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Chapter 62
Management of Patients
With Cerebrovascular
Disorders
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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.
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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%)
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Fig 58-3
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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
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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
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Pathophysiology
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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
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Fig 58-5
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Manifestations of Ischemic
Stroke
Clinical manifestations may be broadly grouped:
– Motor loss
– Communication loss
– Affect
– Perceptual disturbances
– Sensory loss
– Cognitive impairment
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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)
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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
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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
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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
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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
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Carotid Endarterectomy
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Medical Management During
Acute 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
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Medical Management During
Acute 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
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is very high; correct hypotension
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Medical Management During
Acute 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
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The Nursing ProcessIschemic 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
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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
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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)
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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
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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
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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
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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%
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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
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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
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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
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Manifestations
• Similar to ischemic stroke
• Severe headache is hallmark
– “worst headache ever”
• Early and sudden changes in LOC
• Vomiting
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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
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Intracranial Aneurysms
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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
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Nursing Process—Diagnosis of
the Patient With a Hemorrhagic
Stroke/
Cerebral Aneurysm
• Ineffective tissue perfusion
(cerebral)
• Disturbed sensory perception
• Anxiety
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Collaborative Problems/Potential
Complications
• Vasospasm
• Seizures
• Hydrocephalus
• Rebleeding
• Hyponatremia
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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
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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
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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
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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
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Expected Outcomes
• Demonstrates intact neurologic status
• Demonstrates normal sensory
perceptions
• Is free of complications
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Home Care and Teaching for the
Patient Recovering From a
Stroke
• Prevention of subsequent strokes, health
promotion, and implementation of followup care
• Prevention of and signs and symptoms
of complications
• Medication teaching
• Safety measures
• Adaptive strategies and use of assistive
devices for ADLs
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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
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