Stroke

Stroke 150 150 Tony Guo

Stroke

  • Also known as cerebrovascular accident (CVA)
  • Occurs when there is 
    • ischemia (inadequate blood low) to a part of the brain 
    • hemorrhage (bleeding) into the brain
  • 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

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
  • Modifiable
    • Hypertension
    • Heart disease
    • Serum cholesterol
    • Smoking
    • Obesity
    • Sleep apnea
    • Metabolic syndrome
    • Lack of physical exercise
    • Poor diet
    • Drug and alcohol abuse

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
  • 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

Types of Stroke

  • Strokes are classified based on underlying pathophysiologic findings 
    • Ischemic
      • Thrombotic
  • Men more than women
  • The process of clot formation (thrombosis) results in a narrowing of the lumen, which blocks the passage of the blood through the artery.
  • Most common cause of stroke (60%) 
  • Often associated with HTN and DM
  • Many times they are preceded by TIA
  • Extent of stroke depends on
    • Rapidity of onset
    • Size of damaged area
    • Presence of collateral circulation
  • Embolic
  • Men more than women
  • An embolus is a blood clot or other debris circulating in the blood. When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks the flow of blood.
  • Results in infarction and edema of area supplied by involved vessel
  • 2nd most common cause of 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
  • Hemorrhagic 
  • A burst blood vessel may allow blood to seep into and damage brain tissues until clotting shuts off the leak.
  • Intracerebral/intraparenchymal hemorrhage
  • Slightly higher in women
  • 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%
  • Manifestations 
    • Neurologic deficits
    • Headache
    • Nausea and/or vomiting
    • Decreased levels of consciousness
    • Hypertension
  • Subarachnoid/ intraventricular hemorrhage
  • Slightly higher in women
  • Intracranial bleeding into cerebrospinal fluid–filled space between arachnoid and pia mater
  • Commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse
  • 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

Clinical manifestation

  • 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
  • Manifestation of right-brain and left brain stroke
Right-brain damage (stroke on right side of the brain) Left-brain damage (stroke on left side of the brain)
  • Paralyzed left side: hemiplegia
  • Paralyzed right side: hemiplegia
  • Left-sided neglect
  • Impaired speech/language aphasias
  • Spatial-perceptual deficits
  • Impaired right/left discrimination
  • Tends to deny or minimize problems
  • Slow performance, cautious
  • Rapid performance, short attention span
  • Aware of deficits: depression, anxiety
  • Impulsive, safety problems
  • Impaired comprehension related to language, math
  • Impaired judgment
  • Impaired time concepts

 

  • Motor function
    • Most obvious effect of stroke
    • Include impairment of
      • Mobility
      • Respiratory function
      • Swallowing and speech
      • Gag reflex
      • Self-care abilities
    • 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
  • 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
    • Dysphasia refers to impaired ability to communicate
      • 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.
    • Used interchangeably with aphasia
      • Nonfluent
        • Minimal speech activity with slow speech
      • Fluent 
        • Speech is present but contains little meaningful communication
  • 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
  • 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
  • Spatial-Perceptual alterations
    • Stroke on right side of brain is more likely to cause problems in spatial-perceptual orientation
      • Incorrect perception of self and illness
      • Unilateral neglect of affected side
        • Homonymous hemianopsia
      • Agnosia
      • Apraxia
  • 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

Diagnostic studies

  • Diagnostic studies are done to
    • Confirm that it is a stroke 
    • Identify the likely cause of stroke
  • MRI or non-contrast CT scan 
    • Indicate size and location of lesion 
    • Differentiate between ischemic and hemorrhagic stroke
  • Other studies
    • CTA or MRA
    • Cerebral angiography
    • Digital subtraction angiography 
    • Transcranial Doppler ultrasonography
    • Lumbar puncture
    • LICOX system
    • Cardiac imaging

Emergency management

Etiology Assessment finding Interventions
  • Sudden vascular compromise causing disruption of blood low to brain
  • Thrombosis
  • Trauma
  • Aneurysm
  • Embolism
  • Hemorrhage
  • Arteriovenous malformation
  • Altered level of consciousness
  • Weakness, numbness, or paralysis of portion of body
  • Speech or visual disturbances
  • Severe headache
  • Heart rate  increase or decrease
  • Respiratory distress
  • Unequal pupils
  • Hypertension
  • Facial drooping on affected side
  • Difficulty swallowing
  • Seizures
  • Bladder or bowel incontinence
  • Nausea and vomiting
  • Vertigo
Initial
  • If unresponsive, assess circulation, airway, and breathing.
  • If responsive, monitor airway, breathing, and circulation.
  • Call stroke code or stroke team.
  • Remove dentures.
  • Perform pulse oximetry.
  • Maintain adequate oxygenation (SaO2 >95%) with supplemental O2, if necessary.
  • Establish IV access with normal saline.
  • Maintain BP according to guidelines (e.g., Cardiac Life Support).*
  • Remove clothing.
  • Obtain CT scan or MRI immediately.
  • Perform baseline laboratory tests (including blood glucose) immediately, and treat
  • if hypoglycemic.
  • Position head in midline.
  • Elevate head of bed 30 degrees if no symptoms of shock or injury.
  • Institute seizure precautions.
  • Anticipate thrombolytic therapy for ischemic stroke.
  • Keep patient NPO until swallow reflex evaluated.
Ongoing monitoring
  • Monitor vital signs and neurologic status, including level of consciousness (NIH Stroke Scale), motor and sensory function, pupil size and reactivity, SaO2, and cardiac rhythm.
  • Reassure patient and family.

 

Interprofessional care for stroke

  • Management of modifiable risk factors 
    • Healthy diet
    • Weight control
    • Regular exercise
    • No smoking
    • Limiting alcohol consumption
    • BP management
    • Routine health assessments
  • 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
  • Surgical therapy
    • Surgical interventions for patient with TIAs from carotid disease include
      • Carotid endarterectomy 
      • Transluminal angioplasty
        • insertion of a balloon to open a stenosed artery in the brain and improve blood low
      • Stenting
        • intravascular placement of a stent in an attempt to maintain patency of the artery
    • Postoperative care is important
      • Neurovascular assessment
      • BP management
      • Assessment for complications
        • Stent occlusion 
        • Retroperitoneal hemorrhage 
      • Minimize complications at insertion site
  • Acute care for Ischemic stroke
    • Begins with managing 
      • Airway
      • Breathing
      • Circulation
    • 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
    • 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
    • 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
  • Endovascular therapy
    • Stent retrievers
      • Becoming the most effective way of managing ischemic stroke
  • Acute care for hemorrhagic stroke
    • Goals are the same as for the patient with ischemic stroke
      • Manage 
        • Airway
        • Breathing
        • Circulation
        • Intracranial pressure
    • Hyperdynamic therapy
      • Increase mean arterial pressure
      • Increase cerebral perfusion
      • Crystalloid or colloid solutions
    • Vasospasms can be treated with calcium channel blocker nimodipine (Nimotop)
  • 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
  • Surgical therapy for hemorrhagic stroke
    • Surgical interventions used to treat hemorrhagic strokes include
      • Resection
      • Clipping of an aneurysm
        • The neurosurgeon places a metallic clip on the neck of the aneurysm to block blood low and prevent rupture. 
        • The clip remains in place for life
      • Evacuation of hematomas
    • Procedure is chosen based on cause of stroke
  • Rehabilitation
    • After stroke has stabilized for 12 to 24 hours, interprofessional care shifts from preserving life to lessening complications, disability and attaining optimal functioning
      • Patient may be transferred to a rehabilitation unit, outpatient therapy, or home care–based rehabilitation

 

Nursing management: Stroke

  • Stroke survivorship and coping
    • Stroke support groups within rehab facilities and community are helpful
      • Mutual sharing
      • Teaching
      • Coping
      • Understanding

Nursing diagnoses

  • Decreased intracranial adaptive capacity related to decreased cerebral perfusion pressure of ≤50 to 60 mm Hg and sustained increase in ICP secondary to thrombus, embolus, or hemorrhage
  • Risk for aspiration related to decreased level of consciousness and decreased or absent gag and swallowing reflexes
  • Impaired physical mobility related to neuromuscular and cognitive impairment and decreased muscle strength and control
  • Impaired verbal communication related to aphasia
  • Unilateral neglect related to visual ield cut and loss on one side of body (hemianopsia) and brain injury from cerebrovascular problems
  • Impaired swallowing related to weakness or paralysis of affected muscles
  • Situational low self-esteem related to actual or perceived loss of function and altered body image

Planning

  • Typical 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 (e.g., bladder control)
    • Maximize communication abilities
    • Maintain adequate nutrition
    • Avoid complications of stroke
    • Maintain effective personal and family coping

 

Role of Nursing Personnel

  • Assess clinical manifestations of stroke and determine when clinical manifestations started.
  • Screen patient for contraindications for tissue plasminogen activator (tPA) therapy.
  • Infuse tPA for patients with ischemic stroke who meet the criteria for tPA administration.
  • Assess respiratory status and initiate needed actions such as O2, oropharyngeal or nasopharyngeal airways, suctioning, and patient positioning to prevent aspiration, obstruction, and atelectasis.
  • Assess neurologic status, including intracranial pressure (ICP), if needed.
  • Monitor cardiovascular status, including hemodynamic monitoring, if needed.
  • Assess patient’s ability to swallow (in conjunction with the speech therapist).

Licensed practical/vocational nurse (LPN/LVN)

  • Administer scheduled anticoagulant and antiplatelet medications

Unlicensed Assistive Personnel

  • Obtain vital signs frequently and report these to RN.
  • Measure and record urine output.
  • Assist with positioning patient and turning patient at least every 2 hr (as directed by RN).
  • Perform passive and active range-of-motion exercises (after being trained and evaluated in these procedures).
  • Place equipment needed for seizure precautions in patient room

 

Role of Other Team members

Speech therapy

  • Assess swallowing reflex.
  • Evaluate patient for communication defects (e.g., aphasia).

Physical therapy

  • Position patient in a functional position.
  • Assess function and together with patient, plan a rehabilitation program.

 

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