STROKE Ischemia to part of brain Acid-Base …lahc323325.weebly.com/uploads/1/1/0/6/110686185/chapter...STROKE • Ischemia to part of brain (what other system disease is this similar
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STROKE • Ischemia to part of brain (what other system disease is this similar to?) • Hemorrhage into brain that results in death of brain cells • Severity of loss of function varies according to location and extent of brain damage – Physical, cognitive, and emotional impact on patient and family • Acid-Base Balance • Cognition • Concepts related to Cognition: • Perceptual disturbances/psychosis • Impaired attention • Memory problems • Problems with communication/social cognition • Problems with motor control/cognition • Problems with executive function • Problems with intellectual functioning and learning • Mobility • Oxygenation • Perfusion • Safety • Stress and Coping *What nursing physical assessments are involved? 1 Fall 2019 - Spring 2020
STROKE • Ischemia to part of brain (what other system disease is this similar to?)
• Hemorrhage into brain that results in death of brain cells
• Severity of loss of function varies according to location and extent of brain damage– Physical, cognitive, and
emotional impact on patient and family
• Acid-Base Balance• Cognition• Concepts related to Cognition:
• Perceptual disturbances/psychosis
• Impaired attention• Memory problems• Problems with
communication/social cognition
• Problems with motor control/cognition
• Problems with executive function
• Problems with intellectual functioning and learning
• Mobility• Oxygenation• Perfusion• Safety• Stress and Coping*What nursing physical assessments are involved?
1Fall 2019 - Spring 2020
Presenter
Presentation Notes
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 warning signs of a stroke and treating it as a medical emergency, similar to what would be done with a heart attack. 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 Code Stroke Stroke receiving center
As one of your clinical assignments, you are assisting an RN with health screening at a health fair. Which individual is at greatest risk for experiencing a stroke?a. A 46-year-old white female with hypertension and oral
contraceptive use for 10 yearsb. A 58-year-old white male salesman who has a total
cholesterol level of 285 mg/dlc. A 42-year-old African American female with diabetes
mellitus who has smoked for 30 yearsd. A 62-year-old African American male with hypertension
who is 35 pounds overweight
Audience Response Question
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Presenter
Presentation Notes
Answer: D Rationale: Option D: This individual has five risk factors: age, African American, male, hypertension, and overweight. Option A: This individual has two risk factors: hypertension and oral contraception use. Option B: This individual has two risk factors: male and increased cholesterol level. Option C: This individual has three risk factors: African American, diabetes mellitus, and smoking. Nonmodifiable risk factors include age, gender, ethnicity/race, and family history/heredity. Stroke risk increases with age, doubling each decade after 55 years of age. Two- thirds of all strokes occur in individuals >65 years. Strokes are more common in men, but more women die from stroke than men. Because women tend to live longer than men, they have more opportunity to suffer a stroke. African Americans have a higher incidence of stroke as well as a higher death rate from stroke than whites. A family history of stroke, a prior transient ischemic attack, or a prior stroke also increases the risk of stroke. Modifiable risk factors are those that can potentially be altered through lifestyle changes and medical treatment, thus reducing the risk of stroke. Modifiable risk factors include hypertension, increased cholesterol, elevated blood lipid levels, heart disease, smoking, excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, and drug abuse. The early forms of birth control pills that contained high levels of progestin and estrogen increased a woman’s chance of experiencing a stroke, especially if she also smoked heavily. Newer, low-dose oral contraceptives have lower risks for stroke except in those individuals who are hypertensive and smoke. Other conditions that may increase stroke risk include migraine headaches, inflammatory conditions, and hyperhomocystinemia. Sickle cell disease is another known risk factor for stroke.
Risk Factors Non-Modifiable• Age• Gender• Ethnicity/race• 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
Primary prevention is the priority for decreasing morbidity and mortality risk
Management of modifiable risk factor
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Presenter
Presentation Notes
Most effective way to decrease burden of stroke is prevention and teaching Risk factors can be divided into non-modifiable and modifiable risks Stroke risk increases with multiple risk factors Primary prevention is a priority for decreasing morbidity and mortality risk from stroke. The goals of stroke prevention include health promotion for a healthy lifestyle and management of modifiable risk factors to prevent a stroke. Patients with known risk factors such as diabetes mellitus, hypertension, obesity, high serum lipids, or cardiac dysfunction require close management. 2/3 occur in individuals over age 65- doubles each decade after 55 years More women die from stroke because they tend to live longer and thus have more opportunity to suffer a stroke. The higher incidence (twice as high) and death rate from stroke among African Americans (compared to any other ethnic group) may be related in part to higher incidence of hypertension, obesity, and diabetes mellitus. Genetic risk factors are important in the development of all vascular diseases, including stroke. A person with a family history of stroke has an increased risk of having a stroke. Genes encoding products involved in lipid metabolism, thrombosis, and inflammation are believed to be potential genetic factors for stroke. Individuals who have at least two first-degree relatives with a history of subarachnoid hemorrhage or aneurysm should be screened to rule out anomalies in their cerebral vasculature. Ninety-percent of strokes are a result of modifiable risk factors. Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. New recommendations by the American Heart Association include home BP monitoring with a goal of SBP less than 140 mm Hg. Heart disease, myocardial infarction, cardiomyopathy, cardiac valve abnormalities, and cardiac congenital defects, is a risk factor for stroke. Atrial fibrillation is responsible for about 25% of all strokes. The incidence of atrial fibrillation increases with age. Oral anticoagulants (e.g., warfarin, dabigatran [Pradaxa]) and adherence to these medications plays an important role in the prevention of stroke. The risk for stroke in people with diabetes mellitus is five times higher than in the general population. Smoking nearly doubles the risk of ischemic stroke, and smokers are four times as likely to have a hemorrhagic stroke than nonsmokers 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. Illicit drug use, especially cocaine use, has been associated with stroke risk. A waist circumference to hip circumference ratio equal to or above the mid-value for the population increases the risk of ischemic stroke three-fold. In addition, obesity is also associated with hypertension, high blood glucose, and elevated blood lipid levels, all of which increase the risk of stroke. Benefits of physical activity can occur with even light to moderate regular activity. The American Stroke Association recommends 40 minutes of exercise 3 to 4 days per week in order to reduce risk of stroke. A diet high in fat and low in fruits and vegetables may increase stroke risk. Women who experience migraine with aura are at an increased risk for stroke. American Heart Association recommends smoking cessation and alternatives to estrogen oral contraceptives for these women to reduce the incidence of stroke. Other conditions that may increase the risk for strokes include inflammatory conditions (rheumatoid arthritis), sickle cell disease, lack of exercise, and obesity. Management of modifiable risk factors Healthy diet Weight control Regular exercise No smoking Limiting alcohol consumption BP management Routine health assessments
Cerebral Arteries
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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 TIA
• 1/3 progress to stroke
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Presenter
Presentation Notes
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. A TIA should be treated as a medical emergency as it is usually a precursor to ischemic stroke. Teach people at risk for TIAs to seek medical attention immediately with any stroke-like symptom and to identify the time of onset of symptoms.
Types of Stroke
• Ischemic- Thrombotic- Embolic
• Hemorrhagic- Intracerebral- Subarachnoid
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Based on previously learned knowledge, what is the priority plan of care?
Ischemic Stroke• Thrombotic:
– Occurs from injury to a blood vessel wall and formation of a blood clot
– Results in narrowing of blood vessel
– 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
Inadequate blood flow to brain from partial or complete occlusion of an artery
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Presenter
Presentation Notes
The lumen of the blood vessel becomes narrowed, and if it becomes occluded, infarction occurs. Thrombosis develops readily where atherosclerotic plaques have already narrowed blood vessels. Thrombotic strokes are more common in older individuals, especially those with high cholesterol, atherosclerosis, or diabetes. A majority of thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate atherosclerosis.
Ischemic Stroke• Embolic:
– Results in infarction and edema of area supplied by involved vessel
• Sudden onset with severe clinical manifestations– Warning signs are less
Occurs when an embolus lodges in and occludes a cerebral artery
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Presenter
Presentation Notes
Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel. The patient with an embolic stroke commonly has severe clinical manifestations that occur suddenly. Embolic strokes can affect any age group. Rheumatic heart disease is a cause of embolic stroke in young to middle-aged adults. An embolus arising from an atherosclerotic plaque is more common in older adults. Warning signs are less common with embolic than with thrombotic stroke. The embolic stroke often occurs rapidly, giving little time to accommodate to an obstructed blood vessel with the development of collateral circulation. The patient usually remains conscious, although he or she may have a headache. The effects of the emboli are initially characterized by severe neurologic deficits, which can be temporary if the clot breaks up and allows blood to flow. Smaller emboli then continue to obstruct smaller vessels, which in turn involve smaller portions of the brain with fewer deficits noted. The prognosis is related to the amount of brain tissue deprived of its blood supply. Recurrence of embolic stroke is common unless the underlying cause is aggressively treated.
– Subarachnoid space or ventricles• Subarachnoid or
intraventricular hemorrhage
• What intervention will the patient immediately need?
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Hemorrhagic StrokeIntracerebral hemorrhage• Bleeding within brain caused by rupture of a
vessel– Sudden onset of symptoms (HA, N/V)– Progression over minutes to hours because
of ongoing bleeding– Hemorrhage occurs during activity
Subarachnoid hemorrhage (SAH)– 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– Silent killer
• Loss of consciousness may or may not occur
• High mortality rate• Survivors often suffer significant
complications and deficits 10Fall 2019 - Spring 2020
Presenter
Presentation Notes
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% Hypertension is most common cause Hemorrhage occurs during activity Sudden onset with progression over minutes to hours Extent of symptoms varies and depends on amount, location, and duration of bleeding Approximately half of intracerebral hemorrhages occur in the putamen and internal capsule, central white matter, thalamus, cerebellar hemispheres, and pons. Initially, patients experience a severe headache with nausea and vomiting. Hemorrhage in the pons is the most serious because basic life functions (e.g., respiration) are rapidly affected. Massive hypertensive hemorrhage rupturing into a lateral ventricle of the brain. Vessel usually ruptures in the basal ganglia Fifty percent of the deaths occur within the first 48 hours. {See next slide for figure.} Other causes include vascular malformations, coagulation disorders, anticoagulant and thrombolytic drugs, trauma, brain tumors, and ruptured aneurysms. A blood clot within the closed skull can result in a mass that causes pressure on brain tissue, displaces brain tissue, and decreases cerebral blood flow, leading to ischemia and infarction. Aneurysms may be saccular or berry aneurysms, ranging from a few millimeters to 20 to 30 mm in size, or fusiform atherosclerotic aneurysms. Other causes of SAH include trauma and illicit drug (cocaine) abuse. The patient may have warning signs and symptoms if the ballooning artery applies pressure to brain tissue, or minor warning symptoms may result from leaking of an aneurysm before major rupture. In general, cerebral aneurysms are viewed as a “silent killer” as individuals do not have warning signs or symptoms of an aneurysm until rupture has occurred. Other symptoms include focal neurologic deficits (including cranial nerve deficits), nausea, vomiting, seizures, and stiff neck. Complications of aneurysmal subarachnoid hemorrhage include rebleeding before surgery or other therapy is initiated and cerebral vasospasm (narrowing of the blood vessels), which can result in cerebral infarction. Despite improvements in surgical techniques and management, many patients with SAH die. Some die almost immediately when a rupture occurs. Others die from subsequent bleeding. Survivors may be left with significant morbidity, including cognitive difficulties.
Diagnostic Studies –STROKE
• Confirm that it is a stroke• Identify the likely cause of
Why is it important to differentiate between ischemic and hemorrhagic stroke It is important to rule out the presence of a different kind of brain lesion. See Table 57-5 for more information. Tests also guide decisions about therapy to prevent a secondary stroke. Serial CT scans may be used to assess the effectiveness of treatment and to evaluate recovery. Rapid access to these diagnostic tools is important, since the results will determine treatment options for the patient. MRI is more effective in identifying ischemic stroke than CT scans. A CT scan is a rapid diagnostic tool to rule out hemorrhage. CT angiography (CTA) provides visualization of cerebral blood vessels. It can provide an estimate of perfusion and detect filling defects in cerebral arteries. MRA can detect vascular lesions and blockages, similar to CTA. Angiography can identify cervical and cerebrovascular occlusion, atherosclerotic plaques, and malformation of vessels. Intra-arterial digital subtraction angiography (DSA) reduces the dose of contrast material, uses smaller catheters, and shortens the length of the procedure compared with conventional angiography. Transcranial Doppler (TCD) ultrasonography is a noninvasive study that measures the velocity of blood flow in the major cerebral arteries. A lumbar puncture may be done to look for evidence of red blood cells in the cerebrospinal fluid if a subarachnoid hemorrhage is suspected but the CT does not show hemorrhage. The LICOX system may be used as a diagnostic tool for evaluating the progression of stroke. Cardiac imaging is also recommended because many strokes are caused by blood clots from the heart.
Interprofessional Care –STROKE
• Primary assessment is focused on – Cardiac status– Respiratory status– Neurologic assessment
• Secondary assessment includes a comprehensive neurologic examination– Clear documentation of
initial and ongoing neurologic examinations is essential to note changes in patient status
NIH Stroke Scale –comprehensive neurologic examination of:• Level of consciousness• Cognition• Motor abilities• Cranial nerve function• Sensation • Proprioception• Cerebellar function • Deep tendon reflexes
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Interprofessional Care –STROKE Surgical TherapyFor patient with TIAs from carotid disease include:• Carotid
endarterectomy• Transluminal
angioplasty• StentingPreoperativePostoperative
13Fall 2019 - Spring 2020
Presenter
Presentation Notes
Evaluation must be done to confirm that the signs and symptoms of a TIA are not related to other brain lesions, such as a developing subdural hematoma or an increasing tumor mass. {See next 2 slides for figures of carotid endarterectomy and stenting.} Transluminal angioplasty is the insertion of a balloon to open a stenosed artery in the brain and improve blood flow. The balloon is threaded up to the carotid artery via a catheter inserted in the femoral artery. In a carotid endarterectomy (CEA), the atheromatous lesion is removed from the carotid artery to improve blood flow. Carotid endarterectomy is performed to prevent impending cerebral infarction. A, A tube is inserted above and below the blockage to reroute the blood flow. B, Atherosclerotic plaque in the common carotid artery is removed. C, Once the artery is stitched closed, the tube can be removed. A surgeon may also perform the technique without rerouting the blood flow. Brain stent used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant the stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery and then inflated. The stent expands due to inflation of the balloon. C, The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery open and improving the flow of blood. Brain stent used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant the stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery and then inflated. The stent expands due to inflation of the balloon. C, The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery open and improving the flow of blood
Interprofessional Care –STROKE Surgical Therapy
• Neurovascular assessment• BP management• Assessment for
complications– Stent occlusion – Retroperitoneal hemorrhage – Minimize complications at
insertion site
Postoperative care is important
Fall 2019 - Spring 2020 14
Presenter
Presentation Notes
You minimize complications at the insertion site by keeping the patient’s leg straight for the prescribed amount of time.
Interprofessional Care –STROKE
• Elevated BP is common immediately after a stroke –permissive hypertension– Body’s attempt to maintain
cerebral perfusion• Control fluid and electrolyte
balance –adequate hydration*
• Promotes perfusion • Decreases further brain injury
• Manage ICP– Use interventions that improve
venous drainage
• Goals for interprofessionalcare:
• Preserving life• Preventing further brain
damage• Reducing disability
• Time of onset of symptoms is critical information
Table 57-7 outlines the emergency management of the patient with a stroke. Patients may have difficulty keeping an open and clear airway because of a decreased level of consciousness or decreased or absent gag and swallowing reflexes. Oxygen administration, artificial airway insertion, intubation, and mechanical ventilation may be required. Many patients may worsen in the first 24 to 48 hours. The American Heart Association recommends that acute care facilities have stroke teams in place. The stroke team generally consists of a registered nurse, neurologist, radiologist, and radiologic technician. Use of drugs to lower BP is recommended only if BP is markedly increased (mean arterial pressure greater than 130 mm Hg or systolic pressure greater than 220 mm Hg). In the case of an acute stroke, IV antihypertensives such as metoprolol (Lopressor) and nicardipine (Cardene) are preferred. Although low BP immediately following a stroke is uncommon, hypotension and hypovolemia should be corrected if present. Overhydration may compromise perfusion by increasing cerebral edema. Adequate fluid intake during acute care via oral, IV, or tube feedings is a priority. Also monitor urine output to make sure the patient does not become dehydrated. If secretion of antidiuretic hormone (ADH) increases in response to the stroke, urine output decreases, and fluid is retained. Low serum sodium (hyponatremia) may occur. IV solutions with glucose and water are avoided because they are hypotonic and may further increase cerebral edema and ICP. Glycemic control should be maintained to avoid extreme hypo- or hyperglycemia. In general, decisions regarding individualized fluid and electrolyte replacement therapy are based on the extent of intracranial edema, manifestations of increased ICP, central venous pressure levels, electrolyte levels, and intake and output. Increased ICP is more likely to occur with hemorrhagic strokes but can occur with ischemic strokes. Increased ICP from cerebral edema usually peaks in 72 hours and may cause brain herniation. Management of increased ICP includes practices that improve venous drainage, such as elevating the head of the bed, maintaining head and neck in alignment, and avoiding hip flexion. Additional measures for reduction of increased ICP include management of hyperthermia (goal temp = 96.8 to 98.6° F [36° to 37° C ]), drug therapy to prevent seizures, pain management, avoidance of hypervolemia, and management of constipation. Cerebrospinal fluid drainage may be used in some patients to reduce ICP.
Interprofessional Care –STROKE
Acute ischemic stroke:• 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
Preventive Drug Therapy• 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
• What medication are you familiar with?
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Presenter
Presentation Notes
Aspirin is most frequently used antiplatelet agent Common dose for aspirin is 81 to 325 mg/day. Other drugs include ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine), and combined dipyridamole and aspirin (Aggrenox). For patients who have atrial fibrillation, oral anticoagulation can include warfarin (Coumadin) and the direct factor Xa inhibitors: rivaroxaban (Xarelto), dabigatran (Pradaxa), and apixaban (Eliquis). The primary advantage of direct factor Xa inhibitors (compared to warfarin) is that these drugs do not need close monitoring or dosage adjustments. Statins (simvastatin [Zocor], lovastatin [Mevacor]) have also been shown to be effective in the prevention of stroke for individuals who have experienced a TIA in the past. Patients are screened carefully before tPA can be given. Screening includes a noncontrast CT or MRI scan to rule out hemorrhagic stroke, blood tests for coagulation disorders, and screening for recent history of gastrointestinal bleeding, stroke, or head trauma within the past 3 months; major surgery within 14 days, or recent active internal bleeding within 22 days. During infusion of the drug, the patient’s vital signs and neurologic status are monitored closely to assess for improvement or for potential deterioration related to intracerebral hemorrhage. Control of BP (SBP less than 185) is critical during treatment and for 24 hours following. Intra-arterial infusion of tPA may be used for patients with occlusions of the middle cerebral artery who can be treated within 6 hours of symptom onset. tPA produces localized fibrinolysis by binding to the fibrin in the thrombi. The fibrinolytic action of tPA occurs as the plasminogen is converted to plasmin, whose enzymatic action then digests fibrin and fibrinogen, thus breaking down the clot. Other fibrinolytic agents cannot be substituted for tPA. To be effective intra-arterial tPA must be administered within 6 hours of the onset of stroke symptoms for patients with an ischemic stroke when mechanical thrombectomy is not an option. In the intra-arterial tPA procedure, the neurovascular specialist inserts a thin, flexible catheter into an artery (usually the femoral artery) and guides the catheter (using angiogram) to the area of the clot. The tPA is administered through the catheter and immediately targets the clot. Less tPA is needed when it is delivered directly to the clot, which can reduce the possibility of intracranial hemorrhage.
Interprofessional Care –STROKE
• After stroke has stabilized for 12 to 24 hours, interprofessional 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 once medically cleared
Acute ischemic stroke:• 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, clopidogel (Plavix)• Bedside swallow
evaluation by RN
Fall 2019 - Spring 2020 17
Presenter
Presentation Notes
Platelet inhibitors include aspirin, ticlopidine (Ticlid), clopidogrel (Plavix), and dipyridamole (Persantine). Additionally, the use of statins has been shown to be effective for the patient with an ischemic stroke. For patients who have atrial fibrillation, oral anticoagulants include warfarin and the direct factor Xa inhibitors: rivaroxaban (Xarelto), dabigatran (Pradaxa), and apixaban (Eliquis). The use of anticoagulants (e.g., heparin) in the emergency phase following an ischemic stroke is generally not recommended because of the risk for intracranial hemorrhage. Acetylsalicylic acid (aspirin) at a dose of 325 mg may be initiated within 24 to 48 hours after the onset of an ischemic stroke. Complications of aspirin (with higher doses) include gastrointestinal bleeding. Aspirin administration should be done cautiously if the patient has a history of peptic ulcer disease.
– Resection– Clipping of an aneurysm– Evacuation of hematomas
Manage:• ABC & ICP• Management of
hypertension is main focus –why?
• SBP < 160 mm Hg• Anticoagulants and
platelet inhibitors are contraindicated
• Seizure prophylaxis is situation-specific
Fall 2019 - Spring 2020 18Coiling
Clipping and wrapping on aneurysm
Presenter
Presentation Notes
Oral and IV agents are used to maintain BP within a normal to high-normal range Systolic BP less than 160 mm Hg. Seizure prophylaxis in the acute period after intracerebral and subarachnoid hemorrhages is situation-specific and should be discussed with the Interprofessional care team. Surgical procedure is chosen based on cause of stroke Surgical interventions for hemorrhagic stroke include immediate evacuation of aneurysm-induced hematomas or cerebellar hematomas larger than 3 cm. Individuals who have an arteriovenous malformation (AVM) may experience a hemorrhagic stroke if the AVM ruptures. The treatment of AVM is surgical resection and/or radiosurgery (i.e., gamma knife). Both may be preceded by interventional neuroradiology to embolize the blood vessels that supply the AVM. In a subarachnoid hemorrhage, bleeding from a damaged vessel causes blood to accumulate between the brain and skull. The leaked blood can irritate, damage, or destroy the surrounding brain cells. When blood enters the subarachnoid space, it mixes with the cerebrospinal fluid (CSF). This can block CSF circulation, thus causing increased pressure on the brain. The open spaces in the brain (ventricles) may enlarge, resulting in hydrocephalus. This further increases ICP (due to the large accumulation of blood) and can result in further brain injury. Insertion of a ventriculostomy for CSF drainage can dramatically improve these situations by reducing the ICP. Goals for managing ICP are the same for patients with SAH as they are for patients dealing with acute stroke. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm. Patients may have multiple aneurysms. Treatment of an aneurysm involves clipping or coiling the aneurysm to prevent rebleeding. Clipping of the aneurysm involves the neurosurgeon placing a metallic clip on the neck of the aneurysm to block blood flow and prevent rupture. The clip remains in place for life. A, A hydrogel-coated platinum coil is used to occlude an aneurysm. The softness of the platinum allows the coil to assume the shape of irregularly shaped aneurysms while posing little threat of rupture of the aneurysm. B, A catheter is inserted through an introducer (small tube) in an artery in the leg. The catheter is threaded up to the cerebral blood vessels. C, Platinum coils attached to a thin wire are inserted into the catheter and then placed in the aneurysm until the aneurysm is filled with coils. Packing the aneurysm with coils prevents the blood from circulating through the aneurysm, reducing the risk of rupture. Eventually, a thrombus forms within the aneurysm, and the aneurysm becomes sealed off from the parent vessel by the formation of an endothelialized layer of connective tissue.
Interprofessional Care –STROKE
Hemorrhagic Stroke• Hyperdynamic therapy to
increase cerebral perfusion:– Vasoconstricting agents– Crystalloid or colloid
solutions• Vasospasms can be treated
with a calcium channel blocker nimodipine (Nimotop)
Postoperative care and management:Brain surgery (Chapter 56)
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Presenter
Presentation Notes
Increase mean arterial pressure After aneurysmal occlusion via clipping or coiling, hyperdynamic therapy (hemodilution-induced hypertension using vasoconstricting agents such as phenylephrine or dopamine [Intropin] and hypervolemia) may be instituted in an effort to increase the mean arterial pressure and increase cerebral perfusion. Volume expansion is achieved via crystalloid or colloid solution. Interventions to treat cerebral vasospasm either before or following aneurysm clipping or coiling include administration of the calcium channel blocker nimodipine (Nimotop), which is given to patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize cerebral damage. Nimodipine restricts the influx of calcium ions into cells by reducing the number of open calcium channels. Although nimodipine is a calcium channel blocker, its exact mechanism of action in reducing vasospasm is not well-understood. Subarachnoid and intracerebral hemorrhage can involve bleeding into the ventricles of the brain. This situation produces hydrocephalus, which further damages brain tissue from increased ICP. Insertion of a ventriculostomy for cerebrospinal fluid drainage can result in dramatic improvement in these situations.
Clinical Manifestations of Stroke
• 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 –why?
20Fall 2019 - Spring 2020
Presenter
Presentation Notes
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.
Clinical Manifestations–STROKE
Impairment of• Mobility
– Loss of skilled voluntary movement (akinesia)
– Impairment of integration of movements– Alterations in muscle tone– Alterations in reflexes
• Changes from hyporeflexia to hyperreflexia
• 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
Symptoms are caused by the destruction of motor neurons in the pyramidal pathway (nerve fibers from the brain that pass through the spinal cord to the motor cells). Initial depressed reflexes progresses to hyperactive reflexes for most patients. Because the pyramidal pathway crosses at the level of the medulla, a lesion on one side of the brain affects motor function on the opposite side of the body (contralateral).
Clinical Manifestations –STROKE
• Paralyzed or weak side needs special attention when positioned
• Optimize musculoskeletal function
• Walking, Eating , Toileting• Balance training• Transferring from bed to
chair– Methods for using the weak
or paralyzed side
Motor Function• Goal is to maintain
optimal function by prevention of joint contractures and muscular atrophy
• In acute phase, range-of-motion exercises and positioning are important
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Presenter
Presentation Notes
Avoidance of pulling the patient by arm to avoid shoulder displacement Prevent foot drop Hand splints to reduce spasticity Musculoskeletal Function If muscles are still flaccid several weeks after stroke, prognosis for regaining function is poor Focus of care is on preventing additional loss Most patients begin to show signs of spasticity with exaggerated reflexes within 48 hours following the stroke = Spasticity at this phase of stroke denotes progress toward recovery. As improvement continues, small voluntary movements of the hip or shoulder may be accompanied by involuntary movements in the rest of the extremity (synergy). The final stage of recovery occurs when the patient has voluntary control of isolated muscle groups. The goal of the Bobath approach is to help the patient gain control over patterns of spasticity by inhibiting abnormal reflex patterns. Therapists and nurses use the Bobath approach to encourage normal muscle tone, normal movement, and promotion of bilateral function of the body. An example is to have the patient transfer into the wheelchair using the weak or paralyzed side and the stronger side to facilitate more bilateral functioning. Constraint-induced movement therapy (CIMT) encourages the patient to use the weakened extremity by restricting movement of the normal extremity. The ability of patients to comply with this approach is challenging and may limit its use. Supportive or assistive equipment, such as canes, walkers, and leg braces, may be needed on a short- or long-term basis for mobility. The physical therapist usually selects the most appropriate supportive device(s) to meet individual needs and instructs the patient regarding use. Incorporate physical therapy activities into the patient’s daily routine for additional practice and repetition of rehabilitation efforts. Passive range-of-motion exercise is begun on the first day of hospitalization. If the stroke is due to subarachnoid hemorrhage, the movement is limited to the extremities. Position each joint higher than the joint proximal to it to prevent dependent edema. Specific deformities on the weak or paralyzed side that may be present in patients with stroke include internal rotation of the shoulder; flexion contractures of the hand, wrist, and elbow; external rotation of the hip; and plantar flexion of the foot. 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 Use of a footboard for the patient with spasticity is controversial. Rather than preventing plantar flexion (footdrop), the sensory stimulation of a footboard against the bottom of the foot increases plantar flexion. Likewise, experts disagree on whether hand splints facilitate or diminish spasticity. The decision regarding the use of footboards or hand splints is made on an individual patient basis. Do not use rolled washcloths in place of hand cones.
Clinical Manifestations –STROKE
Cardiovascular system• Goals aimed at maintaining homeostasis• Adjusting fluid intake to individual needs of the patient• Monitoring lung sounds for crackles and wheezes
(pulmonary congestion)• Monitoring heart sounds for murmurs • Watch for orthostatic hypotension before ambulating
patient for 1st time• ↓ cardiac reserves from secondary diagnoses of
cardiac disease = cardiac efficiency may be compromised
• After stroke, patient is at risk for venous thromboembolism (VTE)
Respiratory system• Management of respiratory system is a nursing priority
– Risk for atelectasis– Risk for aspiration pneumonia– Risks for airway obstruction– May require endotracheal intubation and
mechanical ventilation • Monitoring lung sounds for crackles and wheezes
(pulmonary congestion)
Neurologic system• Monitor closely to
detect changes suggesting extension of the stroke↑ ICP
• Vasospasm• Recovery from stroke
symptoms
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Presenter
Presentation Notes
The primary clinical assessment tool to evaluate and document neurological status in acute stroke patients is the NIH Stroke Scale (NIHSS). It can serve as a measure of stroke severity and is a predictor of both short- and long-term outcomes of stroke patients. It serves as a data collection tool for planning patient care and provides a common language for exchanging information among health care providers. Additional neurologic assessment includes mental status, pupillary responses, and extremity movement and strength. Also closely monitor vital signs. A decreasing level of consciousness may indicate increasing ICP. Monitor ICP and cerebral perfusion pressure as well if the patient is in a critical care environment. Record your nursing assessment on flow sheets to communicate the patient's neurologic status to the stroke team. CARDIOVASCULAR: In addition to decreased cardiac reserves secondary to cardiac disease, cardiac efficiency may be further compromised by fluid retention, overhydration, dehydration, and/or blood pressure variations. Central venous pressure, pulmonary artery pressure, or hemodynamic monitoring may be used as indicators of fluid balance or cardiac function in the critical care unit. Bedside monitors or telemetry may record cardiac rhythms. Hypertension is sometimes seen following a stroke as the body attempts to increase cerebral blood flow. It is also important to monitor for orthostatic hypotension before ambulating the patient for the first time. Neurologic changes can occur with a sudden decrease in BP. Teach the patient active range-of-motion exercises if the patient has voluntary movement in the affected extremity. For the patient with hemiplegia, passive range-of-motion exercises should be done several times a day. Additional measures to prevent VTE include positioning minimize the effects of dependent edema and using sequential compression devices for bedridden patients. VTE prophylaxis may include low-molecular-weight heparin (e.g., enoxaparin [Lovenox]). The nursing assessment for VTE includes measuring the calf and thigh daily, observing for swelling of the lower extremities, noting unusual warmth of the leg, and asking the patient about pain in the calf. 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 RESPIRATORY: Advancing age and immobility increase the risk for atelectasis and pneumonia. Risk for aspiration pneumonia is high because of impaired consciousness or dysphagia. All patients should be effectively screened for their ability to swallow and kept NPO until dysphagia has been ruled out. Nursing interventions to support adequate respiratory function are individualized to meet the needs of the patient (include frequent assessment of airway patency and function, oxygenation, suctioning, patient mobility, positioning of the patient to prevent aspiration, and encouraging deep breathing). Oral care at least every 2 hours for patients on mechanical ventilation reduces the occurrence of ventilator-assisted pneumonia. Interventions related to maintenance of airway function are described in NCP 58-1.
Clinical Manifestations–STROKE
• Assess patient for both ability to speak and ability to understand
• Speak slowly and calmly, using simple words or sentences
• Gestures may be used to support verbal cues• Speech, comprehension, and language deficits
are most difficult problem for patient and family– Speech therapists can assess and formulate
a plan to support communication
Communication• Receptive – loss
of comprehension
• Expressive – loss of production of language
• Global – total inability to communicate
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Presentation Notes
Assess patient for both ability to speak and ability to understand Speech, comprehension, and language deficits are most difficult problem for patient and family The left hemisphere is dominant for language skills in right-handed persons and in most left-handed persons. Aphasia occurs when a stroke damages the dominant hemisphere of the brain. Language disorders involve expression and comprehension of written and spoken words. Aphasia occurs when stroke damages dominant hemisphere of brain and affects language Dysphasia refers to impaired ability to communicate Many patients experience dysarthria –mechanics/muscular control of speech Aphasia occurs when stroke damages dominant hemisphere of brain and affects language Dysphasia refers to impaired ability to communicate Many patients experience dysarthria –mechanics/muscular control of speech Your role in meeting psychologic needs of patient is primarily supportive Assess patient for both ability to speak and ability to understand Speak slowly and calmly, using simple words or sentences Gestures may be used to support verbal cues An alert patient is usually anxious because of lack of understanding about what has happened and because of difficulty with communicating or inability to communicate. The stroke patient with aphasia may easily be overwhelmed by verbal stimuli. (Guidelines for communicating with a patient who has aphasia are presented in Table 57-10.) Nursing interventions that support communication include (1) frequent, meaningful communication; (2) allowing time for the patient to comprehend and answer; (3) using simple, short sentences; (4) using visual cues; (5) structuring conversation so that it permits simple answers by the patient; and (6) praising the patient honestly for improvements with speech. A picture board may be helpful for communicating with the stroke patient.
Clinical Manifestations –STROKE
Intellectual Function• Both memory and judgment may
be impaired as a result of stroke• Impairments can occur with strokes
affecting either side of brain, some deficits are related to hemisphere in which stroke occurred– A left-brain stroke is more likely to
result in memory problems related to language
– Patients with a left-brain stroke often are very cautious in making judgments
– The patient with a right-brain stroke tends to be impulsive and to move quickly
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
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Presentation Notes
Patients may be frustrated by mobility and communication problems. Intellectual functioning Impairments can occur with strokes affecting either side of brain, some deficits are related to hemisphere in which stroke occurred A left-brain stroke is more likely to result in memory problems related to language. Patients with a left-brain stroke often are very cautious in making judgments. The patient with a right-brain stroke tends to be impulsive and to move quickly. An example of behavior in people with right-brain stroke is that they try to rise quickly from a wheelchair without locking the wheels or raising the footrests. On the other hand, people with a left-brain stroke would move slowly and cautiously from the wheelchair. Patients with either type of stroke may have difficulty making generalizations, which interferes with their ability to learn.
Clinical Manifestations –STROKE
Agnosia (pictures slide 16)Apraxia
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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– Related to hemisphere of brain in
which stroke occurred – Visual problems
Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemianopsia shows that food on the left side is not seen and thus is ignored.
(Modified from Hoeman SP: Rehabilitation nursing, ed 2, St Louis, 1995, Mosby.)
Presenter
Presentation Notes
Visual problems may include Diplopia (double vision) Loss of the corneal reflex Ptosis (drooping eyelid) Homonymous hemianopsia Spatial-perceptual orientation can also occur in people with left-brain stroke. Spatial-perceptual problems may be divided into four categories. The first is due to damage of the parietal lobe and causes the patient to have an incorrect perception of self and illness. In this situation, patients may deny their illnesses or not recognize their own body parts. The second category occurs when the patient neglects all input from the affected side (erroneous perception of self in space). This may be worsened by homonymous hemianopsia, in which blindness occurs in the same half of the visual fields of both eyes. The patient also has difficulty with spatial orientation, such as judging distances. The third spatial-perceptual deficit is agnosia, the inability to recognize an object by sight, touch, or hearing. The fourth deficit is apraxia, the inability to carry out learned sequential movements on command. Because patients may or may not be aware of their spatial-perceptual alterations, you need to assess for this potential problem as it will impact rehabilitation and recovery.
Clinical Manifestations –STROKE
• May initially receive IV infusions to maintain fluid and electrolyte balance
• First feeding should be approached carefully– Test swallowing, chewing,
gag reflex, and pocketing before beginning oral feeding
– May require nutrition support –failed swallow test
• Feedings must be followed by scrupulous oral hygiene
Nutrition• Stress of illness
contributes to a catabolic state that can interfere with recovery
• Nutritional needs require quick assessment and treatment –what types of diet will you anticipate?
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Presentation Notes
Patients should have their nutritional needs addressed in the first 72 hours of admission to the hospital, as nutrition is important for recovery and healing. Safety Alert Oral Feeding After Stroke • The gag reflex may be impaired due to dysphagia and needs to be assessed. Therefore the first oral feeding should be carefully planned. 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 exercises to stimulate swallowing should be started. The speech therapist or occupational therapist is usually responsible for designing this program. However, you may be involved in helping to develop the program in some clinical settings. The patient should remain in a high Fowler’s position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following. Various dietary items may be recommended by the speech therapist. Foods should be easy to swallow and provide enough texture, temperature (warm or cold), and flavor to stimulate a swallow reflex. Crushed ice can be used as a stimulant. Instruct the patient to swallow and then swallow again. Pureed foods are not usually the best choice because they are often bland and too smooth. Thin liquids are often difficult to swallow and may promote coughing. Thin liquids can be thickened with the use of a commercially available thickening agent (e.g., Thick-It). Avoid milk products because they tend to increase the viscosity of mucus and increase salivation. Place food on the unaffected side of the mouth. The inability to feed oneself can be frustrating and may result in malnutrition and dehydration. Interventions to promote self-feeding include using the unaffected upper extremity to eat; employing assistive devices such as rocker knives, plate guards, and nonslip pads for dishes; removing unnecessary items from the tray or table, which can reduce spills; and providing a nondistracting, calm environment to decrease sensory overload and distraction. The effectiveness of the dietary program is evaluated in terms of maintenance of weight, adequate hydration, and patient satisfaction. These interventions should be introduced in the acute care setting.
Clinical Manifestations –STROKE
• In acute stage, poor bladder control results in incontinence– Efforts should be made to
promote normal bladder function– Avoid use of indwelling catheters– Bladder retraining program
• Constipation is most common bowel problem– Prophylactic stool softeners or
fiber – Physical activity promotes bowel
function– High-fiber diet and adequate
fluid intake
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
Fall 2019 - Spring 2020 28
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Presentation Notes
Toileting interventions Bowel control Constipation Incontinence High-fiber diet and adequate fluid intake Patients with stroke frequently have constipation, which responds to the following dietary management: Fluid intake of 2500 to 3000 mL daily unless contraindicated Prune juice (120 mL) or stewed prunes daily Cooked fruit 3 times daily Cooked vegetables 3 times daily Whole-grain cereal or bread 3 to 5 times daily Nursing measures are also focused on promoting urinary continence. Initially, the patient may experience frequency, urgency, and incontinence. Although motor control of the bowel is usually not a problem, patients are frequently constipated. Constipation is associated with immobility, weak abdominal muscles, dehydration, and diminished response to the defecation reflex. Urinary and bowel elimination problems may also be related to inability to verbalize the need to eliminate and difficulty with managing clothing (resulting in incontinence). Scheduled toileting and clothes that are easily removed may encourage independence. If an indwelling catheter must be used initially, it should be removed as soon as the patient is medically and neurologically stable. A bladder retraining program consists of (1) adequate fluid intake with most of it given between 7:00 AM and 7:00 PM; (2) scheduled toileting every 2 hours using bedpan, commode, or bathroom; (3) noting signs of restlessness, which may indicate the need for urination, and (4) assessment for bladder distention by palpation. Encourage patients to wear pants without drawstrings, buttons, or zippers, as these can be difficult to manage if motor or sensory deficits exist. Assessment of postvoid residual volume is often done using bladder ultrasound. The ultrasound measures how much urine is in the bladder following voiding. If urine remains in the bladder, incomplete emptying is a problem and may cause urinary tract infections. A coordinated program by the entire nursing staff is needed to achieve urinary continence. If the patient does not have a daily or every-other-day bowel movement, check the patient for impaction. The patient who has liquid stools should also be checked for stool impaction. Depending on the patient’s fluid balance status and swallowing ability, fluid intake should be at least 1800 to 2000 mL/day and fiber intake up to 25 g/day. Bowel retraining may need to occur, and this training will continue into the rehabilitation phase. A bowel management program consists of placing the patient on the bedpan or bedside commode or taking the patient to the bathroom at a regular time daily to reestablish bowel regularity. A good time for the bowel program is 30 minutes after breakfast because eating stimulates the gastrocolic reflex and peristalsis but may need to be adjusted as individual bowel habits may vary.
Clinical Manifestations –STROKE
• Prevention of skin breakdown– Pressure relief by position
changes, special mattresses, wheelchair cushions
• Position patient on weak or paralyzed side for only 30 minutes
– Good skin hygiene– Emollients to dry skin– Early mobility!
Integumentary• Susceptible to skin
breakdown r/t:• Loss of sensation• Decreased
circulation• Immobility
• Compounded by patient age, poor nutrition, dehydration, edema, and incontinence
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Presentation Notes
An example of a position change schedule is side-backside, with a maximum duration of 2 hours for any position. If an area of redness develops and does not return to normal color within 15 minutes of pressure relief, the epidermis and dermis are damaged. Do not massage the damaged area because this may cause additional damage.
Clinical Manifestations –STROKE
• Patients with a stroke may be coping with many losses (sensory, intellectual, communicative, functional, sexual, etc.)– Grief, mourning, depression
• Patient’s family should be given careful, detailed explanation of what has happened to patient
• Social services referral is often helpful
Coping• Family members
usually have not had time to prepare for illness
• Often a family disease• Emotionally• Socially• Financially • Changing roles
and responsibilities
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Presentation Notes
A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. Reactions to this threat vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow. During the acute phase of caring for the stroke patient, caregiver, and family, nursing interventions designed to facilitate coping involve providing information and emotional support. Explanations to the patient about what has happened and about diagnostic and therapeutic procedures should be clear and understandable, with reinforcement as needed. Should be clear and understood by patient, Repeat/reinforcement information as needed Decision making and upholding the patient’s wishes during this challenging time are of upmost importance. Advance directives should be honored, and family meetings or updates should be held daily about feeding tube placement or tracheostomy. If the family is extremely anxious and upset during the acute phase, explanations may need to be repeated at a later time. The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. The patient, caregiver, and family often go through the process of grief and mourning associated with the losses. Some patients experience long-term depression with symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. In addition, the time and energy required to perform previously simple tasks can result in anger and frustration. Interventions for atypical emotional response Distract the patient Explain to patient and family that emotional outbursts may occur Maintain a calm environment Avoid shaming or scolding patient Assist coping process Support communication between patient and family Discuss lifestyle changes from deficits Discuss changing roles and responsibilities within family Being an active listener to allow expression of fear, frustration, and anxiety Include family in goal planning and patient care Support family conferences Identify support groups and referrals Family members must cope with three aspects of patient’s behavior 1. Recognition of behavioral changes resulting from neurologic deficits that are not changeable 2. Responses to multiple losses both by patient and family 3. Behaviors that may have been reinforced during the early stages of stroke as continued dependency Stroke support groups within rehab facilities and community are helpful Mutual sharing Teaching Coping Understanding Family therapy is a helpful adjunct to rehabilitation. Open communication, information regarding the total effects of stroke, education regarding stroke treatment, and therapy are helpful. Sexual function Person who has had a stroke may be concerned about loss of sexual function Common concerns about sexual activity are impotence and occurrence of another stroke during sex Many patients are comfortable talking about their anxieties and fears regarding sexual function if the nurse is comfortable and open to topic
Nursing Management –STROKE
• Goals include that patient will– Maintain stable or improved
level of consciousness– Attain maximum physical
functioning– Maximize self-care abilities
and skills– Maintain stable body functions– Maximize communication
abilities – Maintain adequate nutrition– Avoid complications of stroke– Maintain effective personal
and family coping
Diagnoses include but are not limited to:• Risk for impaired
Nursing diagnoses for the person with a stroke may include, but are not limited to, the following: Decreased intracranial adaptive capacity related to decreased cerebral perfusion pressure of ≤50-60 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 Establish the goals of nursing care together with the patient, caregiver, and family. Typical goals are that the patient will (1) maintain a stable or improved level of consciousness, (2) attain maximum physical functioning, (3) attain maximum self-care abilities and skills, (4) maintain stable body functions (e.g., bladder control), (5) maximize communication abilities, (6) maintain adequate nutrition, (7) avoid complications of stroke, and (8) maintain effective personal and family coping.
Nursing Management –STROKEAMBULATORY CARE
• Nurses have an excellent opportunity to prepare patient and family for discharge through
• Teaching• Demonstration/return
demonstration• Practice• Evaluation of self-care skills
• This all begins at ADMISSION!
Patient is usually discharged (medically cleared) from acute care setting to:• Home• Intermediate or long-
term care facility• Rehabilitation facility • Critical factor:
independence in ADLs
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Presentation Notes
Rehab care that was initiated in the hospital continued in rehab REHAB NURSE Rehabilitation nurse assesses patient and family with Rehabilitation potential of patient Physical status of all body systems Presence of complications caused by stroke or other chronic conditions Cognitive status of patient The rehabilitation nurse assesses Rehab potential Physical status Complications Cognitive status Family resources and support Expectations of rehab Ideally, discharge planning with the patient and caregiver starts early in the hospitalization and promotes a smooth transition from one care setting to another. Rehabilitation requires a team approach so the patient and family can benefit from the combined, expert care of a stroke team. A critical factor in discharge planning is the patient’s level of independence in performing ADLs. Ongoing rehabilitation is essential to maximize patient’s abilities Process of maximizing patient’s capabilities and resources to promote optimal functioning Physical, mental, and social well-being Goals are set mutually by patient, family, nurse, stroke/rehab team The goals of rehabilitation are to prevent deformity and maintain and improve function. Most patients recover in the first 6 months following a stroke, with maximum benefit one year after a stroke. The stroke interprofessional team is composed of many members, including nurses, physicians, psychiatrist, physical therapist, occupational therapist, speech therapist, registered dietitian, respiratory therapist, vocational therapist, recreational therapist, social worker, psychologist, pharmacist, and chaplain. Physical therapy focuses on mobility, progressive ambulation, transfer techniques, and equipment needed for mobility. Occupational therapy emphasizes retraining for skills of daily living such as eating, dressing, hygiene, and cooking. Occupational therapists are also skilled in cognitive and perceptual evaluation and training. Speech therapy focuses on speech, communication, cognition, and eating abilities. Total care is considered in discharge planning: medications, nutrition, mobility, exercises, hygiene, and toileting. Follow-up care is carefully planned to permit continuing nursing; physical, occupational, and speech therapy; as well as medical care. Community resources should be identified to provide recreational activities, group support, spiritual assistance, respite care, adult day care, and home assistance based on the individual patient’s needs.
• Stroke is a significant cause of death and disability
• What is the likely cause of death for a patient that suffered a stroke?
33Fall 2019 - Spring 2020
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Presentation Notes
Stroke can result in a profound disruption in the life of an older person. The magnitude of disability and changes in total function can leave patients wondering if they can ever return to their “old self,” and loss of independence may be a major concern. The ability to perform ADLs may require many adaptive changes because of physical, emotional, perceptual, and cognitive deficits. Home management may be a particular challenge if the patient has an older spouse caregiver who also has health problems. There may be limited family members (including adult children) living in close proximity to provide help. The rehabilitative phase and assisting the older patient to deal with the residual deficits of stroke, as well as aging, can provide a challenging nursing experience. Patients may become fearful and depressed because they think they may have another attack or die. The fear can become immobilizing and interfere with effective rehabilitation. Changes may occur in the patient-spouse relationship. The dependency resulting from a stroke may be threatening to the relationship. The spouse may also have chronic medical problems that can affect the ability to take care of the stroke survivor. The patient may not want anyone other than the spouse to provide care, thus putting a significant burden on the spouse. Optimizing quality of life is the ultimate goal.
