Strokeby

Ann Van EerdenApril, 2011

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Learning Outcomes Learner will define CVA Learner will distinguish the causes of CVA Learner will state risk factors for CVA Learner will recognize clinical manifestations of

a stroke Learner will identify the nursing diagnosis “at

risk for falls.” Learner will discern conditions related to risk for

falls Learner will develop nursing outcomes and

interventions

Table of Contents Welcome to Your Clinical What is a Stroke? Causes of Stroke Risk Factors Clinical Manifestations “At Risk for Falls” Conditions Related to “At Risk for Fa

lls” References

Welcome to the first day at your new clinical site!

You learn that the patient you have been assigned for the day has a medical diagnosis

of stroke, more specifically, a left sided cerebrovascular accident. Would you like to

continue?

Yes! No, I think I am going to drop this class.

Before you make that decision, please stay for awhile; you’ll feel

much better after this tutorial!

Your instructor greets you and introduces you to the night nurse who immediately

begins giving you report. This is your first time on a medical unit. Your mind is

racing; you are trying to recall everything that you remember about stroke, and

nothing comes to mind. Would you like a review?

Yes, please! No thanks, I’ve decided to change my major.

Ha! Ha! But, before you make that official, you might feel better if you take a few minutes to review stroke

with this tutorial.

A stroke is a BRAIN ATTACK! It means that there is an interrupted flow of blood to the brain.

What do you think might cause this interruption?

A ThrombusYou are correct! Is

there anything else?

An EmbolismYou are correct! Is

there anything else?

A HemorrhageYou are correct! Is

there anything else?

A thrombus is the most common cause of stroke. It accounts for 60% of all strokes.

It occurs more often in men.The onset is usually during or after sleep.The signs and symptoms develop slowly.

(Lewis, 2004, p. 1528)

An embolic stroke occurs when an embolus occludes a cerebral artery.

It occurs more often in men.The onset is rapid.It is a single event.

(Lewis, 2004, p. 1529)

(Used with permission of Emily Gillis)

Hemorrhagic strokes are either an intracerebral hemorrhage or a subarachnoid hemorrhage.

An intracerebral hemorrhage has a sudden onset and a very poor prognosis.

A subarachnoid hemorrhage is caused by an aneurysm and often follows

strenuous activity.(Lewis, 2004, p. 1529)

(Used with permission of Emily Gillis)

Okay! The night nurse has left and its time for you to take over. Mr. C. V. Accident is still sleeping and a nursing assistant offers

to get his breakfast tray, so you have time to get organized. Let’s use the nursing

process.

Do you remember the process?

Click on each box below for a review.ASSESS

DIAGNOSE

PLAN

IMPLEMENT

EVALUATE

Mr. C.V. Accident’s Chart Mr. C.V. Accident is a 72 year old

African- American with a history of hypertension. He is overweight, does not

exercise, and smokes one pack of cigarettes per day. His wife died last year

and since her death his diet consists primarily of fast food.

There are a number of risk factors that contribute to stroke. Some are

modifiable, others are not.Click here to review the modifiable risk factors.Click here to review the non-modifiable risk factors.

Modifiable Risk Factors Atrial fibrillation Carotid stenosis Cigarette smoking Diabetes Heavy alcohol consumption Hypercoagulability Hyperlipidemia Hypertension Obesity Oral contraceptive use Physical inactivity Sickle cell disease (Lewis, 2004, p. 1526)

Non-Modifiable Risk Factors

Age Gender Race Family history Prior stroke, TIA, or heart

attack(Lewis, 2004, p. 1525)

Hypertension is the most important modifiable risk factor. Hypertension is a

sustained elevation in blood pressure.It is defined as a systolic blood pressure equal

to or greater than 140 mm Hg OR a diastolic blood pressure equal to or greater than 90 mm

Hg for extended periods of time.Would you like to review what happens with

hypertension? (Lewis, 2004, p.779)

Yes No thanks.

Hypertension Flow ChartIncreased Blood

Pressure

Injury to vessels

Inflammation

Plaque develops and leads to atherosclerosis

Risk of thrombus and emboli and INCREASED RISK FOR

STROKE

What does high blood pressure do

to the blood vessels?

What happens to injured vessels?

Do you remember what happens to the inflamed vessels?

And what does atherosclerosis

lead to?

Atherosclerosis is often described as hardening and thickening of the arteries.

How does this lead to stroke?

Lipids in the arteries develop into

Plaque leads to narrowing and thickening of the arteries

PLAQUE

PLAQUEnarrows arteries and

can lead to hypertension and

ultimately STROKE!

PLAQUEmay break off and

occlude the artery and ultimately cause

STROKE!

Other factors affect these processes.They are:

AgingGenetics

InflammationStress

Contribution of Aging

Aging

Aorta and arteries decrease in elasticity

Increase in systolic blood pressure

Increased risk for stroke

What does aging do to the aorta and arteries?

What does this do to blood pressure?

Contribution of GeneticsSickle cell disease

Increased risk of thrombus

Increased coagulation

Vessel lining becomes inflamed

Sickles adhere to endothelium

Increased risk for stroke

What do the sickle cells adhere to?

What happens to the vessel lining?

What else do these sickle cells promote?

What is the risk associated with

increased coagulation?

Contribution of InflammationInjury to Endothelial

Cell

Inflammatory cells migrate to injury

Contribute to development of atherosclerotic plaques

Atherosclerosis

Increased risk for stroke

Hypertension

Do you remember what happens to an injured

cell?

What do these cells do?

What is this plaque build up called in the

vessels?

What modifiable risk factor does this contribute to?

Contribution of the Stress ResponseStress

Sympathetic Nervous System releases epinephrine and

norepinephrine

Increased blood pressure and increased mechanical

stress

Endothelial Cell Injury

Atherosclerosis

Increased risk for stroke

Hypertension

What does stress do to the sympathetic nervous system?

What happens to your blood pressure?

Do you remember what this does to the

cells?

And this leads to hardening of the

arteries, also known as?

Do you remember which risk factor

develops because of this?

What Are Modifiable Risk Factors that Contributed to Mr. C.V. Accident’s Stroke?

AgeNo, this is not

modifiable.

HypertensionYes, this is

correct.

RaceNo, race is not

modifiable.

WeightYes, this is modifiable.

Activity LevelYes, this is modifiable.

Family HistoryNo, this is not

modifiable.

DietYes, this is modifiable.

SexNo, this is not

modifiable.

HeightThis is not a risk factor.

ProfessionThis is not a risk factor.

SmokingYes, this is modifiable.

Hair ColorThis is not a risk factor.

Mr. C. V. Accident’s history indicates that while he was at church with his daughter, the

right side of his face started drooping. Suddenly, he was unable to lift his right arm,

and his speech became slurred.

His daughter acted quickly and immediately called 9-1-1.

Mr. C.V. Accident had an ischemic stroke. Because he got to the hospital in LESS THAN

THREE HOURS from the onset of his symptoms and a CT scan excluded the

diagnosis of hemorrhagic stroke, Mr. C. V. Accident received recombinant tissue-type plasminogen activator (tPA), a

thrombolytic agent.

How does tPA work?

Here is how tPA works:

Tissue plasminogen activator (tPA) targets the

thrombus and catalyzes the conversion of

plasminogen to plasmin resulting in thrombolysis.

Mr. C.V. Accident is diagnosed with a left sided cerebral accident. This means that the left side of his brain has been damaged and that the right side of his body

will be impaired. Damage to the right side of his brain would result in impairment to the left side of his body.

(Used with permission of Emily Gillis)

In your assessment, what are some of the clinical manifestations you might see with Mr. C.V.

Accident? (Remember he has a left sided CVA.)

Right sided hemiplegia

Yes, you are correct!

Homonymous hemianopsia

Yes, this is the loss of the visual field at the

vertical midline of both eyes and is true of all

strokes!

Left sided weakness

No, not with a left sided CVA.

Impaired speech and language

Yes, this is true!

ImpulsivityNo, this is true for right sided

strokes.

Right sided neglect

Yes, this is true for left sided

brain damage.

Difficulty in learning new information

Yes, this is true for any stroke!

Impaired concept of timeNo, this is true for right sided

strokes.

Your assessment is complete, now, its time for a nursing

diagnoses for Mr. C.V. Accident.

Do you think Mr. C.V. Accident is at risk for falls?

YES MAYBE NO

Falls are one of the most common medical complications after stroke.

7% incidence first week after stroke25%-37% incidence between one and six months

post-stroke40%-50% incidence six to twelve months after

stroke55%-73% incidence one year after stroke

(Verheyden, 2010)

(Microsoft Clip Art)

So, Mr. C.V. Accident isAT RISK FOR FALLS related to

Balance Impairment

Hemi-neglect

Self-care deficit

Cognitive impairment

Hemiparesis

Hemianopsia

At risk for falls related to balance impairment

Outcome: Mr. C.V. Accident will remain free from falls

Which nursing intervention would you use?

(Microsoft Clip Art)

Encourage Mr. C.V. Accident to use walking aids when ambulating.

Yes! You are correct!

Monitor Mr. C.V. Accident’s fluid intake.This may be valuable for other reasons, but it will not

decrease the risk of falls related to balance impairment.

At risk for falls related to hemi-neglect

Outcome: Mr. C.V. Accident will remain free from falls

Which nursing intervention would you use?

Offer Mr. C.V. Accident frequent reminders to be aware of his left side.

You are correct!

Assess Mr. C.V. Accident’s pain level.While this may be a great intervention if Mr. C.V. Accident

exhibits signs of pain, this will not help him address his hemi-neglect.

At risk for falls related to self care deficit

Outcome: Mr. C.V. Accident will remain free from falls

Which nursing intervention would you use?

(Microsoft Clip Art)

Monitor Mr. C.V. Accident’s vital signs every four hours.While vital signs are important, this will not keep Mr. C.V.

Accident from falling while dressing himself.

Assist Mr. C.V. Accident with dressing.Hooray! You are correct!

At risk for falls related to cognitive impairment

Outcome: Mr. C.V. Accident will remain free from falls

Which nursing intervention would you use?

(Microsoft Clip Art)

Orient Mr. C.V. Accident to his environment. Include the location and way to use his call button.

Correct!

Assess neurological status with the Glasgow coma scale.This is appropriate if Mr. C.V. Accident exhibits an altered level of

consciousness, but it will not keep him free from falls.

At risk for falls related to hemiparesisOutcome: Mr. C.V. Accident will remain free

from fallsWhich nursing intervention would you use?

(Microsoft Clip Art)

Perform neurological assessment every four hours.Sorry! This will not prevent Mr. C.V. Accident from falling.

Encourage Mr. C.V. Accident to use assistive devices for walking.Hooray! You are correct! If he uses his assistive devices, the risk for

falls will be decreased.

At risk for falls related to hemianopsiaOutcome: Mr. C.V. Accident will remain free

from fallsWhich nursing intervention would you use?

(Microsoft Clip Art)

Place items in Mr. C.V. Accident’s field of vision.Correct! You are doing a great job!

Encourage Mr. C.V. Accident to increase his fluid intake.While fluids are important, this will not prevent falls.

Click here to help Mr. C.V. Accident find

the knife.

Wow! Mr. C.V. Accident’s care plan is done! Its time to implement the nursing interventions, and evaluate them as the day goes on. This first

clinical is almost over and it is going very well!

References

Centers for Disease Control and Prevention (n.d.). Stroke Facts. Retrieved from http://www.cdc.gov/stroke/facts.htmm.

Lewis, S.M., Heitkemper, M. M., & Dirksen, S. Medical surgical nursing: assessment and management of clinical problems, ed 6, St. Louis, 2004, Mosby.

Microsoft Clip Art

Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott. Verheyden, G., Weerdesteyn, V., Pickering, R., Hyndman, D., Lennon, S., Geurts, A., & Ashburn, A. (2010). Interventions for preventing falls in people after stroke.