Cerebrovascular Disease

Cerebrovascular Disease

Ischemic StrokeHemorrhagic Stroke

ISCHEMIC STROKE

Also known as brain attack is a abrupt loss of function resulting from

disrupted blood supply to a part of the brain.

Five Types according to causes:

Large artery thrombosis – are due to atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction.

Small penetrating artery thrombosis – affects one or more vessels and are the most common type of ischemic stroke.

- also known as Lacunar strokes because of the cavity that is created once the infracted brain tissue disintegrates.

Cardiogenic embolic strokes – are associated with cardiac dysrhythmias, usually atrial fibrillation. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting in a stroke. Emboli stroke may be prevented by the use of anticoagulant therapy in patients with atrial fibrillation.

Cryptogenic stroke – iatrogenic.

other strokes – from the use of cocaine, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.

Stroke Continuum: Time Course Classification

Transient Ischemic Attack- may serve as a warning of approaching strokes- greatest incidence is in the first month following the first attack. - temporary episodes of neurologic dysfunction manifested by a sudden loss of motor, sensory, or visual function. - last for a few seconds or minutes but no longer than 24 hours.

Reversible Ischemic Neurologic Deficit- sign and symptoms are consistent but more distinct than a TIA- last for more than 24 hours- symptoms revolve in days without permanent neurologic deficits.

Stroke in Evolution- worsening of neurologic sign and symptoms over several minutes or hours.- Progressing stroke

Complete Stroke- stabilization of the neurologic signs and symptoms - indicates no further progression of hypoxic insult to the brain from this particular ischemic event.

Risk Factors

Controllable Risk Factors Uncontrollable Risk Factors 1. Hypertension 1. Age

2. Cardiovascular diseases 2. Sex

3. High cholesterol levels 3. Race

4. Obesity 4. Genetics

5. Elevated hematocrit

6. Diabetes Mellitus

7. Use of Oral Contraceptive

8. Smoking

9. Excessive alcohol consumption

10. Drug abuse

Pathophysiology

Occlusion of artery

Dec blood flow

Dec oxygenation and nutrition of brain

Dec energy stores

Pathophysiology

Open Ca channels

Inc Ca, Na and Cl Dec K

Inc cell death

Inc glutamine and aspartate

Assessment

Motor Loss Communication Loss Perceptual Disturbances Sensory Loss Cognitive Impairment and Psychological

Effects- Cognitive impairment - Psychological problems

Cooperation of Left and Right Hemispheric Stroke

Left Hemispheric Stroke Right Hemispheric Stroke

Paralysis or weakness on right side of the body

Paralysis or weakness on left side of the body

Right visual field deficit Left visual field loss

Aphasia (expressive, receptive, or global)

Spatial-perceptual deficits

Altered intellectual ability Increase distractibility

Slow, cautions behavior Impulsive behavior and poor judgment

Lack of awareness of deficits

Diagnostic Examination

Non Contrast Computed Tomography scan 12-lead electrocardiogram –standard test Carotid ultrasound – standard test Cerebral angiography Transcranial Doppler flow studies Transthoracic or transesophageal echocardiography Magnetic resonance imaging Xenon CT Single photon emission CT Carotid phonoangiography Oculoplethysmography Carotid angiography Digital subtraction angiography

Medical Management

Warfarin Sodium (Coumadin) Platelet-inhibiting medication

Aspirin - most cost effective- 50 mg/d

Dipyridamole (Persantine)- 400 mg/d

Clopidogrel (Plavix)Ticlopidine (Ticlid)

Thrombolytic Therapy Therapy for patients with ischemic stroke not receiving t-PA Endarterectomy

Criteria for t-PA Administration

– 18 years of age or older– NIH stroke scale of 22– Time of onset of stroke known and is 3 hours or less– BP systolic < 185; diastolic of < 110– Not a minor stroke or rapidly resolving stroke– No seizure at onset of stroke – Not taking warfarin– Prothrombine time < 15 second or INR < 1.7– Not receiving heparin during the past 48 hours with elevated partial thromboplastin

time– Platelet count of > 100,000– Blood glucose level between 50 and 400 mg/dL– No acute myocardial infarction– No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm– No major surgical procedures within 14 days– No stroke or serious head injury within 3 months– No gastrointestinal or urinary bleeding within last 21 days– Not lactating or postpartum within last 30 days.

Dosage and administrationof t-PA administration

– Weight the patient– Minimum dose is 0.9 mg/kg; maximum of 90 mg. – Load the 10% of the dose and is administered over 1

minute– The remaining dose is administered over 1 hour via a

infusion pump– After infusion is completed, flush the line with 20 ml of

normal saline solution.– Monitor the vital signs every 15 minutes for the first 2 hours,

every 30 minutes for the next 6 hours, then every hours for 16 hours.

Side effects

Bleeding at the insertion site of IVF, urinary catheter. ET tube, NGT, urine, stool, emesis, and etc.

Intracranial bleeding

Therapy for patients with ischemic stroke not receiving t-PA

Administer osmotic diuretics Maintaining PCO2 within the range of 30-35

mmHg Elevate the head of the bed Intubation with an endotracheal tube, if

necessary Continuous hemodynamic monitoring Neurologic assessment

Endarterectomy

– used to manage TIAs– most frequently performed peripheral vascular

procedure– removal of an atherosclerotic plaque or thrombus

from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral artery.

Post operative Nursing management for Endarterectomy

Maintain adequate blood pressure Close cardiac monitoring Assess neurologic status Assess the cranial nerves VI, X, XI, and XII. Observe fro swelling and hematoma

formation.

Managing potential complication

Maintain cardiac output Administer oxygenation

Potential Complication

– Decrease cerebral blood flow due to increase ICP

– Inadequate oxygen delivery to the brain– Pneumonia

NURSING PROCESS: The Patient Recovering from an Ischemic Stroke

Assessment

Change in the level of consciousness or responsiveness as evidenced by movement, resistance to change of position and response to stimulation; orientation to time, place, and person.

Presence or absence of voluntary and involuntary movements of the extremities; muscle tone; body posture; and position of the head.

Stiffness or flaccidity of the neck Eye opening, comparative size of pupil and papillary reactions to light and

ocular position Color of the face and extremities; temperature and moisture of the skin Quality and rates of pulse and respiration; arterial blood gas values as

indicated, body temperature, and arterial pressure Ability to speak Input and output q 24 hours Presence of bleeding Maintain blood pressure within the desire parameters.

Nursing Diagnosis

Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury

Acute pain (painful shoulder) related to hemiplegia and disuse Self-care deficits (hygiene, toileting, grooming, and feeding)

related to stroke sequelae Disturbed sensory perception related to altered sensory

reception, transmission, and/or integration. Impaired swallowing Incontinence related to flaccid bladder, detrusor instability,

confusion, or difficulty in communicating

Nursing Diagnosis

Disturbed thought processes related to brain damages, confusion, or inability to follow instructions

Impaired verbal communication related to brain damages

Risk for impaired skin integrity related to hemiparesis/hemiplegia, or decreased mobility

Interrupted family processes related to catastrophic illness and care giving burdens

Sexual dysfunction related to neurologic deficits or fear of failure

Planning and Goals

For the patient to improve mobility Avoidance of shoulder pain Achievement of self-care Relief of sensory and visual deprivation Prevention of aspiration Continence of bowel and bladder Improvement of thought process Achieving a form of communication Maintain skin integrity Restore family functioning Improvement in sexual functions Absence of complication

Nursing Interventions

1. Improving mobility and preventing joint deformities a. Preventing shoulder adduction

Assist in maintaining body alignment and prevent compressive neuropathies

Applying a posterior splint during sleep at night to the affected extremity.

Place a pillow in the axilla when there is a limited external rotation of the shoulder.

b. Positioning the hand and fingers

The hand is placed in slight supination. (palms facing upward) If upper extremity is flaccid, use a volar resting splint If the

extremity is spastic, use a dorsal wrist splint, instead of hand roll

c. Changing position

Change position q2 hours. Place the patient in a lateral position, a pillow is placed

between the legs before the patient is turned. If possible, the patient is placed in a prone position for 15 to

30 minutes several times a day.


d. Establishing an exercise program

Passive exercise and put through a full range in motion 4 or 5 times a day .

Quadriceps muscle setting and gluteal setting exercises are started early in

e. Preparing for ambulation

Use a tilt table, which slowly brings the patients. Chair should be low enough Use of parallel bars. A chair or wheelchair should be available

if the patent suddenly becomes fatigue. A three or four pronged cane


f. Preventing shoulder pain

The nurse should never lift the patient by flaccid shoulder or pull on the affected arm or shoulder.

The flaccid arm is positioned on a table or with pillows while the patient is seated.

The patient is instructed to interlace the finger, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward.

Pushing the heel of the hand firmly down on a surface is useful Amitriptyline hydrochloride (Elavil)


2. Enhancing self-care As soon as the patient can sit up, personal hygiene activities

are encourage. Use of assistive devices The family are instructed to bring clothing that are size larger

than that normally worn Clothing fitted with front or fide fasteners or Velcro Closure is

most suitable. The patient is dressed better in a seated position. Keep the environment organized and uncluttered. The clothing are placed on the affected side in the order in

which the garments are to be put on. Use a large mirror while dressing


3. Managing sensory-perceptual difficulties Approached on the side where visual perception is intact All visual stimuli should be placed on this side. E.g. clock,

calendar and television) The patient can be taught to turn the head in the direction of

the defective visual field The nurse should make eye contact with the patient and draw

his or her attention to the affected side Stand at a position that encourage the patient Increase the natural or artificial lighting in the room and provide

eyeglasses. Constantly remind the patient about the other side of the body. Place the extremities where the patient can see them.


4. Managing dysphagia Advice to take smaller boluses of food, and taught

about which foods are easier to swallow The patient is initially started on a thick liquid or

purred diet. Having the patient sit upright position Instruct to him or her to tuck the chin toward the

chest as he or she swallow to prevent aspiration.


5. Managing Tube feeding Elevate the head of the bed at least 30 degrees Check the position of the tube before feeding,

ensuring the cuff of the tracheotomy tube is inflated. Give the tube feeding slowly Aspirate periodically to ensure that the feeding are

passing through the gastrointestinal tract.


6. Attaining bowel and bladder control Intermittent catheterization Upright posture and standing position are helpful for

male patients during this aspect of rehabilitations


7. Improving thought processes Review the neuropsychological testing Observes the patient’s performance and progress,

gives feedback


8. Improving communication A consistent schedule, routines, and repetitions help

the patient to function despite significant deficits. A written copy of daily schedule, a folder of personal

information, checklists, and an audiotape list help improve the patient’s memory and concentration.

The patient’s attention, speak slowly and keep the language of instruction consistent.

One instruction at a time and time to allow the patient to process what has been said.


9. Maintaining Skin integrity Frequent assessment of the skin with the emphasis

on the bony areas. Use specialty bed Regular timing and positioning schedule


10. Improving family coping They are given information about the expected outcomes Counseled the family to avoid doing for the patient those

things that he or she can do. Inform the family that the rehabilitation of the hemiplegic

patient requires progress may be slow. The family can help by approaching the patient with supportive

and optimistic attitude, focusing on the abilities that remains, The family should be prepared to expect occasional episodes

of emotional lability. Explain to the family that patient’s laughter does not

necessarily mean happiness, as well as crying does not reflect sadness.


11. Helping the patient cope with sexual dysfunction Providing information, education, reassurance, how

to adjust to the medication, providing counseling regarding coping skills and suggesting about alternative positions to the patient and the partner about


Evaluation:

The patient expected outcome may include:

1. Achieve improved mobility Avoids deformities (contractures and footdrop) Participates in prescribed exercise program Achieves sitting balance Uses unaffected side to compensate for loss of function of hemiplegics side2. Report the absence of shoulder pain Demonstrates shoulder mobility; exercises shoulder Elevates the arms and hands at intervals3. Achieves self-care; performs hygiene care: uses adaptive equipment4. Turn head to see people or objects5. demonstrates improved swallowing ability6. Achieves normal bowel and bladder elimination

7. Participates in cognitive improvement program8. demonstrates improved communication9. Maintains intact skin without breakdown Demonstrates normal skin turgor Participates in turning and positioning activities

10. Family members demonstrate a positive attitude and coping mechanism Encourage patients in exercise programs Take an active part in rehabilitation process Contact respite care programs or arrange for other family members to

assume some responsibilities for care

11. Has positive attitude regarding alternative approaches to sexual expression

Evaluation:

HEMORRHAGIC STROKE

are caused of bleeding in the brain tissue, the ventricles, or the subarachnoid space.

Types of Hemorrhagic Stroke

Primary intracerebral hemorrhage– is from spontaneous rupture of small vessels

accounts for approximately 80%– caused by uncontrolled hypertension

Secondary intracerebral hemorrhage– associated with arteriovenous malformations,

intracranial aneurysms or certain medications.

Intracerebral Hemorrhage

most common in patients with hypertension and cerebral atherosclerosis because degenerative changes from these diseases caused by rupture vessel.

also due to certain types of arterial pathology, brain tumor, and the use of medication.

bleeding usually is arterial in origin and most commonly in the cerebral lobes, basal ganglia, thalamus, brain stem and cerebrum.

most fatal if the bleeding cause intraventricular hemorrhage

Intracranial (Cerebral) Aneurysms

dilatation of the walls of the cerebral artery that develops as a result of weakness in the arterial wall.

Most commonly affected by an aneurysm:

Internal carotid artery Anterior cerebral artery Anterior communicating artery Posterior communicating artery Posterior cerebral artery Middle cerebral artery

Arteriovenous Malformations

abnormality in embryonal development that leads to a tangle of arteries and veins in the brain without a capillary bed.

most common in young people.

Subarachnoid Hemorrhage

may occur as a result of arteriovenous malformations

Pathophysiology

Pathophysiology

Hypertension

Inc pressure to the vessels

Rupture of the blood vessels

Bleeding

Pathophysiology

Compression of the adjacent to the brain tissue

Neuronal dysfunction

Clinical Manifestation:

sudden severe headache often loss of consciousness nuchal rigidity visual disturbances such as diplopia, ptosis, visual

loss tinnitus dizziness hemiparesis

Diagnostic Findings:

Computed Tomography Cerebral angiography – confirms the diagnosis Lumbar puncture Toxicology screening Use of Hunt-Hess Classification of systems

Hunt-Hess Classification of systems

I Asymptomatic, or mild headache and slight nuchal rigidity

II Cranial nerve palsy, abducens, moderate-to-severe headache, nuchal rigidity

III Mild focal deficit, lethargy, or confusion

IV Stupor, moderate to severe hemiparesis, early decerebrate rigidity

V Deep coma, decerebrate rigidity, moribund appearance

Add one grade for serious systemic disease or severe vasospasm on angiography

Modified classification adds the following

0 Unrupture aneurysm

Ia No acute meningeal/brain reaction, but with fixed neurological deficit

Medical Management:

1. Cerebral Hypoxia and Decrease Blood Flowa. administering oxygenb. maintaining the hemoglobin and hematocrit level c. adequate hydration through IV fluidsd. avoid extreme hypertension or hypotensione. treat seizures

2. Vasospasma. surgery to clip aneurysmb. Calcium-Channel blocker through IV administration

- nimopidipine- verapamil- nifedipine

c. Endovascular technique

Medical Management:

3. Increase ICPa. lumbar puncturedb. ventricular catheter drainagec. diuretics (mannitol)

4. Systemic Hypertensiona. antihypertensive therapy

- labetalol (Normodyne)- nicardipine (Cardene)- nitroprusside (Nitropress)

b. Hemodynamic monitoring c. Anti-seizure agentsc. Stool softener

5. Surgical Managementa. extracranial-intracranial arterial bypass

Post-operative complication

– Disorientation – Amnesia– Korsokoff’s syndrome– Personality changes– GI bleeding– Intraoperative embolization– Postoperative internal artery occlusion – Fluid and electrolyte disturbances

NURSING PROCESS: The patient with a Hemorrhagic Stroke

Assessment

altered level of consciousness – early sign sluggish pupillary reaction motor and sensory dysfunction cranial nerve deficits speech difficulties and visual disturbances headache and nuchal rigidity

Nursing Diagnosis

Ineffective cerebral tissue perfusion related to bleeding

Disturbed sensory perception related to medically imposed restrictions

Anxiety related to illness and/or medically imposed restrictions

Planning and Goals

Improve cerebral tissue perfusion Relief of sensory and perceptual deviation Relief of anxiety Absence of complication

Nursing Intervention:

1. Optimizing Cerebral Tissue Perfusion– Monitor neurologic deterioration– Check hourly the blood pressure, pulse, LOC, papillary

responses and motor function. And any changes should be reported immediately

2. Implementing Aneurysm Precaution– Provide a nonstimulating environment – Prevent further increase in ICP pressure – Bed rest – Provide quiet, nonstressful environment– Visitor are restricted (except for the family)– Elevate head in 15-30 degrees – Avoid sudden increase in blood pressure

Nursing Intervention:

– Avoid vasalva maneuver, straining, forceful sneezing, pushing up in bed, acute flexion or rotation of the head and neck and cigarette smoking

– Instruct the patient to exhale through the mouth during voiding or defecation

– No enema are permitted– Dim lighting– Coffee and tea, unless contraindicated– Thigh-high elastic compression stockings or sequential compression

boots – The nurse administers all personal care – External stimuli are keep in minimum.

3. Relieving Sensory Deprivation and Anxiety – Keeping the patient well informed of the plan of care – Provide information and support to the family

Potential Complication:

Vasospasm Seizure Hydrocephalus Rebleeding

Managing Potential Complications:

Vasospasm– Calcium-channel blocker– Fluid volume expanders

Seizure– Maintaining the airway– Prevent injury– Drug of choice: phenytoin (Dilantin)

Hydrocephalus– Ventriculoperitoneal shunt– Any change in patients responsiveness are reported immediately

Rebleeding– Monitor for initial signs of hemorrhage usually after 2 weeks of after

hemorrhage– Administer anti-fibrinolytic agents (epsilon-aminocaproic acid) as

prescribed to delay the lysis of the clot surrounding the rupture

Evaluation:

The patient is expected outcome:

Demonstrates intact neurologic status and normal vital signs and respiratory patterns

– Is alert and oriented to time, place and person– Demonstrates normal speech patterns and intact cognitive

processes– Demonstrate normal and equal strength, movement, and

sensation of all four extremities– Exhibits normal deep tendon reflexes and papillary responses

Demonstrates normal sensory perceptions– States rationale for aneurysm precaution

Exhibits clear thought process

Exhibits reduced anxiety level– Is less restless– Exhibits absence of physiologic indicators of anxiety

Is free of complication – Exhibits absence of vasospasm– Exhibits normal vital signs and neuromuscular activity

without seizures– Verbalizes understanding of seizure precautions– Exhibits normal mental status and normal motor and

sensory status Report no visual changes

Evaluation:

Cerebrovascular Disease

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