Nursing Care of Patients with Cerebrovascular Disorders PDF

Nursing Care of Patients with Cerebrovascular Disorders Nursing Process for Management of Care P. Miskin, DHSc, MScN, RN, PHN 1 Stroke ▪ Stroke: ▪ Ischemia to a part of brain ▪ Hemorrhage into brain → Hypoxic injury to the brain resulting in cell death ▪ Also known as… ▪ Brain attack ▪ Cerebrovascul...

Nursing Care of Patients with Cerebrovascular Disorders Nursing Process for Management of Care P. Miskin, DHSc, MScN, RN, PHN 1 Stroke ▪ Stroke: ▪ Ischemia to a part of brain ▪ Hemorrhage into brain → Hypoxic injury to the brain resulting in cell death ▪ Also known as… ▪ Brain attack ▪ Cerebrovascular accident ▪ Severity of loss of function varies according to location and extent of brain damage 2 Biological Basis ▪ Main physiological concepts: 1. Brain is a high energy system ▪ Needs continuous supply of O2 and glucose 2. Cranial vault is a rigid compartment ▪ No adaptive capacity ▪ Cerebral perfusion: ▪ CPP = MAP – ICP, minimally acceptable => 50 ▪ Autoregulation maintains perfusion across a wide range of BP ▪ Low CPP results in loss of autoregulation and hypoxic insult 3 Epidemiology ▪ 4th most common cause of death in the United States and Canada ▪ Leading cause of serious, long-term disability ▪ About 800,000 people have a stroke each year ▪ 15%-30% with permanent disability ▪ Lifelong change for survivor and family ▪ Huge burden on resources ▪ Most effective way to decrease the burden of stroke is prevention and teaching 4 Risk Factors Non-modifiable: ▪ Age ▪ Gender ▪ Ethnic ancestry ▪ Heredity/family history 5 Risk Factors Modifiable: ▪ Hypertension / heart disease ▪ Serum cholesterol ▪ Poor diet / obesity ▪ Sleep apnea ▪ Metabolic syndrome ▪ Lack of physical exercise ▪ Substance abuse / smoking ▪ Oral contraceptives 6 NCLEX Style Question As one of your clinical assignments, you are assisting an RN with health screening at a health fair. Which individual is at greatest risk for experiencing a stroke? a. A 46-year-old white female with hypertension and oral contraceptive use for 10 years b. A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dl c. A 42-year-old African American female with diabetes mellitus who has smoked for 30 years d. A 62-year-old African American male with hypertension who is 35 pounds overweight 7 Transient Ischemic Attack (TIA) ▪ TIA is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia ▪ Symptoms typically last < 1 hour ▪ There is no way to predict outcome ▪ 1/3 do not experience another event ▪ 1/3 have additional TIAs ▪ 1/3 progress to stroke 8 Types of Stroke ▪ Ischemic ▪ Thrombotic ▪ Embolic ▪ Hemorrhagic ▪ Intracerebral ▪ Subarachnoid 9 Stroke ▪ Shared feature of all types but extremely important for ischemic strokes! ▪ Ischemic core: ▪ Adjacent to the flow obstruction ▪ Irreversible hypoxic injury ▪ Penumbra: ▪ Adjacent to the ischemic core ▪ Hypoxic cell ▪ Potentially viable if re-perfused in time 10 Ischemic Stroke: Thrombotic ▪ Injury to a blood vessel wall and formation of a blood clot ▪ Results in narrowing or occlusion of blood vessel ▪ Most common type of stroke (60%) ▪ Often associated with HTN and DM ▪ Many times they are preceded by TIA 11 Ischemic Stroke: Embolic ▪ An embolus lodges in and occludes a cerebral artery ▪ Infarction and edema of area supplied by involved vessel ▪ 2nd most common cause of stroke ▪ Sudden onset with severe clinical manifestation ▪ Warning signs are less common ▪ Commonly recurrences 12 Lacunar Strokes ▪ Minor deficits ▪ Paralysis and sensory loss ▪ Lacunae ▪ Small, deep penetrating arteries ▪ High incidence: ▪ Chronic hypertension ▪ Elderly ▪ DIC Hemorrhagic Strokes ▪ Bleeding into ▪ Brain tissue itself ▪ Intracerebral or intraparenchymal hemorrhage ▪ Subarachnoid space or ventricles ▪ Subarachnoid or intraventricular hemorrhage 14 Hemorrhagic Stroke: Intracerebral Hemorrhage ▪ Bleeding within brain caused by rupture of a vessel ▪ Sudden onset of symptoms ▪ Progression over minutes to hours ▪ Hemorrhage occurs during activity ▪ Neurologic deficits ▪ Headache ▪ Nausea and/or vomiting ▪ Decreased levels of consciousness ▪ Hypertension ▪ Poor prognosis 15 Hemorrhagic Stroke: Subarachnoid Hemorrhage (SAH) ▪ Intracranial bleeding into cerebrospinal fluid–filled space between arachnoid and pia mater ▪ Commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse 16 Cerebral Aneurysms ▪ Majority are in Circle of Willis ▪ Incidence ↑ with age; higher in women ▪ Silent killer ▪ Loss of consciousness may / may not occur ▪ High mortality rate ▪ Survivors often suffer significant complications and deficits 17 Assessment ▪ S &S related to the location of the stroke ▪ Neural tissue destruction is the basis for neurologic dysfunction ▪ Affects many body functions ▪ Related to the artery involved and the area/half of the brain it supplies ▪ Time of the onset of symptoms /length of period of ischemia is important 18 Assessment: Motor Function ▪ Most obvious effect of stroke ▪ Include impairment of: ▪ Mobility ▪ Respiratory function ▪ Swallowing and gag reflex: ▪ Hold food! ▪ Bedside swallow screen ▪ Speech therapy referral ▪ Self-care abilities ▪ Characteristic motor deficits ▪ Loss of skilled voluntary movement = akinesia ▪ Impairment of integration of movements ▪ Alterations in muscle tone ▪ Alterations in reflexes ▪ Changes from hyporeflexia to hyperreflexia 19 Assessment: Communication ▪ Aphasia ▪ Receptive ▪ Expressive ▪ Global ▪ Dysphasia ▪ Used interchangeably with aphasia ▪ Non-fluent ▪ Fluent ▪ May experience dysarthria ▪ Disturbance in muscular control of speech ▪ Impairments may involve ▪ Pronunciation ▪ Articulation ▪ Phonation 20 Assessment: Affect ▪ Changes in affect common ▪ Emotional responses may be attenuated or exaggerated ▪ May have a significant grief response 21 Assessment: Cognition ▪ Possible impairment: ▪ Memory ▪ Judgement ▪ Deficits related to the location (hemisphere) 22 Assessment: Perception / Elimination ▪ Right sided stroke is more likely to cause problems in spatialperceptual orientation ▪ Incorrect perception of self and illness ▪ Unilateral neglect of affected side ▪ Homonymous hemianopsia ▪ Agnosia ▪ Apraxia ▪ Altered bowel / urinary elimination 23 Acute Management Any sudden onset of neurological symptoms should prompt an evaluation for stroke! ▪If in community / outpatient setting – Call 911! ▪Inpatient settings – call Rapid Response / Stroke team! ▪The clock is running! Cincinnati Pre-hospital Scale 25 Acute Management of Stroke ▪ Goals for collaborative care during the acute phase are ▪ Preserving life ▪ Preventing further brain damage ▪ Reducing disability ▪ The time of onset of symptoms is critical information! ▪ Rapid diagnosis and early intervention essential 26 ER / Unit Assessment 1 2 3 4 5 ABCDs Determine LSN (last seen normal) time! Imaging studies (CT) Definite treatment Nursing unit ▪ Baseline neurologic assessment ▪ Elevated BP is common immediately after a stroke ▪ May reflect body’s attempt to maintain cerebral perfusion ▪ Control fluid and electrolyte balance ▪ Manage ICP ▪ Prevent disability / further injury ER / Unit Assessment Assessment: Diagnostic Studies ▪ Time is the brain! ▪ Early diagnose and initiation of definite treatment ▪ Rapid assessment and triage Evaluation (10 min) Stroke team alert (15 min) ▪ Rapid access to imaging studies: ▪ ▪ ▪ ▪ Non-contrast CT MRI Echocardiography Other studies CT (25 min) CT Eval (45 min) 29 Assessment: Diagnostic Studies Ischemic stroke: Hemorrhagic stroke: ▪ Case specific treatment ▪ Assess if candidate for reperfusion treatment ▪ Reperfusion or other treatment CT Eval (45 min) Definite treatment (60 min) In patient (180 min) 30 Thrombolytic Therapy ▪ Inclusion Criteria ▪ Symptom onset 18 y.o. ▪ CT-no intracerebral hemorrhage, mass effect, densities ▪ Exclusion Criteria ▪ Stroke or head Trauma last 3 months ▪ Seizure with onset of symptoms ▪ SBP >185 or DBP>110 ▪ High risk of bleeding, Tx with IV or SubQ Heparin within 48 hrs ▪ Glucose 400; INR >1.7 ▪ Rapidly deteriorating ▪ Recent MI Thrombolytic Therapy (cont.) ▪ Thrombolytics ▪ Used to reestablish blood flow through a blocked artery to prevent cell death ▪ tPA Must be administered within 3 to 4 ½ hours of onset of clinical signs of ischemic stroke ▪ Novel agents may expand timeframe (e.g. Retaplase up to 6 hours) ▪ Neuro assessment with tpa infusion ▪ Q15 minutes during infusion ▪ Q30 minutes for next 6 hours ▪ Q1 hour until 24 hours after treatment ▪ Goal BP higher than normal ▪ Maintain BP @ < 180/105 for 24 hours ▪ Monitor for hyperglycemia Longer than 3-4.5 Hours ▪ Oxygen ▪ Supportive care ▪ Transcranial doppler study ▪ Intra arterial t-PA ▪ Mechanical retrieval: ▪ Merci Retrieval System ▪ Stent Retrieval System ▪ PTA (percutaneous balloon angioplasty) Acute Care: Post Reperfusion Post reperfusion: ▪ After the patient has stabilized and to prevent further clot formation, patients with strokes caused by thrombi and emboli may be treated with anticoagulants and platelet inhibitors ▪ ASA, ticlopidine, clopidorgel, dipyridamole ▪ Ongoing CV and neuro assessment 34 Acute Care: Hemorrhagic Stroke ▪ Same priorities as ischemic stroke ▪ Anticoagulants and platelet inhibitors are contraindicated ▪ Initial treatment focused on the control of hypertension ▪ Seizure prophylaxis is situationspecific ▪ Careful assessment and choice of definite treatment based on the presentation and cause ▪ Surgical interventions: ▪ Resection ▪ Clipping of an aneurysm ▪ Evacuation of hematomas ▪ Procedure is chosen based on cause of stroke 35 Acute Care: Hemorrhagic Stroke ▪ Hyperdynamic therapy ▪ Increase mean arterial pressure ▪ Increase cerebral perfusion ▪ Crystalloid or colloid solutions ▪ Vasospasms can be treated with calcium channel blocker nimodipine (Nimotop) 36 Health Promotion / Prevention ▪ Management of modifiable risk factors ▪ Measures to prevent development of a thrombus or embolus are used in patients at risk for stroke ▪ Antiplatelet drugs are used in patients who have had a TIA related to atherosclerosis ▪ Aspirin is most frequently used antiplatelet agent ▪ Surgical interventions for patient with TIAs from carotid disease include ▪ Carotid endarterectomy ▪ Transluminal angioplasty ▪ Stenting 37 Carotid Endarterectomy Brain Stents 38 Post-surgical Care ▪ Postoperative care is important ▪ Neurovascular assessment ▪ BP management ▪ Assessment for complications ▪ Stent occlusion ▪ Retroperitoneal hemorrhage ▪ Minimize complications at insertion site 39 Rehabilitation ▪ Primary assessment is focused on ▪ Cardiac status ▪ Respiratory status ▪ Neurologic assessment ▪ If patient is stable, obtain ▪ Description of current illness ▪ Secondary assessment includes a comprehensive neurologic examination ▪ Level of consciousness ▪ Include NIH Stroke Scale ▪ Cognition ▪ Motor abilities ▪ Special attention to symptom onset and duration, nature, and changes 40 Nursing Diagnoses / Planning ▪ NDx ▪ Decreased intracranial adaptive capacity ▪ Risk for aspiration ▪ Impaired physical mobility ▪ Impaired verbal communication ▪ Unilateral neglect ▪ Impaired swallowing ▪ Situational low self-esteem ▪ Goals: the pt will…. ▪ Maintain stable / improved LOC ▪ Attain maximum physical functioning ▪ Maximize self-care abilities / skills ▪ Maintain stable body functions ▪ Maximize communication abilities ▪ Maintain adequate nutrition ▪ Avoid complications of stroke ▪ Maintain effective personal and family coping 41 Implementation ▪ Respiratory system ▪ Management of respiratory system is a nursing priority ▪ ▪ ▪ ▪ Risk for atelectasis Risk for aspiration pneumonia Risks for airway obstruction May require endotracheal intubation and mechanical ventilation ▪ Swallow screen ▪ Speech therapy referral ▪ Cardiovascular system ▪ Goals aimed at maintaining homeostasis ▪ Many patients with stroke have decreased cardiac reserves from secondary diagnoses of cardiac disease ▪ Cardiac efficiency may be compromised ▪ Continuous assessment ▪ Prevent DVT 42 Implementation Neurologic system Monitor closely to detect changes suggesting Extension of the stroke ↑ ICP Vasospasm Recovery from stroke symptoms ▪ Musculoskeletal system ▪ Goal is to maintain optimal function ▪ Accomplished by prevention of joint contractures and muscular atrophy ▪ In acute phase, range-of-motion exercises and positioning are important ▪ Paralyzed or weak side needs special attention 43 Implementation ▪ Integumentary system ▪ Susceptible to skin breakdown related to ▪ Loss of sensation ▪ Decreased circulation ▪ Immobility ▪ Compounded by patient age, poor nutrition, dehydration, edema, and incontinence ▪ Gastrointestinal system ▪ Stress of illness contributes to a catabolic state that can interfere with recovery ▪ Constipation is most common bowel problem ▪ Prophylactic stool softeners or fiber ▪ Physical activity promotes bowel function 44 Implementation ▪ Urinary system ▪ Incontinence ▪ Promote normal bladder function ▪ Avoid use of indwelling catheters ▪ Bladder retraining program ▪ Avoid bladder overdistention ▪ Nutrition ▪ Quick assessment and treatment essential ▪ IV infusions fluid and electrolyte maintenance ▪ May require nutrition support ▪ First feeding should be approached carefully ▪ Test swallowing, chewing, gag reflex, and pocketing before beginning oral feeding ▪ Meticulous oral hygiene PC! 45 Communication / Sensorium ▪ Your role in meeting psychologic needs of patient is primarily supportive ▪ Assess patient for both ability to speak and ability to understand ▪ Speak slowly and calmly, using simple words or sentences ▪ Gestures may be used to support verbal cues ▪ Sensory-perceptual alterations ▪ Related to hemisphere of brain in which stroke occurred ▪ Visual problems may include ▪ ▪ ▪ ▪ Diplopia (double vision) Loss of the corneal reflex Ptosis (drooping eyelid) Homonymous hemianopsia 46 Gerontological Considerations Stroke is a significant cause of death and disability 66% of strokes that require hospitalization occur in adults > 65 Patient, caregiver, and family require ongoing assessment and adaptation to changing needs 47 Questions & Answers ☺ 48