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Stroke: NURSING MANAGEMENT Zoya Minasyan, RN, MSN-Edu

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Structures and Functions of Nervous System Left hemisphere of cerebrum, lateral surface, showing major lobes and areas of the brain.

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Structures and Functions of Nervous System Structural features of neurons: dendrites, cell body, and axons.

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Structures and Functions of Nervous System Major divisions of the central nervous system (CNS).

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Structures and Functions of Nervous System The cranial nerves are numbered according to the order in which they leave the brain.

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Structures and Functions of Nervous System Arteries of the head and neck. Brachiocephalic artery, right common carotid artery, right subclavian artery, and their branches. The major arteries to the head are the common carotid and vertebral arteries.

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Structures and Functions of Nervous System Arteries at the base of the brain. The arteries that compose the circle of Willis are the two anterior cerebral arteries joined to each other by the anterior communicating cerebral artery and to the posterior cerebral arteries by the posterior communicating arteries.

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Structures and Functions of Nervous System The vertebral column (three views).

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Stroke Stroke occurs when ischemia or hemorrhage into the brain results in death of brain cells. Also known as a brain attack Functions are lost or impaired Such as movement, sensation, or emotions that were controlled by the affected area of the brain Severity of the loss of function varies according to the location and extent of the brain involved.

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Risk Factors Most effective way to decrease the burden of stroke is prevention. Risk factors can be divided into non modifiable and modifiable risks.

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Risk Factors Modifiable Hypertension Metabolic syndrome Heart disease Heavy alcohol consumption Poor diet Drug abuse Sleep apnea Obesity Physical inactivity Smoking Non modifiable Age Gender Race Heredity/family history

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Types of Stroke Strokes are classified on the basis of underlying pathophysiologic findings. Ischemic Thrombotic Embolic Hemorrhagic

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Major Types of Stroke

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Ischemic Stroke Ischemic strokes result from Inadequate blood flow to the brain from partial or complete occlusion of an artery 80% of all strokes are ischemic strokes. Ischemic strokes can be Thrombotic Embolic

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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 Lacunar strokes a stroke from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue. thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate atherosclerosis

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Pathogenesis of Atherosclerosis A, Damaged endothelium. B, Diagram of fatty streak and lipid core formation. C, Diagram of fibrous plaque. Raised plaques are visible: some are yellow, others are white. D, Diagram of complicated lesion: thrombus is red, collagen is blue. Plaque is complicated by red thrombus deposition.

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Pathogenesis of Atherosclerosis Developmental stages: Fatty streaks Earliest lesions Characterized by lipid-filled smooth muscle cells Potentially reversible Fibrous plaque Beginning of progressive changes in the arterial wall Lipoproteins transport cholesterol and other lipids into the arterial intima. Fatty streak is covered by collagen, forming a fibrous plaque that appears grayish or whitish. Result = Narrowing of vessel lumen Complicated lesion Continued inflammation can result in plaque instability, ulceration, and rupture. Platelets accumulate and thrombus forms. Increased narrowing or total occlusion of lumen

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Ischemic Stroke Embolic stroke Occurs when an embolus lodges in and occludes a cerebral artery Results in infarction and edema of the area supplied by the involved vessel Second most common cause of stroke Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms. Onset of embolic stroke is usually sudden and may or may not be related to activity. Patient usually remains conscious, although he may have a headache.

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Ischemic Stroke Transient ischemic attack Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain Symptoms last

Collaborative Care Acute Care Surgical interventions for stroke Ischemic stroke MERCI (mechanical embolus removal in cerebral ischemia) Hemorrhagic stroke Immediate evacuation of aneurysm-induced hematomas Cerebellar hematomas >3 cm After stroke has stabilized for 12 to 24 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning. Patient may be transferred to a rehabilitation unit, outpatient therapy, or home carebased rehabilitation.

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Merci Embolus Retriever in Cerebral Ischemic Stroke The MERCI retriever removes blood clots in patients who are experiencing ischemic strokes. The retriever is a long, thin wire that is threaded through a catheter into the femoral artery. The wire is pushed through the end of the catheter up to the carotid artery. The wire reshapes itself into tiny loops that latch onto the clot and the clot can then be pulled out. To prevent the clot from breaking off, a balloon at the end of the catheter inflates to stop blood flow through the artery.

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Clipping and Wrapping of Aneurysms

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GDC Coil: Gugleilmi detachable coils A, A coil is used to occlude an aneurysm. Coils are made of soft, spring like platinum. 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.

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Nursing Management Nursing Assessment If the patient is stable, obtain Description of the current illness with attention to initial symptoms History of similar symptoms previously experienced Current medications History of risk factors and other illnesses Family history of stroke or cardiovascular disease

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Nursing Management Nursing Assessment Comprehensive neuro examination Level of consciousness Cognition Motor abilities Cranial nerve function Sensation Deep tendon reflexes

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Nursing Management Nursing Diagnoses Risk for ineffective cerebral tissue perfusion Ineffective airway clearance Impaired physical mobility Impaired verbal communication Impaired urinary elimination Impaired swallowing Situational low self-esteem

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Nursing Management Planning Goals are that the 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. Avoid complications of stroke. Maintain effective personal and family coping.

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Nursing Management Nursing Implementation Health promotion To reduce the incidence of stroke, the nurse should focus teaching toward stroke prevention. Particularly in persons with known risk factors Education about hypertension control and adherence to medication Teaching patients and families about Early symptoms Stroke TIA When to seek health care for symptoms

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Nursing Management Nursing Implementation Respiratory system Management of the respiratory system is a nursing priority. Risk for atelectasis Risk for aspiration pneumonia Risks for airway obstruction May require tracheal intubation and mechanical ventilation

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Nursing Management Nursing Implementation Neurologic system Monitor closely to detect changes suggesting Extension of the stroke ICP Vasospasm Recovery from stroke symptoms Table 58-8, page 1472 the NIH Stroke Scale (NIHSS)national institutes of health stroke scale.

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Nursing Management: Nursing Implementation Cardiovascular system Goals aimed at maintaining homeostasis Many patients with stroke have decreased cardiac reserves from the secondary diagnoses of cardiac disease. Monitoring vital signs frequently Monitoring cardiac rhythms Calculating intake and output, noting imbalances Regulating IV infusions Adjusting fluid intake to the individual needs of the patient Monitoring lung sounds for crackles and rhonchi (pulmonary congestion) Monitoring heart sounds for murmurs After stroke, patient is at risk for deep vein thrombosis. Related to immobility, loss of venous tone, and muscle pumping in leg Most effective prevention is keeping the patient moving.

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Nursing Management Nursing Implementation Musculoskeletal system Goal is to maintain optimal function. prevention of joint contractures and muscular atrophy range-of-motion exercises and positioning are important. Paralyzed or weak side needs special attention when positioned. Avoidance of pulling the patient by the arm to avoid shoulder displacement Hand splints to reduce spasticity

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Nursing Management Nursing Implementation Integumentary system Susceptible to breakdown related to Loss of sensation Decreased circulation Immobility Compounded by patient age, poor nutrition, dehydration, edema, and incontinence Pressure relief by position changes, special mattresses, or wheelchair cushions Good skin hygiene Early mobility Position patient on the weak or paralyzed side for only 30 minutes.

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Nursing Management Nursing Implementation Gastrointestinal system Stress of illness. Constipation. Patients may be placed on stool softeners. Physical activity promotes bowel function. Urinary system promote normal bladder function. Avoid the use of indwelling catheters.

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Nursing Management Nursing Implementation Nutrition Nutritional needs require quick assessment and treatment. May initially receive IV infusions to maintain fluid and electrolyte balance May require nutritional support First feeding should be approached carefully. Test swallowing, chewing, gag reflex, and pocketing before beginning oral feeding. Feedings must be followed by oral hygiene.

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Nursing Management Nursing Implementation Communication Nurses role in meeting psychologic needs of the patient is primarily supportive. Patient is assessed for both the ability to speak and the ability to understand. Speak slowly and calmly, using simple words or sentences. Gestures may be used to support verbal cues.

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Nursing Management Nursing Implementation Sensory-perceptual alterations Blindness in same half of each visual field is a common problem after stroke. Known as homonymous hemi anopsia A neglect syndrome (decrease in safety, increase risk for injury) Other visual problems may include Diplopia (double vision) Ptosis (drooping eyelid)

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Homonymous Hemianopsia (Food on left side is not seen) Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemi anopsia Shows that food on the left side is not seen and thus is ignored.

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Nursing Management Nursing Implementation Coping Affects family Emotionally Socially Financially Changing roles and responsibilities Explain What has happened Diagnosis Therapeutic procedures Should be clear and understood by patient. social services referral is often helpful.

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Nursing Management: Nursing Implementation Ambulatory and home care Patient is usually discharged to home, an intermediate or long-term care facility, or a rehabilitation facility. discharge planning with the patient and family starts early in the hospitalization and promotes a smooth transition from one care setting to another. prepare the patient and family for discharge through Education Demonstration Practice Evaluation of self-care skills Rehabilitation to promote optimal functioning. Physical, mental, and social well-being

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Loss of Postural Stability Loss of postural stability is common after stroke. The patient is unable to sit upright and tends to fall sideways. Appropriate support with pillows or cushions should be provided.

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Nursing Management Nursing Implementation Ambulatory and home care (contd) Musculoskeletal interventions Balance training Transferring from bed to chair Bobath method 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. CIMT is a more recent approach. Constraint-induced movement therapy (CIMT) encourages the patient to use the weakened extremity by restricting movement of the normal extremity. This approach is challenging, and the ability of patients to comply may limit its use.

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Nursing Management Nursing Implementation Ambulatory and home care (contd) After acute phase, a dietitian can assist in determining appropriate daily caloric intake based on the patients Size Weight Activity level Nurse and speech therapist must assess ability of patient to swallow solids and fluids and must adjust the diet appropriately. Inability to feed oneself can be frustrating and may result in malnutrition and dehydration.

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Assistive Devices for Eating A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips are helpful for some persons. B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the other. C, Plate guards help keep food on the plate. D, Cup with special handle.

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Nursing Management Nursing Implementation Implement a bowel management program for problems with Bowel control Constipation Incontinence High-fiber diet and adequate fluid intake

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Nursing Management Nursing Implementation Patients with stroke on right side of brain Difficulty in judging position, distance, and movement Impulsive, impatient, and denying problems related to stroke Respond best to directions given verbally Patients with stroke on left side of brain Slower in organization and performance of tasks Impaired spatial discrimination Have fearful, anxious response to stroke Respond well to nonverbal cues

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Nursing Management Nursing Implementation Interventions for atypical emotional response Distract the patient. Explain that emotional outbursts may occur. Maintain a calm environment. Avoid shaming. Patients with a stroke may be coping with many losses Often go through the process of grief Some patients experience long-term depression Support communication between the patient and family. Discuss lifestyle changes. Discuss changing roles within the family. Be an active listener. Include family in goal planning and patient care. Support family conferences.

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Nursing Management Nursing Implementation Family members must cope with Recognition of behavioral changes resulting from neurologic deficits that are not changeable Responses to multiple losses by both the patient and the family. 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 Education Coping Understanding

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Nursing Management Nursing Implementation Speech, comprehension, and language deficits are the most difficult problem for the patient and family. Speech therapists can assess and formulate a plan to support communication. Nurses can be a role model for patients with aphasia.

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A patient with right-sided paresthesias and hemiparesis is hospitalized and diagnosed with a thrombotic stroke. Over the next 72 hours, the nurse plans care with the knowledge that the patient: 1. Is ready for aggressive rehabilitation. 2. Will show gradual improvement of the initial neurologic deficits. 3. May show signs of deteriorating neurologic function as cerebral edema increases. 4. Should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits. Question #1

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While performing health screening at a health fair, the nurse identifies which of the following individuals at greatest risk for experiencing a stroke? 1. A 46-year-old white female with hypertension and oral contraceptive use for 10 years. 2. A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dL. 3. A 42-year-old African American female with diabetes mellitus who has smoked for 30 years. 4. A 62-year-old African American male with hypertension who is 35 pounds overweight. Question #2

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Answer #2 Answer: 4 Rationale: Option 4: This individual has five risk factors: age, African American, male, hypertension, and overweight. Option 1: This individual has two risk factors: hypertension and oral contraception use. Option 2: This individual has two risk factors: male and increased cholesterol level. Option 3: This individual has three risk factors: African American, diabetes mellitus, and smoking.

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Answer #2 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. Early forms of birth control pills that contained high levels of progestin and estrogen increased a womans 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. Sickle cell disease is another known risk factor for stroke.

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A patient with a stroke has dysphagia. Before allowing the patient to eat, which of the following actions should the nurse take first? 1. Check the patients gag reflex. 2. Request a soft diet with no liquids. 3. Place the patient in high-Fowlers position. 4. Test the patients ability to swallow with a small amount of water. Question #3

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Answer #3 Answer: 1 Rationale: 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 begin exercises to stimulate swallowing. To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated), and give the patient a small amount of crushed ice or ice water to swallow.

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Case Study 73-year-old man was admitted to the hospital with right-sided paresis and expressive aphasia. He had been experiencing periods of confusion, right-sided weakness, and slurred speech for the past several weeks. These episodes were brief and resolved completely within an hour. No treatments were sought.

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Case Study 1 History of COPD, MI 15 years prior, and atrial fibrillation Over the first 24 hours of admission, his neurologic deficits gradually progressed. By day 2 of admission, he had right-sided flaccid paralysis and global aphasia.

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Discussion Questions Case Study 1. What is probably the cause of his stroke? 2. Could this stroke have been prevented?

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Discussion Questions Case Study 3. What are the priority nursing interventions for him? 4. What teaching will you need to do for him and his family?