Cerebrovascular Diseases


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Cerebrovascular Diseases

  1. 1. Management of Patients with Cerebrovascular Disorders
  2. 2. Cerebrovascular Disorders <ul><li>$53.6 Functional abnormality of the CNS that occurs when the blood supply is disrupted </li></ul><ul><li>Stroke is the primary cerebrovascular disorder and the third leading cause of death in the U.S. </li></ul><ul><li>Stroke is the leading cause of serious long-term disability in the U.S. </li></ul><ul><li>Direct and indirect costs of stroke are billion </li></ul>
  3. 3. Prevention <ul><li>Nonmodifiable risk factors </li></ul><ul><ul><li>Age (over 55), male gender, African American race </li></ul></ul><ul><li>Modifiable risk factors: see Chart 62-1 </li></ul><ul><ul><li>Hypertension: the primary risk factor </li></ul></ul><ul><ul><li>Cardiovascular disease </li></ul></ul><ul><ul><li>Elevated cholesterol or elevated hematocrit </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Oral contraceptive use </li></ul></ul><ul><ul><li>Smoking and drug and alcohol abuse </li></ul></ul>
  4. 4. Stroke <ul><li>“ Brain attack” </li></ul><ul><li>Sudden loss of function resulting from a disruption of the blood supply to a part of the brain </li></ul><ul><li>Types of stroke: see Table 62-1 </li></ul><ul><ul><li>Ischemic (80% to 85%) </li></ul></ul><ul><ul><li>Hemorrhagic (15% to 20%) </li></ul></ul>
  5. 5. Ischemic Stroke <ul><li>Disruption of the blood supply due to an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue </li></ul><ul><li>Types </li></ul><ul><ul><li>Large artery thrombosis </li></ul></ul><ul><ul><li>Small penetrating artery thrombosis </li></ul></ul><ul><ul><li>Cardiogenic embolism </li></ul></ul><ul><ul><li>Cryptogenic </li></ul></ul><ul><ul><li>Other </li></ul></ul>
  6. 6. Pathophysiology
  7. 7. Manifestations of Ischemic Stroke <ul><li>Symptoms depend upon the location and size of the affected area </li></ul><ul><li>Numbness or weakness of face, arm, or leg, especially on one side </li></ul><ul><li>Confusion or change in mental status </li></ul><ul><li>Trouble speaking or understanding speech </li></ul><ul><li>Difficulty in walking, dizziness, or loss of balance or coordination </li></ul><ul><li>Sudden, severe headache </li></ul><ul><li>Perceptual disturbances </li></ul><ul><li>See Tables 62-2 and 62-3 </li></ul>
  8. 8. Types of Paralysis
  9. 9. Abnormal Visual Fields
  10. 10. Cerebrovascular Terms <ul><li>Hemiplegia </li></ul><ul><li>Hemiparesis </li></ul><ul><li>Dysarthria </li></ul><ul><li>Aphasia: expressive aphasia, receptive aphasia </li></ul><ul><li>Hemianopsia </li></ul>
  11. 11. Transient Ischemic Attack (TIA) <ul><li>Temporary neurologic deficit resulting from a temporary impairment of blood flow </li></ul><ul><li>“ Warning of an impending stroke” </li></ul><ul><li>Diagnostic work-up is required to treat and prevent irreversible deficits </li></ul>
  12. 12. Carotid Endarterectomy
  13. 13. Carotid Endarterectomy
  14. 14. Preventive Treatment and Secondary Prevention <ul><li>Health maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease </li></ul><ul><li>Carotid endarterectomy </li></ul><ul><li>Anticoagulant therapy </li></ul><ul><li>Antiplatelet therapy: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid) </li></ul><ul><li>Statins </li></ul><ul><li>Antihypertensive medications </li></ul>
  15. 15. Medical Management During Acute Phase of Stroke <ul><li>Prompt diagnosis and treatment </li></ul><ul><li>Assessment of stroke: NIHSS assessment tool </li></ul><ul><li>Thrombolytic therapy </li></ul><ul><ul><li>Criteria for tissue plasminogen activator ( tPA): see Chart 62-2 </li></ul></ul><ul><ul><li>IV dosage and administration </li></ul></ul><ul><ul><li>Patient monitoring </li></ul></ul><ul><ul><li>Side effects: potential bleeding </li></ul></ul>
  16. 16. Medical Management During Acute Phase of Stroke (cont.) <ul><li>Elevate HOB unless contraindicated </li></ul><ul><li>Maintain airway and ventilation </li></ul><ul><li>Provide continuous hemodynamic monitoring and neurologic assessment </li></ul><ul><li>See the guidelines in Appendix B </li></ul>
  17. 17. Hemorrhagic Stroke <ul><li>Caused by bleeding into brain tissue, the ventricles, or subarachnoid space </li></ul><ul><li>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 </li></ul>
  18. 18. Hemorrhagic Stroke (cont.) <ul><li>Brain metabolism is disrupted by exposure to blood </li></ul><ul><li>ICP increases due to blood in the subarachnoid space </li></ul><ul><li>Compression or secondary ischemia from reduced perfusion and vasoconstriction injures brain tissue </li></ul>
  19. 19. Manifestations <ul><li>Similar to ischemic stroke </li></ul><ul><li>Severe headache </li></ul><ul><li>Early and sudden changes in LOC </li></ul><ul><li>Vomiting </li></ul>
  20. 20. Medical Management <ul><li>Prevention: control of hypertension </li></ul><ul><li>Diagnosis: CT scan, cerebral angiography, and lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage </li></ul><ul><li>Care is primarily supportive </li></ul><ul><li>Bed rest with sedation </li></ul><ul><li>Oxygen </li></ul><ul><li>Treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding </li></ul>
  21. 21. Intracranial Aneurysms
  22. 22. Nursing Process—Assessing the Patient Recovering From an Ischemic Stroke <ul><li>Acute phase </li></ul><ul><ul><li>Ongoing/frequent monitoring of all systems including vital signs and neurologic assessment: LOC and motor, speech, and eye symptoms </li></ul></ul><ul><ul><li>Monitor for potential complications including musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of increased ICP and meningeal irritation </li></ul></ul><ul><li>After the stroke is complete </li></ul><ul><ul><li>Focus on patient function; self-care ability, coping, and teaching needs to facilitate rehabilitation </li></ul></ul>
  23. 23. Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke <ul><li>Impaired physical mobility </li></ul><ul><li>Acute pain </li></ul><ul><li>Self-care deficits </li></ul><ul><li>Disturbed sensory perception </li></ul><ul><li>Impaired swallowing </li></ul><ul><li>Urinary incontinence </li></ul>
  24. 24. Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke (cont.) <ul><li>Disturbed thought processes </li></ul><ul><li>Impaired verbal communication </li></ul><ul><li>Risk for impaired skin integrity </li></ul><ul><li>Interrupted family processes </li></ul><ul><li>Sexual dysfunction </li></ul>
  25. 25. Collaborative Problems/Potential Complications <ul><li>Decreased cerebral blood flow </li></ul><ul><li>Inadequate oxygen delivery to brain </li></ul><ul><li>Pneumonia </li></ul>
  26. 26. Nursing Process—Planning Patient Recovery After an Ischemic Stroke <ul><li>Major goals include: </li></ul><ul><ul><li>Improved mobility </li></ul></ul><ul><ul><li>Avoidance of shoulder pain </li></ul></ul><ul><ul><li>Achievement of self-care </li></ul></ul><ul><ul><li>Relief of sensory and perceptual deprivation </li></ul></ul><ul><ul><li>Prevention of aspiration </li></ul></ul><ul><ul><li>Continence of bowel and bladder </li></ul></ul>
  27. 27. Nursing Process—Planning Patient Recovery After an Ischemic Stroke (cont.) <ul><li>Major goals include (cont): </li></ul><ul><ul><li>Improved thought processes </li></ul></ul><ul><ul><li>Achievement of a form of communication </li></ul></ul><ul><ul><li>Maintenance of skin integrity </li></ul></ul><ul><ul><li>Restoration of family functioning </li></ul></ul><ul><ul><li>Improved sexual function </li></ul></ul><ul><ul><li>Absence of complications </li></ul></ul>
  28. 28. Interventions <ul><li>Focus on the whole person </li></ul><ul><li>Provide interventions to prevent complications and to promote rehabilitation </li></ul><ul><li>Provide support and encouragement </li></ul><ul><li>Listen to the patient </li></ul>
  29. 29. Improving Mobility and Preventing Joint Deformities <ul><li>Turn and position the patient in correct alignment every 2 hours </li></ul><ul><li>Use splints </li></ul><ul><li>Practice passive or active ROM 4 to 5 times day </li></ul><ul><li>Position hands and fingers </li></ul><ul><li>Prevent flexion contractures </li></ul><ul><li>Prevent shoulder abduction </li></ul><ul><li>Do not lift by flaccid shoulder </li></ul><ul><li>Implement measures to prevent and treat shoulder problems </li></ul>
  30. 30. Positioning to Prevent Shoulder Abduction
  31. 31. Prone Positioning to Help Prevent Hip Flexion
  32. 32. Improving Mobility and Preventing Joint Deformities <ul><li>Perform passive or active ROM 4 to 5 times day </li></ul><ul><li>Encourage patient to exercise unaffected side </li></ul><ul><li>Establish regular exercise routine </li></ul><ul><li>Use quadriceps setting and gluteal exercises </li></ul><ul><li>Assist patient out of bed as soon as possible: assess and help patient achieve balance and move slowly </li></ul><ul><li>Implement ambulation training </li></ul>
  33. 33. Interventions <ul><li>Enhance self-care </li></ul><ul><ul><li>Set realistic goals with the patient </li></ul></ul><ul><ul><li>Encourage personal hygiene </li></ul></ul><ul><ul><li>Ensure that patient does not neglect the affected side </li></ul></ul><ul><ul><li>Use assistive devices and modification of clothing </li></ul></ul><ul><li>Provide support and encouragement </li></ul><ul><li>Implement strategies to enhance communication: see Chart 62-4 </li></ul><ul><li>Encourage the patient with visual field loss to turn his head and look to side </li></ul>
  34. 34. Interventions (cont.) <ul><li>Nutrition </li></ul><ul><ul><li>Consult with speech therapist or nutritionist </li></ul></ul><ul><ul><li>Have patient sit upright to eat, preferably OOB </li></ul></ul><ul><ul><li>Use chin tuck or swallowing method </li></ul></ul><ul><ul><li>Feed thickened liquids or pureed diet </li></ul></ul><ul><li>Bowel and bladder control </li></ul><ul><ul><li>Assess and schedule voiding </li></ul></ul><ul><ul><li>Implement measures to prevent constipation: fiber, fluid, and toileting schedule </li></ul></ul><ul><ul><li>Provide bowel and bladder retraining </li></ul></ul>
  35. 35. Nursing Process—Assessment of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm <ul><li>Complete an ongoing neurologic assessment: use neurologic flow chart </li></ul><ul><li>Monitor respiratory status and oxygenation </li></ul><ul><li>Monitor ICP </li></ul><ul><li>Monitor patients with intracerebral or subarachnoid hemorrhage in the ICU </li></ul><ul><li>Monitor for potential complications </li></ul><ul><li>Monitor fluid balance and laboratory data </li></ul><ul><li>Reported all changes immediately </li></ul>
  36. 36. Nursing Process—Diagnosis of the Patient With a Hemorrhagic Stroke/ Cerebral Aneurysm <ul><li>Ineffective tissue perfusion (cerebral) </li></ul><ul><li>Disturbed sensory perception </li></ul><ul><li>Anxiety </li></ul>
  37. 37. Collaborative Problems/Potential Complications <ul><li>Vasospasm </li></ul><ul><li>Seizures </li></ul><ul><li>Hydrocephalus </li></ul><ul><li>Rebleeding </li></ul><ul><li>Hyponatremia </li></ul>
  38. 38. Nursing Process—Planning Care of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm <ul><li>Goals may include: </li></ul><ul><ul><li>Improved cerebral tissue perfusion </li></ul></ul><ul><ul><li>Relief of sensory and perceptual deprivation </li></ul></ul><ul><ul><li>Relief of anxiety </li></ul></ul><ul><ul><li>Absence of complications </li></ul></ul>
  39. 39. Aneurysm Precautions <ul><li>Absolute bed rest </li></ul><ul><li>Elevate HOB 30° to promote venous drainage or keep the bed flat to increase cerebral perfusion </li></ul><ul><li>Avoid all activity that may increase ICP or BP; implement Valsalva maneuver, acute flexion, and rotation of the neck or head </li></ul><ul><li>Exhale through mouth when voiding or defecating to decrease strain </li></ul>
  40. 40. Aneurysm Precautions (cont.) <ul><li>Nurse provides all personal care and hygiene </li></ul><ul><li>Provide nonstimulating, nonstressful environment: dim lighting, no reading, no TV, and no radio </li></ul><ul><li>Prevent constipation </li></ul><ul><li>Restrict visitors </li></ul>
  41. 41. Interventions <ul><li>Relieve sensory deprivation and anxiety </li></ul><ul><li>Keep sensory stimulation to a minimum for aneurysm precautions </li></ul><ul><li>Implement reality orientation </li></ul><ul><li>Provide patient and family teaching </li></ul><ul><li>Provide support and reassurance </li></ul><ul><li>Implement seizure precautions </li></ul><ul><li>Implement strategies to regain and promote self-care and rehabilitation </li></ul>
  42. 42. Home Care and Teaching for the Patient Recovering From a Stroke <ul><li>Prevention of subsequent strokes, health promotion, and implementation of follow-up care </li></ul><ul><li>Prevention of and signs and symptoms of complications </li></ul><ul><li>Medication teaching </li></ul><ul><li>Safety measures </li></ul><ul><li>Adaptive strategies and use of assistive devices for ADLs </li></ul>
  43. 43. Home Care and Teaching for the Patient Recovering From a Stroke (cont.) <ul><li>Nutrition: diet, swallowing techniques, and tube feeding administration </li></ul><ul><li>Elimination : bowel and bladder programs and catheter use </li></ul><ul><li>Exercise and activities : recreation and diversion </li></ul><ul><li>Socialization, support groups, and community resources </li></ul><ul><li>See Chart 62-6 </li></ul>