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.

3. Prevention Nonmodifiable risk factors
Age (over 55), male gender, African-American race
Modifiable risk factors
Hypertension is 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
Ischemic (80–85%)
Hemorrhagic (15–20%)

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 artery thrombosis
Cardiogenic embolism
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
loss of half of the visual field, Loss of peripheral vision, diplopia.
Cognitive Deficits (Short- and long-term memory loss, Decreased attention span, Impaired ability to concentrate
Emotional Deficits (Depression, Withdrawal, Fear, hostility, and anger, Feelings of isolation)
Cognitive Deficits: (Short- and long-term memory loss, Decreased attention span, Impaired ability to concentrate, Poor abstract reasoning, Altered judgment)
Emotional Deficits: (Loss of self-control, Emotional lability, Decreased tolerance to stressful situations, Depression, Withdrawal, Fear, hostility, and anger, Feelings of isolation)

8. Terms: Hemiplegia Hemiparesis Dysarthria (Difficulty in forming words)
Aphasia: expressive aphasia, receptive aphasia
Hemianopsia: blindness of half of the field of vision in one or both eyes
Apraxia: inability to perform previously learned purposeful motor acts on a voluntary basis

9. Comparison of Left and Right Hemispheric Strokes
Left Hemispheric Stroke
Right Hemispheric Stroke
Paralysis or weakness on right side of body
Paralysis or weakness on left side of body
Right visual field deficit
Left visual field deficit
Aphasia (expressive, receptive, or global)
Spatial-perceptual deficits Increased distractibility
Altered intellectual ability
Impulsive behavior and poor judgment
Slow, cautious behavior
Lack of awareness of deficits

10. Transient Ischemic Attack (TIA)
Temporary neurologic deficit resulting from a temporary impairment of blood flow
“Warning of an impending stroke”
Classic symptom is fleeting blindness in one eye.
Diagnostic workup is required to treat and prevent irreversible deficits

11. Carotid Endarterectomy

12. 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,
Antihypertensive medications

13. Medical Management—Acute Phase of Stroke
Prompt diagnosis and treatment
Assessment of stroke
Thrombolytic therapy
IV dosage and administration
Patient monitoring
Side effects—potential bleeding
Elevate HOB unless contraindicated
Maintain airway and ventilation
Continuous hemodynamic monitoring and neurologic assessment

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 angiopathy, arterial venous malformations, intracranial aneurysms, or medications such as anticoagulants.
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 causes injury to brain tissue.

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

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

17. Nursing Process: The Patient Recovering from an Ischemic Stroke—Assessment
Acute phase
Ongoing/frequent monitoring of all systems including vital signs and neurologic assessment—LOC, motor symptoms, speech, 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

18. Nursing Process: The Patient Recovering from an Ischemic Stroke—Diagnoses
Impaired physical mobility
Acute pain
Self-care deficits
Disturbed sensory perception
Impaired swallowing
Urinary incontinence
Disturbed thought processes
Impaired verbal communication
Risk for impaired skin integrity
Interrupted family processes
Sexual dysfunction

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

20. Nursing Process: The Patient Recovering from an Ischemic Stroke—Planning
Major goals may 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
Improved thought processes
Achieving a form of communication
Maintaining skin integrity
Restored family functioning
Improved sexual function
Absence of complications

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

22. Improving Mobility and Preventing Joint Deformities
Turn and position in correct alignment every 2 hours
Use of splints
Passive or active ROM 4–5 times day
Positioning of hands and fingers
Prevention of flexion contractures
Prevention of shoulder abduction
Do not lift by flaccid shoulder
Measures to prevent and treat shoulder proclaims

23. Positioning to Prevent Shoulder Abduction

24. Prone Positioning to Help Prevent Hip Flexion

25. Improving Mobility and Preventing Joint Deformities
Passive or active ROM 4–5 times day
Encourage patient to exercise unaffected side
Establish regular exercise routine
Quadriceps setting and gluteal exercises
Assist patient out of bed as soon as possible- assess and help patient achieve balance, move slowly
Ambulation training

26. Interventions Enhancing self-care Support and encouragement
Set realistic goals with the patient
Encourage personal hygiene
Assure that patient does not neglect the affected side
Use of assistive devices and modification of clothing
Support and encouragement
Strategies to enhance communication
Encourage patient to turn head, look to side with visual field loss

27. Interventions Nutrition Bowel and bladder control
Consult with speech therapy or nutritional services
Have patient sit upright, preferably OOB, to eat
Chin tuck or swallowing method
Use of thickened liquids or pureed (مهروس) diet
Bowel and bladder control
Assessment of voiding and scheduled voiding
Measures to prevent constipation—fiber, fluid, toileting schedule
Bowel and bladder retraining

28. Nursing Process: The Patient with a Hemorrhagic Stroke—Assessment
Complete and ongoing neurologic assessment—use neurologic flow chart
Monitor respiratory status and oxygenation
Monitoring of ICP
Patients with intracerebral or subarachnoid hemorrhage should be monitored in the ICU
Monitor for potential complications
Monitor fluid balance and laboratory data
All changes must be reported immediately

29. Nursing Process: The Patient with a Hemorrhagic Stroke—Diagnoses
Ineffective tissue perfusion (cerebral)
Disturbed sensory perception
Anxiety

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

31. Nursing Process: The Patient with a Hemorrhagic Stroke—Planning
Goals may include:
Improved cerebral tissue perfusion
Relief of sensory and perceptual deprivation
Relief of anxiety
The absence of complications

32. Aneurysm Precautions Absolute bed rest
Elevate HOB 30° to promote venous drainage or flat to increase cerebral perfusion
Avoid all activity that may increase ICP or BP; Valsalva maneuver, acute flexion or rotation of neck or head
Exhale through mouth when voiding or defecating to decrease strain
Nurse provides all personal care and hygiene
Nonstimulating, nonstressful environment; dim lighting, no reading, no TV, no radio
Prevent constipation
Visitors are restricted

33. Interventions Relieving sensory deprivation and anxiety
Keep sensory stimulation to a minimum for aneurysm precautions
Realty orientation
Patient and family teaching
Support and reassurance
Seizure precautions
Strategies to regain and promote self-care and rehabilitation

34. Home Care and Teaching for the Patient Recovering from a Stroke
Prevention of subsequent strokes, health promotion, and follow-up care
Prevention of and signs and symptoms of complications
Medication teaching
Safety measures
Adaptive strategies and use of assistive devices for ADLs
Nutrition—diet, swallowing techniques, tube feeding administration
Elimination—bowel and bladder programs, catheter use
Exercise and activities, recreation and diversion
Socialization, support groups, and community resources