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Cerebrovascular Disease
 

Cerebrovascular Disease

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    Cerebrovascular Disease Cerebrovascular Disease Presentation Transcript

    • Cerebrovascular Disease
      • Ischemic Stroke
      • Hemorrhagic Stroke
    • ISCHEMIC STROKE
      • Also known as brain attack
      • is a abrupt loss of function resulting from disrupted blood supply to a part of the brain.
    • Five Types according to causes:
      • Large artery thrombosis – are due to atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction.
      • Small penetrating artery thrombosis – affects one or more vessels and are the most common type of ischemic stroke.
      • - also known as Lacunar strokes because of the cavity that is created once the infracted brain tissue disintegrates.
      • Cardiogenic embolic strokes – are associated with cardiac dysrhythmias, usually atrial fibrillation. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting in a stroke. Emboli stroke may be prevented by the use of anticoagulant therapy in patients with atrial fibrillation.
      • Cryptogenic stroke – iatrogenic.
      • other strokes – from the use of cocaine, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.
    • Stroke Continuum: Time Course Classification
      • Transient Ischemic Attack
      • - may serve as a warning of approaching strokes
      • - greatest incidence is in the first month following the first attack.
      • - temporary episodes of neurologic dysfunction manifested by a sudden loss of motor, sensory, or visual function.
      • - last for a few seconds or minutes but no longer than 24 hours.
      • Reversible Ischemic Neurologic Deficit
      • - sign and symptoms are consistent but more distinct than a TIA
      • - last for more than 24 hours
      • - symptoms revolve in days without permanent neurologic deficits.
      • Stroke in Evolution
      • - worsening of neurologic sign and symptoms over several minutes or hours.
      • - Progressing stroke
      • Complete Stroke
      • - stabilization of the neurologic signs and symptoms
      • - indicates no further progression of hypoxic insult to the brain from this particular ischemic event.
    • Risk Factors 10. Drug abuse 9. Excessive alcohol consumption 8. Smoking 7. Use of Oral Contraceptive 6. Diabetes Mellitus 5. Elevated hematocrit 4. Genetics 4. Obesity 3. Race 3. High cholesterol levels 2. Sex 2. Cardiovascular diseases 1. Age 1. Hypertension Uncontrollable Risk Factors Controllable Risk Factors
    •  
    •  
    • Pathophysiology Occlusion of artery Dec blood flow Dec oxygenation and nutrition of brain Dec energy stores
    • Pathophysiology Open Ca channels Inc Ca, Na and Cl Dec K Inc cell death Inc glutamine and aspartate
    • Assessment
      • Motor Loss
      • Communication Loss
      • Perceptual Disturbances
      • Sensory Loss
      • Cognitive Impairment and Psychological Effects
      • - Cognitive impairment
      • - Psychological problems
    • Cooperation of Left and Right Hemispheric Stroke Lack of awareness of deficits Impulsive behavior and poor judgment Slow, cautions behavior Increase distractibility Altered intellectual ability Spatial-perceptual deficits Aphasia (expressive, receptive, or global) Left visual field loss Right visual field deficit Paralysis or weakness on left side of the body Paralysis or weakness on right side of the body Right Hemispheric Stroke Left Hemispheric Stroke
    • Diagnostic Examination
      • Non Contrast Computed Tomography scan
      • 12-lead electrocardiogram –standard test
      • Carotid ultrasound – standard test
      • Cerebral angiography
      • Transcranial Doppler flow studies
      • Transthoracic or transesophageal echocardiography
      • Magnetic resonance imaging
      • Xenon CT
      • Single photon emission CT
      • Carotid phonoangiography
      • Oculoplethysmography
      • Carotid angiography
      • Digital subtraction angiography
    • Medical Management
      • Warfarin Sodium (Coumadin)
      • Platelet-inhibiting medication
      • Aspirin
          • - most cost effective
          • - 50 mg/d
      • Dipyridamole (Persantine)
      • - 400 mg/d
      • Clopidogrel (Plavix)
      • Ticlopidine (Ticlid)
      • Thrombolytic Therapy
      • Therapy for patients with ischemic stroke not receiving t-PA
      • Endarterectomy
    • Criteria for t-PA Administration
        • 18 years of age or older
        • NIH stroke scale of 22
        • Time of onset of stroke known and is 3 hours or less
        • BP systolic < 185; diastolic of < 110
        • Not a minor stroke or rapidly resolving stroke
        • No seizure at onset of stroke
        • Not taking warfarin
        • Prothrombine time < 15 second or INR < 1.7
        • Not receiving heparin during the past 48 hours with elevated partial thromboplastin time
        • Platelet count of > 100,000
        • Blood glucose level between 50 and 400 mg/dL
        • No acute myocardial infarction
        • No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm
        • No major surgical procedures within 14 days
        • No stroke or serious head injury within 3 months
        • No gastrointestinal or urinary bleeding within last 21 days
        • Not lactating or postpartum within last 30 days.
    • Dosage and administration of t-PA administration
        • Weight the patient
        • Minimum dose is 0.9 mg/kg; maximum of 90 mg.
        • Load the 10% of the dose and is administered over 1 minute
        • The remaining dose is administered over 1 hour via a infusion pump
        • After infusion is completed, flush the line with 20 ml of normal saline solution.
        • Monitor the vital signs every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, then every hours for 16 hours.
    • Side effects
      • Bleeding at the insertion site of IVF, urinary catheter. ET tube, NGT, urine, stool, emesis, and etc.
      • Intracranial bleeding
    • Therapy for patients with ischemic stroke not receiving t-PA
      • Administer osmotic diuretics
      • Maintaining PCO2 within the range of 30-35 mmHg
      • Elevate the head of the bed
      • Intubation with an endotracheal tube, if necessary
      • Continuous hemodynamic monitoring
      • Neurologic assessment
    • Endarterectomy
        • used to manage TIAs
        • most frequently performed peripheral vascular procedure
        • removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral artery.
    • Post operative Nursing management for Endarterectomy
      • Maintain adequate blood pressure
      • Close cardiac monitoring
      • Assess neurologic status
      • Assess the cranial nerves VI, X, XI, and XII.
      • Observe fro swelling and hematoma formation.
    • Managing potential complication
      • Maintain cardiac output
      • Administer oxygenation
    • Potential Complication
        • Decrease cerebral blood flow due to increase ICP
        • Inadequate oxygen delivery to the brain
        • Pneumonia
    • NURSING PROCESS: The Patient Recovering from an Ischemic Stroke
    • Assessment
      • Change in the level of consciousness or responsiveness as evidenced by movement, resistance to change of position and response to stimulation; orientation to time, place, and person.
      • Presence or absence of voluntary and involuntary movements of the extremities; muscle tone; body posture; and position of the head.
      • Stiffness or flaccidity of the neck
      • Eye opening, comparative size of pupil and papillary reactions to light and ocular position
      • Color of the face and extremities; temperature and moisture of the skin
      • Quality and rates of pulse and respiration; arterial blood gas values as indicated, body temperature, and arterial pressure
      • Ability to speak
      • Input and output q 24 hours
      • Presence of bleeding
      • Maintain blood pressure within the desire parameters.
    • Nursing Diagnosis
      • Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
      • Acute pain (painful shoulder) related to hemiplegia and disuse
      • Self-care deficits (hygiene, toileting, grooming, and feeding) related to stroke sequelae
      • Disturbed sensory perception related to altered sensory reception, transmission, and/or integration.
      • Impaired swallowing
      • Incontinence related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating
    • Nursing Diagnosis
      • Disturbed thought processes related to brain damages, confusion, or inability to follow instructions
      • Impaired verbal communication related to brain damages
      • Risk for impaired skin integrity related to hemiparesis/hemiplegia, or decreased mobility
      • Interrupted family processes related to catastrophic illness and care giving burdens
      • Sexual dysfunction related to neurologic deficits or fear of failure
    • Planning and Goals
      • For the patient to improve mobility
      • Avoidance of shoulder pain
      • Achievement of self-care
      • Relief of sensory and visual deprivation
      • Prevention of aspiration
      • Continence of bowel and bladder
      • Improvement of thought process
      • Achieving a form of communication
      • Maintain skin integrity
      • Restore family functioning
      • Improvement in sexual functions
      • Absence of complication
    • Nursing Interventions
      • Improving mobility and preventing joint deformities
      • a. Preventing shoulder adduction
      • Assist in maintaining body alignment and prevent compressive neuropathies
      • Applying a posterior splint during sleep at night to the affected extremity.
      • Place a pillow in the axilla when there is a limited external rotation of the shoulder.
      • b. Positioning the hand and fingers
      • The hand is placed in slight supination. (palms facing upward)
      • If upper extremity is flaccid, use a volar resting splint If the extremity is spastic, use a dorsal wrist splint, instead of hand roll
      • c. Changing position
      • Change position q2 hours.
      • Place the patient in a lateral position, a pillow is placed between the legs before the patient is turned.
      • If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day.
      Nursing Interventions
      • d. Establishing an exercise program
      • Passive exercise and put through a full range in motion 4 or 5 times a day .
      • Quadriceps muscle setting and gluteal setting exercises are started early in
      • e. Preparing for ambulation
      • Use a tilt table, which slowly brings the patients.
      • Chair should be low enough
      • Use of parallel bars. A chair or wheelchair should be available if the patent suddenly becomes fatigue.
      • A three or four pronged cane
      Nursing Interventions
      • f. Preventing shoulder pain
      • The nurse should never lift the patient by flaccid shoulder or pull on the affected arm or shoulder.
      • The flaccid arm is positioned on a table or with pillows while the patient is seated.
      • The patient is instructed to interlace the finger, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward.
      • Pushing the heel of the hand firmly down on a surface is useful
      • Amitriptyline hydrochloride (Elavil)
      Nursing Interventions
      • 2. Enhancing self-care
      • As soon as the patient can sit up, personal hygiene activities are encourage.
      • Use of assistive devices
      • The family are instructed to bring clothing that are size larger than that normally worn
      • Clothing fitted with front or fide fasteners or Velcro Closure is most suitable.
      • The patient is dressed better in a seated position.
      • Keep the environment organized and uncluttered.
      • The clothing are placed on the affected side in the order in which the garments are to be put on.
      • Use a large mirror while dressing
      Nursing Interventions
      • 3. Managing sensory-perceptual difficulties
      • Approached on the side where visual perception is intact
      • All visual stimuli should be placed on this side. E.g. clock, calendar and television)
      • The patient can be taught to turn the head in the direction of the defective visual field
      • The nurse should make eye contact with the patient and draw his or her attention to the affected side
      • Stand at a position that encourage the patient
      • Increase the natural or artificial lighting in the room and provide eyeglasses.
      • Constantly remind the patient about the other side of the body.
      • Place the extremities where the patient can see them.
      Nursing Interventions
      • 4. Managing dysphagia
      • Advice to take smaller boluses of food, and taught about which foods are easier to swallow
      • The patient is initially started on a thick liquid or purred diet.
      • Having the patient sit upright position
      • Instruct to him or her to tuck the chin toward the chest as he or she swallow to prevent aspiration.
      Nursing Interventions
      • 5. Managing Tube feeding
      • Elevate the head of the bed at least 30 degrees
      • Check the position of the tube before feeding, ensuring the cuff of the tracheotomy tube is inflated.
      • Give the tube feeding slowly
      • Aspirate periodically to ensure that the feeding are passing through the gastrointestinal tract.
      Nursing Interventions
      • 6. Attaining bowel and bladder control
      • Intermittent catheterization
      • Upright posture and standing position are helpful for male patients during this aspect of rehabilitations
      Nursing Interventions
      • 7. Improving thought processes
      • Review the neuropsychological testing
      • Observes the patient’s performance and progress, gives feedback
      Nursing Interventions
      • 8. Improving communication
      • A consistent schedule, routines, and repetitions help the patient to function despite significant deficits.
      • A written copy of daily schedule, a folder of personal information, checklists, and an audiotape list help improve the patient’s memory and concentration.
      • The patient’s attention, speak slowly and keep the language of instruction consistent.
      • One instruction at a time and time to allow the patient to process what has been said.
      Nursing Interventions
      • 9. Maintaining Skin integrity
      • Frequent assessment of the skin with the emphasis on the bony areas.
      • Use specialty bed
      • Regular timing and positioning schedule
      Nursing Interventions
      • 10. Improving family coping
      • They are given information about the expected outcomes
      • Counseled the family to avoid doing for the patient those things that he or she can do.
      • Inform the family that the rehabilitation of the hemiplegic patient requires progress may be slow.
      • The family can help by approaching the patient with supportive and optimistic attitude, focusing on the abilities that remains,
      • The family should be prepared to expect occasional episodes of emotional lability.
      • Explain to the family that patient’s laughter does not necessarily mean happiness, as well as crying does not reflect sadness.
      Nursing Interventions
      • 11. Helping the patient cope with sexual dysfunction
      • Providing information, education, reassurance, how to adjust to the medication, providing counseling regarding coping skills and suggesting about alternative positions to the patient and the partner about
      Nursing Interventions
    • Evaluation:
      • The patient expected outcome may include:
      • 1. Achieve improved mobility
      • Avoids deformities (contractures and footdrop)
      • Participates in prescribed exercise program
      • Achieves sitting balance
      • Uses unaffected side to compensate for loss of function of hemiplegics side
      • 2. Report the absence of shoulder pain
      • Demonstrates shoulder mobility; exercises shoulder
      • Elevates the arms and hands at intervals
      • 3. Achieves self-care; performs hygiene care: uses adaptive equipment
      • 4. Turn head to see people or objects
      • 5. demonstrates improved swallowing ability
      • 6. Achieves normal bowel and bladder elimination
      • 7. Participates in cognitive improvement program
      • 8. demonstrates improved communication
      • 9. Maintains intact skin without breakdown
      • Demonstrates normal skin turgor
      • Participates in turning and positioning activities
      • 10. Family members demonstrate a positive attitude and coping mechanism
      • Encourage patients in exercise programs
      • Take an active part in rehabilitation process
      • Contact respite care programs or arrange for other family members to assume some responsibilities for care
      • 11. Has positive attitude regarding alternative approaches to sexual expression
      Evaluation:
    • HEMORRHAGIC STROKE
      • are caused of bleeding in the brain tissue, the ventricles, or the subarachnoid space.
    • Types of Hemorrhagic Stroke
      • Primary intracerebral hemorrhage
        • is from spontaneous rupture of small vessels accounts for approximately 80%
        • caused by uncontrolled hypertension
      • Secondary intracerebral hemorrhage
        • associated with arteriovenous malformations, intracranial aneurysms or certain medications.
    • Intracerebral Hemorrhage
      • most common in patients with hypertension and cerebral atherosclerosis because degenerative changes from these diseases caused by rupture vessel.
      • also due to certain types of arterial pathology, brain tumor, and the use of medication.
      • bleeding usually is arterial in origin and most commonly in the cerebral lobes, basal ganglia, thalamus, brain stem and cerebrum.
      • most fatal if the bleeding cause intraventricular hemorrhage
    • Intracranial (Cerebral) Aneurysms
      • dilatation of the walls of the cerebral artery that develops as a result of weakness in the arterial wall.
    • Most commonly affected by an aneurysm:
      • Internal carotid artery
      • Anterior cerebral artery
      • Anterior communicating artery
      • Posterior communicating artery
      • Posterior cerebral artery
      • Middle cerebral artery
    • Arteriovenous Malformations
      • abnormality in embryonal development that leads to a tangle of arteries and veins in the brain without a capillary bed.
      • most common in young people.
    • Subarachnoid Hemorrhage
      • may occur as a result of arteriovenous malformations
    • Pathophysiology
    • Pathophysiology Hypertension Inc pressure to the vessels Rupture of the blood vessels Bleeding
    • Pathophysiology Compression of the adjacent to the brain tissue Neuronal dysfunction
    • Clinical Manifestation:
      • sudden severe headache
      • often loss of consciousness
      • nuchal rigidity
      • visual disturbances such as diplopia, ptosis, visual loss
      • tinnitus
      • dizziness
      • hemiparesis
    • Diagnostic Findings:
      • Computed Tomography
      • Cerebral angiography – confirms the diagnosis
      • Lumbar puncture
      • Toxicology screening
      • Use of Hunt-Hess Classification of systems
    • Hunt-Hess Classification of systems Modified classification adds the following No acute meningeal/brain reaction, but with fixed neurological deficit Ia Unrupture aneurysm 0 Deep coma, decerebrate rigidity, moribund appearance Add one grade for serious systemic disease or severe vasospasm on angiography V Stupor, moderate to severe hemiparesis, early decerebrate rigidity IV Mild focal deficit, lethargy, or confusion III Cranial nerve palsy, abducens, moderate-to-severe headache, nuchal rigidity II Asymptomatic, or mild headache and slight nuchal rigidity I
    • Medical Management:
      • 1. Cerebral Hypoxia and Decrease Blood Flow
      • a. administering oxygen
      • b. maintaining the hemoglobin and hematocrit level
      • c. adequate hydration through IV fluids
      • d. avoid extreme hypertension or hypotension
      • e. treat seizures
      • 2. Vasospasm
      • a. surgery to clip aneurysm
      • b. Calcium-Channel blocker through IV administration
      • - nimopidipine
      • - verapamil
      • - nifedipine
      • c. Endovascular technique
    • Medical Management:
      • 3. Increase ICP
      • a. lumbar punctured
      • b. ventricular catheter drainage
      • c. diuretics (mannitol)
      • 4. Systemic Hypertension
      • a. antihypertensive therapy
      • - labetalol (Normodyne)
      • - nicardipine (Cardene)
      • - nitroprusside (Nitropress)
      • b. Hemodynamic monitoring
      • c. Anti-seizure agents
      • c. Stool softener
      • 5. Surgical Management
      • a. extracranial-intracranial arterial bypass
    • Post-operative complication
        • Disorientation
        • Amnesia
        • Korsokoff’s syndrome
        • Personality changes
        • GI bleeding
        • Intraoperative embolization
        • Postoperative internal artery occlusion
        • Fluid and electrolyte disturbances
    • NURSING PROCESS: The patient with a Hemorrhagic Stroke
    • Assessment
      • altered level of consciousness – early sign
      • sluggish pupillary reaction
      • motor and sensory dysfunction
      • cranial nerve deficits
      • speech difficulties and visual disturbances
      • headache and nuchal rigidity
    • Nursing Diagnosis
      • Ineffective cerebral tissue perfusion related to bleeding
      • Disturbed sensory perception related to medically imposed restrictions
      • Anxiety related to illness and/or medically imposed restrictions
    • Planning and Goals
      • Improve cerebral tissue perfusion
      • Relief of sensory and perceptual deviation
      • Relief of anxiety
      • Absence of complication
    • Nursing Intervention:
      • 1. Optimizing Cerebral Tissue Perfusion
        • Monitor neurologic deterioration
        • Check hourly the blood pressure, pulse, LOC, papillary responses and motor function. And any changes should be reported immediately
      • 2. Implementing Aneurysm Precaution
        • Provide a nonstimulating environment
        • Prevent further increase in ICP pressure
        • Bed rest
        • Provide quiet, nonstressful environment
        • Visitor are restricted (except for the family)
        • Elevate head in 15-30 degrees
        • Avoid sudden increase in blood pressure
    • Nursing Intervention:
        • Avoid vasalva maneuver, straining, forceful sneezing, pushing up in bed, acute flexion or rotation of the head and neck and cigarette smoking
        • Instruct the patient to exhale through the mouth during voiding or defecation
        • No enema are permitted
        • Dim lighting
        • Coffee and tea, unless contraindicated
        • Thigh-high elastic compression stockings or sequential compression boots
        • The nurse administers all personal care
        • External stimuli are keep in minimum.
      • 3. Relieving Sensory Deprivation and Anxiety
        • Keeping the patient well informed of the plan of care
        • Provide information and support to the family
    • Potential Complication:
      • Vasospasm
      • Seizure
      • Hydrocephalus
      • Rebleeding
    • Managing Potential Complications:
      • Vasospasm
        • Calcium-channel blocker
        • Fluid volume expanders
      • Seizure
        • Maintaining the airway
        • Prevent injury
        • Drug of choice: phenytoin (Dilantin)
      • Hydrocephalus
        • Ventriculoperitoneal shunt
        • Any change in patients responsiveness are reported immediately
      • Rebleeding
        • Monitor for initial signs of hemorrhage usually after 2 weeks of after hemorrhage
        • Administer anti-fibrinolytic agents (epsilon-aminocaproic acid) as prescribed to delay the lysis of the clot surrounding the rupture
    • Evaluation:
      • The patient is expected outcome:
      • Demonstrates intact neurologic status and normal vital signs and respiratory patterns
        • Is alert and oriented to time, place and person
        • Demonstrates normal speech patterns and intact cognitive processes
        • Demonstrate normal and equal strength, movement, and sensation of all four extremities
        • Exhibits normal deep tendon reflexes and papillary responses
      • Demonstrates normal sensory perceptions
        • States rationale for aneurysm precaution
      • Exhibits clear thought process
      • Exhibits reduced anxiety level
        • Is less restless
        • Exhibits absence of physiologic indicators of anxiety
      • Is free of complication
        • Exhibits absence of vasospasm
        • Exhibits normal vital signs and neuromuscular activity without seizures
        • Verbalizes understanding of seizure precautions
        • Exhibits normal mental status and normal motor and sensory status
      • Report no visual changes
      Evaluation: