Care of cerebrovascular disease
Patients with cerebrovascular disease have varying degrees of neurological impairment, poor or no self-care ability, and even consciousness and mental impairment that can affect treatment, so their care is very important. In addition to careful observation of changes in the condition, implementation of treatment orders and general basic care, we should also provide appropriate professional care for neurological dysfunction in order to improve the treatment effect of cerebrovascular disease.
Routine emergency care
Routine emergency care for patients with cerebrovascular disease includes.
(1) Transfer to the neurological intensive care unit (NICU) for observation and treatment if available.
(2) Observe for changes in consciousness and pupils. Call the patient regularly or perform pain stimulation to understand the patient’s consciousness; determine whether there is brain herniation by observing pupil changes.
(3) Observe the respiratory frequency, rhythm, amplitude, color of the lips and extremities; keep the head in lateral position; adjust the indicators of the ventilator and observe the operation of the ventilator for those who are mechanically ventilated, regularly aspirate sputum to keep the airway open, and give oxygen when necessary.
(4) Regularly monitor blood pressure and observe the temperature and color of the terminal extremities.
(5) Perform cardiac monitoring to observe heart rate, rhythm and various wave amplitude changes of ECG.
(6) Establish and maintain infusion access to ensure that medications are applied at all times.
(7) Retain a gastric tube and urinary catheter if necessary.
Care of coma
Coma in patients with cerebrovascular disease indicates critical condition, and the quality of its care is related to the success rate of resuscitation. Therefore, the care of coma plays an important role in the acute treatment of cerebrovascular disease patients.
I. Routine care
(1) Observation of vital signs: regularly measure and record changes in body temperature, pulse, respiration and blood pressure.
(2) Observation of specialist conditions: observe the patient’s response to external stimuli and verbal signals, as well as the response of the limbs to painful stimuli, and record changes in consciousness, pupils and eye movements.
(3) Maintain room temperature and humidity to prevent patients from catching cold and complicating respiratory infections; perform regular ventilation and ultraviolet air disinfection to prevent cross-infection in the ward.
II. Prevention of complications
(1) Skin care: place the patient on the air mattress bed, make the bed sheet flat, clean, without wrinkles, place rubber sheet under the middle sheet to prevent urine and stool pollution, keep the skin dry and clean. Place air pillows or air rings on the sacrococcygeal region, bilateral iliac bones, external ankles and occipital bones and other skeletal prominence. Turn the patient once every 1 to 2 hours and massage the skin with 50% ethanol regularly to prevent decubitus ulcers.
(2) Eye care: cover both eyes or single eye with petroleum jelly to prevent foreign body from falling in; apply 0.5% gentamycin eye ointment regularly to prevent corneal ulceration; for bilateral eyelid conjunctival edema, use 0.25% chloramphenicol eye drops regularly to prevent infection.
(3) Oral care: wipe the mouth with external saline cotton balls 3 to 4 times a day. If oral inflammation occurs, give 1:5000 furacilin solution to clean the oral cavity; if white discharge from oral mucosa occurs, suggesting fungal infection, give 4% sodium bicarbonate solution to clean the oral cavity; if oral ulcers occur, give 1% hydrogen peroxide to clean the trauma, and treat with ultraviolet radiation.
(4) Keep the respiratory tract unobstructed: try to take the lateral position, and the head should be tilted to the side when lying down to prevent the back of the tongue and secretions from obstructing the respiratory tract; when there are secretions and vomit, use the suction device to suck clean immediately to prevent accidental aspiration and suffocation.
(5) Prevention of urinary tract infection: patients with urinary incontinence or retention should be given a balloon type indwelling urinary catheter, which should be opened once every 4 hours; the bladder should be flushed with 1:5000 furacilin solution 250ml once or twice a day; the perineum should be flushed once a day; disposable urine bags should be changed twice a week.
(6) Dietary care: Give nasal homogenized diet, maintain daily calories at 1500-2000 calories and fluid volume at 2000-2500 ml. A small amount of gastric juice should be extracted before each meal injection of homogenization to observe the presence of upper gastrointestinal bleeding. Change the nasal feeding tube every 2 to 4 weeks.
(7) Keep the stool unobstructed: for patients who still cannot defecate with the application of slow defecation, give a corker every other day to promote defecation, and those who still cannot succeed can be given a small dose of low-pressure unreserved enema.
Rehabilitation care
(1) Basic position: When the patient is lying down, the head and trunk should be in a straight line, with the face facing slightly towards the hemiplegic side. The shoulders and hips are each slightly padded with a pillow, so that the upper limbs are kept slightly out of the booth and the elbow joint is extended on the pillow. The lower extremity is straightened, the knee joint is slightly flexed, and a brace, sandbag or cotton pad is placed on the bottom of the foot. In the lateral position, the upper limb of the paralyzed side was kept in the outward shoulder booth, and the upper limb was kept in the elbow extension, wrist extension and finger extension position; the lower limb was kept in the appropriate hip flexion and knee flexion position, and air pillows were disposed at the knee joint and outer ankle to keep the foot dorsiflexion position. Give the patient to turn every 2 hours, and place pillows on the shoulder and lumbar area when lying on the side.
(2) Passive movement of the limbs: The patient lies down and the nurse carries out passive movement of each joint of the limbs, including shoulder abduction, hip flexion, elbow flexion, wrist, finger joint, knee joint and ankle joint at regular intervals, 3 to 5 times a day for 20 minutes each time.
(3) Wake-up promotion care: call the patient’s name frequently and give verbal signal stimulation; regularly instruct family members to massage the patient’s limbs and whole body skin to increase external stimulation; give the patient earphones with a pocket-sized transceiver in both ears to promote wake-up with words and music together.
Care of paralysis
Paralysis is the most common symptom in patients with cerebrovascular disease. Proper care is beneficial to the prevention of complications and recovery of limb function.
I. Care of hemiplegia
(1) Establish the level of care according to the muscle strength of the hemiplegic side of the patient, pay attention to the correct position of the hemiplegic side of the limb, and maintain the functional position of the large joints and hands.
(2) Patients with muscle strength around grade IV can walk with support, give first level of care to support toileting and pay attention to prevent falls.
(3) Bedridden patients with muscle strength below grade III need to be placed in bed stalls to prevent patients from falling out of bed when they turn over or sit up by themselves.
(4) For patients with hemiplegic side limb strength of grade III or below, assist in turning and passive limb movement regularly.
(5) For conscious patients, assist in maintaining sitting position several times a day. If the patient is hemiplegic on the right side of the limb, train the left hand to use utensils or practice writing.
(6) Depending on the patient’s consciousness and muscle strength, functional limb exercises can be performed several days after the onset of the disease; patients with cerebral hemorrhage should generally be strictly bedridden for 2 to 4 weeks, and in about 1 week after the onset of the disease, limb rehabilitation training can be performed in bed if the condition allows.
(7) For patients with combined aphasia, simple speech training can be performed daily.
(8) Patients who are depressed should actively carry out psychological care, encourage patients to carry out functional exercises of the limbs, and train the ability to take care of themselves.
Care for tetraplegia
(1) Maintain the correct position, place pillows or cotton pads on the shoulders and hips when lying down, make the upper limbs in the position of shoulder joint abduction, elbow joint and wrist joint extension when lying on the side, and slightly flex the hip, knee and ankle joint dorsiflexion on the lower limbs.
(2) Turn over once every 1 to 2 hours and massage the skin of the bone elevation regularly.
(3) Patients with swallowing difficulties are given a nasal homogenized diet to ensure adequate caloric and water intake.
(4) Those with urinary retention or incontinence are given an indwelling urinary catheter, which is opened once every 4 hours, bladder flushing once or twice a day, and disposable urine bags are changed twice a week.
(5) For patients with combined consciousness disorders, pay attention to head tilted to one side, do regular back-buttoning and sputum aspiration to prevent accidental aspiration of oral secretions or vomitus.
(6) Perform passive activities on the patient’s limbs once a day in the morning and once in the afternoon, 3 to 5 times for each joint and 10 to 20 minutes for each activity.
(7) Conscious patients can be trained to sit several times a day, and early rehabilitation of quadriplegia can be performed according to the patient’s condition.
Third, the care of ball palsy
(1) For those with dysarthria, listen patiently to their meaning and ask them to express it in words if necessary.
(2) For those who choke, the patient or his/her family should be taught how to eat, such as drinking through a straw, eating mushy food, drinking or eating in a sitting position.
(3) For those who have difficulty swallowing, a gastric tube should be left in place for medication administration and feeding; train to eat during the recovery period.
(4) Those who have more secretions from the mouth and nasopharynx should be assisted to spit out or suck out in time.
(5) Replace the nasal feeding tube once every 2 to 4 weeks.
Care of upper gastrointestinal bleeding
Upper gastrointestinal bleeding is a common comorbidity of cerebrovascular disease. In the case of small amount of bleeding, it only manifests as vomiting or coffee-like gastric contents pumped out from the gastric tube, but in the case of large amount of bleeding, fresh blood may be vomited and hemorrhagic shock may occur, and emergency treatment should be given.
I. Routine care
(1) The patient should lie down with the head to the side, disposable padded towels and curved plates should be placed at the jaws of patients with small amount of bleeding, and a wash basin or bucket should be prepared at the bedside of patients with large amount of vomiting to collect the vomit.
(2) Measure and record pulse, blood pressure and heart rate regularly, and give low-flow oxygen to those with accelerated heart rate.
(3) Abstain from food and water and drugs during bleeding. For patients with massive vomiting of blood, quickly establish intravenous access, and cooperate with the doctor for anti-shock treatment if there is a drop in blood pressure.
(4) For patients with large amount of bleeding, immediately check the blood routine, blood type and do cross-matching blood test.
II. Hemostasis and blood transfusion treatment
Care of decubitus ulcers
Decubitus ulcers are the most common complication in patients with cerebrovascular disease due to improper care. They occur within 24 hours and 2-4 weeks after the onset of the disease and can cause serious infection and aggravate the disease. Therefore, prevention of decubitus ulcers is particularly important for nursing care.
I. Skin care for prevention of decubitus ulcers
(1) For patients with hemiplegia or quadriplegia, strictly implement the system of turning once every one to two hours, with gentle movements, and forbid dragging patients in bed to avoid skin abrasions.
(2) Keep the bed sheet flat, free of wrinkles and crumbs, and change the diapers or sheets polluted by urine and stool in time.
(3) Keep the skin clean, take care of the back once a day in the morning and afternoon, rub the bed once or twice a week, and massage the sacrococcygeal and bony elevated areas when turning over.
(4) Air pillows or air rings can be placed on pressure-prone areas or bone elevation areas, and air beds or automatic turning beds can be used if available.
Second, the care of bedsores
(1) When the skin is red and swollen and hardened at the site of pressure, avoid further pressure on the site and apply 2% iodine or 0.5% iodophor locally several times a day.
(2) When blisters appear in the reddened area of the skin, draw out the fluid in the blisters under aseptic operation, keep the epidermis intact and apply 0.5% iodophor locally several times a day to keep the wound surface dry.
(3) When epidermal breakage occurs at the blister site, apply 0.5% iodophor locally, once every 4 hours; use fresh egg endothelium on the wound surface to promote epidermal healing, and give infrared light irradiation once in the morning and once in the afternoon for 15-20 minutes each time.
(4) When the epidermis is necrotic and ulcers are formed, the area gradually expands and reaches the subcutaneous tissue, give 3% hydrogen peroxide locally to remove the decaying tissue, then clean the trauma with saline, apply 0.5% iodophor locally and keep the trauma dry. Change the medication once a day, and disinfect the surrounding skin with 75% ethanol at each change.
(5) When the ulcer reaches deep into the muscle tissue, local debridement surgery is required. Bacterial culture and drug sensitivity test are done on the traumatic secretions before surgery, systemic antibiotics are applied after surgery, and the traumatic surface is covered with petroleum jelly gauze and the medication is changed regularly every day.