2522 Week 10
Outline...
• Acute Assessment &
Interventions
• Stable Assessment &
Rehabilitation
STROKE
...AKA ‘BRAIN ATTACK’
Death of brain tissue due to a disturbance in
blood supply to the brain.
Ischemic: loss of blood flow
Hemorrhagic: bleeding into the brain or onto
the surface of the brain
Result: brain tissue damage and neurological
deficits
Prevention is key!!!
Prevention = Health Promotion =
Education via Community & Public Health
Risk Factors
Non-modifiable
• Age
• Gender
• Ethnicity and race
• Heredity/family history
• Low birth weight
Modifiable
• Hypertension
• Metabolic syndrome
• Heart disease
• Heavy alcohol consumption
• Oral contraceptive use
• Physical inactivity
• Smoking
• Sleep apnea
Pathophysiology
Ischemic Stroke (80%)
Thrombotic
stroke
Embolic
stroke
Hemorrhagic Stroke (15%)
Subarachnoid
hemorrhage
Intracerebral
hemorrhage
ACUTE ASSESSMENT &
INTERVENTION
In depth assessment AFTER client
receives treatment & is stable
Motor
Elimination
Communication
SpatialPerceptual
Affect
Intellectual
Diagnosis…
Preserve life
Prevent further brain damage
Reduce disability
Diagnostic Studies
When symptoms of a stroke occur, diagnostic
studies are done to
– confirm that it is a stroke.
– identify the likely cause of the stroke.
CT is the primary diagnostic test used after a
stroke.
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Assessment
CT Scan
60 Minutes
Initial Interventions…
Airway
– Patency
Breathing
– Pulse Ox & O2
– Monitor ventilation
Circulation
– IV access
– BP  High or low???
Disability (NEURO)
–
–
–
–
Position head midline
CT scan STAT
HOB 30 degrees
Seizure precautions
Copyrights apply
Cerebral Blood Flow
Hyper & Hypotension
CPP = MAP – ICP
(+Autoregulation)
Hypertension is common immediately after stroke.
– Drugs to lower BP are used only if BP is markedly
increased.
Fluid and electrolyte balance must be controlled
carefully.
– Adequate hydration promotes perfusion and
decreases further brain injury.
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Acute Care - Interventions
1. Ensure patent airway.
2. Call stroke code or stroke team.
3. Remove dentures.
4. Perform pulse oximetry.
5. Maintain adequate oxygenation.
6. Obtain IV access with normal saline.
7. Maintain BP according to guidelines.
8. Remove clothing.
9. Insert Foley catheter
10.Obtain CT scan immediately.
11.Perform baseline laboratory tests.
12.Position head midline.
13.Elevate head of bed 30 degrees if no symptoms of
shock or injury occur.
14.Institute seizure precautions.
15.Anticipate thrombolytic therapy for ischemic stroke.
16.Keep client NPO until swallow reflex evaluated
.
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Search for causes…
Ongoing Interventions…
• VS & neuro status
• Recombinant tissue plasminogen activator
(tPA)
• Aspirin
• Plavix
• Anticoagulants
• Surgery
Recombinant tissue plasminogen activator (tPA)
Inclusion Criteria
•
•
Diagnosis of ischemic stroke causing disabling
neurologic deficit in a patient who is 18 years of age
or older.
Time from last known well (onset of stroke
symptoms) less than 4.5 hours before alteplase
administration.
Absolute Exclusion Criteria
• Any source of active hemorrhage or
any condition that could increase the
risk of major hemorrhage after
alteplase administration
• Any hemorrhage on brain imaging
Relative Exclusion Criteria
• Historical
• Clinical
• CT or MRI Findings
• Laboratory
• Glucose = less than 2.7 mmol/L or greater than 22 mmol/L
• Elevated activated partial-thromboplastin time (aPTT)
• International Normalized Ratio greater than 1.7
• Platelet count below 100,000 per cubic millimetre
Canadian Stroke Best Practices, 2018
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Antiplatelet
Therapy
For clients not treated with TPA
– Acetylsalicylic acid (ASA)
– Clopidogrel
Surgical Interventions for Stroke
1. Ischemic stroke
• EVT
2. Hemorrhagic stroke
• Immediate evacuation of aneurysm-induced
hematomas
• Cerebellar hematomas >3 cm
3. Aneurysms
• Clipping or coiling
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Acute Endovascular Thrombectomy
Treatment (EVT)
Figure 60-8 Endovascular treatment removes blood clots in clients who are experiencing ischemic strokes. The retriever is
a long, thin wire that is threaded through a catheter into the femoral artery. The wire is pushed through the end of the catheter
up to the carotid artery. The wire reshapes itself into tiny loops that latch onto the clot, and the clot can then be pulled out. To
prevent the clot from breaking off, a balloon at the end of the catheter inflates to stop blood flow through the artery.
Copyright © 2019 Elsevier Canada, a
division of Reed Elsevier Canada, Ltd.
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Clipping and Wrapping of Aneurysms
Fig. 60-9. Clipping of aneurysms.
GDC Coil
Mr. Williams is a 63-year-old man who was
admitted to hospital with manifestations of a
stroke.
WATCH:
https://www.heartandstroke.ca/stroke/signs-ofstroke (0-1:19 minutes)
Note your assessment findings while watching.
Diagnostic Studies
Cardiac assessment
– Electrocardiogram
– Chest x-ray
– Cardiac markers i.e. Troponin
– Echocardiography
Blood glucose
35
Other Diagnostic Studies
•
•
•
•
•
•
CTA
MRI, MRA
Cerebral or carotid angiography
Digital subtraction angiography
Transcranial Doppler ultrasonography
Lumbar puncture
36
STABLE ASSESSMENT &
INTERVENTION
NURSING MANAGEMENT
Assessment for STABLE client
– HPI, meds, RF’s, FHx
– Comprehensive neuro exam
Planning
– Goals
• Maximize communication abilities.
• Avoid complications of stroke.
• Maintain effective personal and family coping.
Implementation
– Health promotion
• Remember: prevention=promotion=teaching
• Removal & reduction of risk factors, reinforce health
behaviors
• Ultimately the client’s choice!
– Address & intervene regarding system issues
identified
– Ambulatory & home care
• Rehabilitation
Evaluation
Assess goals - the client will:
– maintain stable or improved level of consciousness.
– attain maximum physical functioning.
– maximize self-care abilities and skills.
– maintain stable body functions.
– maximize communication abilities.
– avoid complications of stroke.
– maintain effective personal and family coping
40
Rehabilitation when the client is
stable
• After stroke has stabilized for 12–72 hours,
collaborative care shifts from preserving life to
lessening disability and attaining optimal
functioning.
• Client may be transferred to a rehabilitation
unit, outpatient therapy, or home care-based
rehabilitation.
Transfer of Care
Ambulatory and home care
–
–
–
–
–
–
–
Ensure clear communication of client status
Nutrition
Mobility
Exercises
Hygiene
Toileting
Education provided
• Self-care skills
– Family/support system
42
Assessment
When the client is stable, obtain
 description of the current illness with attention
to initial symptoms.
 history of similar symptoms previously
experienced.
 current medications.
 history of risk factors and other illnesses.
 family history of stroke or cardiovascular
disease.
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Comprehensive
Neurological
Exam
• Level of consciousness
Canadian Neurological
Scale vs GCS
• Cognition
• Motor abilities
• Cranial nerve function
• Sensation
• Proprioception
• Cerebellar function
• Deep tendon reflexes
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Canadian Neurological Stroke Scale
Notify MD STAT if:
• a decrease of > 1
point and/or
• changes noted in
pupil size or
reaction to light
or
• changes in vital
signs
45
Nursing Documentation
Retrieved from:
https://www.strokenetworkseo.ca/sites/strokenetworkseo.ca/files/neuro_assessment_gzwart.pdf
Ongoing Monitoring
Respiratory and Neurological systems
Respiratory system
– Risk for atelectasis
– Risk for aspiration pneumonia
– Risks for airway obstruction
– May require endotracheal intubation and mechanical ventilation
Neurological system
– Monitor closely to detect changes suggesting
• extension of the stroke.
• ↑ ICP.
• Vasospasm.
• recovery from stroke symptoms.
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Ongoing Monitoring
Cardiovascular system
Cardiac efficiency may be compromised.
• Monitoring vital signs frequently
• Monitoring cardiac rhythms
• Calculating intake and output, noting imbalances
• Regulating IV infusions
DVT risk due to immobility, loss of venous tone, and ↓ muscle pumping in leg
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Motor
Nutrition &
Communication
Elimination
SpatialPerceptual
Affect
Intellectual
Motor Function
• Most obvious effect of stroke
• Include impairment of
– Mobility
– Respiratory function
– Swallowing and speech
– Gag reflex
– Self-care abilities
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Ongoing Monitoring
Musculo-skeletal system
Goals are to maintain optimal function and prevent injury.
– Prevent joint contractures and muscular atrophy
– Range-of-motion exercises
– Positioning
*Paralyzed or weak side needs special attention when positioning and during
transfers
Positioning
– Trochanter roll at hip to prevent external rotation
– Hand splints to prevent hand contractures
– Arm supports with slings and lap boards to prevent shoulder displacement
– Avoidance of pulling the client by the arm to avoid shoulder displacement
– Posterior leg splints, footboards, or
high-topped tennis shoes to prevent foot drop
– Hand splints to reduce spasticity
52
Communication
Aphasia is the total loss of comprehension and use of language.
VS
Dysphagia refers to difficulty related to the comprehension or use
of language and is due to partial disruption or los
Dysarthria: disturbance in the muscular control of speech. Does
not affect the meaning of communication or the comprehension
of language, but it does affect the mechanics of speech.
Impairments may involve
•pronunciation
•articulation
•phonation
Occurs when damage occurs to dominant hemisphere of the brain
**Left hemisphere for RH and most LH
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Dysphagia
Four categories
– Expressive
– Receptive
– Anomic/amnesic
– Global
A massive stroke
may result in
global aphasia, in
which all
communication
and receptive
function are lost.
Ongoing Monitoring and Supports
Communication
Monitor for changes
Speak slowly and calmly, using simple words or
sentences.
Gestures may be used to support verbal cues.
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Affect
May have difficulty controlling their emotions.
Emotional responses may be exaggerated or
unpredictable.
Depression
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Managing Atypical Emotional Responses
• Distract the client.
• Explain to family and client that emotional
outbursts may occur.
• Maintain a calm environment.
• Avoid shaming or scolding client.
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Memory and/or
judgement may be
impaired
Intellectual
Function
**left-brain stroke is
more likely to result in
memory problems
related to language.
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Right sided stroke is more likely to
cause problems in spatial–perceptual
orientation.
Spatial–Perceptual
Alterations
Four categories:
1. Anosognosia
2. Erroneous perception of self in
space
3. Agnosia
4. Apraxia
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Ongoing Monitoring
Sensory–perceptual alterations
•
Blindness in same half of each visual field is a common problem after
stroke.
– Known as homonymous hemianopsia
•
Other visual problems may include
– diplopia (double vision).
– loss of the corneal reflex.
– ptosis (drooping eyelid).
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Homonymous Hemianopsia
(Food on left side is not seen)
Figure 60-12 Spatial and perceptual deficits in stroke. Perception of a client with homonymous
hemianopsia shows that food on the left side is not seen and thus is ignored.
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Nutrition
Nutrition should be a priority assessment
– NPO until swallowing assessment completed
– May initially receive IV infusions to maintain fluid and electrolyte
balance
– Swallow screening within 24 hours of hospital arrival
– May require nutritional support
Interprofessional:
– Dietician
– Speech-language pathology
– Occupational therapist
– Nursing
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Assistive Devices for Eating
Figure 60-13 Assistive devices for eating. A, The curved fork fits over the hand. The rounded plate helps keep
food on the plate. Special grips and swivel handles are helpful for some persons. B, Knives with rounded
blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the
other. C, Plate guards help keep food on the plate. D, Cup with special handle.
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Elimination
Most problems with urinary and bowel
elimination occur initially and are temporary.
• Urinary frequency, urgency or incontinence
• Constipation
• Implement a bowel management program for
problems with
– bowel control.
– constipation.
– incontinence.
• High-fibre diet and adequate fluid intake
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Ongoing Monitoring
Gastrointestinal and Genitourinary systems
Gastrointestinal system
Prevention and monitoring for constipation
• Stool softeners or fibre
• Fluid intake
• Physical activity
Genitourinary system
Managing incontinence
• promote normal bladder function.
*Avoid the use of in-dwelling urinary catheters
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Ongoing Monitoring
Integumentary system
Increased risk of skin breakdown due to:
• Loss of sensation
• Decreased circulation
• Immobility
*Compounded by client age, poor nutrition, dehydration, edema, and
incontinence
NB to prevent and monitor for pressure ulcers
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IPT
An interprofessional and specialized approach:
– Physicians
– Nurses
– occupational therapists
– Physiotherapists
– speech-language pathologists
– social workers
– Dieticians
– Pharmacist
– Discharge planner
– Psychologist
– Palliative
– Spiritual care
Ongoing Monitoring
Psychosocial and Coping
Affects family
• Emotionally
• Socially
• Financially
– Changing roles and responsibilities
– ? Social work
NB to provide client and family education
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Psychosocial and Coping
Nurse may assist the coping process
• Support communication between the client and family.
• Discuss lifestyle changes.
• Discuss changing roles within the family.
• Be an active listener.
• Include family in goal planning and client care.
• Support family conferences.
Stroke support groups – family and client
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Another Perspective…
Thank You