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Chapter 62
Management of Patients With
Cerebrovascular Disorders
Copyright © 2008 Lippincott Williams & Wilkins.
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.
• Direct and indirect costs of stroke are $53.6
billion
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Prevention
• 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 or elevated hematocrit
– Obesity
– Diabetes
– Oral contraceptive use
– Smoking and drug and alcohol abuse
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Stroke
• “Brain attack”
• Sudden loss of function resulting from a disruption
of the blood supply to a part of the brain
• Types of stroke: see Table 62-1
– Ischemic (80% to 85%)
– Hemorrhagic (15% to 20%)
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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
– Large artery thrombosis
– Small penetrating artery thrombosis
– Cardiogenic embolism
– Cryptogenic
– Other
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Pathophysiology
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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
• See Tables 62-2 and 62-3
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Cerebrovascular Terms
• Hemiplegia
• Hemiparesis
• Dysarthria
• Aphasia: expressive aphasia, receptive aphasia
• Hemianopsia
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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
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Carotid Endarterectomy
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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, dipyridamole (Persantine),
clopidogrel (Plavix), and ticlopidine (Ticlid)
• Statins
• Antihypertensive medications
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Medical Management During
Acute Phase of Stroke
• Prompt diagnosis and treatment
• Assessment of stroke: NIHSS assessment tool
• Thrombolytic therapy
– Criteria for tissue plasminogen activator (tPA):
see Chart 62-2
– IV dosage and administration
– Patient monitoring
– Side effects: potential bleeding
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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
• See the guidelines in Appendix B
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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
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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
• 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
• Care is primarily supportive
• Bed rest with sedation
• Oxygen
• Treatment of vasospasm, increased ICP,
hypertension, potential seizures, and prevention
of further bleeding
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Intracranial Aneurysms
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Nursing Process—Assessing the Patient
Recovering From an Ischemic Stroke
• Acute phase
– Ongoing/frequent monitoring of all systems including
vital signs and neurologic assessment: LOC and
motor, speech, and 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
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Nursing Process—Diagnosis of the Patient
Recovering From an Ischemic Stroke
• Impaired physical mobility
• Acute pain
• Self-care deficits
• Disturbed sensory perception
• Impaired swallowing
• Urinary incontinence
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Nursing Process—Diagnosis of the Patient
Recovering From an Ischemic Stroke
(cont.)
• Disturbed thought processes
• Impaired verbal communication
• Risk for impaired skin integrity
• Interrupted family processes
• Sexual dysfunction
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Collaborative Problems/Potential
Complications
• Decreased cerebral blood flow
• Inadequate oxygen delivery to brain
• Pneumonia
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Nursing Process—Planning Patient
Recovery After an Ischemic Stroke
• Major goals 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
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Nursing Process—Planning Patient
Recovery After an Ischemic Stroke (cont.)
• Major goals include (cont):
– Improved thought processes
– Achievement of a form of communication
– Maintenance of skin integrity
– Restoration of family functioning
– Improved sexual function
– Absence of complications
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Interventions
• Focus on the whole person
• Provide interventions to prevent complications
and to promote rehabilitation
• Provide support and encouragement
• Listen to the patient
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Improving Mobility and Preventing
Joint Deformities
• Turn and position the patient in correct alignment
every 2 hours
• Use splints
• Practice passive or active ROM 4 to 5 times day
• Position hands and fingers
• Prevent flexion contractures
• Prevent shoulder abduction
• Do not lift by flaccid shoulder
• Implement measures to prevent and treat shoulder
problems
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Positioning to Prevent Shoulder Abduction
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Prone Positioning to Help Prevent
Hip Flexion
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Improving Mobility and Preventing
Joint Deformities
• Perform passive or active ROM 4 to 5 times day
• Encourage patient to exercise unaffected side
• Establish regular exercise routine
• Use quadriceps setting and gluteal exercises
• Assist patient out of bed as soon as possible:
assess and help patient achieve balance and
move slowly
• Implement ambulation training
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Interventions
• Enhance self-care
– Set realistic goals with the patient
– Encourage personal hygiene
– Ensure that patient does not neglect the affected side
– Use assistive devices and modification of clothing
• Provide support and encouragement
• Implement strategies to enhance communication: see
Chart 62-4
• Encourage the patient with visual field loss to turn his
head and look to side
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Interventions (cont.)
• Nutrition
– Consult with speech therapist or nutritionist
– Have patient sit upright to eat, preferably
OOB
– Use chin tuck or swallowing method
– Feed thickened liquids or pureed diet
• Bowel and bladder control
– Assess and schedule voiding
– Implement measures to prevent constipation:
fiber, fluid, and toileting schedule
– Provide bowel and bladder retraining
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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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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
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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
• Exercise and activities: recreation and diversion
• Socialization, support groups, and community
resources
• See Chart 62-6
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