nursing module for brain stroke
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Nursing Care of the AcuteStroke Patient
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StrokeStroke Facts in AmericaFacts in America Third leading cause of
death in the United
States 750,000 Americans
suffer strokes eachyear
160,000 deaths eachyear
4,000,000 strokesurvivors
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StrokeStroke Facts in AmericaFacts in America A leading cause of
adult disability
Many strokes arepreventable
Every 45 seconds,someone suffers astroke
Twice as manywomen die fromstroke every year thanfrom breast cancer
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Types of Stroke
Ischemic: embolic or thrombotic
blocked blood flow to the brain Hemorrhagic: ICH, SAH, ruptured cerebral
aneurysm
TIA: This is a stroke, although symptomsresolve within an hour
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Signs and Symptoms of Stroke Sudden numbness or weakness of the face, arm
or leg, especially on one side of the body
Sudden confusion, trouble speaking orunderstanding
Sudden trouble seeing in one or both eyes
Sudden dizziness, loss of balance or coordination
or trouble walking
Sudden severe headache with no known cause
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Risk Factors
High blood pressure
Carotid artery disease
Physical inactivity
Excess alcohol intake
Atrial fibrillation
Diabetes
Heart disease
Smoking Family history
Prior stroke/TIA
High cholesterol
Obesity
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Brain Anatomy
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Treatment for Ischemic Stroke tPA=Thrombolytic agent
Document time of symptom
onset. (If awoke withsymptoms, must go by timewhen last seen normal)
Immediate head CT (checkfor blood)
Evaluate for tPAadministration (reviewexclusion/inclusion criteria)
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Treatment Cont If not a tPA candidate, ASA in ED. Rectal ASA
if fails swallow eval. or if swallow eval. notcomplete.
Keep NPO, until a formal swallow eval. isdone.
Admit as Inpatient and perform diagnostictesting: Carotid US, Echo, TEE, ECG
monitoring for a-fib, MRI, fasting Lipid,Clotting disorder blood work(Antiphospholipid, Factor V, Antithrombin III)
Rehabilitation
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tPA Administration Considerations
Must be startedbefore 3 hours fromonset
No blood on head CT Review patients
history for other riskfactors
Accurate weightrecorded Foley catheter prior to
tPA
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tPA Cont Consent explained and signed (BP>185/110) treat with
labetolol 10-20mg IV over 1-2min. May repeat x1 or nitropaste 1-2 inches. If treatmentdoes not lower BP, do not givetPA
NIH stroke scale showssignificant deficits to merittreatment.http://asa.trainingcampus.net
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tPA Contraindications Any recent surgery185/110)
Seizure at the onset of stroke Active internal bleeding (
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Contraindications Cont.. Intracranial neoplasm, AV malformation,
aneurysm Use of anticoagulants with PT>15 or INR >1.7 Platelet count
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Calculation and Documentation of tPA
0.9 mg/kg Do not exceed the 90 mg max dose Mix 100 mg in 100 ml of sterile water, subtract pt
dose from 100 ml and discard the difference.Final concentration 1mg/1ml Withdraw 10% and give IV bolus over 1 minute,
followed by the remainder over 60 min. Double check for correct dose (MD, RN) Document bolus dose and drip dose over 1 hr
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Example of tPA Calculation Patient wt 80 kg
Chart:
0800 tPA bolus 7.2
mg 0801 tPA infusion
64.8 mg in 64.8 mlgiven over 60minutes
0.9mg/kg = 72
72mg in 72 ml
(total dose)
- 10% = 7.2 mg orml (bolus dose)
72 -7.2 = 64.8mg(infusion dose)
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During tPA Administration Check BP every 15 min for 2 hours
Treat hypertension/hypotension as ordered
Monitor Neuro status every 30 min x4
Watch for bleeding puncture sites, urine, stooletc.
Know signs/symptoms of IntracerebralHemorrhage: Any acute neurologicaldeterioration, new HA, N/V, sudden HTN
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Hemorrhage Suspected STOP TPA INFUSION, call MD
immediately
Stat head CT without contrast
Draw blood for PT, PTT, plt ct,fibrinogen, and type and hold
Prepare for administration of cryo andor platelets
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Post tPA Continue to monitor for signs/symptoms of
intracerebral hemorrhage
Therapy/Rehab physician evaluation, if needed
No unnecessary blood draws or invasive proceduresfor 12 hours after tPA
Repeat CT scan 24 hours after tPA to evaluate forbleeding (STAT if suspect intracerebral hemorrhage)
No aspirin, heparin, warfarin, or other antithromboticor antiplatelet drugs 24 hours after tPA
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Other Treatment Options for
Ischemic Strokes
If symptom onset is
greater than 3 hrsconsider: Other interventions (IA,
corkscrew, stenting)
Other trials
(thrombolytics,neuroprotective,hyperglycemia)
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Hemorrhagic Stroke Treatment Do not give antithrombotics
or anticoagulants
Monitor and treat blood
pressure greater than150/105 (Table 6, 2005Guidelines update)
NPO, until swallow eval iscompleted
Anticipate Neurosurgicalconsult
Possible administration ofblood products
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In-patient Considerations Nursing Issues
Started on stroke prevention medications? Clinical pathway followed?
Blood pressure within appropriate parameters? Know signs of suspected Intracranial Hemorrhage
and actions to take DVT prophylaxis addressed by day 2?
IPCs/Lovenox/heparin SQ per orders
Therapies seeing patient? Review PT/OT/STrecommendations
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Inpatient Cont IV fluids (Normal Saline or LR)?
Nutrition? Dietary evaluation. Assistive devices for
feeding. Calorie Counts as ordered. Fever? Treat if greater than 99 F with Tylenol
Blood glucose within appropriate parameters?Obtain sliding scale if necessary.
Positioning? Pillows under affected limbs. TurnQ2hours. Accommodate limitations
Rehab consults as soon as possible, if needed
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JCAHO Guidelines Deep Vein Thrombosis (DVT) Prophylaxis
Discharged on Antithrombotics
Patients with Atrial Fibrillation ReceivingAnticoagulation Therapy
Tissue Plasminogen Activator (t-PA)Considered/Administered
Antithrombotic Medication Within 48 Hours ofHospitalization
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JCAHO Cont Lipid Profile During Hospitalization
Screen for Dysphagia
Stroke Education Smoking Cessation
A Plan for Rehabilitation was Considered
From JCAHO.org website Primary Stroke Center
Standardized measures
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JCAHO Expectations for ED Stroke Team and written protocols to quickly
evaluate and treat stroke patients
Stroke education: 8 hours/year for Stroke TeamMembers
Head CT within 25 min. of being ordered
CT interpretation within 45 min. of order
Lab and (ECG as needed) complete within 45min. of order
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Reference/Recommended Reading
(articles available online)
http://stroke.ahajournals.org/cgi/content/full/34/4/1056 (Stroke. 2003;34:1056.)
2003 American Heart Association, Inc.ASA Scientific Statement
Guidelines for the Early Management of Patients WithIschemic Stroke : A Scientific Statement From the StrokeCouncil of the American Stroke AssociationHarold P. Adams, Jr, MD, Chair; RobertJ. Adams, MD; Thomas Brott,MD; Gregory J. del Zoppo, MD; Anthony Furlan, MD; Larry B. Goldstein,MD; Robert L. Grubb, MD; Randall Higashida, MD; Chelsea Kidwell,MD; Thomas G. Kwiatkowski, MD; John R. Marler, MD George J.
Hademenos, PhD, (ex-officio member) http://www.americanheart.org/presenter.jhtml?identifier=3023366 (Stroke. 2005;36:916-921) 2005 Guidelines Update, Adams, H; Adams,
R; Del Zoppo, Goldstein, LB
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Helpful Information Montana Stroke Initiative:
http://montanastroke.org
State-wide protocols and guidelines Evidence based practice
Stroke education for physicians, primaryproviders, nurses and EMS providers
Mission: To develop a state-wide strokesystem of care that allows patients access tothe best stroke care regardless of where theylive in Montana