cerebrovascular diseases
TRANSCRIPT
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