NSG 5130: Nursing Theory on Stroke

NSG 5130: Level III Nursing Theory - Stroke

Learning Objectives: Differentiate between ischemic and hemorrhagic strokes, describe health patterns and risk factors associated with stroke conditions, identify the clinical significance and nursing implications of diagnostic tests for both ischemic and hemorrhagic strokes, utilize the nursing process as a framework to discuss pre-, during, and post-stroke care (including assessment, nursing diagnoses, goals, and implementation). Collaborative care, drug therapy, nursing care, and acute/non-acute care (health promotion/management) are also crucial components
Learning Resources: Lewis, et al. (2019), Medical-Surgical Nursing in Canada, 4th ed. (Canadian ed.), Chapter 60, Elsevier, Toronto.
Stroke = Cerebral Vascular Accident: Death of brain cells resulting from prolonged ischemia (lack of blood flow) or hemorrhage (bleeding) into the brain. This leads to lost or impaired functions, such as movement, sensation, and emotions, affected by the location and extent.
Blood Flow to the Brain: Stroke occurs when blood flow to the brain is affected by factors such as blood pressure (BP), cardiac output, blood viscosity, and without adequate blood flow (oxygen & glucose), neurons cannot function. The brain needs at least 20% cardiac output. If blood flow is interrupted (e.g., cardiac arrest), metabolism is altered within 30 seconds, stops in 2 minutes, and cellular death occurs within 5 minutes.
Canadian Stroke Statistics: Stroke is the third most frequent cause of death, behind cancer and heart disease, and is the leading cause of serious, long-term disability. Approximately 35% of individuals who experience an initial stroke die within one year. Stroke is more common in men, and men tend to have more thrombolytic or embolic strokes. Women tend to have more hemorrhagic strokes.
Risk Factors:
Non-Modifiable: Age, gender, ethnicity/race, heredity/family history
Modifiable: Hypertension, diabetes (4-5x risk), heart disease, heavy alcohol consumption, oral contraceptive use (estrogen), physical inactivity, smoking (2x risk)
Ischemic Strokes: Inadequate perfusion due to partial or complete occlusion (blockage) of an artery (87% of all strokes). This can have subtypes:
Transient Ischemic Attack (TIA): Brief neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction. Symptoms last less than 1 hour, often less than 15 minutes. Statistics show <50% reported to HCP's, 1/3 never have another TIA, 1/3 have another TIA, and 1/3 have a stroke. Treatment includes antiplatelet drugs (ASA, clopidogrel) and potentially statins to reduce cholesterol.
Thrombotic Stroke: Thrombosis (formation of a blood clot) occurs in a brain vessel usually due to injury, and plaque build-up over time causes narrowing or blockage of blood vessels. Collateral circulation is impacted, often resulting in stepwise progression of symptoms. Warning sign is often TIA.
Embolic Stroke: An embolus (blood clot or other debris) formed elsewhere in the body travels and occludes a cerebral artery. Symptoms are often sudden, and develop quickly.
Hemorrhagic Strokes: Bleeding into brain tissue, the subarachnoid space, or the ventricles (15% of all strokes). This can have subtypes:
Intracerebral Hemorrhage: Bleeding within the brain caused by ruptured blood vessels. This significantly increases intracranial pressure. Hypertension is a common cause. Symptoms are often sudden with progression over minutes to hours due to ongoing bleeding. Warning signs are headache, nausea, and vomiting.
Subarachnoid Hemorrhage: Intracranial bleeding from a vessel just outside the brain, into cerebrospinal fluid. This is commonly caused by a ruptured cerebral aneurysm. A warning sign is often a severe headache; and is associated with higher stroke mortality rates.
Aneurysm: A weak spot or bulging in a blood vessel wall (can be congenital or acquired). Atherosclerosis may contribute to weakening of the wall. There is a risk of rupture that leads to hypovolemia, ischemia/infarction to organs and cells. Surgical intervention may be necessary.
Brain Aneurysm: Congenital or acquired genetic component with a possible screening recommended. Clinical manifestations include: pain behind the eye, vision changes, and potentially double vision - with rupture can lead to a hemorrhagic stroke.
Clinical Manifestations: Manifestations of stroke vary based on the affected brain region. Manifestations are often found in multiple categories of functions: motor function (affects many body functions, impacts communication abilities), elimination, sensation, intellectual function, spatial-perceptual alterations, and personality/affect.
Clinical Manifestations: Motor Function: Patients experience a period of flaccidity which can last from days to weeks, followed by spasticity. Spasticity is related to interruptions in the upper motor neuron's influence. Assessment for mobility, respiratory function, swallowing & speech, gag reflex, and self-care abilities are necessary to address.
Clinical Manifestations: Communication: Patients may have aphasia (total loss in comprehension and use of language) or dysphasia (difficulty with comprehension and use of language). Dysarthria, impaired articulation due to muscular control, often affects pronunciation, articulation, and phonation, yet comprehension is usually still present.
Clinical Manifestations: Affect: Stroke patients may struggle to control their emotions. These emotional responses can be exaggerated or unpredictable due to limitations on communication and mobility. Depression commonly occurs during the first year following the stroke.
Clinical Manifestations: Intellectual Function: Stroke can impact memory and judgment. Left-brain strokes can lead to memory issues or lead to slow and cautious movements. Right-brain strokes can lead to impulsive or quick movements without safety mechanisms.
Clinical Manifestations: Spatial-Perceptual Alterations: Right-brain strokes can cause spatial-perceptual deficits and issues with self-awareness in space, distance judgment, recognition of objects or body parts, and sequential behaviors or commands.
Diagnostics: When stroke symptoms occur, diagnostic studies focus on identifying the cause: ischemic or hemorrhagic. A CT scan is the primary test in stroke to determine likely cause. MRI and cardiac tests are additional considerations to rule out secondary concerns.
Prevention: Key strategies include controlling blood pressure, blood glucose levels, diet and exercise, smoking cessation, routine health assessments and teaching families the ACT FAST! signs of a stroke (Face, Arms, Speech, Time).
Stroke Management: Acute Care: The primary goals of care in the acute phase of a stroke are preserving life, preventing further brain damage, and reducing disability. Acute care begins by initially managing ABCs, altered level of consciousness, breathing, and circulation. The time of onset is a vital piece of information for proper treatment. A comprehensive neuro exam, including level of consciousness, cognition, motor abilities, cranial nerve function, sensation, proprioception (grasp test), cerebellar function (gait, Romberg's, coordination), and deep tendon reflexes is crucial. Managing hypertension, fluid and electrolytes to avoid hypervolemia, along with evaluating increased intracranial pressure (ICP) is vital. Treatment differs based on ischemic (fibrinolytic therapy) and hemorrhagic strokes(managing hypertension, surgical intervention).
Stroke Management: Nursing Management: The management of stroke complications, such as risk for aspiration pneumonia, urinary incontinence, impaired skin integrity, risk for DVT, and impaired swallowing, is addressed. Nursing interventions focus on minimizing complications and promoting patient safety and well-being.
Rehabilitation: Stroke rehabilitation begins 12-24 hours post-stroke stabilization and focuses on achieving patient goals including self-monitoring to maintain physical function, self-care skills, and problem-solving. A multidisciplinary approach will utilize physician, nurses, physiotherapists, occupational therapists, speech-language pathologists, and psychologists.
Rehabilitation Strategies: Strategies include addressing the impact of stroke location (right vs. left side) on patient behavior and response. Patients with right-sided stroke often have difficulty judging position, distance, and movement due to impulsiveness, and often benefit from verbal directions. Patients with left-sided stroke often respond well to nonverbal cues and may have difficulty with memory & language.
Recovery: Understanding the impact of stroke on the brain and relevant therapies are crucial for both patient and family to understand the recovery process.
Related Nursing Diagnoses and Complications Consider diagnoses and complications resulting from stroke, potentially encompassing: Risk for Injury/Falls (environmental modifications), Risk for Impaired Skin Integrity (pressure injury prevention, turning schedules), Risk for Aspiration Pneumonia (assessment of swallowing ability), Risk for Imbalanced Nutrition: Less than Body Requirements (ensure adequate nutrition and hydration), Impaired Swallowing (feeding self-care deficit), Impaired Communication (communication strategies), GI/Urinary dysfunction (constipation is common, efforts should be made to promote normal bladder and bowel functions), and Risk for Deep Vein Thrombosis (DVT) (prevention through mobility & positioning).