Chapter 62 Management of Patients With Cerebrovascular Disorders

Cerebrovascular Disorders • Functional abnormality of the CNS that occurs when the blood supply is disrupted • Occurs when there is ischemia to part of the brain or hemorrage to part of the brain that results in death of brain cells • 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 Copyright © 2008 Lippincott Williams & Wilkins.

Stroke • “Brain attack”; cerebrovascular accident (CVA) • Sudden loss of function resulting from a disruption of the blood supply to a part of the brain • Types of stroke: see Table 58 -1 – Ischemic (80% to 85%) – Hemorrhagic (15% to 20%) 3 Copyright © 2008 Lippincott Williams & Wilkins.

Fig 58 -3 4 Copyright © 2008 Lippincott Williams & Wilkins.

Ischemic Stroke • Disruption of the blood supply due to an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue • Types – Thrombotic stroke (d/t thrombus formation and occlusion at atherosclerotic plaque site) – Lacunar stroke (small penetrating artery thrombosis) – Emboblic stroke (embolus lodges in and occludes a cerebral artery - esp. cardiogenic) – Other may be due to illicit drugs, coagulopathies, dissection of carotid or vertebral arteries Copyright © 2008 Lippincott Williams & Wilkins. 5

Prevention of Ischemic Stroke • 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 – Obesity – Diabetes – Oral contraceptive use – Smoking and drug and alcohol abuse – Sedentary lifestyle Copyright © 2008 Lippincott Williams & Wilkins. 6

Pathophysiology 7 Copyright © 2008 Lippincott Williams & Wilkins.

Manifestations of Ischemic Stroke • Symptoms depend upon the location and size of the affected area, amount of collateral circulation • 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 • Headache • Perceptual, visual disturbances Copyright © 2008 Lippincott Williams & Wilkins. 8

Fig 58 -5 9 Copyright © 2008 Lippincott Williams & Wilkins.

Manifestations of Ischemic Stroke • Clinical manifestations may be broadly grouped: – Motor loss – Communication loss – Affect – Perceptual disturbances – Sensory loss – Cognitive impairment 10 Copyright © 2008 Lippincott Williams & Wilkins.

Cerebrovascular Terms • Hemiplegia (paralysis of one side of body) • Hemiparesis (weakness on one side of body) • Dysarthria (difficulty speaking) • Aphasia( loss of speech) – expressive aphasia – receptive aphasia • Apraxia (inability to perform prelearned action) • Hemianopsia (loss of half of visual field) Copyright © 2008 Lippincott Williams & Wilkins. 11

Cerebrovascular Terms • Agnosia (deficit in ability to recognize previously familiar objects) • Left hemispheric stroke – RIGHT sided weakness and/or visual field defects • Right hemispheric stroke – LEFT sided weakness and/or visual field deficits 12 Copyright © 2008 Lippincott Williams & Wilkins.

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 • Symptoms resolve within 24 hours 13 Copyright © 2008 Lippincott Williams & Wilkins.

Ischemic stroke • Diagnosis – Initial test for stroke is noncontrast CT to r/o hemorrhagic stroke • May also help to localize the lesion – Further workup for ischemic stroke will include attempt to identify source of thrombi or emboli • May include ECG, carotid U/S, cardiac echo, MRI. angiography • See table 58 -3 14 Copyright © 2008 Lippincott Williams & Wilkins.

Preventive Treatment and Secondary Prevention • Management of modifiable risk factors – Health maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease • Anticoagulant therapy • Antiplatelet therapy: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), ticlopidine (ticlid) • Statins • Antihypertensive medications • Carotid endoarterectomy and stenting 15 Copyright © 2008 Lippincott Williams & Wilkins.

Carotid Endarterectomy 16 Copyright © 2008 Lippincott Williams & Wilkins.

Medical Management During Acute Phase of Stroke • Prompt diagnosis and treatment – Antiplatelet – Statin – ACE inhibitor (thrombotic) – If cardioembolic: heparin/warfarin • Thrombolytic therapy – Criteria for tissue plasminogen activator (t. PA): see Chart 62 -2 – Must be administered within 3 hours of symptom onset – Dosage based on wight Copyright © 2008 Lippincott Williams & Wilkins. 17

Medical Management During Acute Phase of Stroke (cont. ) • Elevate HOB unless contraindicated • Maintain airway and ventilation • Provide continuous hemodynamic monitoring and neurologic assessment • Monitor for complications of therapy • Antihypertensive therapy often held unless BP is 18 very high; correct hypotension Copyright © 2008 Lippincott Williams & Wilkins.

Medical Management During Acute Phase of Stroke (cont. ) • Surgical options – Aneurysms and hemorrhage • May require clot evacuation • Aneurysm clipping or coiling – Ischemic stroke • Percutaneous procedure to “retrieve” the clot 19 Copyright © 2008 Lippincott Williams & Wilkins.

The Nursing Process-Ischemic Stroke • Assessment – Focused neurologic assesment, both baseline and ongoing, especially in the acute phase • LOC, orientation, eye opening, pupil assessment, speech, motor activity, GCS – Description of present illness – Risk factors – – – Sensory/perception Swallowing Activity tolerance Vital signs Bowel/bladder function Functional impairment of ADLS Copyright © 2008 Lippincott Williams & Wilkins. 20

• The Nursing Process-Ischemic Stroke Nursing Diagnosis – – – – – Impaired physical mobility Impaired swallowing Ineffective tissue perfusion Ineffective airway clearance Self-care deficit Distrubed sensory perception Disturbed thought processes Impaired verbal communication Unilateral neglect See Nursing Care Plans - 58 -1 Copyright © 2008 Lippincott Williams & Wilkins. 21

The Nursing Process-Ischemic Stroke • Nursing Interventions – Maintain airway and hemodynamic status – Improving mobility and preventing joint deformities • • Preventing shoulder adduction Changing positions Establishing and exercise program - collaborate with PT/OT Assist in active rehabilitation program, teach use of assistive devices for mobility – Enhancing self-care • Resumption of ADLs as able • Teach patient not to neglect affected side • Assistive devices (eating, bathing, toilet, dressing) 22 Copyright © 2008 Lippincott Williams & Wilkins.

The Nursing Process-Ischemic Stroke • Nursing Interventions – Managing sensory-perceptual difficulties • Approach pt. on side of intact visual field • Remind pt of other side of body (affected side) • Arrange environment to use appropriate visual field – Assist with nutrition • Assess swallowing (coughing, dribbling, intake) • Speech therapy referral • Aspiration precautions – Upright, tuck chin, may need thickened liquids • If enteral tube, reduce risk of aspiration 23 Copyright © 2008 Lippincott Williams & Wilkins.

The Nursing Process-Ischemic Stroke • Nursing Interventions – Attaining bowel and bladder control • Establish voiding pattern • Treatment of constipation – High fiber, adequate fluid intake • Improving thought processes – Supportive role • Improving communication – – Atmosphere conducive to communication Do not complete patient’s thoughts Daily schedule to help pt function despite deficits Slow, simple instructions 24 Copyright © 2008 Lippincott Williams & Wilkins.

The Nursing Process-Ischemic Stroke • Expected outcomes – – – – Achieves improved mobility Achieves self-care Demonstrates improved swallowing ability Achieves normal bowel/bladder elimination Participates in cognitive impairment program Demonstrates improved communication Family members demonstrate coping mechanisms 25 Copyright © 2008 Lippincott Williams & Wilkins.

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 • Mortality may be up to 43% Copyright © 2008 Lippincott Williams & Wilkins. 26

Hemorrhagic Stroke • Intracerebral hemorrhage – Bleeding into the brain matter – Most often in patients with HTN and vascular disease – Also brain tumors and drugs (anticoagulants and stimulants) • Intracranial aneurysm – Dilation of the walls of a cerebral artery – May be due to atherosclerosis, congenital weakness, hypertensive disease, trauma, aging 27 Copyright © 2008 Lippincott Williams & Wilkins.

Hemorrhagic Stroke • Arteriovenous malformations – Congenital abnormality that leads to a tangle of arteries and veins – Common in young people • Subarachnoid hemorrhage – May result from aneurysm, AVM, trauma, HTN 28 Copyright © 2008 Lippincott Williams & Wilkins.

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 29 Copyright © 2008 Lippincott Williams & Wilkins.

Manifestations • Similar to ischemic stroke • Severe headache is hallmark – “worst headache

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 • Supportive care • Bed rest with sedation • Surgical or endovascular treatment • Treatment of: • cerebral vasospasm -potential seizures • increased ICP -prevent rebleeding • Severe hypertension Copyright © 2008 Lippincott Williams & Wilkins. 31

Intracranial Aneurysms 32 Copyright © 2008 Lippincott Williams & Wilkins.

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 Copyright © 2008 Lippincott Williams & Wilkins. 33

Nursing Process—Diagnosis of the Patient With a Hemorrhagic Stroke/ Cerebral Aneurysm • Ineffective tissue perfusion (cerebral) • Disturbed sensory perception • Anxiety 34 Copyright © 2008 Lippincott Williams & Wilkins.

Collaborative Problems/Potential Complications • Vasospasm • Seizures • Hydrocephalus • Rebleeding • Hyponatremia 35

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 36 Copyright © 2008 Lippincott Williams & Wilkins.

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 37 Copyright © 2008 Lippincott Williams & Wilkins.

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 Copyright © 2008 Lippincott Williams & Wilkins. 38

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 39 Copyright © 2008 Lippincott Williams & Wilkins.

Expected Outcomes • Demonstrates intact neurologic status • Demonstrates normal sensory perceptions • Is

Home Care and Teaching for the Patient Recovering From a Stroke • Prevention of subsequent strokes, health promotion, and implementation of followup care • Prevention of and signs and symptoms of complications • Medication teaching • Safety measures • Adaptive strategies and use of assistive devices for ADLs 41 Copyright © 2008 Lippincott Williams & Wilkins.

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 • Sexuality: gradual resumption; impotence may need to be addressed • Exercise and activities: recreation and diversion • Socialization, support groups, and community resources – National Stroke Association and American Heart Association Copyright © 2008 Lippincott Williams & Wilkins. 42