Class 11 Hemorrhagic Stroke PDF

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Summary

HEMORRHAGIC STROKES What is it? Prevention bleeding into the brain tissue, the ventricles, or the subarachnoid space. Ruptured Intracranial Aneurysm weakening in the arterial wall Cerebral amyloid angiography Arteriovenous Malformations Certain Medications (such as anticoagulants) Drug use Patho Hyp...

Description

HEMORRHAGIC STROKES Prevention

What is it? 

bleeding into the brain tissue, the ventricles, or the subarachnoid space.

1. Managing Hypertension 2. Stroke risk screenings

Complications

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Cerebral Hypoxia and Decreased Blood Flow Vasospasm (narrowing of the lumen involved) Increased Intracranial Pressure Hypertension

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HYPONATREMIA

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Hydrocephalus

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What can cause the stroke?  Uncontrolled Hypertension (80% of cases)     

Ruptured Intracranial Aneurysm – weakening in the arterial wall Cerebral amyloid angiography Arteriovenous Malformations Certain Medications (such as anticoagulants) Drug use

Patho

See nursing process for explanations

Symptoms are produced when a primary hemorrhage, aneurysm or AVM presses on nearby cranial nerves or brain Or when an aneurysm ruptures causing brain bleed With increased bleeding there is increased ICP

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There are 4 types of hemorrhages:

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Intracerebral hemorrhage – bleeding into brain tissue (most common in pt with HTN and cerebral atherosclerosis) Intracranial aneurysm – dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall. CAUSE OF ANEURSYM IS UNKNOWN! BUT assume its HTN, atherosclerosis etc. Arteriovenous malformations – abnormal embryonal development that leads to tangle of arteries in artery in brain that dilate and rupture Subarachnoid hemorrhage- results of AVM, intracranial aneurysm, trauma, HTN

To TX these types=Sedate to decrease the basil metabolic rate (you have to rest the mind)  Similar to Ischemic Strokes such as motor, sensory, cranial nerve and cognitive disruptions Severe Headache (most common)   Vomiting  Change in LOC  Focal Seizures if Brain Stem is involved

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CT MRI

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Cerebral Angiography confirms the diagnosis of an intracranial aneurysm or AVM Lumbar puncture only if there is no evidence of increased ICP o Lumbar puncture in the presence of ICP could result in brain stem herniation and rebleeding In patients younger than 40, clinicians obtain a toxicology screen for illicit drug use.

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Complications

Hypertension Increased age Male gender Excessive Alcohol intake

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Assessment and Diagnostics

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Depends on the cause and type of cerebrovascular disorder

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Clinical Manifestation

Risk Factors

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Cerebral Hypoxia and Decreased Blood Flow o O2 supplementation, IV fluids to reduce viscosity and improve central blood flow Vasospasm (narrowing of the lumen involved) o Increased vascular resistance that occurs 3 to 14 days after hemorrhage Increased Intracranial Pressure can occur after with either an ischemic or hemorrhagic stroke o CSF drainage may be performed o Mannitol may be administered to control ICP (diuretic) – monitor for s/s of dehydration Hypertension – HTN should be controlled with antihypertensives – monitor for s/s of hypotension Hyponatremia Hydrocephalus (buildup of fluid in brain)

Medical Management

The goals of t(x) are to allow recovery of the brain, prevent rebleed, and prevent/treat complications. Bed rest w/sedation to prevent agitation and stress Management of vasospasm Surgical or medical prevention of rebleeding. Anti-seizure agents prophylactically Analgesics for head and neck pain SCD or compression stockings to prevent DVT Antihypertensive meds – after discharge most pt will require antihypertensive meds to decrease their risk of another Intracerebral hemorrhage Treatment of fever and treatment of hyperglycemia (with an iinsulin drip)

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Surgical management

Nursing Process

In many cases, a primary Intracerebral hemorrhage is not treated surgically but, if the hematoma exceeds 3cm and the Glasgow Coma Scale score decreases surgical intervention is strongly recommended via CRANIOTOMY. Less Invasive options include 1. Endovascular Treatment – occluding the parent artery 2. Aneurysm Coiling – obstruction of the aneurysm site with a coil Although these less invasive options lower risk, yet these aneurysms still have the potential to rupture and cause secondary strokes

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Assessment 

Pt w/ Hemorrhagic Stroke

Complete Neuro Assessment including: o Altered Level of Conscious o Sluggish Pupillary reaction o Motor and sensory dysfunction o Cranial Nerve Deficits (extra ocular eye movements, facial droop presence of ptosis) o Speech Difficulties and visual disturbance o Headache and nuchal rigidity or neurologic deficits

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Alteration in level of consciousness often is the earliest sig of deterioration

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Check for mild drowsiness and slight slurring if speech

Nursing Diagnoses   

Ineffective tissue perfusion related to bleeding or vasospasm Disturbed Sensory perception related to medically imposed restrictions Anxiety related to illness and/or medically imposed restrictions.

Goals: improved cerebral tissue perfusion, relief of sensory and perceptual deprivations, relief anxiety and absence of complications (vasospasm, seizures, hydrocephalus, rebleeding and hyponatremia) Interventions  

Implement Aneurysm Precautions: Done to provide a non-stimulating environment, prevent increases in ICP and prevent bleeding  BED REST IN A QUIET NON STRESSFUL ENVIRONMENT o Activity, pain, stress and anxiety can cause  

Monitoring Pomplications 

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VASOSPASM o Assess for s/s of vasospasm: intensified headaches, decreases in LOC, evidence of aphasia or partial paralysis. o If diagnosed, CCB or fluid volume expanders are prescribed. Its believe Ca+ plays role in vasospasm SEIZURES- seizure precautions. o If one occurs MAINTAINING AIRWAY AND PREVENTING INJURY are the major goals. o Phenytoin (Dilatin) medication of choice.

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S/S of rebleed include: sudden severe headache, N&V, Decreased LOC, and neurologic deficit. Confirmed by CT.

REFRAIN FROM ANY ACTIVITY THAT REQUIRES EXERTION, INCREASES BP OR OBSTRUCTS VENOUS RETURN Valsava maneuver straining forceful sneezing, pushing oneself in bed, acute flexion or rotation of the head and neck and cigarette smoking. No caffeine

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EXHALE THROUGH MOUTH DURING VOIDING OR DEFECATION TO REDUCE STRAIN

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No enemas but stool softeners and mild laxatives are prescribed to prevent constipation o Enemas increase ICP so not good Dim lighting due to photophobia No caffeine unless decaf Anti-embolism stockings or SCDs to prevent DVTmonitor for s/s of DVT

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BP to raise and cause rupture Only family allowed to visit, NO VISITORS Elevate HB 15 30 degrees to promote venous drainage and decrease ICP. o Some M.D.’s may prefer flat to provide more blood to perfuse brain

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HYDROCEPHALUS Blood in the brain space impedes circulation of CSF which results in hydrocephalus o Diagnosed by a CT scan that shows dilated ventricles. o Characterized by sudden onset of lethargy or coma and is managed by a ventriculostomy drain to decrease ICP. REBLEEDING – HTN is the most serious risk to bleed again o Aneurysm Rebleed usually occurs 2 weeks after initial hemorrhage.

Closely monitor patients Neuro and Respiratory especially O2 to prevent infarction. Check BP. Pulse, LOC, pupillary responses, and motor function hourly

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External Stimuli are minimal- no reading, television or radio

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A sign with restrictions must be put on door and discussed with patient and family.

The most effective preventive measure is securing the aneurysm through surgery or endovascular treatment HYPONATREMIA- monitor lab tests frequently. o If persistent hyponatremia for 24 hours CALL HCP. o Pt is then evaluated for SIADH (retaining too much water) or cerebral salt-washing Syndrome (the kidneys are unable to conserve sodium).

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Treatment is Hypertonic 3% saline.

Evaluations      

Alert and oriented to time, place and person Normal speech pattern and cognitive processing Normal and equal strengths in all extremities Demonstrates normal sensory perceptions Reduced anxiety, normal v/s and respirations Free of complications, no visual changes...