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NursingManagementof PatientsExperiencingStroke1228
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StrokeA stroke occurs when the blood supply to part of your
brain is interrupted or severely reduced, deprivingbrain tissue of oxygen and food. Within minutes,brain cells begin to die.
Strokes can be ischemic or hemorrhagic
Also known as a brain attack
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Different STROKES for Different
Folks
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Nursing Knowledge Third most common cause of death in the United
States and Canada
Leading cause of serious, long-term disability
Approximately 35% of individuals who have an initialstroke die within 1 year.
Prevalence for CVA is 2X higher in AA, womenaccount for 60% of CVA r/t deaths, killing 2X asmany women as breast cancer
Hypertension is the single most important modifiablerisk factor that is often undetected and inadequatelytreated.
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Risk FactorsNon-modifiableAge Risk increases with age Doubles each decade
after age 55
Gender Equal in men and women
Race African Americans Native Americans
Heredity Family history of stroke Prior TIA Prior CVA
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Risk Factors cont.Modifiable risk factors
Heart disease A. fib/heart murmur hyperlipidemia
Heavy alcohol consumption >2 drinks/day
Diabetes mellituskeep BS well controlled
Smoking
Metabolic syndrome
Hypertension Most important factor
Obesity Abdominal distribution in
men
Oral contraceptive use High dose estrogen
Physical inactivity
Substance abuse Especially cocaine
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An ounce of PREVENTION is worth a pound of cure
Control HTN
Reduce or control weight
Decrease sodium and fat in diet
Decrease alcohol consumption Comply with medical regimen
Stop smoking
Control any existing diabetes
Regular exercise
Routine health checks and screening
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Test Your Knowledge:Of the following patients, the nurse recognizes
that the one with the highest risk for astroke is:
a. an obese 45-year-old Native American.b. a 35-year-old Asian American woman whosmokes.
c. a 32-year-old white woman taking oral
contraceptives.d. a 65-year-old African American man withhypertension.
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Transient Ischemic Attack (TIA)
mini strokes
Temporary, focal loss of neurologic function
Lasts less than 24 hours
Often less than 15 minutes
Most TIAs resolve within 3 hours
Microemboli that temporarily block blood flow tobrain
Considered a warning sign for impending CVA!!!
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TIA - Signs and SymptomsVisual changes- blurred vision, diplopia, blindness in
one eye, tunnel vision, ptosisTransient weaknessArm, hand, leg
Ataxic gaitTransient numbness Face, arm, hand
Vertigo
AphasiaDysarthriaDysphagia
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Ischemic Stroke Thrombotic stroke Thrombosis occurs in relation to injury to a blood
vessel wall and formation of a blood clot. Result of thrombosis or narrowing of the blood
vessel
Most common cause of stroke
30% to 50% of thrombotic strokes have beenpreceded by a TIA
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Ischemic Stroke Embolic stroke Occurs when an embolus lodges in and occludes a
cerebral artery Second most common cause of stroke
Commonly has a rapid occurrence of severeclinical symptoms.
Patient usually remains conscious, although he mayhave a headache.
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Manifestations of Ischemic StrokeUsually no change in LOCHeadache
Hemiplegia or hemiparesis
Dysphasia
Facial drooping
Ataxia
Some initial symptoms may improve or resolve, with
remaining lesser deficits
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Healthy vessels
A healthy artery easilycarries oxygenated
blood to the braintissue.
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Pathological vessels
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TYPES OF STROKE
Hemorrhagic stroke- Bleeding within the brain
caused by rupture of a
vessel Hypertension is the most
important cause.
Hemorrhage commonlyoccurs during periods of
activity.
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Manifestations of Hemorrhagic StrokeThe neurologic manifestations do not significantlydiffer between ischemic and hemorrhagic strokeHeadache
Nausea and vomitingDecreased LOC (about 50% of patients)Neurologic deficits may be severe depending uponwhat area affected Dilated, fixed pupils Posturing ComaHemiplegia
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Hemorrhagic CVA Intracranial bleeding into cerebrospinal fluidfilled
space between the arachnoid and pia mater
Commonly caused by rupture of a cerebralaneurysm
Worst headache of ones life
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Treatment of AneurysmsGoal is to stop the bleeding and relieve the pressure.Surgical clipping of the aneurysmCoilingCraniotomyBiologic/synthetic wrap-prevents ruptureDespite improvements in surgical techniques andmanagement, still a high rate of mortality and morbidity Complications include Rebleeding before surgery can occur Cerebral vasospasm resulting in cerebral infarction
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Test Your KnowledgeInformation provided by the patient thatwould help differentiate a hemorrhagic strokefrom a thrombotic stroke includes:
a. sensory disturbance
b. a history of hypertension
c. presence of motor weakness
d. sudden onset of severe headache
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A picture is worth 1,000 words
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Overall effects of stroke:Motor
Cross over effect
Lesion on right brain-- left side affected
Lesion on left brainright side affectedImpairment
Mobility, respiratory function, swallowing andspeech, gag reflex, self-care abilities, risk for
injuries
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Left sided stroke
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Right sided stroke
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Motor Function Loss of skilled voluntary movement
Impairment of integration of movements
Alterations in muscle tone Alterations in reflexes
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Communication
Problems more common in left-brain strokeAphasia
Total loss of comprehension and/or use oflanguage
Dysphasia
Difficulty with comprehension and use oflanguage
Can be classified as nonfluent or fluentDysarthria
Poorly articulated speech, slurred speechsecondary to poor muscle control
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Affect Depression
Body image change
Loss of function physically and cognitively
Loss of independence
Difficulty controlling emotionsCries easily
Anger, frustration common
Intellectual function
Impaired memory/judgment
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Spatial-perceptual alterations
Problems more common in right-brain stroke Spatial-perceptual problems may be divided into four
categories.1. Incorrect perception of self and illness
2. Erroneous perception of self in space3. Inability to recognize an object by sight, touch, or
hearing
4. Inability to carry out learned sequential movements on
command
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Elimination
Urinary and bowel elimination deficits usually occurinitially and are usually temporary
Initially frequency, urgency, incontinence
Constipation may be lasting due to decreasedmobility, weakened abdominal muscles, decreasedfood and fluid intake
Long-term effects often related to inability toexpress needs and manage clothing for toileting
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Diagnostic tests Confirmation that it is a stroke Identify cause if possible CT scan- the primary diagnostic test Size and location of the lesion Differentiate between ischemic and hemorrhagic strokes
MRI More detailed, sharper images Can detect smaller, deeper CVAs
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Further testing
Blood flow tests
Ultrasound- of the neck, base of skull
Angiography-arteriogram-dye injected intoarteries then x-rays are taken
Electrical tests
EEG-electrical signals within the brain
Evoked response-how the brain handlesdifferent electrical impulses related to hearing,vision, body sensation, etc.
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Drug TherapyThrombolytic therapy
tPA (tissue plasminogen activator)
Digests fibrin and fibrinogen and thus lyses theclot
Reduces disability
Requires a consent form to be signed
Must be administered within 3 hours of the onset
of clinical signs of ischemic strokeTiming is critical
Accurate history is critical- resent surgery?
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Drug Therapy, cont.Anticoagulants Heparin Sub Q or IV push Heparin drip Short term
Lovenox (low molecular weight heparin) Sub Q or IV Short term
Coumadin (warfarin) Orally Long term anticoagulation
Side effects: bleeding Monitor urine, stools, epistaxis, bleeding gums, easy bruising Caution about high risk activities
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Drug Therapy, cont.
Antiplatelet drugs Platelet inhibitors Prevents further strokes by preventing clot
formation
ASA 50mg to 325mg per dayPossibly baby ASA 81mg or enteric coated
Ticlid, Plavix, Persantine, Aggrenox, ArixtraTeach patient to monitor for sx bleeding at home
Teach dietary requirements
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Drug therapy monitoringBaseline levels -obtain before initiating therapy
PT (PT/INR) to monitor Coumadin therapy
Monitor daily while in acute care setting, once patient
goes home and dose is stable, weekly or monthlyTarget INR is 2.0-3.0
PTT to monitor heparin therapy
Monitor every morning while on therapy in acute care
setting Goal is 1.5-2 times patients baseline PT and PTT
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Treatment Modalities
Carotid endarterectomy
Athreromatous lesionis removed from thecarotid artery toimprove blood flow tothe brain
Reduces the risk ofanother CVA
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Treatment Modalities, cont.
Transluminal angioplasty roto rooter Insertion of a balloon to
push open stenosed artery,thus improving blood flow
Monitor patient afterprocedure due to risk ofbreaking clots loose
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Treatment Modalities, cont.
Stenting
Transvascular placement
of a stent to maintainpatency of artery
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Test Your Knowledge
A patient experiencing TIAs is scheduled for a carotidendarterectomy. The nurse explains that thisprocedure is done to:
a. decrease cerebral edema.
b. reduce the brain damage that occurs during astroke in evolution.
c. prevent a stroke by removing atherosclerotic
plaques blocking cerebral blood flow.d. provide a circulatory bypass around
thrombotic plaques obstructing cranialcirculation.
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Acute Care
The goal is to preserve life, prevent further braindamage, and reduce the amount of disabilityMaintain ABCsAirway assess patency Decreased LOC may result in decreased/absent gag
reflex, impaired swallowing so patient should beNPOAdminister O2, oral or nasal airway Intubation and mechanical ventilation may be needed
Monitor pulse oximetry Suction PRN Position to prevent aspiration
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Acute Care, cont.Get patient to CT!!! Major priority! Start lab tests Blood glucose Treat hypoglycemia
Seizure precautions
Thrombolytic therapy for ischemic stroke restore 02! Manage possible increased ICP in ischemic stroke Cerebral edema peaks in 72 hours Brain herniation can occur Position to improve venous drainage
Elevate HOB 30 degrees Position head/neck in midlineAvoid hip flexion
Mannitol and Lasix may be given to decrease ICP
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Acute Care, cont.IV access with NS Do not overhydrate
Increases cerebral edema1500-2000ml per day
Monitor urinary output
Maintain BP Frequently hypertensive after stroke
Compensatory mechanism to insure brainperfusion
IV BP meds are given only if BP is markedly increased(systolic >220)
Usually oral agents are sufficientInstitute seizure precautions
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Assessment
Neurological assessment
Glasgow coma scale
Pupils
Extremity movement and strengthDecreased LOC
Increase in ICP
Cardiac status should be monitored
Rhythm & rate
or heart rate
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Nursing AssessmentHistory
Precise time of onset of S/S
Medical and surgical history including HTN,previous stroke, TIAs (diagnosed or not), cardiacdx, CHF, valvular dx/replacement, endocarditis,hyperlipidemia, polycythemia, DM, and familyhistory of HTN, CVA
Medications
Oral contraceptives, antihypertensives,anticoagulant agents
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Nursing Assessment Subjective Data- Person accompanying patient may need to
provide information if patient has decreased LOC or isaphasic
Objective Data
Emotional lability, apathy, combativeness Vital signs- tachycardia, HTN
Breath sounds- adventitious may indicate aspiration
Loss of urinary/bowel continence
Seizure Facial drooping
Difficulty swallowing
Vertigo
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Neurological Findings Contralateral motor and sensory deficitsWeakness, paresis, paralysisUnequal pupilsUnequal hand grasps
Unequal leg strength Positive Babinskis sign followed by increased deep
tendon reflexes Flaccidity followed by spasticityAmnesia Personality changeNuchal rigidity
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Deep Vein Thrombosis (DVT) Increased risk of DVT after stroke due to: Immobility Loss of venous tone Decreased muscle pumping activity in legs
Especially on affected sideDo ROM exercises several times a day Compression stockingsHeparin therapy
Measure calf and thigh daily Check for pain in calf when standing
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Post-Stroke CareMusculoskeletalMaintain optimum
functioning ROM and correct
positioning to preventcontractures andmuscular atrophy
Hand splints to maintainflexibility and use ofhands
Trochanter rolls toprevent hip rotation
Arm supports- slingsAvoid pulling patient by
the arm to avoidshoulder displacement
Footboards Leg splints
High top tennis shoes toprevent foot drop
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Pharmacology Post-Stroke Care
Acute & Chronic Heparin IV or SQ
requires lab monitoring
Coumadin what lab?
Plavix reduces plateletaggregation do not takea missed dose with thenext dose.
Mannitol reducesvasogenic edema
Check with HCP beforetaking any herbalmedications
Aspirin anticoagulation,s/s of GI irritation?
Anti-cholesterol agents
why? H2 Blockers reduces
acid in the stomach
Persantine - prevent
platelets from clumpingwith thrombus andembolus formation
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Collaborative CareAfter stroke has stabilized for 12 to 24
hours, collaborative care shifts from
preserving life to lessening disability andattaining optimal functioning.
Patient may be transferred to arehabilitation unit, outpatient therapy, or
home carebased rehabilitation.
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Post-Stroke Care Integumentary system Susceptible to breakdown Loss of sensation Decreased circulation Immobility
Change positions every 2 hours Side-back-sideOnly place on weak/paralyzed side X 30 min.
Special mattresses, WC cushionsAssess for redness, blanching Do not massage damaged area
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Post-Stroke Care Gastrointestinal Severely affected may require enteral or parenteral
nutrition
Use caution with first attempt at oral feeding
Assess for gag reflex by gently stimulating back ofthroat with tongue blade
Swallowing assessment is usually done by giving pt.small amount of crushed ice
Often performed by speech therapy
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Post-Stroke Care Urinary Poor bladder control incontinence
Promote urinary function
Avoid foley catheter ifpossible Increases susceptibility
to UTI Inadequate bladder
tone Notice restlessness-may
indicate need to void
Bladder trainingprogram
Toileting Q 2 hrs duringwhile awake
Toileting 3-4 timesduring night
Using bedpan, BSC, ortoilet
Encourage adequatefluids-dont restrict Give majority between
8am and 7pm
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Test Your Knowledge Bladder training in a male patient who
has urinary incontinence after a strokeincludes:
a. limiting fluid intake
b. keeping a urinal in place at all times
c. assisting the patient to stand to void
d. catheterizing the patient every 4 hours
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Post-Stroke Care
Ambulation/Transfer principals
Bear weight on the unaffected (good) side
Always move toward the unaffected side for easiest
and safest transfers Position chair or WC on the unaffected side and pivot
to the chair on the unaffected leg
Use a hemi-walker on the unaffected side
Always have plenty of assistance if you are uncertainhow well pt. can transfer
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Post-Stroke Care
Instruct patient to chew on unaffected side Prevents pocketing of food on affected side
Constipation
Stool softener
Fluid intake 1800-2000ml per day
Fiber 25 g per day
Physical activity
Assist to toilet, provide privacy
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Communication Patient may be anxious and frustrated Speak slowly and calmlyUse simple words or sentences Look at patient when speaking Give patient time to respondAsk yes or no questions
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Home CarePatient with homonymous hemianopsia has blindness in same half of
each visual field Accommodate by placing items in correct field of vision Self care deficit Avoid fatigue Assistive devices to increase independence Place items on unaffected side Facilitate dressing by using clothing that is one size larger and
made of stretchy fabricUnilateral neglect Approach pt. from unaffected side Instruct pt. to scan full field of vision Talk with patient on the unaffected side
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Examples of Assistive Devices
H C
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Home Care
Risk for injuryInability to perform familiar tasksMisjudging distancesSpilling hot liquids
Encourage pt. think through task step by stepEliminate obstructing hazardsPetsRugs and clutter
Teach sitting and balancing exercisesPatient sits or dangles on edge of bedNext, practice transferring to chairPlace chair on the unaffected side
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Additional thoughts
CopingDepression, anxiety, weight loss, poor appetite,
chronic fatigue, sleep disturbances are commonSexual functioning
Acceptance of physical changes takes time Fear of rejection, another stroke, inability toperform
Careful grooming with attractive clothing Begin slowly and communicate
Trial and error to find optimal positioning Experiment during peak energy times Counseling may be needed
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Additional thoughts Constipation/Incontinence Related to loss of mobility, decreased intake and ability to
self toilet Risk for low self-esteem Feeling of dependence, loss of role function
Powerlessness Dependence, depression & anger physical limitations may
prevent healthy expression, inability to use regular ways toexpress emotions such as exercise, hobbies etc.
Risk for self/other directed violence Some patients may difficulty managing emotions after
suffering a CVA warn patients and families about potentiallabiality
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Community Resources for the
Stroke Patient The National Stroke Association
Referral services
Quarterly newsletter
The American Stroke AssociationAmerican Heart Association
Programs and information on stroke, HTN, diet,exercise, and assistive devices
The Easter Seal Society
Wheelchairs and assistive devices
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CASE STUDY FOR HOME REVIEW
Stroke
Patient Profile
Suzanne, a 66-year-old white woman, awoke in themiddle of the night and fell when she tried to getup and go to the bathroom. She fell because shewas not able to control her left leg. Her husband
took her to the hospital, where she was diagnosedwith an acute ischemic stroke. Because she hadawakened with symptoms, the actual time of onsetwas unknown and she was not a candidate for tPA.
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Subjective Data
Left arm and leg are weak and feel numb Feeling depressed and fearful
Requires help with ADLs
Concerns regarding possibility of another stroke Says she has not taken her drugs for high cholesterol
for many weeks
History of a brief episode of left-sided weakness and
tingling of the face, arm, and hand 3 months earlier,which totally resolved and for which she did not seektreatment
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Objective Data BP 180/110
Left-sided arm weakness (3/5) and legweakness (4/5)
Decreased sensation on the left side,particularly the hand
Left homonymous hemianopsia
Overweight
Alert, oriented, and able to answerquestions appropriately but mild slowness inresponding
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Critical Thinking Questions1.
How does Suzanne's prior health history put her at riskfor a stroke?
2. How can the nurse address Suzanne's concernsregarding having another stroke?
3. What strategies might the nurse use to help Suzanne
and her family cope with her feeling depressed?4. What lifestyle changes should Suzanne make to reduce
the likelihood of another stroke?
5. How will homonymous hemianopsia affect Suzanne's
hygiene, eating, driving, and community activities?6. What are the priority nursing interventions for
Suzanne?
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THE END