Timby/Smith: Introductory
Medical-Surgical Nursing, 12/e
Chapter 38: Caring for Clients With
Cerebrovascular Disorders
Headache #1
 Types of Headaches
o Tension headache: most common; person contracts
the neck and facial muscles for a prolonged period of
time
o Migraine headache: recurrent, severe, last for a day
or more, vascular origin
o Cluster headache: may be a variant of migraine
headaches, episodic, recurring over 6 to 8 weeks,
with only brief periods of recovery between multiple
daily attacks
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Headache #2
 Pathophysiology and Etiology
 Tension Headaches
o Tension headache: occur when a person contracts the
neck and facial muscles for a prolonged period of
time
 Tensed muscles sensitize nociceptors (painrelaying nerves in head), transmit neurochemicals
to brain, which registers the presence and location
of discomfort.
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Headache #3
 Migraine Headaches
o Three sequential contributing cofactors
 Changes in serotonin receptors: promotes dilation of
cerebral blood vessels and pain intensification from
neurochemicals released from the trigeminal nerve
 Fluctuations in reproductive hormones
 Chemicals in certain foods, a food-related allergy, drugs
may trigger migraines
 Cluster Headaches
o Cause is unknown: may be triggered by vasodilating
agents, nitroglycerin, histamine, alcoholic beverages,
acetylcholine
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Headache #4
 Assessment Findings
o Tension headache: pressure or steady constriction on
both sides of head
o Classic Migraines
 Aura—prodromal period before the headache is
marked by a change in mood, difficulty
concentrating, unusual fatigue, throbbing or
bursting pain, nausea, vomiting, vertigo,
sensitivity to light, irritability
o Cluster headache: pain on one side of head, usually
nasal congestion, rhinorrhea, tearing, redness of the
eye
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Headache #5
 Diagnostic Findings
o CT scan, brain scan, head and neck radiographs
 Angiography to rule out other neurologic disorders
 Medical Management
o Tension headaches: relieved by rest, mild analgesic,
stress management techniques
 For severe, recurrent tension headaches,
counseling and psychotherapy may help clients
deal with emotional stressors; antidepressants
may also help clients
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Headache #6
 Medical Management—(cont.)
o Migraine headaches: drug therapy
 Mild analgesics
 Methysergide (Sansert), topiramate (Topamax)—
prevent migraine
 Increase dose gradually; monitor drug levels
 Sumatriptan (Imitrex)—interrupt migraines that
have already developed
 Oral, intranasal spray, or subcutaneous
injection
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Headache #7
 Medical Management—(cont.)
o Cluster headaches: drug therapy
 Dihydroergotamine (Migranal), methysergide
(Sansert), corticosteroids such as triamcinolone
(Aristocort), prednisone (Deltasone)
 Vasoconstricting drugs such as sumatriptan
(Imitrex), anticonvulsants such as gabapentin
(Neurontin), beta-adrenergic blockers such as
atenolol (Tenormin)
o Oxygen: reduces the vasodilating compensatory
response occurring in the brain
o Rhizotomy
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Question #1
The nurse is instructing the client on management and
prevention of migraine headaches. Which of the following
statements indicate the client requiring further instruction?
A) “I will lie down in a darkened room and avoid noise and
movement when an attack occurs.”
B) “Keeping a record of attacks will help identify factors
that bring on a migraine.”
C) “A back massage will promote muscle relaxation.”
D) “I will administer sumatriptan (Imitrex) for headaches
before symptoms of migraines appear.”
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Answer to Question #1
D) “I will administer sumatriptan (Imitrex) for headaches
before symptoms of migraines appear.”
Rationale: This medication is given any time after
symptoms appear; oral doses can be repeated in 2 hours;
a second injection can be repeated in 1 hour if headache is
unrelieved or reoccurs.
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Transient Ischemic Attacks #1
Transient Ischemic Attack (TIA)
 Pathophysiology and Etiology
o Sudden, brief episode of neurologic impairment
caused by a temporary interruption in cerebral blood
flow
o Causes: atherosclerosis, arteriosclerosis, cardiac
disease, diabetes
 TIA is a warning that a cerebrovascular accident
can occur in the near future; one-third of people
who experience TIA subsequently develop a
stroke.
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Transient Ischemic Attacks #2
 Assessment Findings
o Temporary lightheadedness; confusion; speech
disturbances; loss of vision; diplopia; variable changes in
consciousness; and numbness, weakness, impaired muscle
coordination, or paralysis on one side
 Diagnostic Findings
o Examination: auscultation of the carotid artery may reveal
a bruit (abnormal sound caused by blood flowing over the
rough surface of one or both carotid arteries)
o Other: ultrasound examination, carotid arteriogram, CT
scan, MRI
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Transient Ischemic Attacks #3
 Gerontologic considerations: older adults may ignore the
symptoms of a TIA, attributing them to part of the normal
aging process
 Medical Management
o Control blood pressure, lose excess weight, stop
tobacco and alcohol use
o Manage atherosclerosis and cardiac dysrhythmias;
cholesterol-lowering drugs, prophylactic anticoagulant
or antiplatelet
 Aspirin, clopidogrel (Plavix), warfarin (Coumadin)
o Diabetic education
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Transient Ischemic Attacks #4
 Surgical Management
o Carotid endarterectomy
o Percutaneous transluminal angioplasty and stent
placement
 Nursing Management
o Obtain a complete history of symptoms, medical, drug,
allergy histories, weights, capillary blood sugar, vital signs,
smoking history, neurologic examination
o Carotid artery surgery: postoperative
 Frequent neurologic checks to detect paralysis,
confusion, facial asymmetry, aphasia; monitor heart
rhythm
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Cerebrovascular Accident (Stroke) #1
Cerebrovascular Accident (CVA)
 Pathophysiology and Etiology
o Prolonged interruption in the flow of blood through
one of the arteries supplying the brain
 Types of Stroke
o Ischemic stroke: a thrombus or an embolus obstructs
an artery carrying blood to the brain
o Hemorrhagic stroke: a cerebral blood vessel ruptures
and blood is released in the brain; elevated pressure
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Question #2
For which type of stroke does a postmyocardial infarction
(MI) client experiencing atrial fibrillation most at risk?
A) Hemorrhagic stroke
B) Embolic stroke
C) Thrombotic stroke
D) Cerebral aneurysm
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Answer to Question #2
B) Embolic stroke
Rationale: In atrial fibrillation, the blood is not ejected
normally, and small clots may develop in the atria. If these
clots are ejected into the circulation as emboli and travel to
the brain, an embolic stroke occurs.
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Cerebrovascular Accident (Stroke) #2
 Assessment Findings
o Numbness or weakness of one side of the face, arm, or
leg; mental confusion; difficulty speaking or
understanding; impaired walking or coordination; severe
headache
o Hemiplegia (paralysis on one side of the body)
 Right-sided: expressive aphasia, receptive aphasia,
slow and cautious behavior
 Left-sided: spatial–perceptual defects, poor judgment,
midjudge distances
o Hemianopia
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Cerebrovascular Accident (Stroke) #3
 Diagnostic Findings
o CT scan, MRI, transcranial Doppler ultrasonography,
single-photon emission computed tomography
(SPECT), electroencephalogram
o Lumbar puncture; if subarachnoid bleeding has
occurred, cerebrospinal fluid will be bloody
o Cerebral angiography shows displacement or
blockage of cerebral vessels.
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Nursing Care Plan: CVA
 Impaired Swallowing related to hemiplegia
o Use a thickening agent; keep a suction machine.
 Risk for Imbalanced Nutrition
o Request small, frequent nourishment.
 Risk for Impaired Skin Integrity related to immobility
o Use pressure-relieving devices or therapeutic bed.
 Impaired Verbal Communication related to aphasia
o Instruct client to speak slowly.
 Risk for Ineffective Coping
o Acknowledge personal strengths.
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Question #3
A client is hospitalized following a stroke. Three days after
admission, the client is able to converse clearly. One
morning, the client’s daughter runs out of the room and
says, “My mother can’t talk.” Which response by the nurse
is best?
A) Explain to the daughter that this in not uncommon.
B) Assess the client and notify the RN or physician stat.
C) Call the speech therapist to come.
D) Show the daughter how to do the speech exercises.
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Answer to Question #3
B) Assess the client and notify the RN or physician stat.
Rationale: A change in speech pattern may be an indication
that the stroke is extending, so immediate evaluation is
required.
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Cerebral Aneurysms #1
 Pathophysiology and Etiology
o Aneurysms develop at a weakened area in the blood
vessel wall.
o Causes: defect is congenital or secondary to
hypertension and atherosclerosis
 Assessment Findings: sudden and severe headache,
dizziness, nausea, vomiting usually followed by a rapid
loss of consciousness
o If the ruptured aneurysm produces a slow leak, a stiff
neck, headache, visual disturbances, intermittent
nausea develop.
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Cerebral Aneurysms #2
 Diagnostic Findings
o Cerebral angiography, CT scan, MRI, lumbar puncture
 Hunt-Hess Scale
 Medical Management
o Conservative management
o Complete bed rest, prevention of rebleeding at
rupture site, treatment of complications, head of bed
elevated to reduce ICP and cerebral edema,
antihypertensive agents, anticonvulsants,
tranquilizers, osmotic diuretics, corticosteroids
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Cerebral Aneurysms #3
 Surgical Management: craniotomy
 Diagnosis
o Increased intracranial pressure
 Report neurologic changes; keep client calm.
o Seizures
 Institute seizure precautions; implement
anticonvulsant drug therapy.
o Pain related to ICP
 Avoid administering opioid analgesics, except
codeine
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