Management of Patients with Cerebrovascular Disorders: Stroke Flashcards
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
Brain Attack
National Stroke Association uses this term for a better description to convey the message of medical emergency as brain cells are dying.
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 67-1(pg 2010)
— Hemorrhagic (13%)
— Ischemic (87%)
General Pathophysiology of Strokes
- Disruption of blood flow
- Na-K pumps begins to fail
- Cells die
- Causes varying degrees of disabilities
Left hemispheric stroke:
- Paralysis or weakness on right side of body
- Right visual field deficit
- Aphasia (expressive, receptive, or global)
- Altered, intellectual ability
- Slow, cautious behavior
Right hemispheric stroke:
- Paralysis or weakness on the left side of body
- Left visual field deficit
- Spatial- perceptual deficits
- Increased distractibility
- Impulsive behavior and poor judgment
- Lack of awareness of deficits
Ischemic Stroke
- Disruption of the blood supply caused by an obstruction, usually a thrombus or embolism, related to hypertension and diabetes, that causes infarction of brain tissue.
- Often preceded by a transient, ischemic attack
- Embolic – a thrombus (afib?) from heart or elsewhere travels to cerebral vessel and lodges with rapid progression
- Penumbra region is the area around the area of infarction. This brain tissue may be salvaged as it is ischemic with timely intervention to stop the ischemic cascade. The interventions are limiting the extent of secondary brain injury; example: tissue plasminogen activator (t-PA).
Ischemic Stroke
Causes/Types
- Large artery thrombosis
- Small penetrating artery thrombosis
- Cardiogenic embolism
- Cryptogenic (no known cause)
- Other
Ischemia
- Thrombus – Thrombotic Stroke
- Most common; 50 % of all strokes
- Caused by a clot
- Embolus – Embolic stroke
Manifestations of Ischemic Stroke
- Dependent on the location of the lesion, size of the area of inadequate perfusion, and the amount of collateral blood flow.
- Numbness or weakness of face, arm, or leg, especially on one side
- Hemiplegia
- Hemiparesis
- Hemianopsia
- Apraxia
- Aphasia
- Agnosia
- Diplopia
- Dysarthria
- Loss of peripheral vision
- Confusion or change in mental status
- Difficulty in walking, dizziness, or loss of balance or coordination
- Sudden, severe headache (MORE SO HEMERAGIC STROKE)
- Perceptual disturbances
Hemiplegia
paralysis on one side of the body.
Hemiparesis
weakness of one side, or part of it
Apraxia
is the inability to perform a previously learned action
Dysarthria
difficulty speaking or dysphasia- impaired speaking
& Swallowing
Aphasia
expressive: inability to express oneself, receptive: is the inability to understand language
- expressive aphasia- Broca’s area
- receptive aphasia – Wernicke’s area
Hemianopsia
loss of half of the visual field; pts neglect one side of the body/ difficulty judging distance
Agnosia
the loss of the ability to recognize objects through a particular sensory system; it may be visual, auditory or tactile
Diplopia
double vision
Ischemic Stroke Functional recovery:
usually plateaus at 6 months
Ischemic Stroke Prevention
- Refer to Chart 67-2
- Nonmodifiable risk factors
— Age (older than 55 years), male gender, African Americans - Modifiable risk factors
— Hypertension is the primary risk factor
— Cardiovascular disease
— Elevated cholesterol or elevated hematocrit
— Obesity
— Diabetes - Oral contraceptive use
Transient Ischemic Attack (TIA)
- Temporary neurologic deficit resulting from a temporary impairment of blood flow, typically lasting 1 to 2 hours.
- Manifested by a sudden loss of motor, sensory or visual function.
- “Warning of an impending stroke”
- Diagnostic workup is required to treat and prevent irreversible deficits
Ischemic Stroke Medical Management
DX:
- Prevention: control of hypertension
- Diagnosis:
— cerebral angiography
— CT scan
—- 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
Ischemic Stroke Preventive Treatment and Secondary Prevention
- Health maintenance measures including a healthy lifestyle, not smoking, exercise, healthy diet and weight
- Carotid endarterectomy for carotid stenosis
- Anticoagulant therapy for atrial fibrillation
- Antiplatelet therapy
- “Statins”
- Antihypertensive medications
Carotid Endarterectomy
Common in carotid stenosis
An older patient is admitted to the critical care unit after a left carotid endarterectomy this morning. Which nursing assessment finding is the most important to report to the surgeon?
A. Nausea when moving in bed
B. Blood pressure of 148/86 mm Hg
C. Pain rated at 5 on a 1-10 scale
D. Increased drowsiness
D. (Decrease LOC)
Medical Management: Acute Phase of Stroke
- Prompt diagnosis and treatment: refer to Table 67-4
- Assessment of stroke: NIHSS assessment tool
- Thrombolytic therapy
— Criteria for tPA: refer to Chart 67-3
— IV dosage and administration
— Patient monitoring
— Side effects: potential bleeding - Elevate head of bed (HOB) unless contraindicated
- Maintain airway and ventilation
- Continuous hemodynamic monitoring and neurologic assessment
Stroke Diagnostics
CT scan (without contrast )
Management of Stroke
Thrombolytic (t-pa)
(Tissue plasminogen activator)
Altiplase
- Window of time for administration: < 3 Hours
- Restores perfusion by breaking down fibrin in clot
- Dosed by weight
- bolus then drip over an hour
- No blood drawn first 24 hours
NPO until ?
- Assess Gag Reflex and Ability to Swallow
(Nerves not on test) - 7-VII (facial)
- 9- IX (glossopharyngeal)
- 10- X (vagus)
- 12- XII (hypoglossal)
Post Stroke Nursing Care Priorities
Reduce ICP
- HOB elevated
- Prevent hip flexion
- BP
- Neutral head
- pCO2
— normal 35-45
— elevated CO2= vasodialator (more blood to brain)
— low CO2= constriction
- Minimal Interventions at one time
Additional Post Stroke Nursing Care
Correct positioning
- (position unaffected side down)
Preventing shoulder abduction
- (do not lift from the arms)
Prevent DVT
Nursing Process: The Patient Recovering From an Ischemic Stroke— Assessment
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
Nursing Care Post Acute Phase
After the acute phase:
- Mental status
- Sensation/perception
- Motor control
- Swallowing ability
- Nutritional and hydration status (need to heal)
- Skin integrity (turn pt)
- Activity tolerance (every 2 hours lets try to pee)
- Bowel and bladder function (stool softener)
Nursing Process: The Patient Recovering From an Ischemic Stroke—Planning
Major goals may include:
- Improved mobility
- Avoidance of shoulder pain
- Achievement of self-care
- Relief of sensory and perceptual deprivation
- Prevention of aspiration
- Continence of bowel and bladder
- Improved thought processes
- Achieving a form of communication
- Maintaining skin integrity
- Restored family functioning
- Improved sexual function
- Absence of complications
Nursing Process: The Patient Recovering From an Ischemic Stroke—Diagnoses
- Impaired physical mobility
- Acute pain
- Self-care deficits
- Impaired comfort R/T disturbed sensory perception
- Impaired swallowing
- Urinary incontinence
- Constipation
- Acute confusion
- Impaired verbal communication
- Risk for impaired skin integrity
- Interrupted family processes
- Sexual dysfunction
Hemorrhagic Stroke
- Caused by bleeding into brain tissue;
- intracerebral
- subarachnoid space (aneurysms)
- cerebral aneurysm
- or ventricles.
- May be caused by spontaneous rupture of small vessels primarily related to hypertension; (irreversible death)
— subarachnoid hemorrhage caused by a ruptured aneurysm; (linings) - 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
- Primary intracerebral hemorrhage (ICH) from a spontaneous rupture of small vessels accounts for 80 % of hemorrhagic strokes primarily caused by uncontrolled hypertension and cerebral atherosclerosis. The degenerative changes from these diseases cause rupture of the blood vessel. Bleeding due to hypertension occurs most often in deeper structures of the brain; such as basal ganglia and thalamus.
- Secondary intracerebral hemorrhage (ICH) is associated with arteriovenous malformations (AVMs), intracranial aneurysms, intracranial neoplasms, or medication related (anticoagulants, amphetamines).
- Most AVMs are caused by an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain that lacks a capillary bed. The absence of a capillary bed leads to dilation of the arteries and veins and eventually rupture. AVM is the common cause of hemorrhagic stroke in young people.
- An intracranial cerebral aneurysm is a dilation of the walls of a cerebral artery that develops over time as a result of weakness in the arterial wall. These types of lesions usually occur at the bifurcations of the large arteries at the Circle of Willis.
- Subarachnoid hemorrhage (SAH) results from a ruptured intracranial aneurysm in about 50 % of SAH.
- SAH may occur as a result of an AVM, intracranial aneurysm, trauma, or hypertension. The most common causes are a leaking aneurysm in the area of the circle of Willis or a congenital AVM.
- Normal brain metabolism is altered by the bleeding into the brain or bleeding into the subarachnoid space which compresses and injures brain tissue; or by secondary ischemia resulting from decreased perfusion and vasospasm that frequently occurs post SAH.
Primary brain injury:
Occurs at the time of the initial insult to the brain (infarct, hemorrhage, trauma)
Secondary brain injury:
Occurs over hours to days after the initial insult. (Ischemia, hypoxia, cerebral edema, ICP elevation, acidosis)
Aneurysms
Same wherever they are:
- types:
AVM – Arteriovenous Malformation
Avm: web of vessels not formed right
Bleed within that
Hemerragic stroke Manifestations
- Similar to ischemic stroke
- Severe “exploding” headache
- decrease stimulation, cluster care
- Early and sudden changes in LOC
- Vomiting* (increases ICP)
- Bleeding
Functional recovery of hemorrhagic stroke:
Slowly, usually plateaus at about 18 months
Aneurysm Precautions
- Provide a nonstimulating environment, prevent increases in ICP, prevent further bleeding:
- Absolute bed rest with HOB 30 degrees
- Avoid all activity that may increase ICP or BP; Valsalva maneuver (dont bear down), acute flexion or rotation of neck or head
- Stool softener and mild laxatives
- Nonstimulating, nonstressful environment; dim lighting, no reading, no TV, no radio
- Visitors are restricted
Collaborative Problems and Potential Complications
Strokes
- Decreased cerebral blood flow
- Inadequate oxygen delivery to brain
- Pneumonia (aspiration)
- Vasospasm
- Seizures
- Hydrocephalus (increased CSF)
- Rebleeding
- Hyponatremia (causes cerebral edema/ ICP)
Stroke Interventions
- Focus on the whole person
- Provide interventions to prevent complications and promote rehabilitation
- Provide support and encouragement
- Listen to the patient
- Prevent contractures
- Support and encouragement
- Strategies to enhance communication
- Encourage patient to turn head, look to side with visual field loss
- Relieving sensory deprivation and anxiety
- Keep sensory stimulation to a minimum for aneurysm precautions
- Realty orientation
- Patient and family education
- Support and reassurance
- Seizure precautions
- Strategies to regain and promote self-care and rehabilitation
- tuck chin when swallowing
- dont start a thickened or puréed diet w/o speech therapy
Enhancing self-care
- Set realistic goals with the patient
- Encourage personal hygiene
- Ensure that patient does not neglect the affected side
- Use of assistive devices and modification of clothing
Nutrition
- Consult with speech therapy or nutritional services
- Have patient sit upright, preferably out of bed, to eat
- Chin tuck or swallowing method
- Use of thickened liquids or pureed diet
Bowel and bladder control
- Assessment of voiding and scheduled voiding
- Measures to prevent constipation: fiber, fluid, toileting schedule
- Bowel and bladder retraining
Nursing Process: The Patient With a Hemorrhagic Stroke—Assessment
- 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
Nursing Process: The Patient With a Hemorrhagic Stroke—Diagnoses
- Risk for ineffective tissue perfusion (cerebral) related to bleeding or vasospasm
- Anxiety related to illness and/or medically imposed restrictions (aneurysm precautions)
Nursing Process: The Patient With a Hemorrhagic Stroke—Planning
Goals may include:
- Improved cerebral tissue perfusion
- Relief of anxiety
- The absence of complications
Improving Mobility and Preventing Joint Deformities
- Turn and position in correct alignment every 2 hours
- Use of splints
- Passive or active ROM four or five times day
- Positioning of hands and fingers Prevention of flexion contractures
- Prevention of shoulder abduction
- Do not lift by flaccid shoulder
- Measures to prevent and treat shoulder problems
Improving Mobility and Preventing Joint Deformities
- Encourage patient to exercise unaffected side
- Establish regular exercise routine
- Quadriceps setting and gluteal exercises
- Assist patient out of bed as soon as possible; assess and help patient achieve balance; move slowly
- Ambulation training
Home Care and Education for the Patient Recovering from a Stroke
- Prevention of subsequent strokes, health promotion, and follow-up care; refer to Chart 67-6
- 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
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
Stroke Nursing implications:
- place objects within intact field of vision
- Instruct/remind the patient to turn head in the direction of visual loss to compensate for loss of visual field
- Encourage the use of eyeglasses if available
- When educating a patient, do so within patient intact visual field
- Place objects in center of patient intact visual field
- Encourage the use of a cane or other object to identify objects in the periphery of the visual field
- Ensure that the patient driving ability is evaluated
- Explain to the patient the location of an object when placing it near the patient
- Consistently place patient care items in the same location
- Please objects within the patient’s reach on the non-affected side
- Instruct the patient to exercise and increase the strength of the unaffected side
- Encourage the patient to provide range of motion exercises to the affected side
- Provide immobilization as needed to the affected side
- Maintain body alignment in Functional position
- Exercise, unaffected limb to increase mobility, strength, and use
- Support patient during the initial ambulation phase
- Provide support of device for (walker, cane)
- Instruct the patient not to walk without assistance or supportive device
- Provide the patient with alternative methods of communicating
- Support patient and family to alleviate frustration related to difficulty in communicating
- Test the patient pharyngeal reflexes before offering food or fluids
- Assist the patient with meals
- Place food on the unaffected side of mouth
- Allow ample time to eat
Stroke: Assessment & Diagnostic
- Neurological exam with history of onset of symptoms
- CT exam initially and cerebral angiography
- MRI
- 12 lead ECG
- Carotid ultrasound
Stroke priority assessment
- Assess vital signs and neurological status by checking pupils, blood pressure
- Assess for motor changes contralateral (opposite) to site of brain cell death, visual changes, weakness, hemiparesis, numbness, loss of sensation facial drooping, tinnitus, vertigo , darkened or blurred vision, diplopia, ptosis (drooping eye), dysphagia, dysarthria, ataxia, aphasia, headache (“the worst of my life”), nausea/vomiting , loss of bowel/bladder function, changes in LOC, cognitive abilities, changes in affect or memory limitations, spatial/perceptual alterations.
- Assess for transient ischemic attacks (TIA)s
Stroke Priority, laboratory tests/diagnostics
- CT scan or MRI
- CT angiography or MR angiography
- Cardiac, carotid angiography
- Transcranial, Doppler, lumbar puncture (avoid with ICP)
Stroke Priority interventions:
- Prevention such as lifestyle changes and routine, antiplatelet therapy, anticoagulant therapy
- Acute management with oxygenation and ventilation; balance hydration: maintain perfusion without increasing ICP (maintain normal ICP <15 mmhg), assess sodium and glucose levels
- Ischemic stroke: treated with fibrolytic treatment; Keep BP < or = to 180/105; Surgery: carotid endarterectomy, transluminal angioplasty, stenting, mechanical embolus removal
- Hemorrhagic stroke: is managed by controlling hypertension and surgical evacuation of hemorrhage
- Rehabilitation includes multidisciplinary approach; physical/Occupational/speech therapy
Priority medication’s:
ATACS
- Aspirin
- Tissue plasminogen activator (tPA)
- Antihypertensive
- Clopidogrel
- Simvastatin
Tissue plasminogen activator (tPA)
- Thrombolytic
- With ischemic strokes
- 3-4.5 hours from onset of symptoms
- Monitor closely for bleeding
- Administered IV
Aspirin
- Antiplatelet
- Prevention 81-325mg/day
- Monitor for gastric bleeding
Clopidogrel
- Anti-platelet
- Hold prior to surgery or dental procedures
Simvastatin
- Antilipemic
- Control cholesterol
Antihypertensive
- Beta blocker
- ARB
Stroke prevention plan:
- Healthy diet
- Physical activity
- Stop smoking
- Manage high blood pressure
- Manage cholesterol
- Discuss an aspirin regimen or other medication’s
