1、Raising Awareness of Hemorrhagic Stroke,By Kelly A. Taft, RN, BSN Nursing made Incredibly Easy! July/August 2009 2.1 ANCC contact hours Online: 2009 by Lippincott Williams & Wilkins. All world rights reserved.,Stroke Statistics,Third leading cause of death in the U.S.800,000 Americans experience st
2、roke each year30% become permanently disabled20% require institutional care 4 months after the stroke,Definition of Stroke,Acute focal neurologic deficitCaused by a vascular disorder that injures brain tissueTwo main types: ischemic and hemorrhagic Ischemic: caused by interruption of blood flow in a
3、 cerebral vessel Hemorrhagic: rupture of a cerebral blood vessel,Hemorrhagic Stroke,Spontaneous hemorrhage into the brainAccounts for the minority of casesMost frequently fatal strokeMost common etiology for individuals ages 18 to 45,Hemorrhagic Stroke Causes,Intracranial hemorrhage: bleeding direct
4、ly into brain matter (accounts for 41% of hemorrhagic stroke) Usually occurs in bifurcations of major arteries As a result of hypertensive hemorrhage (leads to hyperplasia within the vessel wall, which can lead to “breaks”), atherosclerosis, brain tumors, or certain medicationsSubarachnoid hemorrhag
5、e: bleeding surrounding the brain tissue From arteriovenous malformation (AVM), trauma, or aneurysm20% are of unknown etiology,Picturing Two Types of Hemorrhage,Cerebral Aneurysm,Cerebral aneurysm: dilation of the walls of cerebral arteries that develops as result of weakness in the wall Causes: ath
6、erosclerosis, congenital defect, hypertensive vascular disease, and trauma Commonly affected arteries: internal carotid, anterior cerebral, anterior and posterior communicating, and middle and posterior cerebral,Picturing Cerebral Aneurysm,AVM,AVM: complex tangle of abnormal arteries and veins that
7、lack a capillary bed and are linked by one or more fistulas Blood is shunted from the high pressure arterial system to the low pressure venous system Exposing the draining venous channels them to high pressures and predisposing them to rupture,Brain Edema,Two types: vasogenic and cytotoxic Vasogenic
8、: influx of fluid and solutes into the brain; develops rapidly after injury Cytotoxic: cellular swelling occurs in brain ischemia and traumaBrain edema leads to increased intracranial pressure (ICP), tissue shifts, and brain displacement,Major Risk Factors for Hemorrhagic Stroke,ObesityHypertensionC
9、igarette smokingExcessive alcohol intake,Genetic predisposition for aneurysm formationMale genderIncreased ageAfrican American or Hispanic descent,Symptoms of Hemorrhagic Stroke,HemiparesisConfusionDizziness or loss of balanceDifficulty speaking or understanding speech,Sudden severe headacheLoss of
10、consciousnessNuchal rigidityVisual disturbancesTinnitus,Immediate Complications of Hemorrhagic Stroke,Cerebral hypoxiaDecreased cerebral blood flowExtension of the area of injuryVasospasm: 40% to 50% of the mortality associated with subarachnoid hemorrhage,Vasospasm,Associated with increasing amount
11、s of blood in the subarachnoid cisterns and fissuresLeads to increased vascular resistanceImpedes cerebral blood flow and causes brain ischemia and infarctionFrequently occurring 4 to 14 days after initial hemorrhageSigns & symptoms: worsening headache, decreased LOC, and new focal neurologic defici
12、ts,Diagnostic Tests for Hemorrhagic Stroke,History and physical exam: Rapidity of symptoms Time of onset Pattern of symptoms Mental status Medications patient is takingECGComplete blood cell count, including plateletsElectrolytes,Cardiac enzymes and troponinBlood urea nitrogenCreatinineSerum blood g
13、lucoseProthrombin time, INR, partial thromboplastin timeOxygen saturation,Imaging Studies for Diagnosing Hemorrhagic Stroke,Computed tomography scan: used to determine type of stroke, size, location, and presence of cerebrospinal fluidCerebral angiography: used to confirm diagnosis of cerebral aneur
14、ysm or AVMLumbar puncture: used to confirm subarachnoid hemorrhage,Hunt-Hess Classification of Subarachnoid Hemorrhages,1: Asymptomatic or mild headache and nuchal rigidity (stiff neck) 2: Cranial nerve (CN) palsy (oculomotor CN III or abducens CN VI), moderate to severe headache, and nuchal rigidit
15、y 3: Mild focal deficit, lethargy, or confusion 4: Stupor, moderate to severe hemiparesis, and early decerebrate rigidity 5: Deep coma, decerebrate rigidity, and moribund appearanceAdd one grade for serious systemic disease (such as hypertension or chronic obstructive pulmonary disease) or severe va
16、sospasm on angiography,NIH Stroke Scale,Important tool in the diagnosis of acute hemorrhagic stroke in patients with sudden onset of symptomsShould be readily available to all healthcare professionals who are in direct contact with patient treatment and identification of stroke,Treatment Goals for H
17、emorrhagic Stroke,Consists of a combination of medical and surgical interventions“Window of opportunity” in which viable brain tissue can be savedGoal of medical treatment is to allow brain to recover from bleeding and prevent or minimize rebleeding,Medical Interventions for Hemorrhagic Stroke,Patie
18、nt should be monitored closely in the ICUBedrest with sedation to prevent agitation and stressAnalgesics for head and neck pain,Minimize external stimuliControl of blood glucose levelsICP and BP will be managedSeizure management (as recommended by the AHA),Surgical Interventions for Hemorrhagic Stro
19、ke,Removal of hemorrhage via craniotomy (recommended for cerebral hemorrhage greater than 3 cm in diameter)In aneurysms that havent ruptured, the surgical goal is to prevent bleedingLess invasive procedures include aneurysm coiling or obstruction,Clipping an Aneurysm,Complications of Hemorrhagic Str
20、oke,RebleedingPsychological symptoms: disorientation, personality changes, amnesiaIntraoperative embolizationPostoperative artery occlusionFluid & electrolyte disturbancesGastrointestinal bleeding,Neurologic Nursing Assessment After Stroke Treatment,Altered LOCSluggish pupillary reactionMotor and se
21、nsory dysfunctionCranial nerve deficits,Speech and vision difficultiesHeadache, nuchal rigidity, other neurologic deficitsVital sign changes, including an increase or drop in ICP, BP, or heart rate,Rehabilitation After Hemorrhagic Stroke,Begins in the acute phaseGoal is to return the patient to the
22、highest level of functioning independently while improving quality of lifeFocus on home and community capabilitiesWorks best when patient, family, and healthcare providers work as a team,Rehabilitation Components,Preventing complicationsTreating disabilitiesImproving functionProviding adaptive tools
23、Altering the environment as appropriatePatient/family teaching,Patient and Family Teaching,Signs and symptoms of strokeMeasures to prevent subsequent strokesPotential complicationsPsychosocial consequencesSafety measures to prevent falls,MedicationsAdaptive techniquesAppropriate exerciseDiet modificationsHow to measure BP and when to report to healthcare providerImportance of keeping follow-up appointments,
