Stroke Lewis Chapter 57 Professor Spickler MSN, RN-BC Copyright © 2017, Elsevier Inc. All Rights Reserved. Stroke • Stroke • Ischemia to part of brain • Hemorrhage into brain that results in death of brain cells • Also known as • Brain attack • Cerebrovascular accident Copyright © 2017, Elsevier Inc. All Rights Reserved. Stroke • Severity of loss of function varies according to location and extent of brain damage • Physical, cognitive, and emotional impact on patient and family Copyright © 2017, Elsevier Inc. All Rights Reserved. Stroke • 5th most common cause of death in the United States • Leading cause of serious, long-term disability •About 800,000 people have a stroke each year • 15%-30% with permanent disability • Lifelong change for survivor and family Copyright © 2017, Elsevier Inc. All Rights Reserved. Risk Factors • Most effective way to decrease burden of stroke is prevention and teaching • Risk factors can be divided into non-modifiable and modifiable risks • Stroke risk increases with multiple risk factors Copyright © 2017, Elsevier Inc. All Rights Reserved. Risk Factors Non-Modifiable • Age • Stroke risk doubles each decade after 55 • Gender • More common in men; more women die • Ethnicity/race • Higher incidence in African Americans • Heredity/family history Copyright © 2017, Elsevier Inc. All Rights Reserved. Risk Factors Modifiable • Hypertension • Heart disease • Serum cholesterol • Smoking • Obesity • Sleep apnea • Metabolic syndrome • Lack of physical exercise • Poor diet • Drug and alcohol abuse Copyright © 2017, Elsevier Inc. All Rights Reserved. Audience Response Question 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 Copyright © 2017, Elsevier Inc. All Rights Reserved. Transient Ischemic Attack • History of TIA is associated with an increased risk of stroke • TIA is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of brain Copyright © 2017, Elsevier Inc. All Rights Reserved. Transient Ischemic Attack • Symptoms typically last < 1 hour • There is no way to predict outcome • 1/3 do not experience another event • 1/3 have additional TIAs • 1/3 progress to stroke Copyright © 2017, Elsevier Inc. All Rights Reserved. Types of Stroke • Strokes are classified based on underlying pathophysiologic findings • Ischemic • Thrombotic • Embolic • Hemorrhagic • Intracerebral • Subarachnoid Copyright © 2017, Elsevier Inc. All Rights Reserved. Major Types of Stroke Copyright © 2017, Elsevier Inc. All Rights Reserved. Ischemic Stroke •Ischemic strokes result from • Inadequate blood flow to brain from partial or complete occlusion of an artery •Ischemic strokes can be • Thrombotic • Embolic Copyright © 2017, Elsevier Inc. All Rights Reserved. Ischemic Stroke • Thrombotic stroke • Occurs from injury to a blood vessel wall and formation of a blood clot • Results in narrowing of blood vessel • Most common cause of stroke (60%) • Often associated with HTN and DM • Many times they are preceded by TIA Copyright © 2017, Elsevier Inc. All Rights Reserved. Ischemic Stroke • Thrombotic stroke • Extent of stroke depends on • Rapidity of onset • Size of damaged area • Presence of collateral circulation Copyright © 2017, Elsevier Inc. All Rights Reserved. Ischemic Stroke • Embolic stroke • Occurs when an embolus lodges in and occludes a cerebral artery • Results in infarction and edema of area supplied by involved vessel • 2nd most common cause of stroke Copyright © 2017, Elsevier Inc. All Rights Reserved. Ischemic Stroke • Embolic stroke •Sudden onset with severe clinical manifestations • • • • Warning signs are less common Patient usually remains conscious Prognosis is related to amount of brain tissue deprived of blood supply Commonly recur Copyright © 2017, Elsevier Inc. All Rights Reserved. Hemorrhagic Stroke • Results from bleeding into • Brain tissue itself • Intracerebral or intraparenchymal hemorrhage • Subarachnoid space or ventricles • Subarachnoid or intraventricular hemorrhage Copyright © 2017, Elsevier Inc. All Rights Reserved. Hemorrhagic Stroke • Intracerebral hemorrhage • Bleeding within brain caused by rupture of a vessel • Sudden onset of symptoms • Progression over minutes to hours because of ongoing bleeding • Prognosis is poor with a 30-day mortality rate of 40%-80% Copyright © 2017, Elsevier Inc. All Rights Reserved. Hemorrhagic Stroke • Intracerebral hemorrhage • • • • Hypertension is most common cause Hemorrhage occurs during activity Sudden onset with progression over minutes to hours Extent of symptoms varies and depends on amount, location, and duration of bleeding Copyright © 2017, Elsevier Inc. All Rights Reserved. Hemorrhagic Stroke • Intracerebral hemorrhage • Manifestations • • • • • Neurologic deficits Headache Nausea and/or vomiting Decreased levels of consciousness Hypertension Copyright © 2017, Elsevier Inc. All Rights Reserved. Hemorrhagic Stroke • 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 Copyright © 2017, Elsevier Inc. All Rights Reserved. Hemorrhagic Stroke • Cerebral aneurysm • Majority are in Circle of Willis • Incidence ↑ with age; higher in women • Silent killer • Loss of consciousness may or may not occur • High mortality rate • Survivors often suffer significant complications and deficits Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations of Stroke • Related to location of stroke • Neural tissue destruction is basis for neurologic dysfunction • Affects many body functions • Related to artery involved and area/half of brain it supplies • Time of the onset of symptoms /length of period of ischemia is important Copyright © 2017, Elsevier Inc. All Rights Reserved. Manifestations of Right-Brain and Left-Brain Stroke Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Motor Function • Most obvious effect of stroke • Include impairment of • • • • • Mobility Respiratory function Swallowing and speech Gag reflex Self-care abilities Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Motor Function • Characteristic motor deficits • Loss of skilled voluntary movement • Akinesia • Impairment of integration of movements • Alterations in muscle tone • Alterations in reflexes • Changes from hyporeflexia to hyperreflexia Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Motor Function • An initial period of flaccidity • May last from days to several weeks • Related to nerve damage • Spasticity of muscles follows flaccid stage • Related to interruptions of upper motor neuron influence Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Communication • Aphasia occurs when stroke damages dominant hemisphere of brain and affects language • Receptive – loss of comprehension • Expressive – loss of production of language • Global – total inability to communicate Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Communication • Dysphasia refers to impaired ability to communicate • Used interchangeably with aphasia • Nonfluent • Minimal speech activity with slow speech • Fluent • Speech is present but contains little meaningful communication Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Communication • Many patients experience dysarthria • Disturbance in muscular control of speech • Impairments may involve • Pronunciation • Articulation • Phonation Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Affect • Patients who suffer a stroke may have difficulty controlling their emotions • Emotional responses may be exaggerated or unpredictable • Magnified by • Depression • Changes in body image • Loss of function Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Intellectual Function • Both memory and judgment may be impaired as a result of stroke • Although impairments can occur with strokes affecting either side of brain, some deficits are related to hemisphere in which stroke occurred Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Spatial-Perceptual Alterations • Stroke on right side of brain is more likely to cause problems in spatialperceptual orientation • Incorrect perception of self and illness • Unilateral neglect of affected side • Homonymous hemianopsia • Agnosia • Apraxia Copyright © 2017, Elsevier Inc. All Rights Reserved. Clinical Manifestations Elimination • Most problems with urinary and bowel elimination occur initially and are temporary • When a stroke affects one hemisphere of brain, prognosis for normal bladder function is excellent Copyright © 2017, Elsevier Inc. All Rights Reserved. Diagnostic Studies • Diagnostic studies are done to • Confirm that it is a stroke • Identify the likely cause of stroke • MRI or noncontrast CT scan • Indicate size and location of lesion • Differentiate between ischemic and hemorrhagic stroke Copyright © 2017, Elsevier Inc. All Rights Reserved. Diagnostic Studies • Other studies • • • • • • • CTA or MRA Cerebral angiography Digital subtraction angiography Transcranial Doppler ultrasonography Lumbar puncture LICOX system Cardiac imaging Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care for Stroke Health Promotion • Management of modifiable risk factors • • • • • • • Healthy diet Weight control Regular exercise No smoking Limiting alcohol consumption BP management Routine health assessments Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Preventive Drug Therapy • Measures to prevent development of a thrombus or embolus are used in patients at risk for stroke • Antiplatelet drugs are used in patients who have had a TIA related to atherosclerosis • Aspirin is most frequently used antiplatelet agent Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Surgical Therapy • Surgical interventions for patient with TIAs from carotid disease include • Carotid endarterectomy • Transluminal angioplasty • Stenting Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Surgical Therapy • Postoperative care is important • Neurovascular assessment • BP management • Assessment for complications • Stent occlusion • Retroperitoneal hemorrhage • Minimize complications at insertion site Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Acute Care for Ischemic Stroke • Goals for interprofessional care: Preserving life • Preventing further brain damage • Reducing disability • Time of onset of symptoms is critical information Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Acute Care for Ischemic Stroke • Begins with managing • Airway • Breathing • Circulation Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Acute Care for Ischemic Stroke • Baseline neurologic assessment • Monitor closely for • Signs of increasing neurologic deficit • Increased ICP • Elevated BP is common immediately after a stroke • May reflect body’s attempt to maintain cerebral perfusion Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Acute Care for Ischemic Stroke • Control fluid and electrolyte balance • Adequate hydration • Promotes perfusion • Decreases further brain injury • Manage ICP • Use interventions that improve venous drainage Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Drug Therapy for Ischemic Stroke • Recombinant tissue plasminogen activator (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 • Patients are carefully screened Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Acute Care • After the patient has stabilized and to prevent further clot formation, patients with strokes caused by thrombi and emboli may be treated with anticoagulants and platelet inhibitors • ASA, ticlopidine, clopidogel, dipyridamole Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Endovascular Therapy Stent retrievers • Becoming the most effective way of managing ischemic stroke Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Acute Care for Hemorrhagic Stroke • Goals are the same as for the patient with ischemic stroke • Manage • • • • Airway Breathing Circulation Intracranial pressure Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Drug Therapy for Hemorrhagic Stroke •Anticoagulants and platelet inhibitors are contraindicated •Management of hypertension is main focus • Oral and IV agents are used to maintain BP within a normal to high-normal range •Seizure prophylaxis is situation-specific Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Surgical Therapy for Hemorrhagic Stroke • Surgical interventions used to treat hemorrhagic strokes include • Resection • Clipping of an aneurysm • Evacuation of hematomas • Procedure is chosen based on cause of stroke Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Acute Care for Hemorrhagic Stroke • Hyperdynamic therapy • Increase mean arterial pressure • Increase cerebral perfusion • Crystalloid or colloid solutions • Vasospasms can be treated with calcium channel blocker nimodipine (Nimotop) Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study Audience Response Question (©iStockphoto/Thinkstock) P.D. is diagnosed with a thrombotic stroke. Over the next 72 hours, you plan care with the knowledge that he a. is ready for aggressive rehabilitation. b. will show gradual improvement of the initial neurologic deficits. c. may show signs of deteriorating neurologic function as cerebral edema increases. d. should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits. Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Rehabilitation • After stroke has stabilized for 12 to 24 hours, interprofessional care shifts from preserving life to lessening disability and attaining optimal functioning • Patient may be transferred to a rehabilitation unit, outpatient therapy, or home care–based rehabilitation Copyright © 2017, Elsevier Inc. All Rights Reserved. Interprofessional Care Core Measures for Stroke Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Nursing Assessment • Primary assessment is focused on • Cardiac status • Respiratory status • Neurologic assessment • If patient is stable, obtain • Description of current illness • Pay special attention to symptom onset and duration, nature, and changes Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Nursing Assessment • If the patient is stable, obtain • History of similar symptoms previously experienced • Current medications • History of risk factors and other illnesses • Hypertension, etc. • Family history of stroke, aneurysm or cardiovascular disease Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Nursing Assessment • Secondary assessment includes a comprehensive neurologic examination • Level of consciousness • Include NIH Stroke Scale • Cognition • Motor abilities Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Nursing Assessment • Comprehensive neurologic examination • • • • • Cranial nerve function Sensation Proprioception Cerebellar function Deep tendon reflexes Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Nursing Implementation • Health Promotion • You have an important role in the promotion of a healthy lifestyle • To help reduce the incidence of stroke • Focus on stroke prevention • Teach how to reduce modifiable risk factors • Cause of most strokes Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Respiratory system • Management of respiratory system is a nursing priority • • • • Risk for atelectasis Risk for aspiration pneumonia Risks for airway obstruction May require endotracheal intubation and mechanical ventilation Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Neurologic system • Monitor closely to detect changes suggesting • • • • Extension of the stroke ↑ ICP Vasospasm Recovery from stroke symptoms Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Cardiovascular system • Goals aimed at maintaining homeostasis • Many patients with stroke have decreased cardiac reserves from secondary diagnoses of cardiac disease • Cardiac efficiency may be compromised Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Cardiovascular system • Nursing interventions • • • • Monitoring vital signs frequently Monitoring cardiac rhythms Calculating intake and output, noting imbalances Regulating IV infusions Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Cardiovascular system • • • • Adjusting fluid intake to individual needs of the patient Monitoring lung sounds for crackles and wheezes (pulmonary congestion) Monitoring heart sounds for murmurs Watch for orthostatic hypotension before ambulating patient for 1st time Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Cardiovascular system • After stroke, patient is at risk for venous thromboembolism (VTE) • Weak or paralyzed lower extremities are particularly vulnerable • Related to immobility, loss of venous tone, and ↓ muscle pumping in leg • Most effective prevention is keeping the patient moving Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Musculoskeletal system • Goal is to maintain optimal function • Accomplished by prevention of joint contractures and muscular atrophy • In acute phase, range-of-motion exercises and positioning are important • Paralyzed or weak side needs special attention when positioned Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Optimize musculoskeletal function • Trochanter roll at hip to prevent external rotation • Hand cones to prevent hand contractures • Arm supports with slings and lap boards to prevent shoulder displacement Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Optimize musculoskeletal function • Avoidance of pulling the patient by arm to avoid shoulder displacement • Posterior leg splints, footboards, or high-topped tennis shoes to prevent foot drop • Hand splints to reduce spasticity Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Integumentary system • Susceptible to skin breakdown related to • Loss of sensation • Decreased circulation • Immobility • Compounded by patient age, poor nutrition, dehydration, edema, and incontinence Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Prevention of skin breakdown • Pressure relief by position changes, special mattresses, wheelchair cushions • Position patient on weak or paralyzed side for only 30 minutes • Good skin hygiene • Emollients applied to dry skin • Early mobility Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Gastrointestinal system • Stress of illness contributes to a catabolic state that can interfere with recovery • Constipation is most common bowel problem • Prophylactic stool softeners or fiber • Physical activity promotes bowel function Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Urinary system • • • • In acute stage, poor bladder control results in incontinence Efforts should be made to promote normal bladder function Avoid use of indwelling catheters Bladder retraining program • Avoid bladder overdistention Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Nutrition • Nutritional needs require quick assessment and treatment • May initially receive IV infusions to maintain fluid and electrolyte balance • May require nutrition support Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Nutrition • First feeding should be approached carefully • Test swallowing, chewing, gag reflex, and pocketing before beginning oral feeding • Feedings must be followed by scrupulous oral hygiene Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Communication • Your role in meeting psychologic needs of patient is primarily supportive • Assess patient 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 Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Speech, comprehension, and language deficits are most difficult problem for patient and family • Speech therapists can assess and formulate a plan to support communication Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Sensory-perceptual alterations • Related to hemisphere of brain in which stroke occurred • Visual problems may include • • • • Diplopia (double vision) Loss of the corneal reflex Ptosis (drooping eyelid) Homonymous hemianopsia Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Sensory-perceptual alterations • Patients with stroke on right side of brain • Difficulty in judging position, distance, and movement • Impulsive, impatient, and deny problems related to stroke • Respond best to directions given verbally Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Acute Care • Sensory-perceptual alterations • Patients with stroke on left side of brain • • • • Slower in organization and performance of tasks Impaired spatial discrimination Have fearful, anxious response to stroke Respond well to nonverbal cues Copyright © 2017, Elsevier Inc. All Rights Reserved. Case Study Audience Response Question (©iStockphoto/Thinkstock) P.D. also has dysphagia. Before allowing him to eat, which action should you take first? a. Check the patient’s gag reflex. b. Request a soft diet with no liquids. c. Place the patient in high-Fowler’s position. d. Test the patient’s ability to swallow with a small amount of water. Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Ambulatory Care • Patient is usually discharged from acute care setting to • Home • Intermediate or long-term care facility • Rehabilitation facility • Critical factor: independence in ADLs • Ongoing rehabilitation is essential to maximize patient’s abilities Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Ambulatory Care • Ambulatory Care • Nurses have an excellent opportunity to prepare patient and family for discharge through • • • • Teaching Demonstration/return demonstration Practice Evaluation of self-care skills Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Ambulatory Care • Rehabilitation is process of maximizing patient’s capabilities and resources to promote optimal functioning • Physical, mental, and social well-being • Goals are set mutually by patient, family, nurse, stroke/rehab team Copyright © 2017, Elsevier Inc. All Rights Reserved. Homonymous Hemianopsia 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.) Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Stroke Survivorship and Coping • Family members must cope with three aspects of patient’s behavior 1. Recognition of behavioral changes resulting from neurologic deficits that are not changeable 2. Responses to multiple losses both by patient and family Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management: Stroke Stroke Survivorship and Coping • Three aspects of the patient’s behavior 3. Behaviors that may have been reinforced during the early stages of stroke as continued dependency Copyright © 2017, Elsevier Inc. All Rights Reserved.
