Unit 1: Stroke: Hemorrhagic Flashcards
Hemorrhagic Stroke
bleeding into the brain
-blood is a irritant to the brain
3 Main subtypes of Hemorrhagic Stroke
- Nontraumatic Subarachnoid Hemorrhage (SAH)
- Intracerebral Hemorrhage (ICH)
- Intraventricular Hemorrhage (IVH)
Subarachnoid Hemorrhage
caused by a ruptured aneurysm (weakened blood vessel) and less commonly caused by an arteriovenous malformation (AVM; mass of arteries and veins that is not connected by a capillary network)
- sudden severe headache; “thunderclap” headache b/c intensity of the pain at onset
- neck stiffness and pain occur b/c of the irritation of the meninges, at base of skull, where pooling of blood occurs
- photosensitivity w/ meningeal irritation or inflammation
Aneurysm
weak, dilated vessel
Arteriovenous Malformation (AVM)
mass of arteries and veins that is not connected by a capillary network
Risk Factors for Subarachnoid Hemorrhage (SAH)
- hypertension
- smoking
- heavy alcohol use
- use of sympathetic nervous stimulants (cocaine)
- female gender
- hx of cerebrovascular disease
- postmenopausal state
How does a Cerebral Aneurysm Occur?
- as a result of an inherent weakness or gradually acquired weakness of the medial layer in a segment of a blood vessel; muscular layer that adds shape and tone to the vessel; a weakness in a segment of this layer causes an outpouching of the blood vessel through the outermost adventitial layer
- aneurysm ruptures in the thinnest walled portion of the aneurysm (dome)
Clinical Manifestations of Hemorrhagic Stroke
- similar to ischemic; motor deficit, visual field cuts
- severe headache
- early and sudden changes in LOC
Medical and Surgical Management
prevent and minimize complications such as aneurysm rebleeding and cerebral vasospasm (causes narrowing of blood vessel segments)
- Aneurysm clipping: aneurysms are secured by applying a titanium clip to the neck of the aneurysm or
- Aneurysm coiling: deploying platinum coils into the aneurysm during angiography; reduces blood flow to the aneurysm
- surgical evacuation of a hematoma below the tentorium b/c risk of brainstem compression
- intraventricular hemorrhage managed with CSF drainage
Complications of Hemorrhagic Stroke
- Subarachnoid Hemorrhage causes neurological and systemic complications; ischemic stroke, cerebral edema, pulmonary edema, myocardial ischemia/infarction, acute respiratory distress syndrome (ARDs)
- Vasospasm (causes change in consciousness, new focal (localized) motor weakness
- Hyponatremia
- Seizures (blood is irritant to brain)
Complications: Hyponatremia
may be caused by SIADH or by cerebral salt wasting syndrome (renal salt wasting syndrome)
Nursing Assessments
- Know the patients baseline for neurological status
- Serial neurological assessments; q 1-2 hours
- Vital Signs; q 1-2 hours or more when administering meds that alter BP
- ECG
- Serum Electrolytes
- Intake and Output
Nursing Assessments: Vital Signs
after hemorrhagic stroke, close monitoring of vital signs (BP) is necessary to prevent rebleeding or expansion of hematoma
- If BP lower than prescribed targets, there is risk of hypoperfusion
- If BP higher than prescribed targets, there is risk of increased ICP and rebleeding
Nursing Assessments: Electrocardiogram (ECG)
identification of rhythm disturbances (A-fib, ST segment, or T wave changes associated with MI) is essential in determining potential causes of stroke and intervening in complications of stroke
- after SAH, may experience myocardial stunning
- trending of 12-lead ECGs and cardiac enzymes allows identification of potential myocardial infarction and/or reversible myocardial stunning
Nursing Assessments: Electrolytes
-sodium: to identify disorders of salt and water imbalance resulting in hyponatremia, which places patients who have suffered a stroke at high risk for cerebral edema and neurological deterioration
Nursing Assessments: Intake and Output
- evaluates potential sodium and water imbalance
- approximating volume status
Nursing Interventions
- Perform bedside swallow eval
- Administer Meds as ordered
- Elevate HOB to 30 degrees
- Positioning of HOB if endovascular procedure (15 degrees then increasing gradually)
- Place feeding tube
- Aspiration precautions
- Frequent Positioning; elevate weak limbs to minimize edema
- Seizure precautions
- Administer calcium channel blocker
- often care is supportive
Nursing Interventions Specific to Hemorrhagic Stroke
- Seizure precautions (blood is irritant)
- Administer Calcium Channel Blockers
- Often care is supportive
Interventions: Perform bedside swallow screening
after a stroke, may experience swallowing dysfunction, at risk for aspiration and subsequent pneumonia
>swallowing is complex and involves structures in the brainstem, thalamus, and cerebral cortex as well as tongue and facial movements, many of which can be compromised after stroke
>cranial nerves IX, X, XI, XII contribute to swallowing and innervate the palate and pharynx, assisting in airway protection
-when these cranial nerves have been damaged, aspiration of food or fluid into the lungs can occur
Interventions: Nasogastric or Postpyloric feeding tube
- for nutrition and medication administration
- to facilitate enteral feeding to allow time for swallowing function to improve or for more formal swallowing evaluation to be completed
- if swallowing dysfunction is thought to be a long-term problem or permanent, a percutaneous endoscopically placed gastrostomy tube may be placed by surgeon or gastroenterologist
Methods to prevent aspiration
- providing supervision of the patient while eating to observe for clinical manifestations of aspiration or choking
- maintaining HOB at least 45 degrees or greater while eating or drinking
- reducing distractions to assist a patient in concentrating on eating and drinking
- advocating for evaluation of patient by SLP
- tucking the chin when swallowing
- thickening liquids with fiber additives
- prescribed therapeutic food preparation (soft or pureed)
- communicate appropriate precautions and diet to the other healthcare team members that may be involved w/ feeding the patients (PCT)
Medications prescribed for secondary stroke prevention
-Antihypertensives: used to reduce BP to prevent long-term damage from excessive shear and reduce chance of intracerebral hemorrhage
>Beta blockers (metoprolol [Lopressor])
>Calcium channel blockers (prevent vasospasm, which vasospasm constricts vessels)
>Diuretics
Metoprolol (Lopressor)
antihypertensive; beta blocker
- used to reduce BP and HR
- Side Effect: bradycardia, HF, pulmonary edema, fatigue, weakness, erectile dysfunction
- Nursing: monitor BP, EKG, and pulse frequently during dose adjustment and during therapy; monitor vital signs and EKG q 5-15 min during and for several hours after parenteral administration; if HR <40 bpm (and if cardiac output is also decreased) administer atropine IV
Calcium Channel Blockers
- antihypertensive
- dilates coronary arteries in both normal and ischemic myocardium and inhibit coronary artery spasm
- prevents vasospasm, which vasospasm constricts vessels causing high BP)
- Side Effects: constipation, dizziness, tachycardia, fatigue, flushing, nausea
Diuretics
cause diuresis and subsequent mobilization of excess fluid
- decreases BP; for hypertension
- Side Effect: dehydration electrolyte imbalances, hypovolemia
Nurse Teachings
- stroke diagnosis
- activation of EMS team
- warning S/S of stroke
- risk factors for stroke
- smoking cessation
- medications for secondary prevention of stroke
