A NURSING APPROACH TO THE MANAGEMENT OF CEREBROVASCULAR DISORDERS

By: Dave Jay S. Manriquez, BSN, RN

CEREBROVASCULAR DISORDERS (CVD)

- An umbrella term that refers to any functional abnormality of the central nervous system that occurs when the normal blood supply to the brain is disrupted.

- Disorder of the blood vessel that supplies blood flow to the brain

STROKE- a neurological condition which occurs suddenly, like a ”stroke of lightning”.- a sudden neurological event which results in the new onset of neurological symptoms.- primary CVD in the United States and in the world (3rd leading cause of death)

TWO MAJOR CATEGORIES OF STROKE

I. ISCHEMIC STROKE (85%)- other names: Cerebrovascular Accident (CVA), Brain Attack (“an urgent health care issue similar to a heart attack”)

Causes:

1. Large Artery Thrombotic Strokes (20%)- due to atherosclerotic plaques in the large blood vessels of the brain. - thrombus formation at the site of atherosclerosis which results in tissue

ischemia and infarction. - affected arteries: Left Internal Carotid Artery, Right Internal Carotid Artery, Middle Cerebral Artery, Left Vertebral Artery, Right Vertebral Artery, Basilar Artery

2. Small Penetrating Artery Thrombosis (25%)- most common type - affect one or more blood vessels

- also, LACUNAR STROKES (from the cavity that is created once infarcted brain tissue disintegrates)

3. Cardiogenic Embolic Strokes (20%)- emboli originates from the heart and circulates to the cerebral vasculature, most commonly the Left Middle Cerebral Artery- associated with cardiac dysrhythmias, usually atrial fibrillation. Other major risk factors: a heart attack (myocardial infarction), heart failure, or a hole in the heart PFO (Patent Foramen Ovale)

4. Cryptogenic Stroke- no known cause

5. Others-causes: cocaine use, coagulopathies, migraine, spontaneous dissection of the carotid or vertebral arteries.

Pathophysiology:

Clinical Manifestations:*An Ischemic Stroke can cause a wide variety of clinical deficits depending on:1. Location of the lesion (which vessels are obstructed)

LARGE ARTERY AFFECTED PROVIDES BLOOD SUPPLY TO

SYMPTOMS WITH ARTERIAL BLOCKAGE

Left Internal Carotid Artery or Middle Cerebral Artery

Left Side of the Brain Right Body Weakness, Communication Problems, Right Body Numbness

Right Internal Carotid Artery or Middle Cerebral Artery

Right Side of the Brain Left Body Weakness, Left Body Numbness

Left Vertebral Artery, Right Vertebral Artery, or Basilar Artery

Base of the Brain Brainstem Back of the Brain

Weakness or Numbness on either side of the body, nausea, vomiting, unsteadiness of walking, severe dizziness (vertigo), or coma.

ISCHEMIA

Ion Imbalance

Energy Failure

Acidosis

Depolarization

Cell membranes and proteins break down, Formation of free radicals, Protein production decreased

Cell Injury and Death

Glutamate

Intracellular Calcium

2. Size of the Infarction***Infarction – zone of tissue deprived of blood supply

3. Amount of collateral (secondary or accessory) blood flow

COMMON/ GENERAL SIGNS & SYMPTOMS: Sudden severe headache Numbness/ weakness of the face, arm, or leg, especially on one side of thebody Confusion or change in mental status Trouble speaking or understanding speech Visual disturbances Difficulty walking, dizziness, or loss of balance or coordination

MOTOR LOSS-disturbance of voluntary motor control on the side of the body opposite the

location of the stroke lesion- Hemiplegia (paralysis of one side of the body)- Hemiparesis (weakness of one side of the body)

COMMUNICATION LOSS- Dysarthria (difficulty in speaking)- Dysphasia or aphasia (defective speech or loss of speech)

-Expressive -Receptive -Global (Mixed)- Apraxia (inability to perform a previously learned action)

PERCEPTUAL DISTURBANCES - Homonymous Hemianopsia (loss of half of the visual field)

*Affected side of the body corresponds to affected visual field- Disturbances in Visual-Spatial Relations (perceiving the relation of two or more

objects in spatial areas)*Common among patients with Right Hemispheric Damage

SENSORY LOSS- Slight impairment of touch- Loss of proprioception (ability to perceive the position and motion of body

parts)- Difficulty in interpreting visual, tactile, and auditory stimuli

COGNITIVE IMPAIRMENT AND PSYCHOLOGICAL EFFECTS

- Memory Loss - Poor Comprehension

- Limited Attention Span- Forgetfulness- Lack of Motivation- Depression- Emotional Lability - Hostility

- Frustration- Resentment- Lack of Cooperation

ASSESSMENT & DIAGNOSIS:- History and Complete Physical and Neurologic Examination- Initial Assessment: Airway Patency, Cardiovascular Status, Gross Neurologic

Losses- Stroke Classification: Time Course Classification

Stage 1: Transient Ischemic Attack- temporary episode of neurologic dysfunction manifested by sudden loss of motor, sensory, or visual function lasting a few seconds or minutes but no longer than 24 hours.

Stage 2: Reversible Ischemic Neurologic Deficits- with signs and symptoms that are similar with TIAs but more pronounced and last for more than 24 hours.

Stage 3: Stroke in Evolution- a progressing stroke; worsening of neurologic signs and symptoms over several minutes or hours.

Stage 4: Completed Stroke- stabilization of neurologic signs and symptoms; no further progression of hypoxic insult.

- Diagnostic Tests:1. CT Scan – initial diagnostic test performed as basis for treatment2. 12-Lead ECG 3. Carotid ultrasound4. Cerebral Angiography5. Transcranial Doppler Flow Studies6. Transthoracic or Transesophageal Echocardiography7. MRI of the brain and/or neck 8. Xenon CT and Single Photon Emission CT

***For the patient with TIA, a BRUIT may be heard over the carotid artery. Diminished or absent pulsations in the neck may also be observed. Diagnostic tests may

include:1. Carotid Phonoangiography

- involves auscultation, direct visualization, and recording of carotid bruits

2. Oculoplethysmography-measures the pulsation of blood flow through the ophthalmic artery

3. Carotid Angiography-allows visualization of intracranial and cervical vessels

4. Digital Subtraction Angiography-used to define carotid artery obstruction and provides information on patterns of cerebral blood flow

PRIMARY PREVENTION1. Identifying High-Risk Groups

STROKE RISK FACTORS

Non-Modifiable Partly Modifiable Modifiable

Increasing Age Being Male, Race (e.g. African-Americans)Diabetes MellitusPrior Stroke/TIAsFamily HistoryAsymptomatic Carotid Bruit

Geography/climate (common in Southeastern US , the “Stroke Belt”)Socio-economic factors

HypertensionHeart Disease esp. Atrial Fibrillation Cigarette SmokingTIAs Increased serum cholesterol/lipids Physical InactivityObesityExcessive Alcohol Intake/Drug AbuseAcute Infection

2. Patient and Community Education about Stroke Recognition and Prevention

SECONDARY PREVENTIONNon-Surgical Medical Management1. Treatment of TIA from atrial fibrillation or suspected embolic or thrombotic causes

Warfarin Na (Coumadin)-drug-of-choice for those with atrial fibrillation-INR target: 2.5

Aspirin (50mg) or Dipyridamole 400 mg/d-drug-of-choice if warfarin is contraindicated

2. Thrombolytic Therapy for Ischemic Stroke-For patients with NIHSS score < 22-Administration of recombinant t-PA-Prompt Treatment (within 3 hours)-Contraindications: Bleeding Disorder, Recent MI, Intracranial Pathology, Onset > 3hrs-Eligibility Criteria for t-PA administration-Foley Catheter prior to t-PA-No anticoagulants 24hrs post t-PA therapy-Minimum Dose: 0.9 mg/kg Maximum Dose: 90mg-Administration: Loading dose is 10% of calculated dose administered over 1 minute. Remaining dose is administered over 1 hour via infusion pump. After the infusion, line is flushed with 20ml of NSS to ensure all medication is administered.-Vital Signs Monitoring: BP maintained at <180/100 mmHg-Airway Management-Accurate weight recorded-Watch for side effects: Bleeding esp. intracranial bleeding

3. Therapy for Patients with Ischemic Stroke NOT Receiving Thrombolytic Therapy-Anticoagulant Therapy (IV heparin)-Reduce ICP (diuretics, avoid hyperventilation, positioning to avoid hypoxia, elevate head of bed)-Intubation, if necessary-Continuous Hemodynamic Monitoring (BP<180/100 mmHg)-Neurologic Assessment

4. Managing Potential Complications-Maintain cardiac output at 4-8 L/min-Adequate Oxygenation

Surgical Medical ManagementCarotid Endarterectomy

- Main surgical procedure for the management of TIAs and small stroke- Removal of an atherosclerotic plaque or thrombus from a carotid artery to

prevent stroke in patients with occlusive disease of the extracranial cerebral arteries

- Indicated for patients with symptoms of TIA or mild stroke found to be due to carotid stenosis

- Complications: stroke, cranial nerve injuries, infection, hematoma at the incision site, carotid artery disruption

Nursing ManagementPotential Nursing Diagnoses

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

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

sequelaeo Disturbed sensory perception related to altered sensory reception,

transmission, and/or integrationo Impaired swallowing o Incontinence related to flaccid bladder, detrusor instability, confusion, or

difficulty in communicatingo Disturbed thought processes related to brain damage, confusion, or inability to

follow instructionso Impaired verbal communication related to brain damageo Risk for impaired skin integrity related to hemiparesis/ hemiplegia, or decreased

mobilityo Interrupted family processes related to catastrophic illness and caregiving

burdenso Sexual dysfunction related to neurologic deficits or fear of failure

Nursing InterventionsImproving Mobility and Preventing Joint DeformitiesHemiparesis/Hemiplegia1. Correct positioning to prevent contractures 2. Prevent Shoulder Adduction3. Positioning the Hand and Fingers4. Changing Positions every 2 hours

-pillows between legs in lateral position; maybe positioned prone for 15-30 mins. several times a day with small pillow under the pelvis which helps maintain normal gait and prevent knee and hip flexion contractures

Establishing an Exercise Program1. Passive ROM exercises 4-5 times a day to maintain joint mobility, prevent contractures. 2. Repetition of Activity to form new pathways in the CNS and encourage new patterns of motion. 3. Observe for signs and symptoms that may indicate pulmonary embolus or excessive cardiac workload during exercise.4. Quadriceps muscle setting and gluteal setting exercises are started early to improve

muscle strength needed for walking; performed at least 5 times daily for 10 minutes at a time.Preparing for Ambulation1. Rehabilitation program begins as soon as the patient regains consciousness.2. Tilt tables – used to bring the patient in an upright position esp. those having orthostatic BP changes3. Wheelchair with handbrakes (folding type) – best type of wheelchair 4. Parallel bars as soon as patient achieves balance5. Three- of four-pronged cane as soon as patient gains strength and confidencePreventing Shoulder Pain

Painful Shoulder - arm may be overstretched by use of excessive for when turning or moving pattientsSubluxation of the Shoulder – may result from overstretching the joint capsule and musculature by the force of gravity when the patient stands or sits in the early stages after a strokeShoulder-Hand Syndrome – painful shoulder and generalized swelling of the hand which may cause a “frozen” shoulder and ultimately the atrophy of subcutaneous tissues. 1. Position flaccid arm on a pillow or table while the patient is seated2. Advocate the use of a sling when patient first becomes ambulatory to prevent

the paralyzed upper extremity from dangling without support. 3. ROM exercises. Avoid overstrenuous arm movements.

A. Enhancing Self-Care1. Carry out self-care activities on the UNAFFECTED side.2. Repetition to relearn motor skills. 3. Use of assistive devices.4. Assessment of functional ability.5. Street Clothes to ease movement. Dressing activities done in a seated position.6. Keep environment organized and uncluttered.

B. Managing Sensory-Perceptual Difficulties1. Let patient SCAN the environment by turning the head back and forth.2. Approach patient on the unaffected visual field.3. Increase artificial lighting in the room and encourage use of eyeglasses.4. Constantly remind patient of the other side of the body.

*Amorphosynthesis – tendency of a patient with homonymous hemianopsia to turn away from the affected side of the body and neglect that side and the space on that side

C. Attaining Bowel and Bladder ControlTransient Urinary Incontinence – may arise to a patient who suffered from a stroke due to confusion, inability to communicate needs, and inability to use urinal or bedpan because of impaired motor and postural control

1. Intermittent Catheterization with Sterile technique.2. Offer bedpan or urinal on a schedule.3. Let male patients void in an upright or standing position.

D. Improving Thought Processes1. Collaborate with primary care physician, psychiatrist, and other professionals in

structuring cognitive-perceptual retraining, visual imagery, reality orientation, and cueing procedures to compensate for losses.

2. Supportive Role of the Nurse. E. Improving Communication

1. Collaborate with speech pathologist. 2. Refamiliarize letters of the alphabet.3. Talk slowly. Enunciate words well. Use simple phrases and short sentences.4. Confront patient to facilitate lip reading.5. Do everything to make the atmosphere conducive to communication. Provide support.6. Never attempt to complete the thoughts or sentences of the patient.7. Never hurry the patient. Allow ample time to process thoughts.

F. Maintaining Skin Integrity1. Prevent skin and tissue breakdown.2. Regular turning and proper positioning.3. Keep skin clean and dry always; gentle massage and adequate nutrition.

G. Improving Family Coping1. Provide counseling and refer to support groups.2. Provide information. Provide assurance that their love and interest are part of patient’s therapy. Approach family with optimism.3. Prepare family for episodes of emotional lability.

H. Helping the Patient Cope with Sexual Dysfunction1. Provide relevant information, education, reassurance, adjustment of medications, counseling regarding coping skills, suggestions for alternative positions, and a means of sexual expression.

II. HEMORRHAGIC STROKE (15%)- caused by a tear in the artery’s wall that produces bleeding in the brain tissue, ventricles or subarachnoid spaceCauses:1. PRIMARY INTRACEREBRAL HEMORRHAGE (80%)

- spontaneous rupture of small vessels primarily caused by uncontrolled hypertension, cerebral atherosclerosis, certain types of arterial pathology, brain tumor, and use of meds (oral anticoagulants, amphetamines, and illicit drugs such as crack and cocaine)

2. SECONDARY INTRACEREBRAL HEMORRHAGEIntracranial (Cerebral) Aneurysm- a dilation of the walls of a cerebral artery that develops as a result of the weakness in the arterial wall; usually in the bifurcation of the large arteries at the Circle of Willis.-Cause: Unknown. Research associating it with atherosclerosis, congenital defect of the vessel wall ; hypertensive vascular disease; head trauma; or advancing age. -Most Common Sites: ICA, ACA, ACoA, PCoA, PCA, and MCA.

Arteriovenous Malformations-due to abnormality in embryonal development that leads to a tangle of arteries and veins in the brain without a capillary bed, which leads to dilation of the arteries and veins and eventual rupture. -common cause of hemorrhage among young people

SUBARACHNOID HEMORRHAGE-hemorrhage into the subarachnoid space that may occur as a result of an AVM, intracranial aneurysms, trauma or hypertension. -most common cause: leaking aneurysm in the Circle of Willis or a congenital AVM.

Clinical Manifestations:

May present with neurologic deficits similar with Ischemic Stroke Sudden, Unusually Severe Headache Loss of Consciousness for a Variable Period Signs of Meningeal Irritation: Nuchal Rigidity Visual Disturbances (visual loss, diplopia, ptosis) Tinnitus, Dizziness, Hemiparesis

ASSESSMENT & DIAGNOSIS:

1. CT Scan – to determine the size and location of the hematoma as well as the presence or absence of ventricular blood and hydrocephalus

2. Cerebral Angiography – along with CT Scan confirm the diagnosis of cerebral aneurysm or AVM; provide information about the affected arteries, veins, adjoining vessels, and vascular branches.

3. Lumbar Puncture – performed if there is no evidence of increased ICP, CT Scan results are negative, and confirmed subarachnoid hemorrhage.

4. Toxicology for Illicit Drug Use – performed for patients younger than 40 years old. 5. Hunt-Hess Classification System – guides physician in diagnosing severity of

subarachnoid hemorrhage after aneurismal bleed.

PRIMARY PREVENTION:

1. Manage hypertension and ameliorate other risk factors. 2. Avoid other factors similar with Ischemic Stroke.3. Stroke Risks Screenings.4. Increase public awareness about the association of hemorrhagic stroke with

phenylpropanolamine (a substance in cold and cough agents and appetite suppressants), esp. in women.

SECONDARY PREVENTIONNon-Surgical Medical ManagementGoals:

-To allow the brain to recover from the initial insult (bleeding)-To prevent or minimize risk of rebleeding-To prevent or treat complications

Management:1. Bed rest with sedation to prevent agitation and stress.2. Management of vasospasm.3. Analgesics (Codeine, Acetaminophen) for head and neck pain4. Elastic compression stockings to prevent DVT.

Surgical Management*Not advised for primary intracerebral hemorrhage

1. Craniotomy - surgical evacuation performed in a patient with cerebellar hemorrhage with a diameter > 3 cm and GCS < 14. -done when patient condition is stable

2. Surgery for unruptured aneurysm-optional-goal: to prevent bleeding by isolating the aneurysm from its circulation by means of a ligature or a clip across its neck or by strengthening the arterial wall by wrapping with muslin or other substance to provide support and induce scarring.

3. Extracranial-intracranial Arterial Bypass- performed to establish collateral blood supply to allow surgery on the aneurysm

4. Less Invasive Endovascular Treatments-Endovascular Treatment (occlusion of the parent artery) -Aneurysm Coiling (obstruction of the aneurysm site with a coil)

PostOp Complications: Psychological Symptoms, Intraoperative Emboization, Postoperative Internal Artery Occlusion, F&E Disturbances, GI bleeding

Nursing ManagementPotential Nursing Diagnoses

o Ineffective cerebral tissue perfusion related to bleedingo Disturbed sensory perception related to medically imposed restrictions

(aneurysm precautions)o Anxiety related to illness and/or medically imposed restrictions (aneurysm

precautions)

Nursing Interventions:1. Optimize Cerebral Tissue Perfusion

-Implement Aneurysm Precautions2. Relieving Sensory Deprivation and Anxiety3. Monitoring and Managing Potential Complications

Vasospasm-Assess for: intensified headaches, decrease consciousness, evidence of aphasia or partial paralysis-Administer calcium-channel blockers or fluid volume expanderSeizures-Institute seizure precautions-DOC: Dilantin (Phenytoin)

-provides adequate antiseizure action while causing no drowsinessHydrocephalus-Observe for signs of hydrocephalus-Report changes in responsiveness immediatelyRebleeding-Treat hypertension-Watch for symptoms: sudden severe headache, nausea, vomiting, decreased level of consciousness, neurologic deficit, -Administer antifibrinolytic meds

Bibliography:

Cerebrovascular Disease. (2008). Retrieved June 12, 2009, from Nervous System Diseases: http://www.nervous-system-diseases.com/cerebrovascular-disease.htmlNetwork, S. I. (2002, November). Management of Patients with Stroke; Rehabilitation, Prevention and Management of Complications,and Discharge Planning: A national guideline . Retrieved June 13, 2009, from http://www.sign.ac.uk/pdf/sign64.pdfSmeltzer, S. C. (2004). Brunner & Suddarth'sTextbook of Medical-Surgical Nursing . Philadelphia: Lippincott Williams & Wilkins.Stroke Definitions & Terms. (2006, October 20). Retrieved June 12, 2009, from Harborview Medical Center: http://uwmedicine.washington.edu/Facilities/Harborview/CentersOfEmphasis/Neuro/StrokeCenter/terms.htmStroke Education Presentations & Discussions. (2002, January 01). Retrieved June 12, 2009, from the INTERNET STROKE CENTER: http://www.strokecenter.org/education/index.htmlStroke in Depth. (n.d.). Retrieved June 12, 2009, from How Stuff Works: http://healthguide.howstuffworks.com/stroke-in-depth.htm