Cerebrovascular Disorders and Stroke

Introduction

• Cerebrovascular disorders involve pathological processes affecting blood vessels that supply the brain
• They range from acute events like stroke to chronic conditions such as aneurysms
• Nursing care focuses on minimizing brain injury, preventing complications, and facilitating rehabilitation

Stroke

• Stroke, or "brain attack," occurs when blood supply to part of the brain is disrupted
• Ischemic stroke results from blockage of a blood vessel
• Hemorrhagic stroke occurs from bleeding into brain tissue or subarachnoid space
• Risk factors include hypertension, hyperlipidemia, diabetes, smoking, and atrial fibrillation
• Manifestations depend on the area of the brain affected and can include weakness, paralysis, speech difficulties, vision problems, and altered level of consciousness

Ischemic Stroke

• Thrombotic strokes are caused by blood clots that develop in the arteries supplying the brain
• Embolic strokes occur when a blood clot forms elsewhere in the body and travels to the brain
• Transient ischemic attacks (TIAs) are temporary episodes of neurological dysfunction caused by brief interruption of blood supply

Hemorrhagic Stroke

• Intracerebral hemorrhage involves bleeding directly into the brain tissue
• Subarachnoid hemorrhage (SAH) involves bleeding into the space between the brain and surrounding membranes
• Aneurysms and arteriovenous malformations (AVMs) are common causes of SAH

Assessment and Diagnosis

• Neurological assessment includes evaluation of mental status, cranial nerve function, motor and sensory function, and reflexes
• National Institutes of Health Stroke Scale (NIHSS) is used to quantify neurological deficits
• Computed tomography (CT) scan is typically the first imaging study to rule out hemorrhage
• Magnetic resonance imaging (MRI) provides more detailed information about brain tissue
• Cerebral angiography can identify blockages or abnormalities in blood vessels

Medical Management

• Goals are to minimize brain damage and prevent complications
• Thrombolytic therapy (e.g., alteplase) can dissolve blood clots in ischemic stroke if given within a specific time window
• Endovascular procedures such as thrombectomy can remove large clots
• Control of blood pressure is critical in both ischemic and hemorrhagic stroke
• Surgical interventions may be necessary to evacuate hematomas or repair aneurysms

Nursing Management: Acute Phase

• Monitoring vital signs, neurological status, and cardiac rhythm is essential
• Maintaining airway patency and providing supplemental oxygen are priorities
• Positioning to prevent aspiration and promote venous drainage
• Managing blood pressure according to established protocols
• Administering medications as prescribed, including thrombolytics, antiplatelets, anticoagulants, and antihypertensives
• Monitoring for complications such as increased intracranial pressure, seizures, and aspiration pneumonia

Nursing Management: Rehabilitation Phase

• Focus on maximizing functional abilities and preventing complications
• Physical therapy to improve strength, balance, and mobility
• Occupational therapy to enhance fine motor skills and activities of daily living
• Speech therapy to address communication and swallowing difficulties
• Bowel and bladder training to promote continence
• Psychological support to cope with emotional and cognitive changes

Potential Complications

• Increased intracranial pressure (ICP) due to edema or hemorrhage
• Seizures resulting from brain injury
• Hydrocephalus caused by impaired cerebrospinal fluid circulation
• Vasospasm, a narrowing of blood vessels that can lead to delayed ischemia
• Dysphagia (difficulty swallowing), increasing risk of aspiration pneumonia
• Deep vein thrombosis (DVT) and pulmonary embolism due to immobility
• Pressure ulcers from prolonged bed rest
• Contractures and muscle atrophy due to paralysis

Nursing Interventions to Prevent Complications

• Frequent neurological assessments to detect changes in condition
• Elevating the head of the bed to reduce ICP
• Administering anticonvulsants as prescribed
• Monitoring for signs of vasospasm, such as worsening headache or neurological deficits
• Implementing aspiration precautions, including positioning and dietary modifications
• Applying sequential compression devices (SCDs) and administering anticoagulants to prevent DVT
• Turning and repositioning patients regularly to prevent pressure ulcers
• Performing range-of-motion exercises to maintain joint mobility

Patient Education

• Teach patients and families about stroke risk factors and prevention strategies
• Provide information about medications, including purpose, dosage, and side effects
• Educate about warning signs of stroke and the importance of seeking immediate medical attention
• Explain the rehabilitation process and the importance of adherence to therapy
• Offer resources for support groups and community services

Aneurysms and Arteriovenous Malformations (AVMs)

• Aneurysms are weakened areas in blood vessel walls that can rupture and cause SAH
• AVMs are abnormal tangles of blood vessels that can also rupture
• Diagnosis is typically made with CT angiography or MRI
• Treatment options include surgical clipping, endovascular coiling, and stereotactic radiosurgery

Nursing Care of Patients with Aneurysms and AVMs

• Monitor neurological status and vital signs
• Maintain a quiet environment to reduce stimulation
• Administer medications to prevent vasospasm and control blood pressure
• Provide comfort measures to relieve headache and neck pain
• Educate patients and families about the condition, treatment options, and potential complications

Traumatic Brain Injury

• Traumatic brain injury (TBI) occurs when an external force causes brain dysfunction
• Can result in physical, cognitive, emotional, and behavioral impairments
• Falls, motor vehicle accidents, and assaults are common causes

Concussion

• Mild TBI caused by a bump, blow, or jolt to the head
• May or may not involve loss of consciousness
• Symptoms can include headache, dizziness, confusion, and memory problems

Nursing Care of Patients with Concussion

• Monitor for signs of worsening neurological function
• Provide education about rest and avoiding activities that could cause another head injury
• Administer pain medications as prescribed
• Refer to a healthcare provider if symptoms persist or worsen

Moderate to Severe TBI

• Can result in significant neurological deficits
• May require intensive care monitoring and treatment
• Rehabilitation is often a lengthy and challenging process

Nursing Care of Patients with Moderate to Severe TBI

• Monitor neurological status and vital signs
• Maintain airway patency and provide mechanical ventilation if needed
• Manage intracranial pressure
• Prevent complications such as seizures, infections, and DVT
• Provide supportive care and emotional support to patients and families