cva disorder med surg ppt

5/20/2018 CVA Disorder Med Surg PPT

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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 62

Management of Patients WithCerebrovascular Disorders


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Question

What is agnosia?

A. Failure to recognize familiar objects perceived by thesenses.

B. Inability to express oneself or to understand language.

C. Inability to perform previously learned purposeful motoracts on a voluntary basis.

D. Impaired ability to coordinate movement, often seen asa staggering gait or postural imbalance.


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Answer

A

Agnosis is failure to recognize familiar objects perceived bythe senses. Aphasis is inability to express oneself or tounderstand language. Apraxia is inability to performpreviously learned purposeful motor acts on a voluntary

basis. Ataxia is impaired ability to coordinatemovement, often seen as a staggering gait or posturalimbalance.


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Cerebrovascular Disorders

Functional abnormality of the CNS that occurs when theblood supply is disrupted

Stroke is the primary cerebrovascular disorder and thethird leading cause of death in the U.S.

Stroke is the leading cause of serious long-term disabilityin the U.S.


5/39Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prevention Nonmodifiable risk factors

Age (over 55), male gender, African-American race

Modifiable risk factors

Hypertension is the primary risk factor

Cardiovascular disease

Elevated cholesterol or elevated hematocrit

Obesity

Diabetes

Oral contraceptive use

Smoking and drug and alcohol abuse



Question

Is the following statement True or False?

Ischemic stroke account for 80% to 85% of strokes, whilehemorrhagic stroke accounts for 15% to 20%.



Answer

True

Ischemic stroke account for 80% to 85% of strokes, whilehemorrhagic stroke accounts for 15% to 20%.



Stroke

Brain attack

Sudden loss of function resulting from a disruptionof the blood supply to a part of the brain

Types of stroke

Ischemic (8085%)

Hemorrhagic (1520%)



Ischemic Stroke

Disruption of the blood supply due to an obstruction,usually a thrombus or embolism, that causes infarction of

brain tissue Types

Large artery thrombosis

Small penetrating artery thrombosis

Cardiogenic embolism

Cryptogenic

Other



Pathophysiology

Refer to fig. 62-1



Manifestations of Ischemic Stroke Symptoms 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 status

Trouble speaking or understanding speech

Difficulty in walking, dizziness, or loss of balance or

coordination Sudden, severe headache

Perceptual disturbances



Terms:

Hemiplegia

Hemiparesis

Dysarthria

Aphasia: expressive aphasia, receptive aphasia

Hemianopsia



Transient Ischemic Attack (TIA)

Temporary neurologic deficit resulting from a temporaryimpairment of blood flow

Warning of an impending stroke

Diagnostic workup is required to treat and preventirreversible deficits



Carotid Endarterectomy



Preventive Treatment and SecondaryPrevention

Health maintenance measures including a healthy diet,exercise, and the prevention and treatment of

periodontal disease Carotid endarterectomy

Anticoagulant therapy

Antiplatelet therapy: aspirin, dipyridamole (Persantine),clopidogrel (Plavix), ticlopidine (Ticlid)

Statins

Antihypertensive medications



Medical Management

Acute Phase ofStroke Prompt diagnosis and treatment

Assessment of stroke: NIHSS assessment tool

Thrombolytic therapy Criteria for tPA

IV dosage and administration

Patient monitoring

Side effectspotential bleeding

Elevate HOB unless contraindicated

Maintain airway and ventilation

Continuous hemodynamic monitoring and neurologic assessment



Hemorrhagic Stroke Caused by bleeding into brain tissue, the ventricles, or

subarachnoid space.

May be due to spontaneous rupture of small vessels

primarily related to hypertension; subarachnoidhemorrhage due to a ruptured aneurysm; orintracerebral hemorrhage related to amyloid angiopathy,arterial venous malformations (AVMs), intracranialaneurysms, 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 reducedperfusion and vasoconstriction causes injury to braintissue.



Manifestations

Similar to ischemic stroke

Severe headache

Early and sudden changes in LOC

Vomiting



Medical Management

Prevention: control of hypertension

Diagnosis: CT scan, cerebral angiography, lumbarpuncture if CT is negative and ICP is not elevated toconfirm subarachnoid hemorrhage

Care is primarily supportive

Bed rest with sedation

Oxygen

Treatment of vasospasm, increased ICP, hypertension,potential seizures, and prevention of further bleeding



Nursing Process: The Patient Recoveringfrom an Ischemic StrokeAssessment

Acute phase

Ongoing/frequent monitoring of all systems including

vital signs and neurologic assessmentLOC, motorsymptoms, speech, eye symptoms

Monitor for potential complications includingmusculoskeletal problems, swallowing difficulties,respiratory problems, and signs and symptoms of

increased ICP and meningeal irritation

After the stroke is complete

Focus on patient function; self-care ability, coping,and teaching needs to facilitate rehabilitation



Nursing Process: The Patient Recovering

from an Ischemic StrokeDiagnoses Impaired physical mobility

Acute pain

Self-care deficits

Disturbed sensory perception

Impaired swallowing

Urinary incontinence

Disturbed thought processes

Impaired verbal communication

Risk for impaired skin integrity

Interrupted family processes

Sexual dysfunction


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Collaborative Problems/PotentialComplications

Decreased cerebral blood flow

Inadequate oxygen delivery to brain

Pneumonia


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Nursing Process: The Patient Recovering

from an Ischemic StrokePlanning 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


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Interventions

Focus on the whole person

Provide interventions to prevent complications and toand promote rehabilitation

Provide support and encouragement

Listen to the patient


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Improving Mobility and Preventing JointDeformities

Turn and position in correct alignment every 2 hours

Use of splints

Passive or active ROM 45 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 proclaims


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Positioning to Prevent Shoulder Abduction


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Prone Positioning to Help Prevent HipFlexion


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Improving Mobility and Preventing JointDeformities

Passive or active ROM 45 times day

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


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Interventions

Enhancing self-care

Set realistic goals with the patient

Encourage personal hygiene

Assure that patient does not neglect the affected side

Use of assistive devices and modification of clothing

Support and encouragement Strategies to enhance communication

Encourage patient to turn head, look to side with visualfield loss


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Interventions Nutrition

Consult with speech therapy or nutritional services

Have patient sit upright, preferably OOB, 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 constipationfiber, fluid,toileting schedule

Bowel and bladder retraining


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Nursing Process: The Patient with aHemorrhagic StrokeAssessment

Complete and ongoing neurologic assessmentuseneurologic flow chart

Monitor respiratory status and oxygenation Monitoring of ICP

Patients with intracerebral or subarachnoid hemorrhageshould be monitored in the ICU

Monitor for potential complications

Monitor fluid balance and laboratory data

All changes must be reported immediately


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Nursing Process: The Patient with aHemorrhagic StrokeDiagnoses

Ineffective tissue perfusion (cerebral)

Disturbed sensory perception

Anxiety


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Collaborative Problems/PotentialComplications

Vasospasm

Seizures

Hydrocephalus

Rebleeding

Hyponatremia


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Nursing Process: The Patient with aHemorrhagic StrokePlanning

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 rest

Elevate HOB 30 to promote venous drainage or flat toincrease cerebral perfusion

Avoid all activity that may increase ICP or BP; Valsalvamaneuver, acute flexion or rotation of neck or head

Exhale through mouth when voiding or defecating todecrease strain

Nurse provides all personal care and hygiene

Nonstimulating, nonstressful environment; dim lighting,no reading, no TV, no radio

Prevent constipation

Visitors are restricted


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Interventions

Relieving sensory deprivation and anxiety

Keep sensory stimulation to a minimum for aneurysm

precautions

Realty orientation

Patient and family teaching

Support and reassurance

Seizure precautions

Strategies to regain and promote self-care andrehabilitation


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Home Care and Teaching for the Patient

Recovering from a Stroke Prevention of subsequent strokes, health promotion, and

follow-up care

Prevention of and signs and symptoms of complications

Medication teaching

Safety measures

Adaptive strategies and use of assistive devices for ADLs

Nutritiondiet, swallowing techniques, tube feedingadministration

Eliminationbowel and bladder programs, catheter use

Exercise and activities, recreation and diversion

Socialization, support groups, and community resources


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Question

What are expected patient outcomes for a patientrecovering from a hemorrhagic stroke?

A. Exhibits absence of vasospasm

B. Residual aphasia

C. One to four seizures

D. Complains of visual changes


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Answer

A

Expected patient outcomes for a patient recovering from ahemorrhagic stroke include absence of vasospasm, noseizures, normal speech patterns, and no visual changes.

cva disorder med surg ppt

Documents

disrupted stroke

brain types of stroke

familiar objects

theblood supply

impaired ability

asa staggering gait

tounderstand language

purposeful motor acts