2.2 Nursing Management of Neurological Cerebrovascular Disorders

Question 1

Cerebrovascular Disorder

Answer 1

• Umbrella term for functional abnormalities of CNS
• Stroke is the primary one and 5th leading cause of death.
  Ischemic - 80-87% of strokes
  Hemorrhagic - 13-20% of strokes

Question 2

Strokes

Answer 2

• Profound financial impact related to stroke/disability
• 7 million people alive today after stroke and costs about 33 billion in medical care and lost wages/caregiver burden
• Prevention is the key to strokes

Question 3

Non-Modifiable Risks

Answer 3

• Age, Gender, Race
• Ages 55+ are at higher risk
• Males are at higher risk
• African Americans are at higher risk

Question 4

Modifiable Risk

Answer 4

• Hypertension
• CVD
• Increased Cholesterol
• Obesity
• Diabetes
• Alcohol/Drugs/Smoking
• Woman at childbearing age who take oral contraceptives

Question 5

Categories of Ischemic Stroke

Answer 5

• 20% large artery thrombosis
• 25% small penetrating artery thrombosis
• Atrial defibrillation who develop clots in the atrium can travel to the brain
• Largest portion 30% are cryptogenic strokes (no known cause)
• 5% due to drug or cocaine use

Question 6

Origin of Stroke

Answer 6

• Plaque can develop in any large vessel

Brain, coronary arteries, vessels of legs

Question 7

Ischemic Cascade

Answer 7

• Ischemic strokes can cause a wide variety of neurological deficits depending on size, location, collateral blood flow (flow around occlusion area)
• NIHSS Scale is a stroke scale
  1-4 = Mild stroke
  5-15 = Moderate
  15-20 = Moderate/Severe
  21-42 = Severe

Question 8

Diagnostic Tests for Stroke

Answer 8

• First do a non-contrast CT scan
  (25 minutes or less of patient arriving to ER)
• Stroke alert code to alert everyone
• Monitor ABC’s
• Do they need to be intubated, what are their blood pressure and vital signs
• Keeping head of bed up will help with cerebral perfusion and airway
• Constantly monitor for changes in vital signs and neural status

Question 9

What to do during a stroke

Answer 9

• Change in level of consciousness or change in pupils
• These could be evidence of continued bleed or re-bleed or swelling of the brain
• Ischemic Stroke is treated with TA (Tissue Plasma Activator)
• Never give TA to Hemorrhagic Stroke
• If stroke onset was less than 3 hours treatment can be started (Beyond that TA may not be used)

Question 10

Assessment of Stroke

Answer 10

• First Step is assessment (Acute phase)
• Assess vital signs, level of consciousness, motor symptoms, speech, pupil changes, eyes, nose, intake and output.
• Blood pressure is important, elevation is not good, bleeding, oxygen saturation.
• Can they maintain airways

Question 11

Assessment of Stroke

Answer 11

Post Acute Phase Nursing Care

• Monitor Mental Status (motor control)
• Swallowing ability (gag reflex, aspirations, nutritional hydration, skin integrity)
• Check for numbness, mobility, paralysis, activity tolerance, bowel/bladder function.
• Make a NANDA nursing diagnoses
• Check for decreased cerebral blood flow, inadequate oxygen to the brain, risk of pneumonia, encourage patients to take deep breaths and cough every 2 hours.

Question 12

GOALS of Stroke

Answer 12

• Make sure it is measurable
• Ambulate length of hall or use walker 3 times a day
• Implement our goals by assisting patient out of bed, or teaching proper use of a cane or walker. Physical Therapy.
• Range of motion exercises every 4 hours
• Encourage patient to exercise with unaffected side with passive ROM on affected side
• Encourage person hygiene and do not neglect affected side

Question 13

GOALS of Stroke

Answer 13

• Encourage patient to turn head if there is peripheral vision loss
• Speech therapists teach swallowing and nutritional services.
• Patients should preferably sit up and out of bed to eat
• Bowel and bladder issues, we should assess schedule of voiding
• Measure fiber and fluid intake for patient and adding fiber/liquid if needed to prevent constipation.

Question 14

Evaluation of Stroke

Answer 14

• ## If goals were met we can close them out, if they were not met we should re-evaluate and change intervention

Question 15

Transient Ischemic Attack

Answer 15

• Same symptoms. Considered mini stroke or warning sign
• Temporary symptoms that last 1-2 hours.
• Sudden loss of motor/sensory/visual function
• Brain Imaging and CAT scan would still occur
• Does not show signs of ischemia or blockage
• ## These are usually warning signs and are referred to primary care doctor for plaque

Question 16

Transient Ischemic Attack

Answer 16

• They can get Ultrasound/MRI of their carotid
  The main thing for TIA is prevention
• Antihypertensive medications and ACE inhibitors.
• Frequent monitoring of neural and vital signs as well as ABC.
• Keep patients on bed rest with sedation and oxygen therapy

Question 17

Treatment of TIA

Answer 17

• Prevention include antihypertensive medications or ace inhibitors (captopril)
• Diuretics
• Antiplatelet therapy would be secondary treatment to decrease cholesterol levels
• Look for causes and risk factors and treat them to prevent future stroke.

Question 18

Hemorrhagic Stroke

Answer 18

• Rupture of blood vessel caused by uncontrolled hypertension.
• Primary injury results from bleed itself but secondary brain injury can occur related to reduced perfusion to brain

Question 19

Symptoms of Hemorrhagic Stroke

Answer 19

• Severe Headache, changes in level of consciousness or pupils, vomiting, cranial nerve deficits, speech difficulties, visual disturbances.
• Nursing diagnoses include risk of ineffective tissue perfusion, cerebral related bleeding or vasospasm, anxiety
• ## Issues of hemorrhagic strokes include re-bleeding or hematoma expansion. If hematoma expands it can exert pressure on the brain again

Question 20

Symptoms of Hemorrhagic Stroke

Answer 20

• Electrolyte imbalances such as natremia. Vasospasms are related to hyponatremia.

Question 21

Interventions of Hemorrhagic Stroke

Answer 21

• Allow brain to recover from initial insult
• Prevent and minimize risk of re-bleed
• Bed rest, sedation, antiseizure med (Dilantin) surgical treatment for aneurysm
• Seizure precautions, potential for discharge into rehab
• Can patient preform ADL’s, do they need assistive devices, education on whoever will be taking care of them.
• Shoulder pain is common with stroke patients so do not rotate shoulder. Teach caregiver about nutrition, speech therapy, swallow study.
• ## Dysphagia, thickened food

Question 22

Medical Management of Stroke

Answer 22

FAST - CT scan must be within 25 minutes of patient arriving to determine if it is ischemic or hemorrhagic.

Question 23

Nursing Mangement

Answer 23

• ABC’s, frequent neuro checks and keep head of bed up if no contraindications

Question 24

Ischemic Strokes Subtypes

Answer 24

Large Artery Thrombosis
Small Penetrating artery thrombosis
Cardiogenic Embolus (related to A-Fibrillation) 
Cryptogenic (unknown cause)
Drug use related

Question 25

TIA (Transient Ischemic Attack)

Answer 25

• Neurological symptoms similar to stroke
• Lasts 1-2 hours
• CT scan shows no evidence of stroke
• Warning signs (15% of strokes are preceded with TIA)
• Look at carotid, rule out a-fib, looking for plaque