Chapter 57 Nursing Management: Stroke KEY POINTS PATHOPHYSIOLOGY OF STROKE • The brain needs a continuous supply of blood to provide the oxygen and glucose that neurons need to function. A stroke occurs when there is an interruption, either from ischemia to a part of the brain or hemorrhage into the brain, in the blood supply that results in the death of brain cells. • Two major pairs of arteries supply blood to the brain: internal carotid arteries (anterior circulation) and vertebral arteries (posterior circulation). Factors that affect blood flow to the brain include systemic BP, cardiac output, and blood viscosity. • Atherosclerosis, a hardening and thickening of arteries, is the major cause of ischemic stroke. It can lead to thrombus formation and contribute to emboli. RISK FACTORS FOR STROKE • The most effective way to decrease the burden of stroke is prevention. Nonmodifiable risk factors include age, gender, race, and heredity. • Hypertension is the single most important modifiable risk factor. Other risk factors include increased serum cholesterol, smoking, excess alcohol consumption, obesity, physical inactivity, poor diet, cardiac abnormalities, and drug use. TYPES OF STROKE 1 Copyright © 2020 by Elsevier, Inc. All rights reserved. Ischemic Stroke • A transient ischemic attack (TIA) is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain. Symptoms typically last less than 1 hour. Although most TIAs resolve, one third will progress to an ischemic stroke. • An ischemic stroke results from inadequate blood flow to the brain from partial or complete occlusion of an artery. They are divided into thrombotic and embolic strokes. • A thrombotic stroke occurs from injury to a blood vessel wall and formation of a blood clot. The lumen of the blood vessel becomes narrowed, and if it becomes occluded, infarction occurs. • The extent of a thrombotic stroke depends on rapidity of onset, size of the lesion, and presence of collateral circulation. • Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel. The patient often has a rapid occurrence of severe symptoms. Prognosis is related to the amount of brain tissue deprived of its blood supply. Hemorrhagic Stroke • Hemorrhagic strokes result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles. 2 Copyright © 2020 by Elsevier, Inc. All rights reserved. • Intracerebral hemorrhage is bleeding within the brain caused by a rupture of a vessel. Most often there is a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding. The prognosis of intracerebral hemorrhage is poor. • Subarachnoid hemorrhage occurs when there is intracranial bleeding into the cerebrospinal fluid–filled space between the arachnoid and pia mater membranes on the surface of the brain. • They are often caused by rupture of a cerebral aneurysm, trauma, or drug use. • Most are viewed as a “silent killer” as patients do not have warning signs of an aneurysm until rupture has occurred. CLINICAL MANIFESTATIONS OF STROKE • The manifestations are related to the location of the stroke. • A stroke can effect many body functions, including motor activity, bladder and bowel elimination, intellectual function, spatial-perceptual problems, personality, affect, sensation, swallowing, and communication. • Motor deficits include impairment of mobility, respiratory function, swallowing and speech, gag reflex, and self-care abilities. • The patient may have aphasia, dysphasia, dysphagia, and dysarthria (problem with the muscular control of speech). • Patients may find it hard to control their emotions. A stroke can result in both memory and judgment impairments. 3 Copyright © 2020 by Elsevier, Inc. All rights reserved. • A stroke on the right side of the brain is more likely to cause problems in spatialperceptual orientation, including agnosia, apraxia, and unilateral neglect. DIAGNOSTIC STUDIES • Diagnostic studies are done to confirm that it is a stroke and not another brain lesion, such as a subdural hematoma, and to identify the likely cause of the stroke. • Important diagnostic tools for patients who have had a stroke are either an MRI or noncontrast CT scan. These diagnostic measures can show the size and location of the lesion and can distinguish between ischemic and hemorrhagic stroke. INTERPROFESSIONAL CARE Preventive Therapy • The goals of stroke prevention include management of modifiable risk factors to prevent a stroke. Health promotion focuses on healthy diet, weight control, regular exercise, no smoking, controlling hypertension, limiting alcohol consumption, and routine health assessments. • Measures to prevent the development of a thrombus or embolus are used in patients at risk for stroke. Antiplatelet drugs are usually the chosen treatment to prevent further stroke in patients who have had a TIA. • Surgical interventions for the patient with TIAs from carotid disease include carotid endarterectomy, transluminal angioplasty, and stenting. Acute Care: Ischemic Stroke 4 Copyright © 2020 by Elsevier, Inc. All rights reserved. • The goals for interprofessional care during the acute phase are preserving life, preventing further brain damage, and reducing disability. • Acute care begins with managing the airway, breathing, and circulation. Elevated BP is common immediately after a stroke and may be a protective response to maintain cerebral perfusion. • Carry out a baseline neurologic assessment. Monitor patients closely for signs of increasing neurologic deficit and increased ICP. • Fluid and electrolyte balance must be controlled carefully. The goal is to keep the patient adequately hydrated to promote perfusion and decrease further brain injury. • During initial evaluation, the single most crucial point in the patient’s history is the time of onset. Recombinant tissue plasminogen activator (tPA) must be given IV within 3 to 4.5 hours of the onset of signs of ischemic stroke. tPA can reestablish blood flow through a blocked artery to prevent cell death. • After the patient has stabilized and to prevent further clot formation, patients with strokes caused by thrombi and emboli may receive platelet inhibitors and anticoagulants. Acute Care: Hemorrhagic Stroke • Goals for managing airway, breathing, circulation, and intracranial pressure are the same as for the patient with ischemic stroke. • Hemorrhagic strokes may be treated with surgical interventions, including resection, clipping and coiling of an aneurysm, and evacuation of hematomas. The procedure chosen depends on the cause of the stroke. 5 Copyright © 2020 by Elsevier, Inc. All rights reserved. • Drug therapy is used to manage hypertension, reduce the incidence of cerebral vasospasms, and prevent seizures. Rehabilitative Care • Treatment changes as the patient progresses from the acute to the rehabilitation phase. • The Joint Commission has established stroke core measures to improve outcomes after stroke. • After the stroke has stabilized for 12 to 24 hours, interprofessional care shifts from preserving life to lessening disability and reaching optimal function. NURSING MANAGEMENT: STROKE The nursing care of the patient who has had a stroke is comprehensive. Nursing goals are that the patient will maintain a stable or improved level of consciousness, attain maximum physical functioning, attain maximum self-care abilities and skills, maintain stable body functions, maximize communication abilities, maintain adequate nutrition, avoid complications of stroke, and maintain effective personal and family coping. To reduce the incidence of stroke, you have a key role in health promotion and teaching about reducing modifiable risk factors. Acute Care • During the acute phase after a stroke, management of the respiratory system is a nursing priority. Stroke patients are particularly vulnerable to respiratory problems, including atelectasis, airway obstruction, and aspiration pneumonia. 6 Copyright © 2020 by Elsevier, Inc. All rights reserved. • Monitor the patient’s neurologic status closely to detect changes suggesting extension of the stroke, increased ICP, vasospasm, or recovery from stroke symptoms. • Nursing goals for the cardiovascular system are aimed at maintaining homeostasis. Perform a thorough cardiac assessment, manage infusions, and monitor fluid balance. Implement measures to prevent venous thromboembolism (VTE). • To maintain optimal function of the musculoskeletal system, measures are used to prevent joint contractures and muscular atrophy. • The skin of the patient with stroke is particularly susceptible to breakdown related to loss of sensation, decreased circulation, and immobility. • The most common bowel problem for the patient who has had a stroke is constipation. Patients may receive stool softeners and/or fiber. • The primary urinary problem is poor bladder control, resulting in incontinence. Efforts should be made to promote normal bladder function and to avoid the use of indwelling catheters. • The patient may initially receive IV infusions to maintain fluid and electrolyte balance, as well as for giving drugs. Patients with severe impairment may need enteral or parenteral nutrition support. Swallowing ability must be assessed in the first 24 hours. • Assess the patient both for the ability to speak and the ability to understand and support the patient accordingly. • Homonymous hemianopsia (blindness in the same half of each visual field) is a common problem after a stroke. Persistent disregard of objects in part of the visual field should alert you to this possibility. 7 Copyright © 2020 by Elsevier, Inc. All rights reserved. • A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. Use nursing interventions designed to facilitate coping by providing information and emotional support. Ambulatory Care • The patient is usually discharged from the acute care setting to home, an intermediate or long-term care facility, or a rehabilitation facility. • Ongoing rehabilitation is essential to maximize the patient’s abilities. Rehabilitation requires a team approach so that the patient and family can benefit from the combined, expert care of a stroke team. • The goals for rehabilitation of the patient with stroke are mutually set by the patient, family, nurse, and other members of the rehabilitation team. • Initially emphasize the musculoskeletal functions of eating, toileting, and walking for the rehabilitation of the patient. Interventions advance in a manner of progressive activity. • After the acute phase, a dietitian can help determine the appropriate daily caloric intake based on the patient’s size, weight, and activity level. The diet must be adjusted for the ability of the patient to swallow solids and fluids. • A bowel management program is implemented for problems with bowel control, constipation, or incontinence. Nursing measures are focused on promoting urinary continence. • Patients who have had a stroke often have perceptual deficits. For example, patients with a stroke on the right side of the brain usually have difficulty in judging position, distance, and rate of movement. 8 Copyright © 2020 by Elsevier, Inc. All rights reserved. • The patient with a stroke may have many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. As a nurse, you should help patients and families cope with these losses. • Speech, comprehension, and language deficits are the most difficult problems for the patient and family. Speech therapists can assess and formulate a plan of care to support communication. Answer Keys for Questions • Rationales for Bridge to NCLEX Examination Questions 1. Correct answer: b Rationale: Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, and ethnicity (incidence is highest in Blacks; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people). Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, abdominal obesity, metabolic syndrome, and lack of physical exercise. 2. Correct answer: d Rationale: The extent of the stroke depends on the rapidity of onset, size of the lesion, and presence of collateral circulation. 3. Correct answer: d Rationale: A hemorrhagic stroke usually causes a sudden onset of symptoms, which include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase. 9 Copyright © 2020 by Elsevier, Inc. All rights reserved. 4. Correct answer: c Rationale: If the middle cerebral artery is involved in a stroke, the expected manifestations include aphasia, motor and sensory deficit, and hemianopsia on the dominant side and include neglect, motor and sensory deficit, and hemianopsia on the nondominant side. 5. Correct answer: c Rationale: Angiography provides visualization of cerebral blood vessels and can help estimate perfusion and detect filling defects in the cerebral arteries. 6. Correct answer: c Rationale: In a carotid endarterectomy, the atheromatous lesion is removed from the carotid artery to improve blood flow. 7. Correct answer: b Rationale: During initial evaluation, the most crucial point in the patient’s history is the time since onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be given within 3 to 4½ hours of the onset of signs of ischemic stroke; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with acute onset of ischemic stroke. 8. Correct answer: b Rationale: In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. A bladder retraining program consists of (1) adequate fluid intake, with the greatest fluid intake between 7:00 AM and 7:00 PM; and (2) scheduled toileting every 2 hours with the use of a urinal, commode, or bathroom, (3) assisting with clothing and mobility; and (4) encouraging the usual position for urinating. 10 Copyright © 2020 by Elsevier, Inc. All rights reserved. 9. Correct answers: a, c, e Rationale: The patient with a stroke may have many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational. Some patients have long-term depression, manifesting symptoms, including anxiety, weight loss, fatigue, poor appetite, and sleep problems. The time and energy needed to perform previously simple tasks can result in anger and frustration. Reactions vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow. • Answer Guidelines for Case Study in the text. • 1. How did J.K.’s diagnosis (glioblastoma) put her at risk for a stroke? • J.K. has mild hypertension and is otherwise in good health prior to her diagnosis of GBM. One of the complications of GBM debulking is the presence of many feeder vessels to the tumor and thrombosis of other vessels. During surgery it is important for the surgeon to ensure hemostasis in the area of the tumor. Typically, in the immediate postoperative period the blood pressure is low, and increased pressure in the brain is not an issue. However, as the patient has pain and becomes more active, the increase in blood pressure can result in hemorrhage into the tumor bed. Small arteries that may not have had high flow prior to surgery may have greater flow and rupture. • 2. Priority Decision: What potential complications is J.K. at highest risk for developing? • J.K. is at risk for further bleeding and developing increased intracranial pressure. • 3. Priority Decision: Based on the assessment data provided, what are the priority nursing diagnoses? Are there any collaborative problems? 11 Copyright © 2020 by Elsevier, Inc. All rights reserved. • Nursing Diagnoses: Decreased intracranial adaptive capacity, impaired communication, difficulty coping, risk for aspiration, impaired physical mobility, risk for injury • Collaborative Problems: Potential for increased intracranial pressure, seizures, and VTE • 4. Priority Decision: What are the priority nursing interventions for J.K.? • Acute priority nursing interventions for J.K. include protection of the airway and support of J.K.’s respiratory efforts, monitoring her nervous system, and stabilizing her blood pressure. Other interventions include GI and urinary system monitoring for normal function. Assess J.K. for swallowing and speech, mobility, and skin integrity. • 5. Collaboration: What nursing interventions for J.K. can the RN delegate to unlicensed assistive personnel (UAP)? • • Frequent vital signs and report to the RN • • Measure and record urine output • • Place seizure precaution equipment in the patient room • • Help with patient turning and positioning at least every 2 hours (as directed by the RN) • • Help with passive and assisted range of motion • • Help with toileting and bathing • 6. What strategies can you implement to improve communication for J.K.? • Assess the most constructive means of communicating– writing, drawing, or speech. Allow extra time for her to respond to questions and when she is trying to communicate. Decrease environmental stimuli that may be distracting and disrupting to communication efforts. 12 Copyright © 2020 by Elsevier, Inc. All rights reserved. • Present one thought or idea at a time. Keep questions simple or ask questions that can be answered with “yes” or “no.” Use gestures- encourage this by saying, “Show me …” or “Point to what you want.” Do not pretend to understand her. Calmly say you do not understand and encourage the use of nonverbal communication. Allow body contact as much as possible. • 7. Collaboration: How would you involve other interprofessional team members in J.K.’s care? • Speech therapist: Diagnoses dysphagia, recommends the safest position of the head for eating, recommends the ideal food texture and liquid consistency to prevent aspiration. Dietitian: Recommend appropriate diet to meet nutritional needs. PT: Recommend functional position, begin therapy program, recommend transfer techniques and any equipment needed for mobility. • OT: Perform evaluation of perceptual and cognitive abilities and begin retraining for skills of daily living, including eating, dressing, hygiene, and cooking. • 8. Safety: How can you ensure safety for J.K. in light of her homonymous hemianopsia and left-sided neglect? • She will need help with grooming, dressing, eating, and safety. Place items within the visual field to the right. Give consistent reminders to attend to the left and scan for potential danger. The left side, where there is sensory and motor deficit, must be frequently checked for injury, skin breakdown, hygiene, and temperature control. Safety measures include closely observing her, elevating side rails, lowering the height of the bed, and using video monitors. 13 Copyright © 2020 by Elsevier, Inc. All rights reserved. • 9. Patient-Centered Care: How can you address J.K.’s concerns about her finances and selfcare? • Make a referral to a social worker. Tumors of the CNS can be very stressful to the patient and family and may cause overwhelming anxiety related to their finances and ability to return to work. Encourage her to accept help and join a support group after discharge. Teach her and family about the deficits that are present and the risks associated with the deficits. 14 Copyright © 2020 by Elsevier, Inc. All rights reserved.
