Management of Patients with Cerebrovascular Disorders PDF

Chapter 62 Management of Patients with Cerebrovascular Disorders Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Terms Hemiplegia Hemiparesis Dysarthria Aphasia o Expressive aphasia o Receptive aphasia Hemianopsia Agnosia Copyright © 2022...

Chapter 62 Management of Patients with Cerebrovascular Disorders Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Terms Hemiplegia Hemiparesis Dysarthria Aphasia o Expressive aphasia o Receptive aphasia Hemianopsia Agnosia Copyright © 2022 Wolters Kluwer · All Rights Reserved Cerebrovascular Disorders Functional abnormality of the CNS that occurs when the blood supply to the brain is disrupted Stroke is the primary cerebrovascular disorder and the fifth leading cause of death in the United States Stroke is the leading cause of serious long-term disability in the United States Financial impact is profound Copyright © 2022 Wolters Kluwer · All Rights Reserved Risk Factors  Nonmodifiable risk factors o Age, gender, ethnicity  Modifiable risk factors o Hypertension is the primary risk factor o Cardiovascular disease o Elevated cholesterol or elevated hematocrit o Obesity o Diabetes o Oral contraceptive use o Smoking and drug and alcohol abuse Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 What is agnosia? A. Failure to recognize familiar objects perceived by the senses B. Inability to express oneself or to understand language C. Inability to perform previously learned purposeful motor acts on a voluntary basis D. Impaired ability to coordinate movement, often seen as a staggering gait or postural imbalance Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 A. Failure to recognize familiar objects perceived by the senses Rationale: Agnosia is failure to recognize familiar objects perceived by the senses. Aphasia is an inability to express oneself or to understand language. Apraxia is an inability to perform previously learned purposeful motor acts on a voluntary basis. Ataxia is an impaired ability to coordinate movement, often seen as a staggering gait or postural imbalance. Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 Is the following statement true or false? Primary prevention is the best approach to avoiding hemorrhagic and ischemic stroke. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 True Rationale: Primary prevention is the best method to avoid hemorrhagic and ischemic stroke through management of modifiable risk factors including controlling hypertension, consuming alcohol in moderation, exercise, no smoking, and managing diabetes. Copyright © 2022 Wolters Kluwer · All Rights Reserved Preventive Treatment and Secondary Prevention of TIA and Stroke Carotid endarterectomy for carotid stenosis Anticoagulant therapy for atrial fibrillation Antiplatelet therapy “Statins” Antihypertensive medications Copyright © 2022 Wolters Kluwer · All Rights Reserved Transient Ischemic Attack (TIA) Temporary neurologic deficit resulting from a temporary impairment of blood flow “Warning of an impending stroke” Diagnostic workup is required to treat and prevent irreversible deficits Copyright © 2022 Wolters Kluwer · All Rights Reserved Stroke “Brain attack” Sudden loss of function resulting from a disruption of the blood supply to a part of the brain Types of stroke: refer to Table 62-1 o Ischemic = death of tissue due to blockage o Hemorrhagic = leakage of blood into spaces Copyright © 2022 Wolters Kluwer · All Rights Reserved Ischemic Stroke Disruption of the blood supply caused by an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue Types o Large artery thrombosis o Small penetrating artery thrombosis o Cardiogenic embolism o Cryptogenic o Other Copyright © 2022 Wolters Kluwer · All Rights Reserved Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology Copyright © 2022 Wolters Kluwer · All Rights Reserved Manifestations of Ischemic Stroke Symptoms depend on 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management: Acute Phase of Stroke  Prompt diagnosis and treatment: refer to Table 62-4  Assessment of stroke: NIHSS assessment tool  Thrombolytic therapy o Criteria for tPA: refer to Chart 62-3  3-4.5 hours after LWKT based on criteria o IV dosage and administration o Patient monitoring o Side effects: potential bleeding (fall risk)  Elevate head of bed (HOB) unless contraindicated  Maintain airway and ventilation  Continuous hemodynamic monitoring and neurologic assessment Copyright © 2022 Wolters Kluwer · All Rights Reserved Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for Stroke Care  Providing supplemental oxygen if oxygen saturation is below 95%  Elevation of the head of the bed to 30 degrees to assist the patient in handling oral secretions and decrease ICP  Possible hemicraniectomy for increased ICP from brain edema in a very large stroke  Intubation with an endotracheal tube to establish a patent airway, if necessary  Continuous hemodynamic monitoring (the goals for blood pressure in the first 24 hours after a stroke remain controversial for a patient who has not received thrombolytic therapy; antihypertensive treatment may be given to lower the blood pressure by 15% if the systolic blood pressure exceeds 220 mm Hg or the diastolic blood pressure exceeds 120 mm Hg)  Frequent neurologic assessments to determine if the stroke is evolving and if other acute complications are developing (such complications may include seizures, bleeding from anticoagulation, or medication-induced bradycardia, which can result in hypotension and subsequent decreases in cardiac output and cerebral perfusion pressure)  Monitoring for the development of fever (elevated temperature in the first 24 hours after stroke has been associated with increased in-hospital mortality)  Monitoring of blood glucose and management with sliding scale insulin to keep levels in the range of 140 to 180 mg/dL Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of Ischemic Stroke: Acute Phase  Ongoing, frequent monitoring of all systems, including vital signs and neurologic assessment  LOC  Motor symptoms  Speech  Pupil changes I & O  Blood pressure maintenance  Bleeding  Oxygen saturation Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient Recovering from an Ischemic Stroke After the acute phase: o Mental status o Sensation/perception o Motor control o Swallowing ability o Nutritional and hydration status o Skin integrity o Activity tolerance o Bowel and bladder function Copyright © 2022 Wolters Kluwer · All Rights Reserved Collaborative Problems and Potential Complications of the Patient Recovering from an Ischemic Stroke Decreased cerebral blood flow Inadequate oxygen delivery to brain Pneumonia Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient Recovering from an Ischemic Stroke #1 Improving mobility and preventing joint deformities o Prevent shoulder abduction o Position the hands and fingers o Change positions—every 2 hours o Establish an exercise program  Passive or active ROM four or five times day o Prepare for ambulation  Assist patient out of bed as soon as possible Preventing shoulder pain Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient Recovering from an Ischemic Stroke #2  Enhancing self-care o Use of assistive devices and modification of clothing  Adjusting to physical changes  Assisting with nutrition o Consult with speech therapy or nutritional services o Have patient sit upright, preferably out of bed, to eat o Chin tuck or swallowing method o Use of thickened liquids or pureed diet Copyright © 2022 Wolters Kluwer · All Rights Reserved Hemorrhagic Stroke  Caused by bleeding into brain tissue, the ventricles, or subarachnoid space  May be caused by spontaneous rupture of small vessels primarily related to hypertension; subarachnoid hemorrhage caused by 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 caused by blood in the subarachnoid space  Compression or secondary ischemia from reduced perfusion and vasoconstriction causes injury to brain tissue Copyright © 2022 Wolters Kluwer · All Rights Reserved Manifestations of Hemorrhagic Stroke Similar to ischemic stroke Severe headache Early and sudden changes in LOC Vomiting Bleeding Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient with a Hemorrhagic Stroke Complete and ongoing neurologic assessment; use neurologic flow chart Altered LOC Sluggish pupillary reaction Motor and sensory dysfunction Cranial nerve deficits Speech difficulties and visual disturbance Headache and nuchal rigidity Other neurologic deficits Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of Hemorrhagic Stroke Diagnosis: CT scan, cerebral angiography, 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #3 What intervention would not be included in aspiration precautions for a patient in the acute phase of a stroke? A. Referral to speech therapy B. Have patient tuck their chin toward the chest when swallowing C. Thickened fluids or pureed diet D. Raise HOB to 30 degrees when feeding Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 D. Raise HOB to 30 degrees when feeding Rationale: Interventions to prevent aspiration include a referral to speech therapy for swallowing evaluation; having the patient tuck the chin toward the chest when swallowing to close off the trachea, preventing aspiration into the lungs; providing thickened fluids or a pureed diet; and sitting the patient at a full upright position (90 degrees) when feeding or providing fluids. The patient’s HOB should be elevated to 30 degrees at all times to prevent aspiration of secretions but would not prevent aspiration of food or fluids when feeding. Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient Recovering from an Ischemic Stroke #3  Attaining bowel and bladder control o Assessment of voiding and scheduled voiding o Measures to prevent constipation: fiber, fluid, toileting schedule  Improving thought processes  Strategies to enhance communication  Maintaining skin integrity  Improving family coping  Coping with sexual dysfunction  Monitoring and managing potential complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Collaborative Problems and Potential Complications of the Patient with a Hemorrhagic Stroke Vasospasm Seizures Hydrocephalus Rebleeding Hyponatremia Copyright © 2022 Wolters Kluwer · All Rights Reserved Planning and Goals for the Patient with a Hemorrhagic Stroke Goals may include: o Improved cerebral tissue perfusion o Relief of anxiety o The absence of complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with a Hemorrhagic Stroke #1  Optimizing cerebral tissue perfusion; implementing aneurysm precautions o Provide a nonstimulating environment, prevent increases in ICP, prevent further bleeding o Absolute bed rest with HOB 30 degrees o Avoid all activity that may increase ICP or BP; Valsalva maneuver, acute flexion or rotation of neck or head o Stool softener and mild laxatives o Nonstimulating, nonstressful environment; dim lighting, no reading, no TV, no radio o Visitors are restricted Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions of the Patient with a Hemorrhagic Stroke #2 Relieving anxiety o Keep sensory stimulation to a minimum for aneurysm precautions o Realty orientation Monitoring and managing potential complications o Seizure precautions Patient and family education o strategies to regain and promote self-care and rehabilitation Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #4 What are expected patient outcomes for a patient recovering from a hemorrhagic stroke? A. Exhibits absence of vasospasm B. Residual aphasia C. One to four seizures D. Complains of visual changes Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #4 A. Exhibits absence of vasospasm Rationale: Expected patient outcomes for a patient recovering from a hemorrhagic stroke include absence of vasospasm, no seizures, normal speech patterns, and no visual changes Copyright © 2022 Wolters Kluwer · All Rights Reserved Home Care and Education for the Patient Recovering from a Stroke  Prevention of subsequent strokes, health promotion, and follow-up care; refer to Chart 62-6  Prevention of and signs and symptoms of complications  Medication education  Safety measures  Adaptive strategies and use of assistive devices for ADLs  Nutrition: diet, swallowing techniques, tube feeding administration  Elimination: bowel and bladder programs, catheter use  Exercise and activities, recreation and diversion  Socialization, support groups, and community resources Copyright © 2022 Wolters Kluwer · All Rights Reserved Questions?? Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins