1. cerebrovascular disorders functional abnormality of the cns that occurs when the blood supply is...
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Cerebrovascular Disorders
Functional abnormality of the CNS that occurs when the blood supply is disrupted
Stroke is the primary cerebrovascular disorder and the third leading cause of death in the U.S.
Stroke is the leading cause of serious long-term disability in the U.S.
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PreventionNonmodifiable risk factors
Age (over 55), male gender, African-American race
Modifiable risk factorsHypertension is the primary risk factor Cardiovascular diseaseElevated cholesterol or elevated hematocritObesityDiabetes Oral contraceptive useSmoking and drug and alcohol abuse
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Stroke“Brain attack”Sudden loss of function resulting from a
disruption of the blood supply to a part of the brain
Types of stroke
Ischemic (80–85%) Hemorrhagic (15–20%)
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Ischemic Stroke
Disruption of the blood supply due to an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue
TypesLarge artery thrombosisSmall artery thrombosisCardiogenic embolismOther
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Pathophysiology
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Manifestations of Ischemic StrokeSymptoms depend upon the location and size of the
affected area Numbness or weakness of face, arm, or leg,
especially on one side Confusion or change in mental statusTrouble speaking or understanding speechDifficulty in walking, dizziness, or loss of balance or
coordinationSudden, severe headachePerceptual disturbancesloss of half of the visual field, Loss of peripheral
vision, diplopia.Cognitive Deficits (Short- and long-term memory
loss, Decreased attention span, Impaired ability to concentrate
Emotional Deficits (Depression, Withdrawal, Fear, hostility, and anger, Feelings of isolation) 7
Terms:HemiplegiaHemiparesisDysarthria (Difficulty in forming words)Aphasia: expressive aphasia, receptive
aphasiaHemianopsia: blindness of half of the field of
vision in one or both eyesApraxia: inability to perform previously
learned purposeful motor acts on a voluntary basis
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Comparison of Left and Right Hemispheric Strokes
Left Hemispheric Stroke
Right Hemispheric Stroke
Paralysis or weakness on right side of body
Paralysis or weakness on left side of body
Right visual field deficit Left visual field deficit
Aphasia (expressive, receptive, or global)
Spatial-perceptual deficitsIncreased distractibility
Altered intellectual ability Impulsive behavior and poor judgment
Slow, cautious behavior Lack of awareness of deficits
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Transient Ischemic Attack (TIA)Temporary neurologic deficit resulting from a
temporary impairment of blood flow“Warning of an impending stroke”Classic symptom is fleeting blindness in one
eye.Diagnostic workup is required to treat and
prevent irreversible deficits
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Carotid Endarterectomy
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Preventive Treatment and Secondary Prevention
Health maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease
Carotid endarterectomyAnticoagulant therapy Antiplatelet therapy: aspirin, Antihypertensive medications
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Medical Management—Acute Phase of Stroke
Prompt diagnosis and treatmentAssessment of strokeThrombolytic therapy
IV dosage and administrationPatient monitoringSide effects—potential bleeding
Elevate HOB unless contraindicated Maintain airway and ventilationContinuous hemodynamic monitoring and
neurologic assessment13
Hemorrhagic StrokeCaused by bleeding into brain tissue, the
ventricles, or subarachnoid space. May be due to spontaneous rupture of small
vessels primarily related to hypertension; subarachnoid hemorrhage due to a ruptured aneurysm; or intracerebral hemorrhage related to angiopathy, arterial venous malformations, intracranial aneurysms, or medications such as anticoagulants.
Brain metabolism is disrupted by exposure to blood.
ICP increases due to blood in the subarachnoid space.
Compression or secondary ischemia from reduced perfusion and vasoconstriction causes injury to brain tissue. 14
ManifestationsSimilar to ischemic strokeSevere headacheEarly and sudden changes in LOCVomiting
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Medical Management
Prevention: control of hypertensionDiagnosis: CT scan, cerebral angiography,
lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage
Care is primarily supportiveBed rest with sedation OxygenTreatment of vasospasm, increased ICP,
hypertension, potential seizures, and prevention of further bleeding
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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, eye symptoms
Monitor for potential complications including musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of increased ICP and meningeal irritation
After the stroke is completeFocus on patient function; self-care ability, coping,
and teaching needs to facilitate rehabilitation
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Nursing Process: The Patient Recovering from an Ischemic Stroke—DiagnosesImpaired physical mobilityAcute painSelf-care deficitsDisturbed sensory perceptionImpaired swallowingUrinary incontinenceDisturbed thought processesImpaired verbal communicationRisk for impaired skin integrityInterrupted family processesSexual dysfunction
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Collaborative Problems/Potential Complications
Decreased cerebral blood flowInadequate oxygen delivery to brainPneumonia
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Nursing Process: The Patient Recovering from an Ischemic Stroke—PlanningMajor goals may include:
Improved mobility Avoidance of shoulder painAchievement of self-care Relief of sensory and perceptual deprivation Prevention of aspirationContinence of bowel and bladderImproved thought processesAchieving a form of communicationMaintaining skin integrity Restored family functioning Improved sexual function Absence of complications
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InterventionsFocus on the whole personProvide interventions to prevent
complications and to promote rehabilitationProvide support and encouragementListen to the patient
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Improving Mobility and Preventing Joint DeformitiesTurn and position in correct alignment every 2
hoursUse of splintsPassive or active ROM 4–5 times dayPositioning of hands and fingersPrevention of flexion contractures Prevention of shoulder abductionDo not lift by flaccid shoulderMeasures to prevent and treat shoulder
proclaims 22
Positioning to Prevent Shoulder Abduction
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Prone Positioning to Help Prevent Hip Flexion
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Improving Mobility and Preventing Joint Deformities Passive or active ROM 4–5 times dayEncourage patient to exercise unaffected sideEstablish regular exercise routineQuadriceps setting and gluteal exercisesAssist patient out of bed as soon as possible-
assess and help patient achieve balance, move slowly
Ambulation training
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InterventionsEnhancing self-care
Set realistic goals with the patientEncourage personal hygieneAssure that patient does not neglect the
affected sideUse of assistive devices and modification of
clothing Support and encouragementStrategies to enhance communicationEncourage patient to turn head, look to side
with visual field loss
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InterventionsNutrition
Consult with speech therapy or nutritional services
Have patient sit upright, preferably OOB, to eatChin tuck or swallowing methodUse of thickened liquids or pureed (مهروس) diet
Bowel and bladder controlAssessment of voiding and scheduled voidingMeasures to prevent constipation—fiber, fluid,
toileting scheduleBowel and bladder retraining
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Nursing Process: The Patient with a Hemorrhagic Stroke—AssessmentComplete and ongoing neurologic assessment
—use neurologic flow chartMonitor respiratory status and oxygenationMonitoring of ICPPatients with intracerebral or subarachnoid
hemorrhage should be monitored in the ICU Monitor for potential complicationsMonitor fluid balance and laboratory dataAll changes must be reported
immediately
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Nursing Process: The Patient with a Hemorrhagic Stroke—Diagnoses
Ineffective tissue perfusion (cerebral)Disturbed sensory perceptionAnxiety
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Collaborative Problems/Potential ComplicationsVasospasmSeizuresHydrocephalusRebleedingHyponatremia
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Nursing Process: The Patient with a Hemorrhagic Stroke—Planning
Goals may include: Improved cerebral tissue perfusion Relief of sensory and perceptual deprivation Relief of anxiety The absence of complications
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Aneurysm Precautions
Absolute bed restElevate HOB 30° to promote venous drainage
or flat to increase cerebral perfusionAvoid all activity that may increase ICP or BP;
Valsalva maneuver, acute flexion or rotation of neck or head
Exhale through mouth when voiding or defecating to decrease strain
Nurse provides all personal care and hygieneNonstimulating, nonstressful environment; dim
lighting, no reading, no TV, no radioPrevent constipationVisitors are restricted
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Interventions
Relieving sensory deprivation and anxietyKeep sensory stimulation to a minimum for
aneurysm precautionsRealty orientationPatient and family teachingSupport and reassuranceSeizure precautionsStrategies to regain and promote self-care
and rehabilitation
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Home Care and Teaching for the Patient Recovering from a StrokePrevention of subsequent strokes, health promotion,
and follow-up carePrevention of and signs and symptoms of complications Medication teachingSafety measuresAdaptive strategies and use of assistive devices for
ADLsNutrition—diet, swallowing techniques, tube feeding
administrationElimination—bowel and bladder programs, catheter
useExercise and activities, recreation and diversionSocialization, support groups, and community
resources34
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