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Stroke - Outline

Outline
Course

Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)

30 Documents
Students shared 30 documents in this course
Academic year: 2019/2020
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Temple University

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Stroke: - Stroke occurs when there is ischemia or hemorrhage into the brain that results in death of brain cells. - Also known as o Brain attack o Cerebrovascular accident - The brain requires 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. - The term brain attack communicates the urgency of recognizing the clinical manifestations of a stroke and treating a medical emergency, similar to what would be done with a heart attack. - Following the onset of a stroke, immediate medical attention is crucial to decrease disability and death. - Manifestations: o Weakness on one side of body o Gargled speech o Disorientation o Opposite side; R sided weakness -> L sided stroke - Loss of function varies according to the location and extent of brain tissue involved. o Physical, cognitive, and emotional impact on patient and family o Functions such as movement, sensation, or emotions that were controlled by the affected area of the brain are lost or impaired. The severity of the loss of function varies according to the location and extent of the brain involved. o Common long-term disabilities include hemiparesis, inability to walk, complete or partial dependence for activities of daily living (ADLs), aphasia, and depression. In addition to the physical, cognitive, and emotional impact of the stroke on the stroke survivor, the stroke affects the lives of the caregiver and family of the stroke victim. - Fourth most common cause of death in the United States and Canada o Leading cause of serious, long-term disability  15-30% of survivors will live with permanent disability.  26% will require long-term care after 3 months.  Lifelong change for survivor and family - Several conditions are associated with stroke risk: o Atrial fibrillation o Cardiac valve abnormalities o Diabetes mellitus Risk Factors: - Most effective way to decrease the burden of stroke is prevention and teaching. - Risk factors can be divided into non-modifiable and modifiable risks. o Stroke risk increases with multiple risk factors. - Non-modifiable: o Age: Stroke risk doubles each decade after 55. o Gender: More common in men; more women die o Ethnicity/race: Higher incidence in African Americans o Heredity/family history - Modifiable: o Hypertension o Heart disease o Serum cholesterol o Smoking o Excess alcohol consumption o Obesity

o Sleep apnea o Metabolic syndrome o Lack of physical exercise o Poor diet o Drug abuse

o Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated.

o Heart disease, including atrial fibrillation, myocardial infarction, cardiomyopathy, cardiac valve abnormalities, and cardiac congenital defects, is a risk factor for stroke. o Women who drink more than one alcoholic drink per day and men who drink more than two alcoholic drinks per day are at higher risk for hypertension, which increases their chance of stroke. o Illicit drug use, especially cocaine use, has been associated with stroke risk. o A diet high in fat and low in fruits and vegetables may increase stroke risk.

Transient Ischemic Attack: - 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 the brain. - It is important to teach the patient to seek treatment for any stroke symptoms, as there is no way to predict if a TIA will resolve or if it is in fact the development of a stroke. - TIAs may be due to microemboli that temporarily block the blood flow. TIAs are a warning sign of progressive cerebrovascular disease. The signs and symptoms of a TIA depend on the blood vessel that is involved and the area of the brain that is ischemic. - TIAs should be treated as medical emergencies. Teach people at risk for TIA to seek medical attention immediately with any stroke-like symptom and to identify the time of symptom onset. - Symptoms typically last < 1 hour. - 1/3 will progress to an ischemic stroke. - It is important to teach the patient to seek treatment for any stroke symptoms, as there is no way to predict if a TIA will resolve or if it is in fact the development of a stroke. - 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. - TIAs may be due to microemboli that temporarily block the blood flow. TIAs are a warning sign of progressive cerebrovascular disease. The signs and symptoms of a TIA depend on the blood vessel that is involved and the area of the brain that is ischemic. - TIAs should be treated as medical emergencies. Teach people at risk for TIA to seek medical attention immediately with any stroke-like symptom and to identify the time of symptom onset.

Types of Stroke: - Strokes are classified based on the underlying pathophysiologic findings: o Ischemic o Hemorrhagic Major Types of Stroke:

o Manifestations  Neurologic deficits  Diplopia  Difficulty of speech, inarticulate  Headache*

 Nausea and/or vomiting  Decreased levels of consciousness  Sleepy, difficult arousal  Hypertension

  • Subarachnoid hemorrhage (SAH) o Intracranial bleeding into cerebrospinal fluid–filled space between the arachnoid and pia mater o Commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse
  • Cerebral aneurysm: o Majority of aneurysms are in the Circle of Willis. o Silent killer  Loss of consciousness may or may not occur.  Survivors often suffer significant complications and deficits. Clinical Manifestations of Stroke:
  • Related to the location of the stroke o Neural tissue destruction is the basis for neurologic dysfunction. o Affects many body functions  Related to the artery involved and the area/half of the brain it supplies  Time of the onset of symptoms /length of period of ischemia is important.
  • The neurologic manifestations do not significantly differ between ischemic and hemorrhagic stroke.
  • An additional assessment question that you need to ask is the time of the onset of symptoms.
  • This is important for all types of stroke and is especially important for ischemic strokes as it can affect treatment decisions.
  • A stroke can have an effect on many body functions, including motor activity, bladder and bowel elimination, intellectual function, spatial-perceptual alterations, personality, affect, sensation, swallowing, and communication.
  • Motor Function: o Most obvious effect of stroke o Include impairment of  Mobility  Respiratory function  Swallowing and speech

 Gag reflex  Self-care abilities

o 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  Patellar or brachial o An initial period of flaccidity  May last from days to several weeks  Related to nerve damage o Spasticity of the muscles follows the flaccid stage.  Related to interruptions of upper motor neuron influence

  • Communication: o Aphasia occurs when stroke damages dominant hemisphere of the brain and affects language.  Receptive – loss of comprehension  Expressive – loss of production of language  Global – total inability to communicate o The left hemisphere is dominant for language skills in right-handed persons and in most left- handed persons. o Aphasia occurs when a stroke damages the dominant hemisphere of the brain. o Language disorders involve expression and comprehension of written and spoken words. o Dysphasia refers to impaired ability to communicate. o Used interchangeably with aphasia  Nonfluent  Minimal speech activity with slow speech  Fluent  Speech is present but contains little meaningful communication. o Many patients experience dysarthria.  Disturbance in the muscular control of speech o Impairments may involve  Pronunciation  Articulation  Phonation
  • Affect: o Patients who suffer a stroke may have difficulty controlling their emotions. o Emotional responses may be exaggerated or unpredictable.  May be magnified by depression, changes in body image, and loss of function
  • Intellectual Function: o Both memory and judgment may be impaired as a result of stroke. o Although impairments can occur with strokes affecting either side of the brain, some deficits are related to the hemisphere in which the stroke occurred.
  • Spatial-Perceptual Alterations: o Stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation.  Incorrect perception of self and illness  Unilateral neglect  Agnosia:  Apraxia
  • Elimination: o Most problems with urinary and bowel elimination occur initially and are temporary. o When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is excellent.

Diagnostic Studies: - Diagnostic studies are done to o Confirm that it is a stroke o Identify the likely cause of the stroke

  • Drug Therapy for Ischemic Stroke: o 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 hours of onset of clinical signs of ischemic stroke  Intra-arterial tPA can be given within 6 hours.
  • Acute Care: o 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. o ASA, Ticlid, Plavix, Persantine
  • Acute Care for Hemorrhagic Stroke: o Goals are the same as for the patient with ischemic stroke.  Manage airway, breathing, circulation, intracranial pressure.  Hip flexion, pillows under knees, suctioning (preoxygenate first) b/c intracranial pressure o Goals for managing ICP are the same for patients with SAH as they are for patients dealing with acute stroke. o Vasospasms can be treated with the calcium channel blocker nimodipine (Nimotop). o Hydrocephalus is a complication requiring drainage of CSF in those situations it occurs.
  • Drug Therapy for Hemorrhagic Stroke: o Anticoagulants and platelet inhibitors are contraindicated. o Management of hypertension is the main focus.  Oral and IV agents are used to maintain BP within a normal to high-normal range. o Seizure prophylaxis is situation-specific.
  • Surgical Therapy for Hemorrhagic Stroke: o Surgical interventions used to treat hemorrhagic strokes include  Resection  Clipping of an aneurysm  Evacuation of hematomas o Procedure is chosen based on the cause of the stroke.
  • Rehabilitation: o 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. Nursing Management: Stroke:
  • Nursing Assessment: o Primary assessment is focused on  Cardiac status  Respiratory status  Neurologic assessment o If the patient is stable, obtain  Description of the current illness  Pay special attention to symptom onset and duration, nature, and changes.  History of similar symptoms previously experienced  Current medications  History of risk factors and other illnesses  Hypertension, etc.  Family history of stroke or cardiovascular disease o Secondary assessment includes a comprehensive neurologic examination.  Level of consciousness  Include NIH Stroke Scale  Cognition

 Motor abilities o Comprehensive neurologic examination  Cranial nerve function  Sensation  Proprioception  Cerebellar function  Deep tendon reflexes Nursing Implementation:

  • Acute Intervention: o Respiratory system  Management of the respiratory system is a nursing priority.  Risk for atelectasis  Risk for aspiration pneumonia  Risks for airway obstruction  May require endotracheal intubation and mechanical ventilation o Neurologic system  Monitor closely to detect changes suggesting  Extension of the stroke  ↑ ICP

 Vasospasm  Recovery from stroke symptoms o Cardiovascular System:  Goals aimed at maintaining homeostasis  Many patients with stroke have decreased cardiac reserves from the secondary diagnoses of cardiac disease.  Cardiac efficiency may be compromised.  Nursing interventions  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 or for S3 or S4 heart sounds  Watch for orthostatic hypotension before ambulating patient for 1st time  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. o Musculoskeletal:  Goal is to maintain optimal function.  Accomplished by the prevention of joint contractures and muscular atrophy  In the acute phase, range-of-motion exercises and positioning are important.  Paralyzed or weak side needs special attention when positioned.  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  Avoidance of pulling the patient by the arm to avoid shoulder displacement  Posterior leg splints, footboards, or high-topped tennis shoes to prevent foot drop  Hand splints to reduce spasticity  Initially emphasize musculoskeletal functions of Walking, Eating, Toileting

 Have fearful, anxious response to stroke  Respond well to nonverbal cues

  • Ambulatory and Home Care: o Toileting interventions  Implement a bowel management program for problems with  Bowel control, Constipation, Incontinence  High-fiber diet and adequate fluid intake
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Stroke - Outline

Course: Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)

30 Documents
Students shared 30 documents in this course

University: Temple University

Was this document helpful?
Stroke:
-Stroke occurs when there is ischemia or hemorrhage into the brain that results in death of brain cells.
-Also known as
oBrain attack
oCerebrovascular accident
-The brain requires 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.
-The term brain attack communicates the urgency of recognizing the clinical manifestations of a stroke and
treating a medical emergency, similar to what would be done with a heart attack.
-Following the onset of a stroke, immediate medical attention is crucial to decrease disability and death.
- Manifestations:
oWeakness on one side of body
oGargled speech
oDisorientation
oOpposite side; R sided weakness -> L sided stroke
-Loss of function varies according to the location and extent of brain tissue involved.
oPhysical, cognitive, and emotional impact on patient and family
oFunctions such as movement, sensation, or emotions that were controlled by the affected area of
the brain are lost or impaired. The severity of the loss of function varies according to the location
and extent of the brain involved.
oCommon long-term disabilities include hemiparesis, inability to walk, complete or partial
dependence for activities of daily living (ADLs), aphasia, and depression. In addition to the
physical, cognitive, and emotional impact of the stroke on the stroke survivor, the stroke affects
the lives of the caregiver and family of the stroke victim.
-Fourth most common cause of death in the United States and Canada
oLeading cause of serious, long-term disability
15-30% of survivors will live with permanent disability.
26% will require long-term care after 3 months.
Lifelong change for survivor and family
-Several conditions are associated with stroke risk:
oAtrial fibrillation
oCardiac valve abnormalities
oDiabetes mellitus
Risk Factors:
-Most effective way to decrease the burden of stroke is prevention and teaching.
-Risk factors can be divided into non-modifiable and modifiable risks.
oStroke risk increases with multiple risk factors.
- Non-modifiable:
oAge: Stroke risk doubles each decade after 55.
oGender: More common in men; more women die
oEthnicity/race: Higher incidence in African Americans
oHeredity/family history
- Modifiable:
oHypertension
oHeart disease
oSerum cholesterol
oSmoking
oExcess alcohol consumption
oObesity
oSleep apnea
oMetabolic syndrome
oLack of physical exercise
oPoor diet
oDrug abuse
oHypertension is the single most important modifiable risk factor, but it is still often undetected
and inadequately treated.

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