroke • Nursing Interventions • Maintain airway and hemodynamic status • Improving mobility and preventing joint deformities • Preventing shoulder adduction • Changing positions • Establishing and exercise program - collaborate with PT/OT • Assist in active rehabilitation program, teach use of assistive devices for mobility • Enhancing self-care • Resumption of ADLs as able • Teach patient not to neglect affected side • Assistive devices (eating, bathing, toilet, dressing)

23. The Nursing Process-Ischemic Stroke • Nursing Interventions • Managing sensory-perceptual difficulties • Approach pt. on side of intact visual field • Remind pt of other side of body (affected side) • Arrange environment to use appropriate visual field • Assist with nutrition • Assess swallowing (coughing, dribbling, intake) • Speech therapy referral • Aspiration precautions • Upright, tuck chin, may need thickened liquids • If enteral tube, reduce risk of aspiration

24. The Nursing Process-Ischemic Stroke • Nursing Interventions • Attaining bowel and bladder control • Establish voiding pattern • Treatment of constipation • High fiber, adequate fluid intake • Improving thought processes • Supportive role • Improving communication • Atmosphere conducive to communication • Do not complete patient’s thoughts • Daily schedule to help pt function despite deficits • Slow, simple instructions

25. The Nursing Process-Ischemic Stroke • Expected outcomes • Achieves improved mobility • Achieves self-care • Demonstrates improved swallowing ability • Achieves normal bowel/bladder elimination • Participates in cognitive impairment program • Demonstrates improved communication • Family members demonstrate coping mechanisms

26. 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 • Mortality may be up to 43%

27. Hemorrhagic Stroke • Intracerebral hemorrhage • Bleeding into the brain matter • Most often in patients with HTN and vascular disease • Also brain tumors and drugs (anticoagulants and stimulants) • Intracranial aneurysm • Dilation of the walls of a cerebral artery • May be due to atherosclerosis, congenital weakness, hypertensive disease, trauma, aging

28. Hemorrhagic Stroke • Arteriovenous malformations • Congenital abnormality that leads to a tangle of arteries and veins • Common in young people • Subarachnoid hemorrhage • May result from aneurysm, AVM, trauma, HTN

29. 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

30. Manifestations • Similar to ischemic stroke • Severe headache is hallmark • “worst headache ever” • Early and sudden changes in LOC • Vomiting

31. 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 • Supportive care • Bed rest with sedation • Surgical or endovascular treatment • Treatment of: • cerebral vasospasm -potential seizures • increased ICP -prevent rebleeding • Severe hypertension

32. Intracranial Aneurysms

33. 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

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

35. Collaborative Problems/Potential Complications • Vasospasm • Seizures • Hydrocephalus • Rebleeding • Hyponatremia

36. 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

37. 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

38. 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

39. 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

40. Expected Outcomes • Demonstrates intact neurologic status • Demonstrates normal sensory perceptions • Is free of complications

41. 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

42. 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 • Sexuality: gradual resumption; impotence may need to be addressed • Exercise and activities: recreation and diversion • Socialization, support groups, and community resources • National Stroke Association and American Heart Association