NSG 5130: Level III Nursing Theory - Stroke

NSG 5130: Level III Nursing Theory - Stroke

• Stroke is a cerebral vascular accident (CVA)
• Death of brain cells from prolonged ischemia or hemorrhage into the brain
• Function impairment occurs in areas of the affected brain, including movement, sensation, and emotions
• Stroke severity varies by location and extent of brain involvement
• Blood flow to the brain is affected by: blood pressure, cardiac output, blood viscosity
• Without adequate blood flow (oxygen & glucose), neurons cannot function
• Brain needs at least 20% of the cardiac output
• If blood flow is interrupted, neurological metabolism is altered in 30 seconds and the metabolic function stops in 2 minutes
• Cellular death occurs within 5 minutes
• Stroke is the third leading cause of death in Canada, behind cancer and heart disease
• Approximately 35% of stroke victims die within one year
• Stroke is more common in men and they are more likely to have a thrombolytic or embolic stroke
• Women are more likely to experience a hemorrhagic stroke

Learning Objectives

• Differentiate between ischemic and hemorrhagic strokes
• Describe health patterns and risk factors of stroke conditions
• Identify the clinical significance and related nursing implications for various stroke diagnosis tests and procedures
• Utilize the nursing process as a framework to discuss client care pre, during, and post-stroke
• Assessment of associated clinical manifestations
• Nursing diagnoses
• Goals
• Collaborative care, drug therapy, nursing care, acute care, and health promotion/management

Learning Resources

• Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Barry, M., Lok, M., Tyerman, J. & Goldsworthy, S. (2019). Medical-Surgical Nursing in Canada (4th ed.). Elsevier Canada.

Ischemic Strokes

• Insufficient blood flow due to an occlusion of an artery (87% of all strokes)
• Transient Ischemic Attack (TIA): brief neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction. There is no death of brain cells
• Symptoms last less than 1 hour (more often less than 15 minutes).
• Statistics:
  • <50% are reported to health care providers
  • 1/3 never experience another
  • 1/3 will have another TIA
  • 1/3 will experience a stroke
• Start patients on antiplatelet drugs (ASA, clopidogrel), may be started on statins to reduce cholesterol
• Thrombotic Stroke: cerebral infarction caused by thrombosis in relation to vessel wall injury/plaque build up
• Collateral circulation accounts for approximately 50% of all strokes.
• Symptoms occur in a stepwise progression as ischemia increases
• Common warning sign = TIA
• Embolic Stroke: occurs when an embolus (blood clot or other debris) is formed elsewhere and travels to a cerebral artery
• Results in infarction and edema of supplied areas. Symptoms develop quickly

Hemorrhagic Strokes

• Accounts for approximately 15% of all strokes
• Bleeding in the brain's tissues, the subarachnoid space, or ventricles
• Intracerebral hemorrhage: bleeding within the brain caused by rupture of a vessel
• Increases intracranial pressure
• Hypertension is the most common cause
• Symptoms often occur during periods of activity and are often sudden onset with progression over minutes to hours.
• Warning signs: headache, nausea, and vomiting
• Subarachnoid hemorrhage: intracranial bleeding from a vessel outside the brain bleeding into the cerebrospinal fluid
• Commonly is caused by rupture of a cerebral aneurysm
• Significant warning sign = very severe headache

Aneurysm

• Aneurysm: a permanent, localized outpouching or dilation of the vessel wall, this can be congenital or acquired
• If acquired, often due to atherosclerosis
• Risk of rupture, leading to hypovolemia, ischemia, and infarction in other cells and organs
• Requires surgical intervention

Brain Aneurysm

• Congenital or Acquired
• Genetic component
• Screening recommended
• Pain behind the eye,changes in vision, or double vision
• Ruptured Aneurysm = hemorrhagic stroke

Clinical Manifestations

• Motor Function
  • Most obvious effects of stroke include impairment of mobility, respiratory function, swallowing and speech, gag reflex, and self-care abilities
  • Initial period of flaccidity that can last from days to several weeks
  • Spasticity follows flaccidity, related to interruptions of upper motor neuron influences
• Communication
  • Dysarthria: impaired articulation, disturbance in the muscular control of speech (pronunciation, articulation, and phonation), with comprehension still intact
  • Aphasia: total loss of comprehension and language use (expressive is difficulty expressing oneself, receptive is difficulty comprehending, global is both)
  • Common with left-sided brain stroke
• Affect
  • Difficulty controlling emotions
  • Emotional responses can be exaggerated or unpredictable
  • Frustration related to communication and mobility limitations
  • Common for depression to occur during first year post-stroke
• Intellectual Function
  • Memory and judgment are impaired from a stroke
  • Left brain strokes often result in memory problems related to language
  • Left brain strokes often result in slow and cautious movements
  • Right brain strokes often result in impulsive and quick movements, but without appropriate safety mechanisms in place
• Spatial-Perceptual Alterations
  • Strokes on the right side of the brain often causes problems with spatial-perceptual orientation
  • Problems include: denial of injury, erroneous perception of self in space, difficulty judging distance, unable to recognize objects (sight, touch, and hearing), unable to carry out learned sequential movements upon command
• Diagnostic Studies
  • CT: primary diagnostic test after a stroke
  • Goal: performed within 25 minutes of arrival to the ER
  • Goal: read & reported within 45 minutes
• Prevention is Key!
• Blood pressure (BP) and blood glucose control, diet, exercise, and limiting alcohol intake. Teach families to ACT FAST!

Stroke Management - Acute Care

• Goals include preserving life, preventing further brain damage, and reducing disability
• Treatment varies by stroke type and patient changes
• Single most important patient data = time of onset
• Managing ABCs (airway, breathing, and circulation). Altered LOC and prevention of hypoxia
• Comprehensive neuro exam: level of consciousness, cranial nerve function, sensation, proprioception, cerebellar function, and deep tendon reflexes
• Hypertension management, electrolyte/fluid management, and ICP management
• Fibrinolytic therapy for ischemic strokes

Stroke Management - Nursing Management

• Complications: respiratory, cardiac, musculoskeletal, GI, urinary, neuro-sensory, nutrition-related, and affect-related
• Nursing and collaborative measures: depends on complications and nursing diagnoses
• Rehabilitation: begins 12–24 hours after stroke stabilization;
• Rehabilitation goals: techniques for self-monitoring and physical wellness, demonstrate self-care skills, exhibit problem-solving with self-care, and multidisciplinary approach (physician, nurse, physiotherapist, occupational therapist, speech-language pathologist, and psychologist)
• Rehabilitation strategies: patients with stroke on right side of brain might have difficulty judging positions, distances, and movements; impulsive, impatient; need verbal direction
• Left-sided stroke patients often need nonverbal cues due to language being controlled on the left side.
• Recovery from a stroke needs to be assessed with therapy programs involved

Related Nursing Diagnoses and Complications

• Risk for Injury/Falls, Risk for Impaired Skin Integrity (pressure injury prevention/avoid placing on affected side for more than 30 minutes), Risk for Aspiration Pneumonia, Risk for Imbalanced Nutrition (less than body requirements), Risk for Impaired Swallowing, GI/Urinary, Impaired Communication, Impaired Physical Mobility

Additional Notes

• Case studies
• Learning resources

This quiz focuses on Level III Nursing Theory related to strokes, including causes, effects, and statistics. It covers critical understanding of stroke pathology, alterations in neurological function, and implications for nursing practice. Prepare to assess your knowledge on stroke-related nursing care and interventions.