STROKE’’ Ischemiato)partof)brain) AcidBBase)Balance

STROKE •  Ischemia to part of brain (what other system disease is this similar to?)

•  Hemorrhage into brain that results in death of brain cells

•  Severity of loss of func=on varies according to loca=on and extent of brain damage – Physical, cogni=ve, and emo=onal impact on pa=ent and family

•  Acid-‐Base Balance •  Cogni=on •  Concepts related to Cogni=on:

•  Perceptual disturbances/psychosis

•  Impaired aGen=on •  Memory problems •  Problems with

communica=on/social cogni=on

•  Problems with motor control/cogni=on

•  Problems with execu=ve func=on

•  Problems with intellectual func=oning and learning

•  Mobility •  Oxygena=on •  Perfusion •  Safety •  Stress and Coping *What nursing physical assessments are involved? 1 Fall 2019 - Spring 2020

As one of your clinical assignments, you are assisting an RN with health screening at a health fair. Which individual is at greatest risk for experiencing a stroke? a.  A 46-‐year-‐old white female with hypertension and oral

contraceptive use for 10 years b.  A 58-‐year-‐old white male salesman who has a total

cholesterol level of 285 mg/dl c.  A 42-‐year-‐old African American female with diabetes

mellitus who has smoked for 30 years d.  A 62-‐year-‐old African American male with hypertension

who is 35 pounds overweight

Audience Response Question

2 Fall 2019 - Spring 2020

Risk Factors

Non-‐Modifiable •  Age •  Gender •  Ethnicity/race •  Heredity/family history Modifiable •  Hypertension •  Heart disease –serum cholesterol •  Smoking •  Obesity •  Sleep apnea •  Metabolic syndrome •  Lack of physical exercise •  Poor diet •  Drug and alcohol abuse

Primary preven=on is the priority for decreasing morbidity and mortality risk Management of modifiable risk factor

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Cerebral Arteries


Transient Ischemic A>ack

•  History of TIA is associated with an increased risk of stroke

•  TIA is a transient episode of neurologic dysfunc=on caused by focal brain, spinal cord, or re=nal ischemia, but without acute infarc=on of brain

•  Symptoms typically last < 1 hour

•  There is no way to predict outcome •  1/3 do not

experience another event

•  1/3 have addi=onal TIA

•  1/3 progress to stroke


Types of Stroke

•  Ischemic -‐ Thrombo=c -‐ Embolic

•  Hemorrhagic -‐ Intracerebral -‐ Subarachnoid


Based on previously learned knowledge, what is the priority plan of care?

Ischemic Stroke •  Thrombo=c:

– Occurs from injury to a blood vessel wall and forma=on of a blood clot

–  Results in narrowing of blood vessel

– Most common cause of stroke (60%)

•  OYen associated with HTN and DM

•  Many =mes they are preceded by TIA

–  Extent of stroke depends on •  Rapidity of onset •  Size of damaged area •  Presence of collateral circula=on

Inadequate blood flow to brain from parDal or complete occlusion of an artery


Ischemic Stroke •  Embolic:

–  Results in infarc=on and edema of area supplied by involved vessel

•  Sudden onset with severe clinical manifesta=ons – Warning signs are less common

–  Pa=ent usually remains conscious

–  Prognosis is related to amount of brain =ssue deprived of blood supply

–  Commonly recur •  hGps://www.bing.com/videos/search?

q=stroke&&view=detail&mid=47EE8F9C4D19D4D6B6F447EE8F9C4D19D4D6B6F4&&FORM=VRDGAR

Occurs when an embolus lodges in and occludes a cerebral artery


Hemorrhagic Stroke

•  Results from bleeding into –  Brain =ssue itself

•  Intracerebral or intraparenchymal hemorrhage

–  Subarachnoid space or ventricles •  Subarachnoid or intraventricular hemorrhage

•  What interven=on will the pa=ent immediately need?


Hemorrhagic Stroke Intracerebral hemorrhage •  Bleeding within brain caused by rupture of a

vessel –  Sudden onset of symptoms (HA, N/V) –  Progression over minutes to hours

because of ongoing bleeding –  Hemorrhage occurs during ac=vity

Subarachnoid hemorrhage (SAH) –  Intracranial bleeding into cerebrospinal

fluid–filled space between arachnoid and pia mater

–  Commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse

Cerebral aneurysm –  Silent killer

•  Loss of consciousness may or may not occur

•  High mortality rate •  Survivors oYen suffer significant

complica=ons and deficits 10 Fall 2019 - Spring 2020

DiagnosDc Studies –STROKE

•  Confirm that it is a stroke •  Iden=fy the likely cause of

stroke •  Noncontrast CT scan is priority –  Indicate size and loca=on of lesion

– Differen'ate between ischemic and hemorrhagic stroke *

•  NIH Stroke Scale (NIHSS) •  MRI •  BMP, CBC, Coags, T&S, T&C, UA, Toxicology

Other studies: •  CTA or MRA •  Cerebral angiography •  Digital subtrac=on

angiography •  Transcranial Doppler

ultrasonography •  Lumbar puncture •  LICOX system •  Cardiac imaging

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Interprofessional Care –STROKE

•  Primary assessment is focused on – Cardiac status – Respiratory status – Neurologic assessment

•  Secondary assessment includes a comprehensive neurologic examina=on – Clear documenta=on of ini=al and ongoing neurologic examina=ons is essen=al to note changes in pa=ent status

NIH Stroke Scale – comprehensive neurologic examina=on of: •  Level of consciousness •  Cogni=on •  Motor abili=es •  Cranial nerve func=on •  Sensa=on •  Propriocep=on •  Cerebellar func=on •  Deep tendon reflexes

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Interprofessional Care –STROKE Surgical Therapy For pa=ent with TIAs from caro=d disease include: •  Caro=d

endarterectomy •  Transluminal

angioplasty •  Sten=ng Preopera=ve Postopera=ve

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Interprofessional Care –STROKE Surgical Therapy

•  Neurovascular assessment •  BP management •  Assessment for complica=ons – Stent occlusion – Retroperitoneal hemorrhage – Minimize complica=ons at inser=on site

Postopera=ve care is important

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•  Elevated BP is common immediately aYer a stroke –permissive hypertension –  Body’s aGempt to maintain cerebral perfusion

•  Control fluid and electrolyte balance –adequate hydra=on*

•  Promotes perfusion •  Decreases further brain injury

•  Manage ICP – Use interven=ons that improve venous drainage

•  Goals for interprofessional care:

•  Preserving life •  Preven=ng further brain

damage •  Reducing disability

•  Time of onset of symptoms is cri=cal informa=on

•  ABC & ICP •  Baseline neurologic

assessment •  NIH Stroke Scale •  Monitor closely for:

•  Signs of increasing neurologic deficit

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Acute ischemic stroke: •  Recombinant =ssue plasminogen ac=vator (tPA) – Used to reestablish blood flow through a blocked artery to prevent cell death

– Must be administered within 3 to 4 ½ hours of onset of clinical signs of ischemic stroke

– Pa=ents are carefully screened

PrevenDve Drug Therapy •  To prevent

development of a thrombus or embolus are used in pa=ents at risk for stroke

•  An=platelet drugs are used in pa=ents who have had a TIA related to atherosclerosis

•  What medica=on are you familiar with?

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•  AYer stroke has stabilized for 12 to 24 hours, interprofessional care shiYs from preserving life to lessening disability and aGaining op=mal func=oning – Pa=ent may be transferred to a rehabilita=on unit, outpa=ent therapy, or home care–based rehabilita=on once medically cleared

Acute ischemic stroke: •  AYer the pa=ent has

stabilized and to prevent further clot forma=on, pa=ents with strokes caused by thrombi and emboli may be treated with an=coagulants and platelet inhibitors

•  ASA, clopidogel (Plavix) •  Bedside swallow

evalua=on by RN

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Hemorrhagic Stroke •  Surgical interven=ons necessary:

–  Resec=on –  Clipping of an aneurysm –  Evacua=on of hematomas

Manage: •  ABC & ICP •  Management of

hypertension is main focus –why?

•  SBP < 160 mm Hg •  An=coagulants and

platelet inhibitors are contraindicated

•  Seizure prophylaxis is situa=on-‐specific

Fall 2019 - Spring 2020 18 Coiling

Clipping and wrapping on aneurysm


Hemorrhagic Stroke •  Hyperdynamic therapy to increase cerebral perfusion: – Vasoconstric=ng agents – Crystalloid or colloid solu=ons

•  Vasospasms can be treated with a calcium channel blocker nimodipine (Nimotop)

Postopera=ve care and management: Brain surgery (Chapter 56)

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Clinical Manifesta=ons of Stroke

•  Related to loca=on of stroke – Neural =ssue destruc=on is basis for neurologic dysfunc=on

– Affects many body func=ons •  Related to artery involved and area/half of brain it supplies

•  Time of the onset of symptoms /length of period of ischemia is important –why?

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Clinical ManifestaDons –STROKE

Impairment of •  Mobility

–  Loss of skilled voluntary movement (akinesia)

–  Impairment of integra=on of movements –  Altera=ons in muscle tone –  Altera=ons in reflexes

•  Changes from hyporeflexia to hyperreflexia

•  An ini=al period of flaccidity –  May last from days to several weeks –  Related to nerve damage

•  Spas=city of muscles follows flaccid stage –  Related to interrup=ons of upper motor

neuron influence •  Respiratory func=on •  Swallowing and speech •  Gag reflex •  Self-‐care abili=es

Motor FuncDon •  Most obvious

effect of stroke •  Think of 3 nursing

priori=es for each one

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•  Paralyzed or weak side needs special aGen=on when posi=oned

•  Op=mize musculoskeletal func=on

•  Walking, Ea=ng , Toile=ng •  Balance training •  Transferring from bed to chair – Methods for using the weak or paralyzed side

Motor FuncDon •  Goal is to maintain

op=mal func=on by preven=on of joint contractures and muscular atrophy

•  In acute phase, range-‐of-‐mo=on exercises and posi=oning are important

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Cardiovascular system •  Goals aimed at maintaining homeostasis •  Adjus=ng fluid intake to individual needs of the pa=ent •  Monitoring lung sounds for crackles and wheezes

(pulmonary conges=on) •  Monitoring heart sounds for murmurs •  Watch for orthosta=c hypotension before ambula=ng

pa=ent for 1st =me •  ↓ cardiac reserves from secondary diagnoses of

cardiac disease = cardiac efficiency may be compromised

•  AYer stroke, pa=ent is at risk for venous thromboembolism (VTE)

Respiratory system •  Management of respiratory system is a nursing priority

–  Risk for atelectasis –  Risk for aspira=on pneumonia –  Risks for airway obstruc=on –  May require endotracheal intuba=on and

mechanical ven=la=on •  Monitoring lung sounds for crackles and wheezes

(pulmonary conges=on)

Neurologic system •  Monitor closely to

detect changes sugges=ng extension of the stroke ↑ ICP

•  Vasospasm •  Recovery from stroke

symptoms

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•  Assess pa=ent for both ability to speak and ability to understand

•  Speak slowly and calmly, using simple words or sentences

•  Gestures may be used to support verbal cues •  Speech, comprehension, and language deficits

are most difficult problem for pa=ent and family –  Speech therapists can assess and formulate

a plan to support communica=on

CommunicaDon •  Recep%ve – loss

of comprehension

•  Expressive – loss of produc=on of language

•  Global – total inability to communicate

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Intellectual FuncDon •  Both memory and judgment may

be impaired as a result of stroke •  Impairments can occur with

strokes affec=ng either side of brain, some deficits are related to hemisphere in which stroke occurred –  A leY-‐brain stroke is more likely to result in memory problems related to language

–  Pa=ents with a leY-‐brain stroke oYen are very cau=ous in making judgments

–  The pa=ent with a right-‐brain stroke tends to be impulsive and to move quickly

Affect •  Pa=ents who suffer a

stroke may have difficulty controlling their emo=ons

•  Emo=onal responses may be exaggerated or unpredictable

•  Magnified by •  Depression •  Changes in body

image •  Loss of func=on

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Clinical ManifestaDons –STROKE Agnosia (pictures slide 16) Apraxia

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SpaDal-‐Perceptual AlteraDons •  Stroke on right side of brain is more likely to cause problems in spa=al-‐perceptual orienta=on

•  Incorrect percep=on of self and illness

•  Unilateral neglect of affected side –  Related to hemisphere of brain in which stroke occurred

–  Visual problems

Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemianopsia shows that food on the left side is not seen and thus is ignored.

(Modified from Hoeman SP: Rehabilitation nursing, ed 2, St Louis, 1995, Mosby.)


•  May ini=ally receive IV infusions to maintain fluid and electrolyte balance

•  First feeding should be approached carefully – Test swallowing, chewing, gag reflex, and pocke=ng before beginning oral feeding

– May require nutri=on support –failed swallow test

•  Feedings must be followed by scrupulous oral hygiene

NutriDon •  Stress of illness

contributes to a catabolic state that can interfere with recovery

•  Nutri=onal needs require quick assessment and treatment –what types of diet will you an=cipate?

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•  In acute stage, poor bladder control results in incon=nence –  Efforts should be made to promote normal bladder func=on

–  Avoid use of indwelling catheters –  Bladder retraining program

•  Cons=pa=on is most common bowel problem –  Prophylac=c stool soYeners or fiber

–  Physical ac=vity promotes bowel func=on

–  High-‐fiber diet and adequate fluid intake

EliminaDon •  Most problems

with urinary and bowel elimina=on occur ini=ally and are temporary

•  When a stroke affects one hemisphere of brain, prognosis for normal bladder func=on is excellent

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•  Preven=on of skin breakdown – Pressure relief by posi=on changes, special maGresses, wheelchair cushions

•  Posi=on pa=ent on weak or paralyzed side for only 30 minutes

– Good skin hygiene – Emollients to dry skin – Early mobility!

Integumentary •  Suscep=ble to skin

breakdown r/t: •  Loss of sensa=on •  Decreased

circula=on •  Immobility

•  Compounded by pa=ent age, poor nutri=on, dehydra=on, edema, and incon=nence

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•  Pa=ents with a stroke may be coping with many losses (sensory, intellectual, communica=ve, func=onal, sexual, etc.) – Grief, mourning, depression

•  Pa=ent’s family should be given careful, detailed explana=on of what has happened to pa=ent

•  Social services referral is oYen helpful

Coping •  Family members

usually have not had =me to prepare for illness

•  OYen a family disease •  Emo=onally •  Socially •  Financially •  Changing roles

and responsibili=es

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Nursing Management –STROKE

•  Goals include that pa=ent will – Maintain stable or improved level of consciousness

– AGain maximum physical func=oning

– Maximize self-‐care abili=es and skills

– Maintain stable body func=ons – Maximize communica=on abili=es

– Maintain adequate nutri=on – Avoid complica=ons of stroke – Maintain effec=ve personal and family coping

Diagnoses include but are not limited to: •  Risk for impaired

cerebral =ssue perfusion •  Decreased intracranial

adap=ve capacity •  Risk for aspira=on •  Impaired physical

mobility •  Impaired verbal

communica=on •  Risk for skin breakdown •  Unilateral neglect •  Impaired swallowing •  Situa=onal low self-‐

esteem

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Nursing Management –STROKE AMBULATORY CARE

•  Nurses have an excellent opportunity to prepare pa=ent and family for discharge through

•  Teaching •  Demonstra=on/return demonstra=on

•  Prac=ce •  Evalua=on of self-‐care skills

•  This all begins at ADMISSION!

Pa=ent is usually discharged (medically cleared) from acute care setng to: •  Home •  Intermediate or long-‐

term care facility •  Rehabilita=on facility •  Cri=cal factor:

independence in ADLs

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Nursing Management: Stroke Gerontologic Considera=ons

•  Stroke is a significant cause of death and disability

•  What is the likely cause of death for a pa=ent that suffered a stroke?

33 Fall 2019 - Spring 2020

Documents

STROKE’’ Ischemiato)partof)brain) AcidBBase)Balance