Chp. 62 CVA audio

Chapter 62 Management of Patients With Cerebrovascular Disorders : 

Chapter 62 Management of Patients With Cerebrovascular Disorders Karen Larson MBA/TM, MSN, RN

Stroke : 

Stroke Stroke occurs when there is inadequate blood flow to a part of the brain that results in death of brain cells. Also known as a brain attack Disruption of blood flow causes a sudden loss of function Strokes are the leading cause of long-term disability and the third leading cause of death in the United States Strokes are classified based on the underlying pathophysiologic findings (see Table 62-1) Ischemic (80% to 85%) Thrombotic Embolic Hemorrhagic (15% to 20%)

Prevention : 

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

Manifestations of Ischemic Stroke : 

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

Cerebrovascular Terms : 

Cerebrovascular Terms Hemiplegia Hemiparesis Dysarthria Aphasia: expressive aphasia, receptive aphasia Hemianopsia

Manifestations of Right-Brain and Left-Brain Stroke : 

Manifestations of Right-Brain and Left-Brain Stroke

Transient Ischemic Attack (TIA) : 

Transient Ischemic Attack (TIA) Temporary neurologic deficit resulting from a temporary impairment of blood flow “Warning of an impending stroke” Most TIAs resolve within 3 hours Diagnostic work-up is required to treat and prevent irreversible deficits

Preventive Treatment and Secondary Prevention (Ischemic Stroke) : 

Preventive Treatment and Secondary Prevention (Ischemic Stroke) 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

Medical Management During Acute Phase of Stroke : 

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 Elevate HOB unless contraindicated Maintain airway and ventilation Provide continuous hemodynamic monitoring and neurologic assessment See the guidelines in Appendix B

Hemorrhagic Stroke : 

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 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

Manifestations of Hemorrhagic Stroke : 

Manifestations of Hemorrhagic Stroke Similar to ischemic stroke Severe headache Early and sudden changes in LOC Vomiting

Medical Management for Hemorrhagic Stroke : 

Medical Management for Hemorrhagic Stroke 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

Assessing the Patient Recovering From an Ischemic Stroke : 

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

Planning Patient Recovery After an Ischemic Stroke : 

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 Improved thought processes Achievement of a form of communication Maintenance of skin integrity Restoration of family functioning Improved sexual function Absence of complications

Improving Mobility and Preventing Joint Deformities : 

Improving Mobility and Preventing Joint Deformities Turn and position the patient in correct alignment every 2 hours Use splints Position hands and fingers Prevent flexion contractures Prevent shoulder abduction Do not lift by flaccid shoulder Implement measures to prevent and treat shoulder problems 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

Other Nursing Interventions : 

Other Nursing 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 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

Assessment of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm : 

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 patients hemorrhagic stroke in the ICU Monitor for potential complications Monitor fluid balance and laboratory data Reported all changes immediately Goals may include: Improved cerebral tissue perfusion Relief of sensory and perceptual deprivation Relief of anxiety Absence of complications

Aneurysm Precautions : 

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 Nurse provides all personal care and hygiene Provide nonstimulating, nonstressful environment: dim lighting, no reading, no TV, and no radio Prevent constipation Restrict visitors

Nursing Interventions for Hemorrhagic Stroke : 

Nursing Interventions for Hemorrhagic Stroke 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

Teaching for the Patient Recovering From a Stroke : 

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 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