Nursing Process: The Patient With a Hemorrhagic Stroke

NURSING PROCESS:THE PATIENT WITH AHEMORRHAGIC STROKE

Assessment

A complete neurologic assessment is performed initially and should include evaluation for the following:

·      Altered level of consciousness

·       Sluggish pupillary reaction

·       Motor and sensory dysfunction

·      Cranial nerve deficits (extraocular eye movements, facial droop, presence of ptosis)

·      Speech difficulties and visual disturbance

·        Headache and nuchal rigidity or other neurologic deficits

All patients should be monitored in the intensive care unit fol-lowing an intracerebral hemorrhage (Qureshi et al., 2001). Neu-rologic assessment findings are documented and reported as indicated. The frequency of these assessments varies depending on the patient’s condition. Any changes in the patient’s condition require reassessment and thorough documentation; changes should be reported immediately.

Alteration in level of consciousness often is the earliest sign of deterioration in a patient with a hemorrhagic stroke. Because nurses have the most frequent contact with patients, they are in the best position to detect what may be subtle changes. Mild drowsiness and slight slurring of speech may be early signs that the level of consciousness is deteriorating. Frequent nursing as-sessment is crucial in the patient with known or suspected cere-bral aneurysm.

Diagnosis

NURSING DIAGNOSES

Based on the assessment data, the patient’s major nursing diag-noses may include the following:

·      Ineffective cerebral tissue perfusion related to bleeding

·      Disturbed sensory perception related to medically imposed restrictions (aneurysm precautions)

·      Anxiety related to illness and/or medically imposed restric-tions (aneurysm precautions)

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Based on the assessment data, potential complications that may develop include the following:

·      Vasospasm

·       Seizures

·       Hydrocephalus

·       Rebleeding

Planning and Goals

The goals for the patient may include improved cerebral tissue perfusion, relief of sensory and perceptual deprivation, relief of anxiety, and the absence of complications.

Nursing Interventions

OPTIMIZING CEREBRAL TISSUE PERFUSION

The patient is closely monitored for neurologic deterioration oc-curring from recurrent bleeding, increasing ICP, or vasospasm. A neurologic flow record is maintained. The blood pressure, pulse, level of responsiveness (an indicator of cerebral perfusion), pupil-lary responses, and motor function are checked hourly. Respira-tory status is monitored because a reduction in oxygen in areas of the brain with impaired autoregulation increases the chances of a cerebral infarction. Any changes are reported immediately.

Implementing Aneurysm Precautions

Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating envi-ronment, prevent increases in ICP pressure, and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate the blood pressure, which increases the risk for bleeding. Visitors, except for family, are restricted.

The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. Some neurologists, however, prefer that the patient remain flat to increase cerebral perfusion.

Any activity that suddenly increases the blood pressure or ob-structs venous return is avoided. This includes the Valsalva ma-neuver, straining, forceful sneezing, pushing up in bed, acute flexion or rotation of the head and neck (which compromises the jugular veins), and cigarette smoking. Any activity requiring ex-ertion is contraindicated. The patient is instructed to exhale through the mouth during voiding or defecation to decrease strain. No enemas are permitted, but stool softeners and mild lax-atives are prescribed. Both prevent constipation, which would cause an increase in ICP, as would enemas. Dim lighting is help-ful because photophobia (visual intolerance of light) is common. Coffee and tea, unless decaffeinated, are usually eliminated.

Thigh-high elastic compression stockings or sequential com-pression boots may be prescribed to decrease the incidence of deep vein thrombosis resulting from immobility. The legs are ob-served for signs and symptoms of deep vein thrombosis (tender-ness, swelling, warmth, discoloration, positive Homans’ sign), and abnormal findings are reported.

The nurse administers all personal care. The patient is fed and bathed to prevent any exertion that might raise the blood pres-sure. External stimuli are kept to a minimum, including no tele-vision, no radio, and no reading. Visitors are restricted in an effort to keep the patient as quiet as possible. This precaution must be individualized based on the patient’s condition and response to visitors. A sign indicating this restriction should be placed on the door of the room, and the restrictions should be discussed with both patient and family. The purpose of aneurysm precautions should be thoroughly explained to both the patient (if possible) and family.

RELIEVING SENSORY DEPRIVATION AND ANXIETY

Sensory stimulation is kept to a minimum for patients on aneurysm precautions. For patients who are awake, alert, and ori-ented, an explanation of the restrictions helps reduce the patient’s sense of isolation. Reality orientation is provided to help main-tain orientation.

Keeping the patient well informed of the plan of care provides reassurance and helps minimize anxiety. Appropriate reassurance also helps relieve the patient’s fears and anxiety. The family also requires information and support.

MONITORING AND MANAGINGPOTENTIAL COMPLICATIONS

Vasospasm

The patient is assessed for signs of possible vasospasm: intensified headaches, a decrease in level of responsiveness (confusion, dis-orientation, lethargy), or evidence of aphasia or partial paralysis. These signs may develop several days after surgery or on the ini-tiation of treatment and must be reported immediately. If va-sospasm is diagnosed, calcium-channel blockers or fluid volume expanders may be prescribed.

Seizures

Seizure precautions are maintained for every patient who may be at risk for seizure activity. Should a seizure occur, maintaining the airway and preventing injury are the primary goals. Medicationtherapy is initiated at this time if not already prescribed. The medication of choice is phenytoin (Dilantin) because this agent usually provides adequate antiseizure action while causing no drowsiness at therapeutic levels.

Hydrocephalus

Blood in the subarachnoid space impedes the circulation of CSF, resulting in hydrocephalus. A CT scan that indicates dilated ven-tricles confirms the diagnosis. Hydrocephalus can occur within the first 24 hours (acute) after subarachnoid hemorrhage or days (subacute) to several weeks (delayed) later. Symptoms vary ac-cording to the time of onset and may be nonspecific. Acute hydro-cephalus is characterized by sudden onset of stupor or coma and is managed with a ventriculostomy drain to decrease ICP. Symptoms of subacute and delayed hydrocephalus include gradual onset of drowsiness, behavioral changes, and ataxic gait. A ventriculoperitoneal shunt is surgically placed to treat chronic hydrocephalus. Changes in patient responsiveness are reported immediately.

Rebleeding

The rate of recurrent hemorrhage is approximately 2% following a primary intracerebral hemorrhage. Hypertension is the most se-rious risk factor, suggesting the importance of appropriate anti-hypertensive treatment (Qureshi et al., 2001).

Aneurysm rebleeding occurs most frequently in the first 2 weeks after the initial hemorrhage and is considered a major complica-tion. Symptoms of rebleeding include sudden severe headache, nausea, vomiting, decreased level of consciousness, and neuro-logic deficit. A CT scan is performed to confirm rebleeding. Blood pressure is carefully maintained with medications. Antifibri-nolytic medications (epsilon-aminocaproic acid) may be admin-istered to delay the lysis of the clot surrounding the rupture. The most effective preventive treatment is early clipping of the aneurysm if the patient is a candidate for surgery.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

The patient and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare them to return home. Patient and family teaching includes informa-tion about the causes of hemorrhagic stroke and its possible con-sequences. In addition, the patient and family are informed about the medical treatments that are implemented, including surgical intervention if warranted, and the importance of interventions taken to prevent and detect complications (ie, aneurysm precau-tions, close monitoring of the patient). Depending on the presence and severity of neurologic impairment and other complications resulting from the stroke, the patient may be transferred to a re-habilitation unit or center, where additional patient and family teaching will focus on strategies to regain ability to manage self-care. Teaching may also address the use of assistive devices or modification of the home environment to help the patient live with a disability. Modifications of the home may be required to provide a safe environment (Olson, 2001). (See Nursing Research Profile 62-2.)

Continuing Care

During the acute and rehabilitation phase of care for the patient with a hemorrhagic stroke, the focus is on obvious needs, issues, and deficits. The patient and family are reminded of the importance of following recommendations to prevent further hemor-rhagic stroke and keeping follow-up appointments with health care providers for monitoring. 

Referral for home care may be warranted to assess the home environment and the ability of the patient and to ensure that the patient and family are able to manage at home. The physical and psychological status of the patient and ability of the family to cope with any alterations in the patient’s status are monitored during home visits. In addition, the nurse involved in home and continuing care needs to remind patients and family members of the need for continuing health promotion and screen-ing practices. Patients who have not been involved in these practices in the past are educated about their importance and are referred to appropriate health care providers, if indicated. Chart 62-7 lists teaching points for the patient recovering from a stroke.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1)    Demonstrates intact neurologic status and normal vital signs and respiratory patterns

a)     Is alert and oriented to time, place, and person

b)    Demonstrates normal speech patterns and intact cogni-tive processes

c)     Demonstrates normal and equal strength, movement, and sensation of all four extremities

d)    Exhibits normal deep tendon reflexes and pupillary re-sponses

2)    Demonstrates normal sensory perceptions

a)     States rationale for aneurysm precautions

b)    Exhibits clear thought processes

3)    Exhibits reduced anxiety level

a)     Is less restless

b)    Exhibits absence of physiologic indicators of anxiety (eg, normal vital signs; normal respiratory rate; absence of excessive, fast speech)

4)    Is free of complications

a)     Exhibits absence of vasospasm

b)    Exhibits normal vital signs and neuromuscular activity without seizures

c)     Verbalizes understanding of seizure precautions

d)    Exhibits normal mental status and normal motor and sensory status

5)    Reports no visual changes