NSG 5130: Nursing Theory on Stroke

NSG 5130: Level III Nursing Theory - Stroke

• Learning Objectives: Differentiate ischemic and hemorrhagic strokes, describe health patterns and risk factors associated with strokes, identify diagnostic tests and procedures for strokes, utilize the nursing process for stroke care (pre, during, and post); assessment (associated clinical manifestations), nursing diagnoses, goals; implementation (collaborative care, drug therapy, nursing care, acute care, health promotion/management).

Stroke Definition

• Stroke, also called a cerebral vascular accident (CVA), is the death of brain cells due to prolonged ischemia (lack of blood flow) or hemorrhage (bleeding) in the brain.

• Functions lost or impaired include movement, sensation, and emotions controlled by affected brain areas.

• Severity varies based on the location and extent of brain involvement.

Stroke - Blood Flow and Brain Function

• Blood flow is affected by factors including blood pressure (BP), cardiac output, and blood viscosity.

• Without adequate blood flow (oxygen & glucose), neurons cannot function.

• Brain needs at least 20% cardiac output.

• Interrupted blood flow (e.g., cardiac arrest) leads to:

• Neurological metabolism altered within 30 seconds.

• Metabolism stops within 2 minutes causing cellular death within 5 minutes.

Stroke: Canadian Statistics

• Stroke is the third most common cause of death in Canada.

• It's behind cancer and heart disease.

• It leads to serious long-term disability.

• Approximately 35% of individuals with an initial stroke die within one year.

• Strokes are more common in men and women are more likely to experience hemorrhagic strokes.

Risk Factors for Stroke

• Non-modifiable: Age, gender, ethnicity/race, heredity/family history.

• Modifiable: Hypertension, diabetes (4-5 times higher risk), heart disease, heavy alcohol consumption, oral contraceptive use, physical inactivity, smoking (2 times higher risk).

Ischemic Strokes

• Inadequate perfusion due to partial or complete artery occlusion (87% of strokes).

• Types: Transient Ischemic Attack (TIA), Thrombotic Stroke, Embolic Stroke.

Ischemic Stroke: Transient Ischemic Attack (TIA)

• Brief neurological dysfunction caused by focal brain/spinal cord/retinal ischemia, without acute infarction.

• Symptoms last less than 1 hour, often under 15 minutes.

• Statistics:

• Less than 50% of TIA cases are reported to healthcare providers.

• ⅓ of TIA patients will never have another TIA.

• ⅓ will have another TIA.

• ⅓ will have a stroke.

• Treatment: Antiplatelet drugs (Aspirin, clopidogrel) and potentially statins to lower cholesterol.

Ischemic Stroke: Thrombotic Stroke

• Thrombosis (blood clot) occurs within a brain vessel, frequently related to blood vessel injury and plaque buildup.

• Often develops gradually over time (the progression of symptoms correlates with increasing ischemia).

• Accounts for 50% of all strokes.

Ischemic Stroke: Embolic Stroke

• Occurs when an embolus (blood clot or other debris) from elsewhere in the body travels and lodges in a cerebral artery.

• Leads to infarction and edema in the affected area.

• Often a sudden onset of symptoms.

• Second most common type of stroke

Hemorrhagic Strokes

• Bleeding into brain tissue, subarachnoid space, or ventricles.

• Accounts for about 15% of all strokes.

• Types: Intracerebral hemorrhage (bleeding inside the brain) and Subarachnoid hemorrhage (bleeding into the subarachnoid space).

Intracerebral Hemorrhage (ICH)

• Bleeding within the brain from a ruptured blood vessel.

• Often caused by hypertension.

• Symptoms typically onset suddenly, and worsen over minutes to hours as bleeding continues.

• Key Warning Signs: Headache, nausea, vomiting.

Subarachnoid Hemorrhage (SAH)

• Intracranial bleeding into the cerebrospinal fluid (CSF) outside the brain tissue.

• Primarily caused by cerebral aneurysms which are permanent outpouchings or dilations of blood vessels.

• Often characterized by extremely severe headaches.

Aneurysms

• Permanent, localized, outpouching or dilation of a blood vessel.

• Can be congenital or acquired (due to atherosclerosis, weakening of vessel wall).

• Risk of rupture leading to hypovolemia, ischemia, and infarction in other tissues and organs.

• May require surgical intervention.

Brain Aneurysm

• Congenital or acquired
• Genetic component
• Screening recommended
• Clinical manifestations of unruptured brain aneurysm: Pain behind the eye, changes in vision or double vision.
• Ruptured = hemorrhagic stroke

Clinical Manifestations (General)

• Manifestations vary depending on the brain area affected.

• Possible issues: Motor function, communication (aphasia/dysphasia), elimination, sensation, intellectual functioning, spatial-perceptual alterations, and personality/affect.

Right vs. Left Side Stroke

• Right side strokes more often result in spatial-perceptual issues, denial of injury or the stroke, impulsiveness.

• Left side strokes often associated with memory problems related to language, cautious movements, difficulty understanding new info

Clinical Manifestations: Motor Function

• The most obvious result of a stroke is impaired mobility.

• Assessing for movement in limbs, respiration, swallowing/speech abilities, reflex present

Clinical Manifestations: Communication

• Aphasia: Total loss of ability to use language (comprehend and express)
• Dysphasia: Partial loss of comprehension or production of language
• Many experience dysarthria (impaired articulation due to muscular disturbance in speech production).

Clinical Manifestations: Affect

• Stroke patients may experience difficulties with emotional control, exaggerated/unpredictable responses.

• Factors like frustration and communication/mobility limitations often contribute

Clinical Manifestations: Intellectual Function

• Memory, judgement may be impaired after a stroke.

• Left-sided strokes more often result in memory problems related to language, slow cautious movements.

Right-sided strokes more often result in impulsive and quick movements, without proper safety mechanisms in place.

Clinical Manifestations: Spatial-Perceptual Alterations

• Stroke on the right side greatly increases probability of spatial-perceptual issues.

• Possible errors: Mistaken perceptions of self in space, difficulty judging distance or size, unable to recognize objects or carry out learned sequential movements or commands, and denial of injury or stroke exist

Glossary of Stroke Terms

• Terms like Alexia, Agnosia, Agraphia, Aphasia, Apraxia, and Aprosy are included

Diagnostics

• Diagnostic studies used to confirm stroke type (ischemic or hemorrhagic).

• A CT scan is the primary test after the beginning of a stroke; performed and read in <45 minutes from arrival to ER).

• Additional tests (MRI, Cardiac testing).

Prevention

• BP control, blood glucose control.

• Good diet and exercise.

• Smoking cessation.

• Limiting alcohol.

ACT FAST!

• Face: Is it drooping?
• Arms: Can you raise both?
• Speech: Is it slurred or jumbled?
• Time: Call 9-1-1 immediately
• Act quickly for stroke management

Stroke Management: Acute Care

• Goals of acute care: Preserve life, prevent further brain damage, and reduce disability.

• Important patient history: Time of onset is crucial.

• Initial care: Manage ABCs, check vital signs (BP, Temperature, pulse).

Stroke Management: Acute Care - Comprehensive Neuro Exam

• Level of consciousness (using the Canadian Neurological Scale).

• Assessing cognition.

• Reviewing cranial nerve function.

• Assess motor abilities; sensation

• Assessing proprioception using tests.

• Assess cerebellar functioning (e.g., gait, Romberg's, coordination).

• Assess deep tendon reflexes.

Stroke Management: Acute Care- Fluid/Electrolytes/ICP (Intracranial Pressure)

• Monitor and Manage blood pressure.

• Management of fluids/electrolytes: Avoid hypervolemia.

• Management of intra cranial pressure (ICP): Use cooling measures; mannitol or 3% saline if cerebral edema exist.

• Surgical intervention only in severe cases

Stroke Management: Acute Care - Specific to Stroke Type

• Ischemic strokes: Fibrinolytic therapy (tPA) , if appropriate time frame

• Hemorrhagic strokes: Manage hypertension, surgical intervention, seizeure prevention

Stroke Management: Nursing Management

• Assess for complications based on injury type and affected areas.

• Focus on respiratory system. (Risk for aspiration, risk for pneumonia).

• Focus on cardiovascular system (Risk for DVT)

Rehabilitation Strategies

• Starts 12-24 hours after stroke stabilization.
• Learn self monitoring techniques for wellness.
• Build self-care skills.
• Multidisciplinary approach involving physicians, nurses, physiotherapists, occupational therapists; speech-language pathologists and psychologists
• Right-sided stroke patients may be impulsive, impatient, and lack insight, respond better to verbal direction
• Left-sided stroke patients may be slower in organization, respond better to nonverbal aids.

Recovery from Stroke

• Rehabilitate to improve physical function, communication and emotional stability.

Related Nursing Diagnoses and Complications

• Identifying Risk for Injuries/Falls, risk for impaired skin integrity, risk for aspiration pneumonnia, imbalanced nutrition, as risk for DVT, Impaired swallowing, feeding self-care deficits, GI/Urinary issues

Additional Notes:

• Further information in the provided references: Important concepts, guidelines for stroke management (acute care, prevention, rehab stages). Use page numbers if needed.

This quiz focuses on Level III Nursing Theory concerning strokes, covering essential topics such as the differentiation between ischemic and hemorrhagic strokes, their health patterns, risk factors, and diagnostic measures. Students will also explore the nursing process in stroke care, including assessment and implementation of care strategies.