1228 HFStroke Altered Neuro 2011

8/2/2019 1228 HFStroke Altered Neuro 2011

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NursingManagementof PatientsExperiencingStroke1228


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StrokeA stroke occurs when the blood supply to part of your

brain is interrupted or severely reduced, deprivingbrain tissue of oxygen and food. Within minutes,brain cells begin to die.

Strokes can be ischemic or hemorrhagic

Also known as a brain attack


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Different STROKES for Different

Folks


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Nursing Knowledge Third most common cause of death in the United

States and Canada

Leading cause of serious, long-term disability

Approximately 35% of individuals who have an initialstroke die within 1 year.

Prevalence for CVA is 2X higher in AA, womenaccount for 60% of CVA r/t deaths, killing 2X asmany women as breast cancer

Hypertension is the single most important modifiablerisk factor that is often undetected and inadequatelytreated.


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Risk FactorsNon-modifiableAge Risk increases with age Doubles each decade

after age 55

Gender Equal in men and women

Race African Americans Native Americans

Heredity Family history of stroke Prior TIA Prior CVA


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Risk Factors cont.Modifiable risk factors

Heart disease A. fib/heart murmur hyperlipidemia

Heavy alcohol consumption >2 drinks/day

Diabetes mellituskeep BS well controlled

Smoking

Metabolic syndrome

Hypertension Most important factor

Obesity Abdominal distribution in

men

Oral contraceptive use High dose estrogen

Physical inactivity

Substance abuse Especially cocaine


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An ounce of PREVENTION is worth a pound of cure

Control HTN

Reduce or control weight

Decrease sodium and fat in diet

Decrease alcohol consumption Comply with medical regimen

Stop smoking

Control any existing diabetes

Regular exercise

Routine health checks and screening


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Test Your Knowledge:Of the following patients, the nurse recognizes

that the one with the highest risk for astroke is:

a. an obese 45-year-old Native American.b. a 35-year-old Asian American woman whosmokes.

c. a 32-year-old white woman taking oral

contraceptives.d. a 65-year-old African American man withhypertension.


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Transient Ischemic Attack (TIA)

mini strokes

Temporary, focal loss of neurologic function

Lasts less than 24 hours

Often less than 15 minutes

Most TIAs resolve within 3 hours

Microemboli that temporarily block blood flow tobrain

Considered a warning sign for impending CVA!!!


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TIA - Signs and SymptomsVisual changes- blurred vision, diplopia, blindness in

one eye, tunnel vision, ptosisTransient weaknessArm, hand, leg

Ataxic gaitTransient numbness Face, arm, hand

Vertigo

AphasiaDysarthriaDysphagia


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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

30% to 50% of thrombotic strokes have beenpreceded by a TIA


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Ischemic Stroke Embolic stroke Occurs when an embolus lodges in and occludes a

cerebral artery Second most common cause of stroke

Commonly has a rapid occurrence of severeclinical symptoms.

Patient usually remains conscious, although he mayhave a headache.


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Manifestations of Ischemic StrokeUsually no change in LOCHeadache

Hemiplegia or hemiparesis

Dysphasia

Facial drooping

Ataxia

Some initial symptoms may improve or resolve, with

remaining lesser deficits


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Healthy vessels

A healthy artery easilycarries oxygenated

blood to the braintissue.


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Pathological vessels


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TYPES OF STROKE

Hemorrhagic stroke- Bleeding within the brain

caused by rupture of a

vessel Hypertension is the most

important cause.

Hemorrhage commonlyoccurs during periods of

activity.


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Manifestations of Hemorrhagic StrokeThe neurologic manifestations do not significantlydiffer between ischemic and hemorrhagic strokeHeadache

Nausea and vomitingDecreased LOC (about 50% of patients)Neurologic deficits may be severe depending uponwhat area affected Dilated, fixed pupils Posturing ComaHemiplegia


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Hemorrhagic CVA Intracranial bleeding into cerebrospinal fluidfilled

space between the arachnoid and pia mater

Commonly caused by rupture of a cerebralaneurysm

Worst headache of ones life


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Treatment of AneurysmsGoal is to stop the bleeding and relieve the pressure.Surgical clipping of the aneurysmCoilingCraniotomyBiologic/synthetic wrap-prevents ruptureDespite improvements in surgical techniques andmanagement, still a high rate of mortality and morbidity Complications include Rebleeding before surgery can occur Cerebral vasospasm resulting in cerebral infarction


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Test Your KnowledgeInformation provided by the patient thatwould help differentiate a hemorrhagic strokefrom a thrombotic stroke includes:

a. sensory disturbance

b. a history of hypertension

c. presence of motor weakness

d. sudden onset of severe headache


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A picture is worth 1,000 words


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Overall effects of stroke:Motor

Cross over effect

Lesion on right brain-- left side affected

Lesion on left brainright side affectedImpairment

Mobility, respiratory function, swallowing andspeech, gag reflex, self-care abilities, risk for

injuries


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Left sided stroke


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Right sided stroke


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Motor Function Loss of skilled voluntary movement

Impairment of integration of movements

Alterations in muscle tone Alterations in reflexes


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Communication

Problems more common in left-brain strokeAphasia

Total loss of comprehension and/or use oflanguage

Dysphasia

Difficulty with comprehension and use oflanguage

Can be classified as nonfluent or fluentDysarthria

Poorly articulated speech, slurred speechsecondary to poor muscle control


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Affect Depression

Body image change

Loss of function physically and cognitively

Loss of independence

Difficulty controlling emotionsCries easily

Anger, frustration common

Intellectual function

Impaired memory/judgment


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Spatial-perceptual alterations

Problems more common in right-brain stroke Spatial-perceptual problems may be divided into four

categories.1. Incorrect perception of self and illness

2. Erroneous perception of self in space3. Inability to recognize an object by sight, touch, or

hearing

4. Inability to carry out learned sequential movements on

command


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Elimination

Urinary and bowel elimination deficits usually occurinitially and are usually temporary

Initially frequency, urgency, incontinence

Constipation may be lasting due to decreasedmobility, weakened abdominal muscles, decreasedfood and fluid intake

Long-term effects often related to inability toexpress needs and manage clothing for toileting


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Diagnostic tests Confirmation that it is a stroke Identify cause if possible CT scan- the primary diagnostic test Size and location of the lesion Differentiate between ischemic and hemorrhagic strokes

MRI More detailed, sharper images Can detect smaller, deeper CVAs


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Further testing

Blood flow tests

Ultrasound- of the neck, base of skull

Angiography-arteriogram-dye injected intoarteries then x-rays are taken

Electrical tests

EEG-electrical signals within the brain

Evoked response-how the brain handlesdifferent electrical impulses related to hearing,vision, body sensation, etc.


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Drug TherapyThrombolytic therapy

tPA (tissue plasminogen activator)

Digests fibrin and fibrinogen and thus lyses theclot

Reduces disability

Requires a consent form to be signed

Must be administered within 3 hours of the onset

of clinical signs of ischemic strokeTiming is critical

Accurate history is critical- resent surgery?


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Drug Therapy, cont.Anticoagulants Heparin Sub Q or IV push Heparin drip Short term

Lovenox (low molecular weight heparin) Sub Q or IV Short term

Coumadin (warfarin) Orally Long term anticoagulation

Side effects: bleeding Monitor urine, stools, epistaxis, bleeding gums, easy bruising Caution about high risk activities


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Drug Therapy, cont.

Antiplatelet drugs Platelet inhibitors Prevents further strokes by preventing clot

formation

ASA 50mg to 325mg per dayPossibly baby ASA 81mg or enteric coated

Ticlid, Plavix, Persantine, Aggrenox, ArixtraTeach patient to monitor for sx bleeding at home

Teach dietary requirements


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Drug therapy monitoringBaseline levels -obtain before initiating therapy

PT (PT/INR) to monitor Coumadin therapy

Monitor daily while in acute care setting, once patient

goes home and dose is stable, weekly or monthlyTarget INR is 2.0-3.0

PTT to monitor heparin therapy

Monitor every morning while on therapy in acute care

setting Goal is 1.5-2 times patients baseline PT and PTT


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Treatment Modalities

Carotid endarterectomy

Athreromatous lesionis removed from thecarotid artery toimprove blood flow tothe brain

Reduces the risk ofanother CVA


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Treatment Modalities, cont.

Transluminal angioplasty roto rooter Insertion of a balloon to

push open stenosed artery,thus improving blood flow

Monitor patient afterprocedure due to risk ofbreaking clots loose


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Treatment Modalities, cont.

Stenting

Transvascular placement

of a stent to maintainpatency of artery


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Test Your Knowledge

A patient experiencing TIAs is scheduled for a carotidendarterectomy. The nurse explains that thisprocedure is done to:

a. decrease cerebral edema.

b. reduce the brain damage that occurs during astroke in evolution.

c. prevent a stroke by removing atherosclerotic

plaques blocking cerebral blood flow.d. provide a circulatory bypass around

thrombotic plaques obstructing cranialcirculation.


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Acute Care

The goal is to preserve life, prevent further braindamage, and reduce the amount of disabilityMaintain ABCsAirway assess patency Decreased LOC may result in decreased/absent gag

reflex, impaired swallowing so patient should beNPOAdminister O2, oral or nasal airway Intubation and mechanical ventilation may be needed

Monitor pulse oximetry Suction PRN Position to prevent aspiration


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Acute Care, cont.Get patient to CT!!! Major priority! Start lab tests Blood glucose Treat hypoglycemia

Seizure precautions

Thrombolytic therapy for ischemic stroke restore 02! Manage possible increased ICP in ischemic stroke Cerebral edema peaks in 72 hours Brain herniation can occur Position to improve venous drainage

Elevate HOB 30 degrees Position head/neck in midlineAvoid hip flexion

Mannitol and Lasix may be given to decrease ICP


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Acute Care, cont.IV access with NS Do not overhydrate

Increases cerebral edema1500-2000ml per day

Monitor urinary output

Maintain BP Frequently hypertensive after stroke

Compensatory mechanism to insure brainperfusion

IV BP meds are given only if BP is markedly increased(systolic >220)

Usually oral agents are sufficientInstitute seizure precautions


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Assessment

Neurological assessment

Glasgow coma scale

Pupils

Extremity movement and strengthDecreased LOC

Increase in ICP

Cardiac status should be monitored

Rhythm & rate

or heart rate


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Nursing AssessmentHistory

Precise time of onset of S/S

Medical and surgical history including HTN,previous stroke, TIAs (diagnosed or not), cardiacdx, CHF, valvular dx/replacement, endocarditis,hyperlipidemia, polycythemia, DM, and familyhistory of HTN, CVA

Medications

Oral contraceptives, antihypertensives,anticoagulant agents


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Nursing Assessment Subjective Data- Person accompanying patient may need to

provide information if patient has decreased LOC or isaphasic

Objective Data

Emotional lability, apathy, combativeness Vital signs- tachycardia, HTN

Breath sounds- adventitious may indicate aspiration

Loss of urinary/bowel continence

Seizure Facial drooping

Difficulty swallowing

Vertigo


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Neurological Findings Contralateral motor and sensory deficitsWeakness, paresis, paralysisUnequal pupilsUnequal hand grasps

Unequal leg strength Positive Babinskis sign followed by increased deep

tendon reflexes Flaccidity followed by spasticityAmnesia Personality changeNuchal rigidity


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Deep Vein Thrombosis (DVT) Increased risk of DVT after stroke due to: Immobility Loss of venous tone Decreased muscle pumping activity in legs

Especially on affected sideDo ROM exercises several times a day Compression stockingsHeparin therapy

Measure calf and thigh daily Check for pain in calf when standing


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Post-Stroke CareMusculoskeletalMaintain optimum

functioning ROM and correct

positioning to preventcontractures andmuscular atrophy

Hand splints to maintainflexibility and use ofhands

Trochanter rolls toprevent hip rotation

Arm supports- slingsAvoid pulling patient by

the arm to avoidshoulder displacement

Footboards Leg splints

High top tennis shoes toprevent foot drop


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Pharmacology Post-Stroke Care

Acute & Chronic Heparin IV or SQ

requires lab monitoring

Coumadin what lab?

Plavix reduces plateletaggregation do not takea missed dose with thenext dose.

Mannitol reducesvasogenic edema

Check with HCP beforetaking any herbalmedications

Aspirin anticoagulation,s/s of GI irritation?

Anti-cholesterol agents

why? H2 Blockers reduces

acid in the stomach

Persantine - prevent

platelets from clumpingwith thrombus andembolus formation


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Collaborative CareAfter stroke has stabilized for 12 to 24

hours, collaborative care shifts from

preserving life to lessening disability andattaining optimal functioning.

Patient may be transferred to arehabilitation unit, outpatient therapy, or

home carebased rehabilitation.


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Post-Stroke Care Integumentary system Susceptible to breakdown Loss of sensation Decreased circulation Immobility

Change positions every 2 hours Side-back-sideOnly place on weak/paralyzed side X 30 min.

Special mattresses, WC cushionsAssess for redness, blanching Do not massage damaged area


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Post-Stroke Care Gastrointestinal Severely affected may require enteral or parenteral

nutrition

Use caution with first attempt at oral feeding

Assess for gag reflex by gently stimulating back ofthroat with tongue blade

Swallowing assessment is usually done by giving pt.small amount of crushed ice

Often performed by speech therapy


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Post-Stroke Care Urinary Poor bladder control incontinence

Promote urinary function

Avoid foley catheter ifpossible Increases susceptibility

to UTI Inadequate bladder

tone Notice restlessness-may

indicate need to void

Bladder trainingprogram

Toileting Q 2 hrs duringwhile awake

Toileting 3-4 timesduring night

Using bedpan, BSC, ortoilet

Encourage adequatefluids-dont restrict Give majority between

8am and 7pm


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Test Your Knowledge Bladder training in a male patient who

has urinary incontinence after a strokeincludes:

a. limiting fluid intake

b. keeping a urinal in place at all times

c. assisting the patient to stand to void

d. catheterizing the patient every 4 hours


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Post-Stroke Care

Ambulation/Transfer principals

Bear weight on the unaffected (good) side

Always move toward the unaffected side for easiest

and safest transfers Position chair or WC on the unaffected side and pivot

to the chair on the unaffected leg

Use a hemi-walker on the unaffected side

Always have plenty of assistance if you are uncertainhow well pt. can transfer


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Post-Stroke Care

Instruct patient to chew on unaffected side Prevents pocketing of food on affected side

Constipation

Stool softener

Fluid intake 1800-2000ml per day

Fiber 25 g per day

Physical activity

Assist to toilet, provide privacy


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Communication Patient may be anxious and frustrated Speak slowly and calmlyUse simple words or sentences Look at patient when speaking Give patient time to respondAsk yes or no questions


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Home CarePatient with homonymous hemianopsia has blindness in same half of

each visual field Accommodate by placing items in correct field of vision Self care deficit Avoid fatigue Assistive devices to increase independence Place items on unaffected side Facilitate dressing by using clothing that is one size larger and

made of stretchy fabricUnilateral neglect Approach pt. from unaffected side Instruct pt. to scan full field of vision Talk with patient on the unaffected side


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Examples of Assistive Devices

H C


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Home Care

Risk for injuryInability to perform familiar tasksMisjudging distancesSpilling hot liquids

Encourage pt. think through task step by stepEliminate obstructing hazardsPetsRugs and clutter

Teach sitting and balancing exercisesPatient sits or dangles on edge of bedNext, practice transferring to chairPlace chair on the unaffected side


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Additional thoughts

CopingDepression, anxiety, weight loss, poor appetite,

chronic fatigue, sleep disturbances are commonSexual functioning

Acceptance of physical changes takes time Fear of rejection, another stroke, inability toperform

Careful grooming with attractive clothing Begin slowly and communicate

Trial and error to find optimal positioning Experiment during peak energy times Counseling may be needed


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Additional thoughts Constipation/Incontinence Related to loss of mobility, decreased intake and ability to

self toilet Risk for low self-esteem Feeling of dependence, loss of role function

Powerlessness Dependence, depression & anger physical limitations may

prevent healthy expression, inability to use regular ways toexpress emotions such as exercise, hobbies etc.

Risk for self/other directed violence Some patients may difficulty managing emotions after

suffering a CVA warn patients and families about potentiallabiality


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Community Resources for the

Stroke Patient The National Stroke Association

Referral services

Quarterly newsletter

The American Stroke AssociationAmerican Heart Association

Programs and information on stroke, HTN, diet,exercise, and assistive devices

The Easter Seal Society

Wheelchairs and assistive devices


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CASE STUDY FOR HOME REVIEW

Stroke

Patient Profile

Suzanne, a 66-year-old white woman, awoke in themiddle of the night and fell when she tried to getup and go to the bathroom. She fell because shewas not able to control her left leg. Her husband

took her to the hospital, where she was diagnosedwith an acute ischemic stroke. Because she hadawakened with symptoms, the actual time of onsetwas unknown and she was not a candidate for tPA.


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Subjective Data

Left arm and leg are weak and feel numb Feeling depressed and fearful

Requires help with ADLs

Concerns regarding possibility of another stroke Says she has not taken her drugs for high cholesterol

for many weeks

History of a brief episode of left-sided weakness and

tingling of the face, arm, and hand 3 months earlier,which totally resolved and for which she did not seektreatment


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Objective Data BP 180/110

Left-sided arm weakness (3/5) and legweakness (4/5)

Decreased sensation on the left side,particularly the hand

Left homonymous hemianopsia

Overweight

Alert, oriented, and able to answerquestions appropriately but mild slowness inresponding


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Critical Thinking Questions1.

How does Suzanne's prior health history put her at riskfor a stroke?

2. How can the nurse address Suzanne's concernsregarding having another stroke?

3. What strategies might the nurse use to help Suzanne

and her family cope with her feeling depressed?4. What lifestyle changes should Suzanne make to reduce

the likelihood of another stroke?

5. How will homonymous hemianopsia affect Suzanne's

hygiene, eating, driving, and community activities?6. What are the priority nursing interventions for

Suzanne?


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THE END

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1228 HFStroke Altered Neuro 2011

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