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Download Chapter 62 Management of Patients With Cerebrovascular Disorders
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1 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. 2 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 3 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%) 4 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 5 Pathophysiology 6 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) 7 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 8 Comparison of Left and Right Hemispheric Strokes Left Hemispheric Stroke Right Hemispheric Stroke Paralysis or weakness on right Paralysis or weakness on left side of body side of body Right visual field deficit Left visual field deficit Aphasia (expressive, receptive, Spatial-perceptual deficits or global) Increased distractibility Altered intellectual ability Slow, cautious behavior Impulsive behavior and poor judgment Lack of awareness of deficits 9 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 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, Antihypertensive medications 12 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 13 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. 14 Manifestations Similar to ischemic stroke Severe headache Early and sudden changes in LOC Vomiting 15 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 16 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 17 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 18 Collaborative Problems/Potential Complications Decreased cerebral blood flow Inadequate oxygen delivery to brain Pneumonia 19 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 20 Interventions Focus on the whole person Provide interventions to prevent complications and to promote rehabilitation Provide support and encouragement Listen to the patient 21 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 22 Positioning to Prevent Shoulder Abduction 23 Prone Positioning to Help Prevent Hip Flexion 24 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 25 Interventions Enhancing self-care 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 26 Interventions Nutrition 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 ( )مهروسdiet Bowel and bladder control Assessment of voiding and scheduled voiding Measures to prevent constipation—fiber, fluid, toileting schedule Bowel and bladder retraining 27 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 28 Nursing Process: The Patient with a Hemorrhagic Stroke—Diagnoses Ineffective tissue perfusion (cerebral) Disturbed sensory perception Anxiety 29 Collaborative Problems/Potential Complications Vasospasm Seizures Hydrocephalus Rebleeding Hyponatremia 30 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 31 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 32 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 33 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 34
