Acute cerebrovascular disease
Cerebrovascular disease is a general term for brain diseases caused by vascular lesions in the brain and/or systemic blood circulation disorders that result in impaired blood supply to brain tissue, abnormal brain function or structural damage, and is a common and frequent disease of the nervous system. Acute cerebrovascular diseases can be clinically divided into two categories: ischemic cerebrovascular diseases and hemorrhagic cerebrovascular diseases. Ischemic cerebrovascular diseases mainly include transient ischemic attack, cerebral infarction (cerebral thrombosis, cerebral embolism, lacunar infarction)
I. Hemorrhagic cerebrovascular disease
Hemorrhagic cerebrovascular diseases mainly include cerebral hemorrhage and subarachnoid hemorrhage.
Cerebral hemorrhage refers to primary intracerebral parenchymal hemorrhage. The disease is mostly seen in middle-aged and elderly people over 50 years old, mostly in the basal ganglia area, accounting for about 70%, and about 10% in the brain lobes, brainstem and cerebellum. It is characterized by impaired consciousness, headache and neurological localization signs. Mild cerebral hemorrhage can improve significantly with treatment, while severe cases have a high mortality rate.
Subarachnoid hemorrhage is a rupture of a blood vessel at the base of the brain or on the surface of the brain, and blood enters directly into the subarachnoid space. Brain parenchymal hemorrhage or ventricular hemorrhage flowing into the subarachnoid space is secondary to subarachnoid hemorrhage. The disease is most common in young and middle-aged people and presents with sudden severe headache and vomiting with transient disorders of consciousness, positive meningeal stimulation signs, and bloody cerebrospinal fluid. Re-bleeding, cerebral vasospasm, and traffic hydrocephalus are common complications.
The most common cause of cerebral hemorrhage is hypertension, followed by atherosclerosis, also seen in cerebral aneurysm, cerebrovascular malformation, brain aneurysm, hematologic disease, cerebral arteritis, post-infarction cerebral hemorrhage, anticoagulation and thrombolytic therapy. In case of emotional excitement, excessive physical strength and other triggers, there is a rapid increase in blood pressure and blood vessel rupture and bleeding, forming bleeding foci of different sizes in the brain. Hypertensive cerebral hemorrhage usually stops within 30 minutes.
The most common cause of subarachnoid hemorrhage is congenital aneurysm, followed by vascular malformation, hypertension, atherosclerosis, arteritis, and blood disorders. It mostly develops during emotional excitement or excessive exertion.
The acute treatment of cerebral hemorrhage is mainly to prevent further bleeding, reduce intracranial pressure, control cerebral edema, maintain vital functions and prevent complications; the recovery treatment is mainly to carry out functional recovery, improve brain functions, reduce sequelae and prevent recurrence. The acute treatment of subarachnoid hemorrhage is to remove the cause of bleeding, prevent and control secondary cerebral vasospasm, stop further bleeding and prevent recurrence.
(I) Nursing assessment
Health history
(1) History of hypertension, atherosclerosis or cerebral aneurysm, cerebrovascular malformation and hemorrhagic disease.
(2) Any emotional stress, excessive tension, exertion, forceful defecation, or other physical overload before the onset of the disease.
(3) Onset and main manifestations, including headache, motor disorders, sensory disorders, and disorders of consciousness, etc.
Physical assessment
Whole brain manifestations.
(1) abnormal vital signs, breathing is generally fast, in severe cases deep and slow breathing, or tidal breathing, sigh-like breathing, etc.; blood pressure is mostly elevated in the early stage of hemorrhage, unstable blood pressure and continuous decline are signs of central circulatory failure; high fever often appears after hemorrhage, if it is always low fever, it may be absorption fever after hemorrhage.
(ii) Headache and vomiting. Those with clear consciousness or mild impaired consciousness often report headache, which is heavier on the side of the lesion; patients with blurred consciousness or shallow coma can touch the head on the side of the lesion with the healthy hand; vomiting is mostly jet-like, and the vomit is stomach contents or coffee-colored.
③Consciousness disorder, the lighter patient is agitated and unconscious; the more serious patient enters into coma, snoring loudly, eyes fixed in median position, flushed or pale face, sweating, urinary incontinence or urinary retention, etc.
If the pupils on the focal side are dilated and the response to light is dull or absent, it is a sign of cerebellar herniation; if the pupils on both sides are gradually dilated and the response to light is absent, it is a sign of bilateral cerebellar herniation, occipital foramen herniation or deep coma; if the pupils on both sides are narrowed or pinpointed, it is a sign of pontocerebellar hemorrhage.
Focal neurological signs.
① Hemorrhage in the basal ganglia region: varying degrees of hemiparesis, hemianesthesia and hemianopsia on the contralateral side of the lesion, with positive pathological reflexes. Both eyes are often deviated to the side of the lesion. The dominant hemisphere hemorrhage may also have symptoms such as aphasia and dysarthria.
(2) Pontocerebral hemorrhage: peripheral facial palsy and contralateral limb paresis (crossed paresis) are common on the side of hemorrhage; bilateral peripheral facial palsy and quadriplegia appear if the hemorrhage spreads to both sides; pupils on both sides may be pinpointed and both eyes are deviated to the opposite side of the lesion; body temperature is elevated; a few may show decerebral tonicity (two upper limbs are flexed, two lower limbs are straightened, lasting for a few seconds or minutes as paroxysmal decerebral tonicity; limb extension is decerebral tonicity). (The tonicity of the extremities is the detrusor tonicity).
(iii) Lobar hemorrhage: mostly monoparesis or mild hemiparesis on the opposite side of the lesion, or localized limb twitching and sensory disturbance.
(iv) Ventricular hemorrhage: the condition is severe, often accompanied by tonic convulsions and meningeal irritation signs. If the third ventricular hemorrhage affects the thalamus, both eyes can be seen to stare downward.
⑤ Cerebellar hemorrhage: pain in the posterior occipital region on one or both sides, vertigo, blurred vision, nausea and vomiting, unstable walking, nystagmus, ataxia, nagging, peripheral facial palsy, cone bundle sign and cervical tonicity can be detected if there is no coma. If the brainstem is compressed, it may be accompanied by denervation tonicity.
Subarachnoid hemorrhage
(1) Sudden onset of severe splitting headache.
②Various degrees of impaired consciousness or transient loss of consciousness, delirium and coma may be present in critical cases.
③Positive meningeal stimulation sign.
Psycho-social assessment
Patients are prone to depression, nervousness, anxiety, pessimism, despair, and loss of confidence in treatment. Whether the family actively cooperates with the treatment and can provide proper care for the patient. Whether the community health service institutions can provide continuous medical services for the patient after discharge and whether the environmental conditions are suitable for the patient’s rehabilitation training.
Auxiliary examinations
(1) Cranial CT examination is the first choice, which can show high-density shadow at the site of hemorrhage and determine the site, size and shape of the hematoma, as well as whether it has broken into the ventricles of the brain.
(2) Cranial MRI examination can detect small amount of bleeding in the brainstem or cerebellum that cannot be identified by CT, distinguish brain bleeding that cannot be identified by CT after 4-5 weeks of disease, and differentiate old brain bleeding from brain infarction.
(3) Digital subtraction cerebral angiography (DSA), which can detect changes in cerebral blood vessels.
(4) Cerebrospinal fluid examination. Cerebrospinal fluid pressure is increased in subarachnoid hemorrhage and is mostly homogeneous and bloody, but cerebrospinal fluid can be normal in appearance in limited cerebral hemorrhage.
(2) Nursing diagnosis and cooperative problems
(1) Impaired consciousness Associated with cerebral hemorrhage.
(2) Pain: headache Associated with increased intracranial pressure due to hemorrhagic cerebrovascular disease.
(3) Somatic mobility disorder related to paralysis due to hemorrhagic cerebrovascular disease.
(4) Language communication disorder related to hemorrhagic cerebrovascular disease lesions involving the language center.
(5) Hyperthermia is associated with hemorrhagic cerebrovascular disease lesions involving the thermoregulatory center and decreased resistance to secondary infection.
(6) Risk of infection Related to poor drainage of respiratory secretions.
(7) Potential complications: brain herniation, upper gastrointestinal bleeding, pressure sores.
(C) Expected goals
To maintain vital functions, prevent complications, conduct early functional training, reduce sequelae, and prevent recurrence.
(D) Nursing measures
General care
(1) Rest, keep the hospital room quiet, clean, appropriate temperature, fresh air, soft light in the room for patients with headache, limit visits, and ensure adequate rest for patients. Patients with cerebral hemorrhage should be absolutely bedridden during the acute stage, especially within 24 to 48 hours of onset. For subarachnoid hemorrhage, absolute bed rest for 4-6 weeks, avoiding all factors that may cause an increase in blood pressure and cranial pressure.
(2) Diet, high calorie, high protein, high vitamin, moderate amount of fiber, low salt, low sugar, low fat, low cholesterol food should be given. Those with impaired consciousness or gastrointestinal bleeding should be given a nasal fluid diet after 24-48 hours of fasting.
(3) Administer oxygen. Those with respiratory distress, cyanosis, impaired consciousness and severe cerebral tissue blood supply disorders can be given general oxygen concentration nasal catheter, nasal plug or face mask to relieve tissue hypoxia.
(4) Keep the respiratory tract unobstructed, tilt the head to one side when vomiting occurs, denture when unconscious to prevent obstruction of the respiratory tract by accidental inhalation; pad under the shoulder when unconscious to prevent the tongue root from falling back to obstruct the respiratory tract; when sputum discharge is difficult, methods of guiding effective coughing, snapping the chest, wetting the respiratory tract and mechanical aspiration can be used according to the specific situation to remove respiratory secretions in a timely manner.
(5) Oral care, pay attention to clean mouth, brush teeth in the morning and evening, and rinse mouth in time after meals.
(6) Psychological care. In the nursing process, be meticulous and patient, with an amiable attitude, and eliminate the patient’s nervousness. Give the patient enough care and spiritual support, guide the patient to make self-psychological adjustment and reduce anxiety.
(7) Observe the condition, pay attention to the changes in consciousness, headache, pupils, etc., monitor the changes in body temperature, respiration, heart rate, heart rhythm and blood pressure; accurately record the 24-hour fluid intake and output; strengthen ward rounds and report to the physician once changes in the condition are detected.
Symptomatic care
(1) Elevated blood pressure In the acute stage of cerebral hemorrhage, if the systolic blood pressure is >220 mmHg, diastolic blood pressure is >120 mmHg or mean arterial pressure is >130 mmHg, it is prudent to lower the cranial blood pressure and at the same time to maintain the blood pressure at a level slightly higher than before the onset or around 180/105 mmHg; systolic blood pressure is 170-200 mmHg or diastolic blood pressure is 100-110 mmHg. Temporarily, there is no need to use antihypertensive drugs yet, first dehydration to lower the cranial pressure, and closely observe the blood pressure, and then use antihypertensive drugs if necessary. The blood pressure should not be reduced too much, otherwise it may cause cerebral hypoperfusion. Systolic blood pressure <165 mmHg or diastolic blood pressure <95 mmHg does not require blood pressure lowering therapy. For subarachnoid hemorrhage mean arterial pressure >125 mmHg or systolic pressure >180 mmHg, blood pressure can be lowered to normal or pre-initiation level on blood pressure monitoring.
(2) Gastrointestinal bleeding Gastric fluid should be aspirated at each nasal feeding. If the patient has erratic reflux, abdominal distension, coffee-colored gastric fluid or black stool solution, gastrointestinal bleeding is considered, and the physician should be notified immediately to give hemostatic drugs.
(3) Aphasia care Non-verbal communication is an effective way of communication for aphasic patients, which can be carried out with the help of gestures, expressions, nodding or shaking of head, word cards, writing, and physical objects.
(4) Pressure sores Assist the patient to change position frequently, ask the patient to wear soft and loose clothes, keep the mattress soft, flat and clean, and keep the skin clean.
(5) Defecation care
(1) In case of urinary incontinence, wash the perineum, change underwear and bedding, clean up dirt, and use pads to keep the perineum clean and dry.
(2) In case of constipation, give high-fiber food and sufficient water intake; massage the abdomen in the direction of the colon starting from the ascending colon; use laxatives or enemas if necessary, but avoid large amounts of liquid enemas in patients with increased intracranial pressure to prevent further increase of intracranial pressure.
(6) Central hyperthermia Physical cooling is recommended.
Medication care
(1) Control cerebral edema and lower intracranial pressure
Commonly used are dehydrating agents (20% mannitol, 10% glycerol fructose) and diuretics (furosemide). These drugs often cause water and electrolyte disorders, and the main observation should be the changes of in and out volume and serum electrolytes when using the drugs. In addition, the use of 20% mannitol should be careful not to mix with electrolyte solutions to avoid precipitation; if mannitol crystallization occurs due to low temperature, it should be dissolved after heating; intravenous drug speed should be fast, through osmotic diuresis to achieve therapeutic purposes, but the injection speed is too fast, can cause transient headache, blurred vision, dizziness, chills, fever, injection site pain, etc., individual patients may have allergic reactions, and at the same time to Attention to acute renal impairment. Alternating mannitol and glycerol fructose can reduce the dosage of mannitol and alleviate the side effects of mannitol. Glycerol fructose has no renal impairment, can provide energy after entering the body metabolism, and does not require insulin, especially suitable for hyperglycemic patients.
(2) Hemostatic drugs: Hypertensive cerebral hemorrhage mostly does not use hemostatic drugs. Hemostatic drugs are routinely used for ventricular hemorrhage and subarachnoid hemorrhage. Commonly used antifibrinolytic drugs such as 6-aminocaproic acid, hemostatic aromatic acid, lithophoresis, etc. Pay attention to the prevention of renal impairment and deep vein thrombosis.
(3) Calcium channel blockers: Calcium channel blockers can reduce cerebral vascular spasm and improve cerebral blood supply, commonly used nimodipine, flunarizine hydrochloride, etc.. This drug can appear headache, dizziness, weakness, blood pressure, increased heart rate and other side effects, should be observed when using blood pressure changes, slowly change the position, blood pressure is too low when cautiously used or follow medical advice to use dobutamine, alamine and other drugs to raise blood pressure.
(E) Health education
Explain to patients and their families that hypertension, atherosclerosis, cerebral aneurysm, cerebrovascular malformation, hematological disease and hemorrhagic cerebrovascular disease are closely related. You should keep your mood relaxed and avoid tension, excitement and excessive force.
Quit smoking and avoid alcohol, eat more vitamin-rich food and develop the habit of good bowel movement.
Cultivate the patient’s ability to adapt to life after illness. After the disease is stabilized, exercise as early as possible; after entering the recovery period, instruct the patient to train the ability of self-care.
Attachment: care of lumbar puncture
Lumbar puncture is a clinical treatment technique in which a lumbar puncture needle is inserted into the subarachnoid space through the lumbar spinal space to extract cerebrospinal fluid and inject drugs, and it is one of the common clinical examination methods in neurology. Lumbar puncture is important for the diagnosis and treatment of neurological diseases, and it is simple, easy to perform and safe.
Indications and contraindications
(1) Indications
(1) Cerebrovascular lesions.
(ii) Various inflammatory lesions of the central nervous system.
(iii) Brain tumors.
(iv) Central nervous system leukemia.
⑤ Spinal cord lesions.
(2) Contraindications
(1) Infection of the skin, subcutaneous soft tissue or spine at the puncture site.
(②Significantly increased intracranial pressure or signs of brain herniation have appeared.
(③) Acute stage of spinal cord mass or spinal cord trauma in the high cervical segment.
(4) Those with serious systemic infectious diseases, critical condition, agitation, etc.
(3) Complications Low cranial pressure headache is most common after lumbar puncture and can last for 2 to 8 days. The headache can be relieved by lying in a flat position. Drink plenty of water, and if necessary, intravenous saline can be given.
Nursing cooperation of treatment operation
(1) Preoperative preparation
①Preparation of items: lumbar puncture kit (containing lumbar puncture needle, 5ml and 10ml syringes, No. 7 injection needle, cavity towel, gauze, test tube, manometry tube), 2% lidocaine injection, sterilization tray, gloves, adhesive tape, and culture medium can be prepared as needed.
②Patient preparation: introduce the purpose and precautions of lumbar puncture to the patient, and the family members sign to agree to the puncture; the patient empties the urine and stool; eliminate the patient’s nervousness.
(③Environmental preparation: quiet, clean, warm, and screened.
(2) Intraoperative cooperation
①Arrange the patient to lie on a hard bed or put a hard board under him/her.
②Assist the surgeon to maintain the patient’s lumbar puncture position and expose the puncture site.
③Cooperate with disinfection of the puncture site, gloves, towel and 2% lidocaine for local anesthesia.
④When the puncture is successful, observe whether the cerebrospinal fluid flows slowly.
⑤ Ask the patient if there is any discomfort, observe the patient’s face, breathing, pulse, pupils, etc. If abnormalities are found, notify the doctor immediately, stop the puncture and do the corresponding treatment. If the patient feels electric shock-like pain in the lower extremities, tell him that it is caused by the tip of the needle touching the cauda equina and no treatment is needed.
(6) Collect 3 to 5 ml of cerebrospinal fluid in a sterile test tube and send it for examination. If bacterial culture is needed, the test tube and cotton plug should be sterilized under flame.
(7) After the operation, when the puncture needle is removed, the puncture site is disinfected with iodophor and covered with gauze and fixed with adhesive tape. Organize the materials used.
(3) Postoperative care
①Tell the patient to lie flat on the pillow for 4-6 hours, do not raise the head, but turn over to prevent the occurrence of low cranial pressure headache.
(②or intravenous saline drip to extend the bed rest time to 24 hours.
③Observe the puncture site for cerebrospinal fluid leakage, bleeding or infection, and notify the physician for appropriate treatment if there is any abnormality.
Attachment: Operation method
(1) Lumbar puncture position: bend over and hold the knee in the lateral position with the back perpendicular to the bed and the lumbar region as posteriorly convex as possible to widen the vertebral space.
(2) Puncture point: generally take the 3rd or 4th lumbar space as the puncture site, which is equivalent to the intersection of the posterior superior iliac spine line and the posterior midline.
(3) The puncture site is disinfected, and the operator wears gloves, a towel and 2% lidocaine for local anesthesia.
(4) The skin at the puncture site is fixed with the left hand, and the right hand wraps the puncture needle with sterile gauze (with the needle center attached) and slowly enters the needle from the intervertebral space in a perpendicular direction to the spine, with the tip of the needle slightly biased toward the cephalic end, at a depth of about 4-6 cm in adults and about 2-4 cm in children. The needle is slowly withdrawn to prevent brain herniation formation.
(5) Measurement of intracranial pressure should be connected to a manometry tube (normal cerebrospinal fluid pressure is 80-180 mmH2O or 40-50 drops per minute); if a power test (neck compression test) is needed to understand whether there is obstruction in the subarachnoid space, that is, after manometry, compress the jugular vein on one side for about 10 minutes. If the cerebrospinal fluid pressure rises immediately after normal compression and falls to the original level 10-20 seconds after release of compression, it is called negative power test, which indicates that the subarachnoid space is open; if the cerebrospinal fluid pressure cannot rise after compression of the jugular vein, it is positive power test, which indicates that the subarachnoid space is obstructed; if the cerebrospinal fluid pressure rises slowly after compression of the jugular vein and falls slowly after relaxation of pressure, it is also positive power test, which indicates that the subarachnoid space is (6) Remove the manometry tube.
(6) Remove the manometry tube and collect 3~5ml of cerebrospinal fluid in 2~3 test tubes and send them for timely examination.
(7) After the operation, insert the needle core and then pull out the puncture needle, the needle hole should be sterile and covered with a dressing.
(8) Ask the patient to lie flat on the pillow for 4 to 6 hours without raising the head.