Chapter 67 Management of Patients with Cerebrovascular Disorders

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." b) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client." c) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." d) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.)

How is IV t-PA dose calculated and administered?

0.9 mg/kg. 10% is administered as an IV bolus over 1 minute. 90% is administered by IV pump over 1 hour.

Following a CEA, the nurse focuses assessment on the following 4 cranial nerves:

1. 7 Facial 2. 10 Vagus 3. 11 Spinal Accessory 4. 12 Hypoglossal

Interventions to reduce ICP include: (8)

1. Administer osmotic diuretic 2. Maintain partial pressure of arterial CO2 between 30-35 mm Hg 3. Supplemental O2 if SpO2 drops below 92% 4. HOB elevated 25-30 degrees 5. Possible hemicraniectomy 6. Intubation to maintain patent airway if needed 7. Continuous hemodynamic monitoring 8. Frequent Nuerologic Assessment

Nonmodifiable risk factors for stroke: (3)

1. Age (55 years or older) 2. Male gender 3. AA Race

Initial assessment of the patient with a suspected CVA should focus on: (4)

1. Airway patency 2. Altered respiratory pattern 3. CV status 4. Gross neurologic deficits

Hemorrhagic strokes are caused by bleeding into the: (3)

1. Brain tissue 2. Ventricles 3. Subarachnoid Space

Immediate complications of hemorrhagic stroke: (3)

1. Cerebral hypoxia 2. Decreased cerebral blood flow 3. Extension of the injury area

During the acute phase of a stroke, a neurologic flow sheet is maintained to provide data about the following measures of the patient's clinical status: (9)

1. Change in LOC or responsiveness 2. Presence of voluntary or involuntary movement of the extremities 3. Eye opening 4. Color of face and extremities 5. Quality and rate of respirations 6. Ability to speak 7. I & O 8. Presence of bleeding 9. Blood pressure (maintained within the desired parameters)

Types of medications given to stroke patients for secondary prevention: (4)

1. Coumadin until target INR of 2-3 is reached 2. Platelet Inhibiting Medications 3. Statins 4. Anti-hypertensives

Potential complications for any patient who had had an ischemic stroke: (3)

1. Decreased cerebral blood flow 2. Inadequate oxygen delivery to the brain 3. Pneumonia

Risk Factors for Hemorrhagic Stroke: (4)

1. HTN 2. Increased age 3. Male gender 4. Excessive alcohol intake

Triple-H Therapy for vasospasm and the resulting cerebral ischemia

1. Hypervolemia 2. Induced arterial hypertension 3. Hemodilution

Nursing interventions following a CVA: (11)

1. Improving Mobility and Preventing Joint Deformities 2. Enhancing Self Care 3. Adjusting to physical changes 4. Assisting with nutrition 5. Attaining bowel and bladder control 6. Improving thought processes 7. Improving communication 8. Maintaining skin integrity 9. Improving family coping 10. Helping the patient cope with sexual dysfunction 11. Monitoring potential complications

S/S of possible vasospasm: (3)

1. Intensified headache 2. Decreased level of responsiveness 3. Evidence of aphasia or partial paralysis

5 types of ischemic strokes:

1. Large artery thrombotic strokes 2. Small Penetrating Artery Thrombotic Strokes 3. Cardiogenic Strokes 4. Cryptogenic Strokes 5. Other

After the acute phase of a stroke, the nurse monitors the following: (8)

1. Mental status 2. Sensation/perception 3. Motor control 4. Swallowing ability 5. Nutritional and hydration status 6. Skin integrity 7. Activity tolerance 8. Bowel and bladder function

The patient with a stroke may present with any of the following s/s: (6)

1. Numbness or weakness of the face, arm, or leg, especially on one side of the body. 2. Confusion or change in mental status 3. Aphasia (receptive and expressive) 4. Vision problems 5. Difficulty walking (due to dizziness or lack of balance) 6. Sudden severe headache

Potential complications of hemorrhagic stroke: (4)

1. Rebleeding 2. Hematoma expansion 3. Cerebral vasospasm 4. Acute hydrocephalus

Some of the contraindications for thrombolytic therapy: (3)

1. Symptom onset greater than 3 hours before administration 2. Anticoagulated patient 3. Recent intracranial pathology

After subarachnoid hemorrhage, hyponatremia is found in up to 50% of patients. Often a result of either: (2)

1. Syndrome of Inappropriate Antidiuretic Hormone 2. Cerebral Salt-Wasting Syndrome

In aneurysm precautions, the nurse administers all personal care, all external stimuli are kept to a minimum, and the HOB is elevated ___ to ___ degrees.

15-30

Patient position should be changed every ___ hours.

2

Thrombolytic therapy has a treatment window of ___ hours after the onset of a stroke.

3

Exercise is necessary to improve mobility and prevent joint deformities. Affected extremities, then, are exercised passively and put through a full range of motion ___ to ____ times a day.

4-5

Which of the following terms refer to the failure to recognize familiar objects perceived by the senses? a) Agraphia b) Perseveration c) Agnosia d) Apraxia

Agnosia Auditory agnosia is failure to recognize significance of sounds.

As soon as the patient is able to sit up, these activities are encouraged so as to enhance self-care.

All personal hygiene...particularly those on the unaffected side

Most _____ _____ are caused by an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain that lacks a capillary bed. Common cause of strokes in young people.

Arteriovenous Malformations

The most common dysrhythmia associated with cardiogenic embolic strokes.

Atrial Fibrillation

A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? a) Take opioid analgesics. b) Avoid heavy lifting. c) Take an herbal form of feverfew. d) Include peanut butter, bread, or tart foods in the diet.

Avoid heavy lifting. A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because they may increase intracranial pressure and thereby headaches.

Changes in the following vital signs suggest increased ICP. (3)

BP, pulse, respirations

Hemianopsia

Blindness in half of the visual field.

The removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.

Carotid endarterectomy.

Type of surgery used to reduce ICP.

Craniotomy

Agnosias

Deficits in the ability to recognize previously familiar objects

The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Speaking loudly b) Avoiding the use of hand gestures c) Establishing eye contact d) Speaking in complete sentences

Establishing eye contact The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken.

How should the nurse approach the patient with hemianopsia?

From the unaffected side. The nurse may want to stand at a position that encourages the patient to move or turn to visualize who is in the room.

A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? a) Tachycardia, tachypnea, and hypotension b) Nausea, vomiting, and profuse sweating c) Hemiplegia, seizures, and decreased level of consciousness (LOC) d) Difficulty breathing or swallowing

Hemiplegia, seizures, and decreased level of consciousness (LOC) Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased LOC, aphasia, hemiparesis, and increased focal symptoms.

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a) Dexamethasone (Decadron) b) Heparin sodium c) Phenytoin (Dilantin) d) Methyldopa (Aldomet)

Heparin sodium Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain

A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? a) Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. b) Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies. c) Encourage the family to reprimand the client if he doesn't ask for help with transfers and mobility. d) Ask a physician to order a vest and wrist restraints.

Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. The bed alarm will alert staff that the client is attempting to transfer, so they can come to assist.

Two major categories of strokes.

Ischemic Hemorrhagic

Which is the more common type of stroke?

Ischemic (87%) compared to Hemorrhagic (13%)

AKA cerebrovascular event. A sudden loss of function resulting from disruption of the blood supply to a part of the brain.

Ischemic Stroke

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a) Left-sided cerebrovascular accident (CVA) b) Right-sided cerebrovascular accident (CVA) c) Completed Stroke d) Transient ischemic attack (TIA)

Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis.

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? a) Hemiplegia or hemiparesis b) Limited attention span and forgetfulness c) Visual and auditory agnosia d) Lack of deep tendon reflexes

Limited attention span and forgetfulness Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation

Which of the following is accurate regarding a hemorrhagic stroke? a) It is caused by a large-artery thrombosis. b) One of the main presenting symptoms is numbness or weakness of the face. c) Main presenting symptom is an "exploding headache." d) Functional recovery usually plateaus at 6 months.

Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.

The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important? a) Maintaining a patent airway b) Elevating the head of the bed at 30 degrees c) Administering a stool softener d) Monitoring for seizure activity

Maintaining a patent airway Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining the hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation.

The only drug approved by the FDA for the prevention and treatment of vasospasm in subarachnoid hemmorhage.

Nimodipine (Nimotop) a caclcium channel blocker

The initial test for stroke that should occur within 25 minutes of patient's arrival to the ED.

Noncontrast Computed Tomography

Which of the following is the initial diagnostic in suspected stroke? a) Cerebral angiography b) Magnetic resonance imaging (MRI) c) Noncontrast computed tomography (CT) d) CT with contrast

Noncontrast computed tomography (CT) An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

Why must t-PA be administered within a strict time frame?

Revascularization of necrotic tissue (which develops after 3 hours) increases the risk of cerebral edema and hemorrhage.

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? a) Semi-Fowler's b) Supine c) High-Fowler's d) Prone

Semi-Fowler's The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

The most common clinical manifestation of a hemorrhagic stroke in the conscious patient.

Severe Headache (also note vomiting, early sudden change in LOC, Possible focal seizures)

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? a) Dizziness and tinnitus b) Numbness of an arm or leg c) Severe headache d) Double vision

Severe headache The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache.

AKA Lacunar Strokes because of the cavity that is created after the death of infarcted brain tissue. The most common type of ischemic stroke.

Small Penetrating Artery Thrombotic Stroke

The main complications of carotid endarterectomy. (5)

Stroke CN injuries Infection at incision site Hematoma at incision site Carotid artery disruption

Neurologic deficit typically lasting less than 1 hour. Sudden loss of motor, sensory, or visual function. May serve as a sign of impending stroke.

TIA

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? a) A ruptured arteriovenous malformation will cause deficits until it is stopped. b) Intracranial pressure is increased by a space-occupying bleed. c) A ruptured intracranial aneurysm must quickly be repaired. d) Thrombolytic therapy has a time window of only 3 hours.

Thrombolytic therapy has a time window of only 3 hours. Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system.

Type of medication given within a 3-4.5 hour window of stroke onset that works by binding to fibrin and converting plasminogen to plasmin, which stimulates fibrinolysis of the clot.

Tissue Plasminiogen Activator (t-PA)

T or F. If possible, the patient is placed in a prone position for 15-30 minutes several times a day.

True. A small pillow rests from the umbilicus to the upper third of the thigh to promote hyperextension of the hip joints (necessary for ambulation).

80% of hemorrhagic strokes are caused by:

Uncontrolled HTN

Which of the following is the chief cause of intracerebral hemorrhage (ICH)? a) Diabetes b) Uncontrolled hypertension c) Migraine headaches d) Hypercholesterolemia

Uncontrolled hypertension Primary intracerebral hemorrhage (ICH) from a spontaneous rupture of small arteries or arterioles accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension.

Narrowing of the lumen involved in cranial blood vessel. Can occur 7-10 days after initial hemorrhage.

Vasospasm

Once it is determined that the patient is a candidate for t-PA therapy this type of medication is withheld for 24 hours and these types of interventions (3) are withheld as well.

Withhold anticoagulants Do not insert any NG tubes, urinary catheters, and intra-arterial pressure catheters

aneurysm

a weakening or bulge in an arterial wall

Cardiogenic Embolic Strokes may be prevented by the use of ______ therapy in patients with atrial fibrillation.

anticoagulant

dysarthria

defects of articulation due to neurologic causes

dysphagia

difficulty swallowing

aphasia

inability to express oneself or to understand language

expressive aphasia

inability to express oneself; often associated with damage to the left frontal lobe area

receptive aphasia

inability to understand what someone else is saying; often associated with damage to the temporal lobe area

An _____ hemorrhage is most common in patients with hypertension and cerebral atherosclerosis, because degenerative changes from these diseases cause rupture of the blood vessels.

intracerebral

agnosia

loss of ability to recognize objects through a particular sensory system; may be visual, auditory, or tactile

hemiplegia

paralysis of one side of the body, or part of it, due to an injury in the motor area of the brain

As many as 84% of patients who have had a stroke have pain in the ______.

shoulder

infarction

tissue necrosis in an area deprived of blood supply

hemiparesis

weakness of one side of the body, or part of it, due to an injury in the motor area of the brain