【高血壓英文課件】Cerebrovascular-Stroke

CerebrovascularStroke

Dr.Abdul-MonimBatihaAssistantProfessorCriticalCareNursingCerebrovascularStroke

Dr.Abd1Cerebrovasculardiseaseisthemostfrequentneurologicaldisorderofadults.ItisthethirdleadingcauseofmorbidityandmortalityintheUSAafterheartdiseaseandcancer.Itincludesanypathologicalprocessthatinvolvesthebloodvesselsofthebrain.Mostcerebrovasculardiseaseiscausedbythrombosis,embolism,orhemorrhage.Themechanismofeachoftheseetiologiesisdifferent,buttheultimateresultisdamagetoafocalareaofthebrain.CerebrovascularDiseaseCerebrovasculardiseaseisthe2A“brainattack”mustbeviewedasamedicalemergency.Toreversecerebralischemia,patientsmustbeevaluatedpromptly.Ischemicbraininjuryoccurswhenarterialocclusionlastslongerthan2to3hours.Delayinseekingmedicalcaremayeliminatethepotentialfortissue-savingtherapywiththrombolyticagents.Stroke“brainattack”A“brainattack”mustbeviewe3【高血壓英文課件】Cerebrovascular-Stroke4【高血壓英文課件】Cerebrovascular-Stroke5【高血壓英文課件】Cerebrovascular-Stroke6【高血壓英文課件】Cerebrovascular-Stroke7【高血壓英文課件】Cerebrovascular-Stroke8【高血壓英文課件】Cerebrovascular-Stroke9ClassificationofstrokeClassificationofstroke10Approximately750,000strokesoccureveryyearintheUSTheincidenceinmenisgreaterthaninwomen.Itisestimatedthatthereare3millionstrokesurvivorsandthatstrokeisaleadingcauseofdisabilityandaleadingdiagnosisforlong-termcare.EPIDEMIOLOGY

Approximately750,000strokes11Riskfactorsforstrokeincludesmoking,hypertension,obesity,cardiacdisease,hypercholesterolemia,diabetes,anduseofbirthcontrolpills.Preventioneffortsfocusonlifestylechangesthatcanmodifyriskfactors.Inaddition,theappropriateuseofwarfarinoraspirininpatientsatriskforcardiacsourcesofemboli(e.g.,atrialfibrillation)constitutesprimaryprevention.Riskfactorsforstrokeinclud12Whenbloodflowtoanypartofthebrainisimpededasaresultofathrombusorembolus,oxygendeprivationofthecerebraltissuebegins.Deprivationfor1minutecanleadtoreversiblesymptoms,suchaslossofconsciousness.Oxygendeprivationforlongerperiodscanproducemicroscopicnecrosisoftheneurons.Thenecroticareaisthensaidtobeinfarcted.PATHOPHYSIOLOGYWhenbloodflowtoanypartof13Iftheneuronsareischemiconlyandhavenotyetnecrosed,thereisachancetosavethem.Theischemiccascadebeginswithinsecondstominutesafterperfusionfailure,creatingazoneofirreversibleinfarctionandsurroundingareaofpotentiallysalvageable“ischemicpenumbra.”Astrokecausedbyanembolusmaybearesultofbloodclots,fragmentsofatheromatousplaques,lipids,orair.Embolitothebrainmostoftenhaveacardiacsource,secondarytomyocardialinfarctionoratrialfibrillationPATHOPHYSIOLOGYIftheneuronsareischemicon14Ifhemorrhageistheetiologyofastroke,hypertensionoftenisaprecipitatingfactor.Vascularabnormalities,suchasarteriovenousmalformationsandcerebralaneurysms,aremorepronetoruptureandcausehemorrhageinthepresenceofhypertension.Themostfrequentneurovascularsyndromeseeninthromboticandembolicstrokesisduetoinvolvementofthemiddlecerebralartery.PATHOPHYSIOLOGYIfhemorrhageistheetiology15【高血壓英文課件】Cerebrovascular-Stroke16Thisarterymainlysuppliesthelateralaspectsofthecerebralhemisphere.Infarctiontothatareaofthebraincancausecontralateralmotorandsensorydeficits.Iftheinfarctedhemisphereisdominant,speechproblemsresult,anddysphasiamaybepresent.Dysphasia:difficultyinspeakingandputtingwordsintothecorrectorderThisarterymainlysuppliesth17Astrokeisusuallycharacterizedbythesuddenonsetoffocalneurologicalimpairment.Thepatientmayexperiencesignssuchasweakness,numbness,visualchanges,dysarthria,dysphagia,oraphasia.dysarthria:difficultyinspeakingwordsclearly,causedbydamagetothecentralnervoussystemdysphagia:difficultyinSwallowingaphasia:aconditioninwhichapersonisunabletospeakorwrite,ortounderstandspeechorwritingbecauseofdamagetothebraincentrescontrollingspeechCLINICALMANIFESTATIONSAstrokeisusuallycharacteri18Themanifestationsofastrokedependontheanatomicallocationofthelesion.Ifsymptomsresolveinlessthan24hours,theeventisclassifiedasatransientischemicattack(TIA).MostTIAslastforonlyminutestolessthananhour,whichfurthercloudsrecognitionandprompttreatment.Furthermore,thedifferentialdiagnosisofstrokeincludesrulingoutintracerebralhemorrhage,SAH,subduralorepiduralhematoma,neoplasm,seizure,ormigraineheadacheThemanifestationsofastroke19Thetimeofsymptomonsettoadministrationofthrombolytictherapy(or“timetoneedle”)shouldbewithina3-hourwindow.patient’shistoryhelpsdeterminewhathashappenedtotheindividual.Itisimportanttoobtainadescriptionoftheneurologicalevent;howlongitlasted;andwhetherthesymptomsareresolving,completelygone,orthesameasatthetimeofonset.DIAGNOSISThetimeofsymptomonsettoa20Determinationofriskfactorsforstroke,suchashypertension,chronicatrialfibrillation,elevatedserumcholesterol,smoking,oralcontraceptiveuse,orafamilialhistoryofstroke,alsoaidsindiagnosisDeterminationofriskfactors21CTscanofthebrainwithoutcontrast,isobtainedwithin60minutesofarrivalBloodstudies(includingcompletebloodcellcount,electrolytes,glucose,andcoagulationparameters,areobtained)neurologicalexamination,andascreenperformedusingtheNationalInstitutesofHealthStrokeScale(NIHSS)DIAGNOSISCTscanofthebrainwithoutc22Cerebralangiographyhasbeenthegoldstandardforevaluatingcerebralvasculature.(ECG)shouldbeobtainedtoassessforevidenceofarrhythmiaorcardiacischemiaAdditionalteststhatcanbedonearetransesophagealechocardiography(TEE)andHoltermonitoring.Cerebralangiographyhasbeen23Themanagementofanischemicstrokecomprisesfourprimarygoals:1.restorationofcerebralbloodflow(reperfusion),2.preventionofrecurrentthrombosis,3.neuroprotection,CLINICALMANAGEMENTThemanagementofanischemic244.supportivecare.Thefocusofinitialtreatmentshouldbetosaveasmuchoftheischemicareaaspossible.Threeingredientsnecessarytothisareaareoxygen,glucose,andadequatebloodflow.Theoxygenlevelcanbemonitoredthrough(ABGs),andoxygencanbegiventothepatientifindicated.Hypoglycemiacanbeevaluatedwithserialchecksofbloodglucose.ReperfusionmaybeaccomplishedbytheuseofIVtissueplasminogenactivator(t-PA).4.supportivecare.25Cerebralperfusionpressureisareflectionofthesystemicbloodpressure,ICP,functioningautoregulationinthebrain,andheartrateandrhythm.Theparametersmosteasilycontrolledexternallyarethebloodpressureandcardiacrateandrhythm.Arrhythmiasusuallycanbecorrected.Ifthepatientisacandidateforthrombolytictherapy,treatmentwitht-PAbeginsintheemergencydepartment,andheorsheisthenmovedtotheICUforfurthermonitoring.Iftheindividualisnotacandidateforthrombolytictherapy,thecomplexityofthepatient’sproblemsdetermineshisorherplacementintheICU,medicalunit,orstrokespecialtyunit.Cerebralperfusionpressureis26Thrombolyticagents:IVthrombolytictherapyshouldbeinitiatedwithin3hoursorlessoftheonsetofneurologicalsymptoms.ThedirectadministrationofathrombolyticintoavesselisanalternativetoIVt-PA.Suchadministrationiseffectiveinacuteischemicstrokeandcanbegivenupto6hoursaftertheonsetofsymptomsPharmacologicalManagementThrombolyticagents:IVthromb27secondarytreatmentoptionsforstrokeincludeanticoagulationwithantithromboticandantiplateletagents.Ifapatientexperiencesatrialfibrillation,anticoagulationwithwarfarin(Coumadin)maybenecessary.Antiplateletdrugsincludedipyridamole-ER,ticlopidine,clopidogrel,andaspirin.TheseagentsdiscourageplateletsfromadheringtothewallofaninjuredbloodvesselorotherplateletsandaregiventopreventafuturethromboticoremboliceventPharmacologicalManagementsecondarytreatmentoptionsfo28Ifthediastolicbloodpressureisaboveapproximately105mmHg,itmayneedtobeloweredgradually.Thismaybeaccomplishedeffectivelywithlabetalol.TheusualmethodsofcontrollingincreasedICPcanbeinstituted:hyperventilation;fluidrestriction;headelevation;avoidanceofneckflexionorsevereheadrotationthatwouldimpedevenousoutflowfromthehead;andtheuseofosmoticdiuretics(mannitol)todecreasecerebraledemaControlofHTNandIncreasedICPIfthediastolicbloodpressur29Inpatientswithcarotidstenosis,carotidendarterectomymaybeperformedtopreventastroke.SurgicalManagementInpatientswithcarotidsteno30AssessmentPlanEmotionalandBehavioralModificationCommunication(ExpressiveDysphasia&ReceptiveDysphasia)PATIENTEDUCATIONANDDISCHARGEPLANNINGNursingManagementAssessmentNursingManagement31Maintainadequatecerebralperfusionpressure.Obtainvitalsignsandperformaneurologicalassessmenttoestablishabaselineandtomonitorforthedevelopmentofadditionaldeficits.Positionheadofbedat30degreestopromotevenousreturn.Maintainadequatecerebralper32ImplementDVTprecautionsPerformaneurologicalassessmentataminimumofevery2to4hours.

-Verbalresponse,orientation.-Eyeopening,pupilsize,andreactiontolight.-Motorresponse.【高血壓英文課件】Cerebrovascular-Stroke33MonitorvitalsignswithneurologicalchecksAskthephysicianforacceptablelimitsforbloodpressure.Performacardiacassessment.Elevatetheheadofthebed30to45degrees.【高血壓英文課件】Cerebrovascular-Stroke34Avoidactivitiesthatmayincreaseintracranialpressure.

-Avoidextremehiporneckflexion.-Avoidclusteringnursingprocedures.-Provideaquietenvironment.【高血壓英文課件】Cerebrovascular-Stroke35Performaneurysm/AVMprecautions.

-Ensurecompletebedrestinaquiet&darkenedroom.-Elevateheadofbedd30to45degrees.-RestrictTV,radio,andvisitors.-Avoidhot,coldbeveragesandcaffeinproducts.-Avoidstraining&vigorouscoughing.【高血壓英文課件】Cerebrovascular-Stroke36PreventSensory/PerceptualAlteration1-Usefrequentverbalandtactilecuestohelptheclientperformactivitiesofdailyliving.2-Breaktasksdownintosmallstepswhencueing.3-Approachtheclientfromthenon-affectedside.PreventSensory/PerceptualAl374-Teachtheclienttoscanwitheyesandturntheheadsidetoside

(whenvisualimpairmentsoccur).5-Placeobjectswithintheclient’sfieldofvision.6-Placeapatchovertheaffectedeyeifdiplopiaispresent.7-Removeclutterfromtheroom.4-Teachtheclienttoscanwit388-Orienttheclienttotime,place,andpersons.9-Provideastructured,repetitious,&consistentroutineorschedule.10-Presentinformationinaclear,simple,concisemanner.11-Useastep-by-stepapproach.12-Placepicturesandotherfamiliarobjectsintheroom.【高血壓英文課件】Cerebrovascular-Stroke39Preventcomplicationsofimmobility.Assessforneglect.Provideactiveorpassiverangeofmotiontoallextremitieseveryshift.Establishsplintingroutinetoaffectedextremities.Monitordailybloodglucose.Instructinmobilityaids;instructinstrategiesoffallprevention.Preventcomplicationsofimmob40Establishaneffectivemethodofcommunication.Assessabilitytospeakandtofollowsimplecommands.Arrangeforconsultationwithspeechlanguage

pathologisttodifferentiatelanguagedisturbances.Usecommunicationaidssuchaspicturecardsandpantomimetoenhancecommunication.Provideacalm,unrushedenvironment.

Listenattentivelytothepatient.Speakinanormaltone.Establishaneffectivemethod41Maintainadequateairway,oxygensaturation(SpO2)&preventionofatelectasisMonitorbreathsoundseveryshift.Checkoxygensaturationeveryshift.Instructtocoughanddeepbreatheandincentivespirometryevery2hourswhileawake.Assistwithremovalofairwaysecretionsasneeded.Becertaintopreoxygenatebeforesuctioning.Maintainadequateairway,oxyg42Maintainnutrition&preventaspiration.Obtainadmissionweight.Performcranialnerveassessment(includingabilitytoswallow)toidentifydeficits.Obtainconsultationfromspeech–languagepathologisttoseeifpatientissafetoeatorally.Provideproperdietandassistwithfeedingasneeded.Monitorcaloricintake;implementcaloriecountifnecessary.Obtaindietaryconsultationtoobtainrecommendationforsupplements.Maintainnutrition&preventa43AchieveurinarycontinencePerformassessmentofusualpatternsandhabits.Establishatoiletingscheduleusingabedpan,urinal,orbedsidecommode.Monitorforthedevelopmentofurinaryretentionorurinarytractinfection.Usebladderscannertoevaluatecontentsofbladder.Avoiduseofindwellingcathetertopreventinfection.Achieveurinarycontinence44Establishthecauseoftheproblemandtype(bowel/bladder).Determinetheclient’susualvoidingorbowelmovementpattern.Implementanindividualizedbladdertrainingprogram.Useanintermittentcatheterizationprogramifurinaryincontinenceisduetouppermotorlesion.Placetheclientonabedpanorcommodeevery2hours.Encouragefluidsto2000perdayunlesscontraindicated【高血壓英文課件】Cerebrovascular-Stroke45ImpairedPhysicalMobility

-Self-CareDeficitPerformactiveandpassiverange-of-motionexercisesatleastdaily.Positiontheclientinproperbodyalignmentcarefully.Maintaincorrectuseofsplintsandbraces.Useantiembolismstockings;Positionandmobilizetheclientfrequentlyassoonaspossibletopreventdeep-veinthrombosisorpneumonia.MeasurethighsandcalvesdailyandcheckforpositiveHoman’ssign(possibledeep-veinthrombosis).ImpairedPhysicalMobility

-S46PreventdysrhthmiasMonitorvitalsignsclosely.Managebloodpressurecarefully;avoidsharpdropsinbloodpressurethatcouldresultinhypotensionandcauseanischemiceventsecondarytohypotension.Duringcardiacmonitoringphase,identifydysrrhythmias.Treatdysrrhythmiastomaintainadequatecerebralperfusionpressureandreducechanceofneurologicalimpairment.Preventdysrhthmias47Emotional&behavioralmodificationPatientswhohaveexperiencedastrokemaydisplayemotionalproblems,andtheirbehaviormaybedifferentfrombaseline.Emotionsmaybelabile;forexample,thepatientmaycryonemomentandlaughthenext,withoutexplanationorcontrol.Emotional&behavioralmodific48Tolerancetostressmayalsobereduced.Aminorstressorinthepre-strokestatemaybeperceivedasamajorproblemafterthestroke.Patientsmayshowfrustrationoragitationwiththenursingstaffortheirfamilymembers.【高血壓英文課件】Cerebrovascular-Stroke49Itisthenurse’sroletohelpthefamilyunderstandpatient'sbehavioralchanges.&helpmodifythepatient’sbehaviorby-Controllingstimuliintheenvironment,

-Providingrestperiodsthroughoutthedaytopreventthepatientfrombecomingovertired,

-Givingpositivefeedback,

-Providingrepetitionwhenthepatientistryingtorelearnaskill.Itisthenurse’sroletohelp50CommunicationPatientscandemonstratemuchfrustrationwiththeirdeficits.Probablynodeficitproducesmorefrustrationforthepatientandthosetryingtocommunicatewithhimorherthantheoneinvolvingtheproduction&understandingoflanguage.Dysphasiacaninvolvemotorabilities,sensoryfunction,orboth.CommunicationPatientscandemo51IftheareaofbraininjuryisinorneartheleftBroca’sarea,thememoryofmotorpatternsofspeechisaffected.Thisresultsinanexpressivedysphasia,inwhichthepatientunderstandslanguagebutisunabletouseitappropriately.【高血壓英文課件】Cerebrovascular-Stroke52ReceptivedysphasiausuallyisaresultofinjurytotheleftWernicke’sarea,whichisthecontrolcenterforrecognitionofspokenlanguage.Thepatientthereforeisunabletounderstandthesignificanceofthespokenword.

Thepresenceofbothexpressiveandreceptivedysphasiaisreferredtoasglobaldysphasia.【高血壓英文課件】Cerebrovascular-Stroke53Itisimportantforthenursingstafftoinformfamiliesthathavingdysphasiadoesnotmeanthataperson