Nursing Management Stroke

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Nursing Management Stroke
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Describe the incidence of and risk factors for
stroke

• Incidence
• 3rd most common cause of death in US
• Leading cause of serious long-term disability
• Major public health problem in terms of morbidity
  and mortality
• Over 80 of the estimated 51 billion annual cost
  is paid by your tax dollars
• Quality of life issues can not be appropriately
  evaluated

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• Risk factors
• Non-modifiable
• Gender
• Age
• Race
• Heredity
• Modifiable
• Lifestyle habits
• Alcohol
• Tobacco
• HTN
• Diabetes
• Obesity
• Hyperlipidemia

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Explain the mechanisms that affect cerebral blood
flow

• Extra-cranial factors
• Systemic blood pressure
• MAP
• Cardiac output
• Viscosity of blood
• Intracranial factors
• Intracranial pressure
• Atherosclerosis
• Blood vessels (Fig 56-1)

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Compare and contrast the etiology and
pathophysiology of ischemic and hemorrhagic
strokes

• Types of stroke
• Ischemic
• Thrombotic
• Embolic
• Hemorrhagic
• Intracerebral
• Subarachnoid
• Table 56-2p 1528

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• Ischemic Strokes (85)
• Thrombotic Stroke (61)
• Blood clot occludes blood vessel
• 2/3s associated with HTN, DM
• 30-50 have prodromes (TIAs)
• Characteristics
• Men gt women
• Occurs during/after sleep
• Symptoms peak over 72 hours
• Resolution takes up to 2 weeks
• Symptoms occur over several hours
• Permanent neurologic deficits
• Size of lesion
• Collateral circulation

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• Transient Ischemic Attack (TIA)
• Temporary focal loss of neurologic function
  lasting less than 24 hours
• Warning sign of progressing disease
• Carotid involvement
• Amaurosis fugax (transient loss of vision in one
  eye)
• Hemiparesis
• Inability to speak
• Vertebrobasilar
• Tinnitus
• Vertigo blurred vision
• Hemiparesis

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• Embolic Stroke
• Embolus occludes cerebral artery
• Men gt women
• Rapid onset
• Headache
• Recurrence is common unless cause of embolism is
  addressed
• Causes of embolic strokes
• Atrial fib
• Rheumatic fever
• Atherosclerotic plaques

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• Hemorrhage Stroke
• Intracerebrial Hemorrhage Stroke
• Bleeding within the brain that lasts from minutes
  to days caused by a ruptured vessel
• Women gt men
• Often occurs during activity without warning
• Causes
• HTN
• Brain tumors, trauma, thrombolytic drugs,
  ruptured aneurysms
• Symptoms vary with area of bleed
• Severe HA, nausea, vomiting
• Weakness on one side
• Prognosis is poor

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• Subarachnoid Hemorrhage Stroke
• Bleeding beneath the arachnoid and pia mater
  layers (cerebrospinal fluid-filled space) often
  related to HTN, aneurysms, trauma, congenital
  malformations (arteriovenous), anticoagulants,
  sympathomimetics
• Women gt men
• Ballooning vessels may cause prodrome --- often
  sudden with rapid neuro changes
• Severe HA ?
• Often associated with activity
• Prognosis --- guarded
• Surgical interventions

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Correlate the clinical manifestations of stroke
with the underlying pathophysiology

• Functions affected are directly related to the
  brain area supplied by the affected artery
• Neuromotor function
• Motor deficits are the most obvious effect of
  stroke
• Mobility
• Respiratory function
• Swallowing and speech
• Gag reflex
• Self-care abilities

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• Motor Function (deficits)lesions on one side of
  the brain affect motor function on the opposite
  side of the body
• Mobility
• Loss of skilled voluntary movement (akinesia)
• Alterations in reflexes
• Hyporeflexia
• Hyperflexia
• Impairment in integration of movements
• Alterations of muscle tone
• Respiratory function
• Swallowing and speech
• Gag reflex
• Self-care abilities

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• Communication
• Left hemisphere usually dominate for language
• Language disorders
• Expressive
• Receptive (comprehension)
• Aphasia
• Total loss of comprehension and use of language
• Dysphasia
• Fluent
• Speech is present but contains little meaningful
  communication
• Nonfluent
• Minimal speech activity with slow speech that
  requires obvious effort

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• Wernickes area
• Receptive aphasia
• Neither sounds of speech nor meaning are
  understood
• Brocas area
• Expressive aphasia
• Difficulty in speaking and writing
• Dysarthria
• Disturbance in muscular control of speech
• Impairments with pronunciation, articulation,
  phonation
• Comprehension of language intact

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• Affect
• Difficulty controlling emotions
• Responses may be exaggerated or unpredictable
• Intellectual function
• Affected left brain ? memory ? related to
  language and cautious with judgment
• Affected right brain ? impulsive and quick to
  move
• Spatial-perceptual alterations more often
  associated with affected right brain
• Erroneous perception of self and illness
• Deny illness or body parts
• Erroneous perception of self in space
• Neglect input from affected side
• Agnosia
• Inability to recognize an object by sight or
  touch
• Apraxia
• Inability to carry out learned sequential
  movements on command
• Elimination function

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Identify diagnostic studies performed for
patients with strokes

• Diagnostic Studies
• CT
• Indicates size and location of lesion
• MRI
• Differentiates hemorrhage from nonhemorrhage
  infarcts
• Angiography
• Intraarterial digital subtraction angiography
  (DSA)
• Transcranial doppler
• Lumbar puncture

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Describe the collaborative care, drug therapy,
and nutritional therapy for a patient with a
stroke

• Primary prevention
• Health management for the well individual and
  management of modifiable risk factors
• Prevent progression from TIA to complete stroke
• Health management
• Diet Weight control Regular exercise
• No Smoking Limited Alcohol
• Regular health check-ups
• Risk factors require closer management
• Drug therapy (decreases platelet aggregation)
• ASA (81 mg.)
• clopidrogel (Plavix)
• Surgical therapy
• Carotid endarterectomy (CEA)
• Transluminal angioplasty (stent)
• Extracranial-intracranial (EC-IC) bypass

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• Acute Care
• ABCs
• Baseline neuro assessment
• BP
• RXd only if MAP gt 130 mm Hg or systolic gt 220 mm
  Hg
• Correct hypotension and hypovolemia
• Drug induced hypertension for vasospam following
  hemorrhagic aneurysm
• FE balance
• ? ICP
• Peaks in 72 hours
• Hyperthermia
• Associated with poorer prognosis

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• Drug therapy
• Thrombolytic drug therapy
• Recombinant tissue plasminogen activator (t-PA)
• Must be administered within 3 hours of clinical
  symptoms
• Careful screening (R/O hemorrhagic stroke,
  coagulation disorders, GI bleeds, head trauma
  within last 3 mons or major surgery in past 14
  days)
• Platelet inhibitors
• ASA, clopidrogel (Plavix)
• Anticoagulants
• Heparin, warfarin (Coumadin)
• Other drug therapies
• Control temperature and seizures

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• Surgical therapy
• Evacuation of hematomas gt 3 cm
• Clipping, wrapping or coiling aneurysms
• Ventriculostomy and drainage
• Arteriovenous malformation
• Resection or gamma knife (radiation)

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Describe the acute nursing management of the
patient with a stroke

• Assessment
• 1st assess respiratory, cardiac, brief neuro and
  hx
• 2 ? comprehensive neuro
• LOC
• Cognition
• Motor abilities
• Cranial nerve function
• Sensation
• Proprioception
• Cerebellar abilities
• Deep tendon reflexes

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• Nursing diagnosis (NCP 56-1)
• Planning
• Goals
• Maintain stable or improved LOC
• Attain maximum physical functioning
• Attain maximum self-care abilities and skills
• Maintain stable body functions (bowel and
  bladder)
• Maximize communication abilities
• Maintain adequate nutrition
• Avoid complications of stroke
• Maintain effective personal and family coping

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• Implementation
• Health Promotion
• Acute intervention
• Respiratory
• Airway maintenance
• Advanced age and immobility ? atelectasis and
  pneumonia
• Impaired consciousness and/or dysphagia
  aspiration ? aspiration pneumonia ??
• Neurologic
• GCS
• Management of ? ICP
• Cardiovascular
• Hydration status (FE)
• BP
• DVTs
• Musculoskeletal
• Prevention of joint contractures and muscular
  atrophy

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• Integumentary
• Prevent skin breakdown
• Turn q 2 hours SBS affected side 30 min
• GI
• IVs
• Tube feeding
• Oral feedings
• High Fowlers with head flexed forward
• Swallow 2x
• Avoid milk products
• Constipation
• Adequate fluid
• 25 g fiber
• Timing and stimulation

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• Urinary system
• Acute
• Poor bladder control and incontinence
• Avoid catheters if possible
• Intermittent
• Bladder retraining
• Adequate fluid intake
• Schedules toileting q 2 hours
• Observe for sifns of restlessness that may
  indicated need for urination
• Communication
• Initial assessment includes ability to speak and
  understand
• Note Guidelines in Table 56-9

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• Sensory-perceptual alterations
• Homonymous hemianopsia
• Neglect syndrome
• Diplopia
• Ptosis
• Coping

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• Rehabilitation
• Reflects the shift from preservation of life to
  the lessening of disability and attainment of
  optimal function
• Patients level of independence in performing
  ADLs determines discharge planning

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Describe the rehabilitative nursing management of
the patient with a stroke

• Discharge Planning
• Based on ability to perform ADLs and support
  system
• Rehabilitation
• Process of maximizing the patients capabilities
  and resources tp promote optimal functioning
• Musculoskeletal System
• Progresses from flaccid to spastic to control of
  isolated muscle groups
• Nutritional therapy
• Bowel function
• Bladder function
• Sensory-perceptual
• Affect
• Coping
• Sexual Function
• Communication
• Community Integration

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Explain the psychosocial impact of a stroke on
the patient and family
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