Focus on Stroke: Nursing Management
Stroke: NURSING
MANAGEMENT
Zoya Minasyan, RN, MSN-Edu
Structures and Functions of Nervous System
Left hemisphere of cerebrum, lateral surface, showing major lobes and areas of the brain.
Structures and Functions of Nervous System
Structural features of neurons: dendrites, cell body, and axons.
Structures and Functions of Nervous System
Major divisions of the central nervous system (CNS).
Structures and Functions of Nervous System
The cranial nerves are numbered according to the order in which they leave the brain.
Structures and Functions of Nervous System
Arteries of the head and neck. Brachiocephalic artery, right common carotid artery, right subclavian artery, and their branches. The major arteries to the head are the common carotid and vertebral arteries.
Structures and Functions of Nervous System
Arteries at the base of the brain. The arteries that compose the circle of Willis are the two anterior
cerebral arteries joined to each other by the anterior communicating cerebral artery and to the posterior
cerebral arteries by the posterior communicating arteries.
Structures and Functions of Nervous System
The vertebral column (three views).
Stroke
Stroke occurs when ischemia or hemorrhage into the brain results in death of brain cells.
Also known as a brain attack
Functions are lost or impaired
Such as movement, sensation, or emotions that were controlled by the affected area of the brain
Severity of the loss of function varies according to the location and extent of the brain involved.
Risk Factors
Most effective way to decrease the burden of stroke is prevention.
Risk factors can be divided into non modifiable and modifiable risks.
Risk Factors
Modifiable
Hypertension
Metabolic syndrome
Heart disease
Heavy alcohol consumption
Poor diet
Drug abuse
Sleep apnea
Obesity
Physical inactivity
Smoking
Non modifiable
Age
Gender
Race
Heredity/family history
Types of Stroke
Strokes are classified on the basis of underlying pathophysiologic findings.
Ischemic
Thrombotic
Embolic
Hemorrhagic
Major Types of Stroke
Ischemic Stroke
Ischemic strokes result from
Inadequate blood flow to the brain from partial or complete occlusion of an artery
80% of all strokes are ischemic strokes.
Ischemic strokes can be
Thrombotic
Embolic
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
•
Lacunar strokes
• a stroke from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue.
• thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate atherosclerosis
Pathogenesis of Atherosclerosis
A, Damaged endothelium.
B, Diagram of fatty streak and lipid core formation.
C, Diagram of fibrous plaque. Raised plaques are visible: some are yellow, others are white.
D, Diagram of complicated lesion: thrombus is red, collagen is blue. Plaque is complicated by red thrombus deposition.
Pathogenesis of Atherosclerosis
Developmental stages:
Fatty streaks
Earliest lesions
Characterized by lipid-filled smooth muscle cells
Potentially reversible
Fibrous plaque
Beginning of progressive changes in the arterial wall
Lipoproteins transport cholesterol and other lipids into the arterial intima.
Fatty streak is covered by collagen, forming a fibrous plaque that appears grayish or whitish.
Result = Narrowing of vessel lumen
Complicated lesion
Continued inflammation can result in plaque instability, ulceration, and rupture.
Platelets accumulate and thrombus forms.
Increased narrowing or total occlusion of lumen
Ischemic Stroke
Embolic stroke
Occurs when an embolus lodges in and occludes a cerebral artery
Results in infarction and edema of the area supplied by the involved vessel
Second most common cause of stroke
Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms.
Onset of embolic stroke is usually sudden and may or may not be related to activity.
Patient usually remains conscious, although he may have a headache.
Ischemic Stroke
Transient ischemic attack
Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain
Symptoms last <1 hour
•
Most TIAs resolve
• encourage patients to go to the emergency room at symptom onset since once a TIA starts, one does not know if it will persist and become a true stroke, or if it will resolve.
•
In general, one third of individuals who experience a TIA will not experience another event, one third will have additional TIAs, and one third will progress to stroke.
Hemorrhagic Stroke
•
•
Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles
Often a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding
Intracerebral hemorrhage
Bleeding within the brain caused by rupture of a vessel
Hypertension is the most important cause.
Hemorrhage commonly occurs during periods of activity.
Hemorrhagic Stroke
Massive hypertensive hemorrhage rupturing into a lateral ventricle of the brain.
Hemorrhagic Stroke
Intracerebral hemorrhage
Manifestations
Neurologic deficits
Headache
Nausea and/or vomiting
Decreased levels of consciousness
Hypertension
Hemorrhagic Stroke
Subarachnoid hemorrhage
Intracranial bleeding into cerebrospinal fluid–filled space between the arachnoid and pia mater
Commonly caused by rupture of a cerebral aneurysm
Majority of aneurysms are in the circle of Willis.
“Worst headache of one’s life”
Other causes of subarachnoid hemorrhage include trauma and illicit drug
(cocaine) abuse.
people who have a hemorrhagic stroke due to a ruptured aneurysm can die during the first episode or die from subsequent bleeding.
increases with age, higher in women than men.
Loss of consciousness may or may not occur. focal neurologic deficits (including cranial nerve deficits), nausea, vomiting,
seizures, and stiff neck.
Most frequent surgical procedure to prevent re bleeding is clipping of the aneurysm.
Clinical Manifestations
Affects many body functions
Motor activity
Elimination
Intellectual function
Spatial-perceptual
Personality
Affect
Sensation
Communications
Clinical Manifestations
Motor Function
Most obvious effect of stroke
Include impairment of
Mobility
Respiratory function
Swallowing and speech
Gag reflex
Self-care abilities
Loss of skilled voluntary movement
Alterations in muscle tone
Alterations in reflexes
Clinical Manifestations
Motor Function
An initial period of flaccidity
(also known as hypotonicity is a condition characterized by a decrease or loss of normal muscle tone due to the deterioration of the lower motor nerve cells).
May last from days to several weeks
Related to nerve damage
Spasticity of the muscles follows the flaccid stage.
(an abnormal increase in muscle tension and a reduced ability of a muscle to stretch)
Related to interruptions in upper motor neuron influence
Clinical Manifestations
Communication
Patient may experience aphasia when a stroke damages the dominant hemisphere of the brain.
Aphasia is the total loss of comprehension and use of language.
Dysphasia refers to difficulty related to the comprehension or use of language and is due to partial disruption or loss.
Types of Aphasia
Broca’s
Damage to frontal lobe, speak in short phrases that makes sense but with great effort. “Walk doge””Book –book table”. They are aware of it and become frustrated.
Wernicke’s
Left temporal lobe damage. Long sentences with no meaning, difficult to understand the meaning of the speech. They are not aware of it.
Global
Severe communication difficulties, limited in ability to speak.
A massive stroke may result in global aphasia, in which all communication and receptive function are lost.
Clinical Manifestations
Communication
Many patients experience dysarthria.
Disturbance in the muscular control of speech
Dysarthria does not affect the meaning of communication or the comprehension of language, but it does affect the mechanics of speech.
Some patients experience a combination of aphasia and dysarthria.
Impairments may involve
Pronunciation
Articulation
Phonation
Clinical Manifestations
Affect
•
Patients who suffer a stroke may have difficulty controlling their emotions.
•
Depression and feelings associated with changes in body image and loss of function can make this worse.
•
Patients may also be frustrated by mobility and communication problems.
Emotional responses may be exaggerated or unpredictable.
•
An example of unpredictable affect is as follows:
•
A well-respected lawyer has returned home from the hospital following a stroke. During meals with his family, he becomes frustrated and begins to cry because of difficulty getting food into his mouth and chewing, something that he was able to do easily before his stroke.
Clinical Manifestations
Intellectual Function
Both memory and judgment may be impaired as a result of stroke.
A left-brain stroke is more likely to result in
memory problems related to language.
Clinical Manifestations
Spatial–Perceptual Alterations
Stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation.
However, this may occur with left-brain stroke.
An example of behavior with right-brain stroke is the patient who tries to rise quickly from a wheelchair without
locking the wheels or raising the footrests.
The patient with a left-brain stroke would move slowly and cautiously from the wheelchair.
Clinical Manifestations
Spatial-Perceptual Alterations
Spatial-perceptual problems may be
Incorrect perception of self and illness perception of self in space
Inability to recognize an object by sight, touch, or hearing
Inability to carry out learned sequential movements on command
A stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation, although this can also occur with left-brain stroke as well.
Clinical Manifestations
Elimination
Most problems with urinary and bowel elimination occur initially and are temporary.
When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is intact
partial sensation of bladder and voluntary urination is present
Initially, the patient may experience frequency, urgency, and incontinence.
•
Constipation is associated with immobility, weak abdominal muscles, dehydration, and diminished response to the defecation reflex.
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.
A CT scan can rapidly distinguish between ischemic and hemorrhagic stroke and help determine the size and
location of the stroke. Serial CT scans may be used to assess the effectiveness of treatment and to evaluate recovery.
Diagnostic Studies
CTA
CT angiography (CTA) provides visualization of cerebral blood vessels
MRI, MRA
MRI is used to determine the extent of brain injury
Angiography may detect vascular lesions and blocksges
Cerebral angiography
Angiography can identify cervical and cerebrovascular occlusion, atherosclerotic
plaques, and malformation of vessels
Digital subtraction angiography
Intraarterial digital subtraction angiography (DSA) reduces the dose of contrast
material, uses smaller catheters, and shortens the length of the procedure compared with conventional angiography
Transcranial Doppler ultrasonography
Transcranial Doppler (TCD) ultrasonography is a noninvasive study that measures the
velocity of blood flow in the major cerebral arteries.
Lumbar puncture
LICOX system
The LICOX system may be used as a diagnostic tool for evaluating the progression of stroke, brain O2 and temperature, page 1432
LICOX catheter
The LICOX brain tissue oxygen system involves a catheter inserted through an intracranial bolt , placed in white matter of the brain. (A). The system measures oxygen in the brain (PbtO
2 and intracranial pressure (ICP) (B).
), brain tissue temperature,
Diagnostic Studies of Nervous System
Normal images of the brain. A, CT scan. B, MRI.
38
Diagnostic Studies of Nervous System
Cerebral angiogram illustrating an arteriovenous malformation (arrow).
Collaborative Care
Prevention
Goals of stroke prevention include
Health promotion
Education and management of modifiable risk factors
Patients with known risk factors require close management.
Diabetes mellitus
Hypertension
Obesity
High serum lipids
Cardiac dysfunction
Collaborative Care
Prevention
Antiplatelet drugs are usually the chosen treatment
•
Aspirin is the most frequently used as antiplatelet agent.
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Common dose for aspirin is 81 to 325 mg/day.
•
Other drugs include ticlopidine (Ticlid), clopidogrel
(Plavix), dipyridamole (Persantine), and combined dipyridamole and aspirin (Aggrenox).
•
Oral anticoagulation using warfarin is the treatment of choice for individuals with atrial fibrillation.
Collaborative Care
Prevention
Surgical interventions
Carotid end-arterectomy (tube inserted above and below the blockage, remove the plaque, stitch the artery close, remove the tube)
Transluminal angioplasty (insertion of balloon to open artery in the brain and to improve blood flow)
Stenting (inflate the balloon cath, imlpant the stent, deflate the balloon and remove, leave the stent permanently in place holding the artery open to improve the blood flow)
Extracranial-intracranial bypass (EC-IC) anastomosing
(surgically connecting) external artery to internal arterysuperficial temporal to middle cerebral artery
Carotid End-arterectomy
Carotid endarterectomy is performed to prevent impending cerebral infarction. A, A tube is inserted above and below the blockage to reroute the blood flow. B, Atherosclerotic plaque in the common carotid artery is removed. C, Once the artery is stitched closed , the tube can be removed. A surgeon may also perform the technique without rerouting the blood flow.
Brain Stent
Brain stent used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant the stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery and then inflated. The stent expands due to the inflation of the balloon. C, The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery open and improving the flow of blood.
Collaborative Care
Acute Care
Goals for collaborative care during the acute phase are
Preserving life
Preventing further brain damage
Reducing disability
Begins with managing the ABCs
Airway
Breathing
Circulation
Collaborative Care
Acute Care
Causes
Sudden vascular compromise causing disruption of blood flow to the brain
Thrombosis
Trauma
Aneurysm
Embolism
Hemorrhage
Collaborative Care:
Acute Care
Assessment findings
Altered level of consciousness
Weakness, numbness, or paralysis
Speech or visual disturbances
Severe headache
↑ or ↓ heart rate
Respiratory distress
Unequal pupils
Hypertension
Facial drooping on affected side
Difficulty swallowing
Seizures
Bladder or bowel incontinence
Nausea and vomiting
Vertigo
Collaborative Care
Acute Care
Interventions
Ensure patent airway.
Call stroke code or stroke team.
Remove dentures.
Perform pulse oximetry.
Maintain adequate oxygenation.
Obtain IV access.
Maintain BP.
Obtain CT scan immediately.
Perform baseline laboratory tests.
Position head midline.
Elevate head of bed 30 degrees if no symptoms of shock or injury occur.
Institute seizure precautions.
Anticipate thrombolytic therapy for ischemic stroke.
Collaborative Care
Acute Care
Watch for hypertension post stroke.
Drugs to lower BP are used only if BP is markedly increased. (metoprolol, cardene)
Fluid and electrolyte balance must be controlled carefully.
Adequate hydration promotes perfusion and decreases further brain injury.
Adequate fluid intake during acute care via oral, intravenous (IV), or tube feedings should be 1500 to 2000 mL/day.
Overhydration may compromise perfusion by increasing cerebral edema.
Collaborative Care
Acute Care
Interventions
Monitor vital signs and neurologic status.
Level of consciousness
Monitor sensory function
Pupil size and reactivity
O
2 saturation
Cardiac rhythm
Collaborative Care:
Acute Care
Recombinant
tissue plasminogen activator
(tPA)
Used to reestablish blood flow through a blocked artery
to prevent cell death in patients with acute onset of ischemic stroke symptoms
Must be administered within 3 to 4.5 hours of onset of clinical signs of ischemic stroke
Pt screened before tPA can be given:
non contrast CT or MRI scan to rule out hemorrhagic stroke
blood tests for coagulation disorders screening for recent history of gastrointestinal bleeding, stroke, or head trauma within the past 3 months, or major surgery within 14 days.
Collaborative Care
Acute Care
Aspirin is used within 24 to 48 hours of stroke.
Platelet inhibitors and anticoagulants may be used in thrombus and embolus stroke patients after stabilization.
•
Contraindicated for patients with hemorrhagic stroke
•
The use of anticoagulants (e.g., heparin) in the emergency phase following an ischemic stroke generally is not recommended because of the risk for intracranial hemorrhage.
•
•
•
Dose of aspirin is 325 mg.
Common anticoagulants include warfarin (Coumadin).
Platelet inhibitors include aspirin, ticlopidine (Ticlid), clopidogrel (Plavix), and dipyridamole (Persantine).
Collaborative Care
Acute Care
Surgical interventions for stroke
Ischemic stroke
MERCI (mechanical embolus removal in cerebral ischemia)
Hemorrhagic stroke
Immediate evacuation of aneurysm-induced hematomas
Cerebellar hematomas >3 cm
After stroke has stabilized for 12 to 24 hours, collaborative 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.
Merci Embolus Retriever in Cerebral Ischemic Stroke
The MERCI retriever removes blood clots in patients 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.
Clipping and Wrapping of Aneurysms
GDC Coil: Gugleilmi detachable coils
A, A coil is used to occlude an aneurysm. Coils are made of soft, spring like platinum . The softness of the platinum allows the coil to assume the shape of irregularly shaped aneurysms while posing little threat of rupture of the aneurysm.
B, A catheter is inserted through an introducer (small tube) in an artery in the leg. The catheter is threaded up to the cerebral blood vessels.
C, Platinum coils attached to a thin wire are inserted into the catheter and then placed in the aneurysm until the aneurysm is filled with coils. Packing the aneurysm with coils prevents the blood from circulating through the aneurysm, reducing the risk of rupture.
Nursing Management
Nursing Assessment
If the patient 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
Nursing Management
Nursing Assessment
Comprehensive neuro examination
Level of consciousness
Cognition
Motor abilities
Cranial nerve function
Sensation
Deep tendon reflexes
Nursing Management
Nursing Diagnoses
Risk for ineffective cerebral tissue perfusion
Ineffective airway clearance
Impaired physical mobility
Impaired verbal communication
Impaired urinary elimination
Impaired swallowing
Situational low self-esteem
Nursing Management
Planning
Goals are that the patient 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.
Nursing Management
Nursing Implementation
Health promotion
To reduce the incidence of stroke, the nurse should focus teaching toward stroke prevention.
Particularly in persons with known risk factors
Education about hypertension control and adherence to medication
Teaching patients and families about
Early symptoms
Stroke
TIA
When to seek health care for symptoms
Nursing Management
Nursing Implementation
Respiratory system
Management of the respiratory system is a nursing priority.
Risk for atelectasis
Risk for aspiration pneumonia
Risks for airway obstruction
May require tracheal intubation and mechanical ventilation
Nursing Management
Nursing Implementation
Neurologic system
Monitor closely to detect changes suggesting
Extension of the stroke
↑ ICP
Vasospasm
Recovery from stroke symptoms
Table 58-8, page 1472 the NIH Stroke Scale
(NIHSS)national institutes of health stroke scale .
Nursing Management: Nursing Implementation
Cardiovascular system
Goals aimed at maintaining homeostasis
Many patients with stroke have decreased cardiac reserves from the secondary diagnoses of cardiac disease.
Monitoring vital signs frequently
Monitoring cardiac rhythms
Calculating intake and output, noting imbalances
Regulating IV infusions
Adjusting fluid intake to the individual needs of the patient
Monitoring lung sounds for crackles and rhonchi (pulmonary congestion)
Monitoring heart sounds for murmurs
After stroke, patient is at risk for deep vein thrombosis.
Related to immobility, loss of venous tone, and ↓ muscle pumping in leg
Most effective prevention is keeping the patient moving.
Nursing Management
Nursing Implementation
Musculoskeletal system
Goal is to maintain optimal function. prevention of joint contractures and muscular atrophy
range-of-motion exercises and positioning are important.
Paralyzed or weak side needs special attention when positioned.
Avoidance of pulling the patient by the arm to avoid shoulder displacement
Hand splints to reduce spasticity
Nursing Management
Nursing Implementation
Integumentary system
Susceptible to breakdown related to
Loss of sensation
Decreased circulation
Immobility
Compounded by patient age, poor nutrition, dehydration,
edema, and incontinence
Pressure relief by position changes, special mattresses, or wheelchair cushions
Good skin hygiene
Early mobility
Position patient on the weak or paralyzed side for only 30 minutes.
Nursing Management
Nursing Implementation
Gastrointestinal system
Stress of illness.
Constipation.
Patients may be placed on stool softeners.
Physical activity promotes bowel function.
Urinary system
promote normal bladder function.
Avoid the use of indwelling catheters.
Nursing Management
Nursing Implementation
Nutrition
Nutritional needs require quick assessment and treatment.
May initially receive IV infusions to maintain fluid and electrolyte balance
May require nutritional support
First feeding should be approached carefully.
Test swallowing, chewing, gag reflex, and pocketing before beginning oral feeding.
Feedings must be followed by oral hygiene.
Nursing Management
Nursing Implementation
Communication
Nurse’s role in meeting psychologic needs of the patient is primarily supportive.
Patient is assessed for both the ability to speak and the ability to understand.
Speak slowly and calmly, using simple words or sentences.
Gestures may be used to support verbal cues.
Nursing Management
Nursing Implementation
Sensory-perceptual alterations
Blindness in same half of each visual field is a common problem after stroke.
Known as homonymous hemi anopsia
A neglect syndrome (decrease in safety, increase risk for injury)
Other visual problems may include
Diplopia (double vision)
Ptosis (drooping eyelid)
Homonymous Hemianopsia
(Food on left side is not seen)
Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemi anopsia
Shows that food on the left side is not seen and thus is ignored.
Nursing Management
Nursing Implementation
Coping
Affects family
Emotionally
Socially
Financially
Changing roles and responsibilities
Explain
What has happened
Diagnosis
Therapeutic procedures
Should be clear and understood by patient.
social services referral is often helpful.
Nursing Management: Nursing Implementation
Ambulatory and home care
Patient is usually discharged to home, an intermediate or long-term care facility, or a rehabilitation facility.
discharge planning with the patient and family starts early in the hospitalization and promotes a smooth transition from one care setting to another.
prepare the patient and family for discharge through
Education
Demonstration
Practice
Evaluation of self-care skills
Rehabilitation to promote optimal functioning.
Physical, mental, and social well-being
Loss of Postural Stability
Loss of postural stability is common after stroke. The patient is unable to sit upright and tends to fall sideways. Appropriate support with pillows or cushions should be provided.
Nursing Management
Nursing Implementation
Ambulatory and home care (cont’d)
Musculoskeletal interventions
Balance training
Transferring from bed to chair
Bobath method
Therapists and nurses use the Bobath approach to encourage normal muscle tone, normal movement, and promotion of bilateral function of the body.
An example is to have the patient transfer into the wheelchair using the weak or paralyzed side and the stronger side to facilitate more bilateral functioning.
CIMT is a more recent approach. Constraint-induced movement therapy (CIMT) encourages the patient to use the weakened
extremity by restricting movement of the normal extremity. This approach is challenging, and the ability of patients to comply may limit its use.
Nursing Management
Nursing Implementation
Ambulatory and home care (cont’d)
After acute phase, a dietitian can assist in determining appropriate daily caloric intake based on the patient’s
Size
Weight
Activity level
Nurse and speech therapist must assess ability of patient to swallow solids and fluids and must adjust the diet appropriately.
Inability to feed oneself can be frustrating and may result in malnutrition and dehydration.
Assistive Devices for Eating
A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips 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.
Nursing Management
Nursing Implementation
Implement a bowel management program for problems with
Bowel control
Constipation
Incontinence
High-fiber diet and adequate fluid intake
Nursing Management
Nursing Implementation
Patients with stroke on right side of brain
Difficulty in judging position, distance, and movement
Impulsive, impatient, and denying problems related to stroke
Respond best to directions given verbally
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
Nursing Management
Nursing Implementation
Interventions for atypical emotional response
Distract the patient.
Explain that emotional outbursts may occur.
Maintain a calm environment.
Avoid shaming.
Patients with a stroke may be coping with many losses
Often go through the process of grief
Some patients experience long-term depression
Support communication between the patient and family.
Discuss lifestyle changes.
Discuss changing roles within the family.
Be an active listener.
Include family in goal planning and patient care.
Support family conferences.
Nursing Management
Nursing Implementation
Family members must cope with
Recognition of behavioral changes resulting from neurologic deficits that are not changeable
Responses to multiple losses by both the patient and the family.
Behaviors that may have been reinforced during the early stages of stroke as continued dependency
Stroke support groups within rehab facilities and community are helpful.
Mutual sharing
Education
Coping
Understanding
Nursing Management
Nursing Implementation
Speech, comprehension, and language deficits are the most difficult problem for the patient and family.
Speech therapists can assess and formulate a plan to support communication.
Nurses can be a role model for patients with aphasia.
Question #1
A patient with right-sided paresthesias and hemiparesis is hospitalized and diagnosed with a thrombotic stroke. Over the next 72 hours, the nurse plans care with the knowledge that the patient:
1. Is ready for aggressive rehabilitation.
2. Will show gradual improvement of the initial neurologic deficits.
3. May show signs of deteriorating neurologic function as cerebral edema increases.
4. Should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits.
Question #2
While performing health screening at a health fair, the nurse identifies which of the following individuals at greatest risk for experiencing a stroke?
1. A 46-year-old white female with hypertension and oral contraceptive use for 10 years.
2. A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dL.
3. A 42-year-old African American female with diabetes mellitus who has smoked for 30 years.
4. A 62-year-old African American male with hypertension who is
35 pounds overweight.
Answer #2
Answer: 4
Rationale:
Option 4: This individual has five risk factors: age, African
American, male, hypertension, and
overweight.
Option 1: This individual has two risk factors: hypertension and oral contraception use.
Option 2: This individual has two risk factors: male and increased cholesterol level.
Option 3: This individual has three risk factors: African
American, diabetes mellitus, and smoking.
Answer #2
Nonmodifiable risk factors include age, gender, ethnicity/race, and family history/heredity.
Stroke risk increases with age, doubling each decade after 55 years of age. Two thirds of all strokes occur in individuals >65 years. Strokes are more common in men, but more women die from stroke than men. Because women tend to live longer than men, they have more opportunity to suffer a stroke. African Americans have a higher incidence of stroke, as well as a higher death rate from stroke than whites. A family history of stroke, a prior transient ischemic attack, or a prior stroke also increases the risk of stroke.
Modifiable risk factors are those that can potentially be altered through lifestyle changes and medical treatment, thus reducing the risk of stroke. Modifiable risk factors include hypertension, increased cholesterol, elevated blood lipid levels, heart disease, smoking, excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, and drug abuse.
Early forms of birth control pills that contained high levels of progestin and estrogen increased a woman’s chance of experiencing a stroke, especially if she also smoked heavily. Newer, lowdose oral contraceptives have lower risks for stroke except in those individuals who are hypertensive and smoke. Other conditions that may increase stroke risk include migraine headaches, inflammatory conditions. Sickle cell disease is another known risk factor for stroke.
Question #3
A patient with a stroke has dysphagia. Before allowing the patient to eat, which of the following actions should the nurse take first?
1. Check the patient’s gag reflex.
2. Request a soft diet with no liquids.
3. Place the patient in high-Fowler’s position.
4. Test the patient’s ability to swallow with a small amount of water.
Answer #3
Answer: 1
Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade.
If a gag reflex is present, the patient will gag spontaneously.
If it is absent, defer the feeding, and begin exercises to stimulate swallowing.
To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated), and give the patient a small amount of crushed ice or ice water to swallow.
Case Study
73-year-old man was admitted to the hospital with right-sided paresis and expressive aphasia.
He had been experiencing periods of confusion, right-sided weakness, and slurred speech for the past several weeks.
These episodes were brief and resolved completely within an hour. No treatments were sought.
Case Study 1
History of COPD, MI 15 years prior, and atrial fibrillation
Over the first 24 hours of admission, his neurologic deficits gradually progressed.
By day 2 of admission, he had right-sided flaccid paralysis and global aphasia.
Discussion Questions
Case Study
1.
What is probably the cause of his stroke?
2.
Could this stroke have been prevented?
3.
Discussion Questions
Case Study
What are the priority nursing interventions for him?
4.
What teaching will you need to do for him and his family?
