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 clinical significance of diagnostic tests and procedures for both ischemic and hemorrhagic strokes, utilize nursing process as framework to discuss client care pre, during, and post stroke, including assessment (associated clinical manifestations), nursing diagnoses, goals, implementation (collaborative care, drug therapy, nursing care, acute care, non-acute care (health promotion/management)).

Stroke - Cerebral Vascular Accident

• A stroke is the death of brain cells due to prolonged ischemia or hemorrhage in the brain.
• This leads to loss or impairment of functions like movement, sensation, and emotions.
• Stroke severity depends on the location and extent of brain involvement.
• Blood flow to the brain is affected by factors such as blood pressure, cardiac output, blood viscosity.
• Brain function requires at least 20% cardiac output to operate.
• Interruption of blood flow, like cardiac arrest, can lead to neurological changes and death of brain cells within short timeframes (ex: altered metabolism in 30 seconds, metabolism stops in 2 minutes, and cellular death within 5 minutes)

Stroke - Canadian Statistics

• Stroke is the third most common cause of death in Canada, falling behind cancers and heart disease.
• Approximately 35% of stroke patients die within one year of their initial stroke.
• Stroke is more common in men, though women are more likely to suffer fatal strokes.
• Men and women differ in type of stroke experienced (men more likely to have thrombotic or embolic, and women more likely to experience hemorrhagic).

Risk Factors

• Non-Modifiable: Age, gender, ethnicity/race, and heredity/family history.
• Modifiable: Hypertension, diabetes (4-5x increased risk), heart disease, heavy alcohol consumption, oral contraceptive use (estrogen), physical inactivity, smoking (2x increased risk).

Ischemic Strokes

• Inadequate blood flow due to artery blockage (87% of all strokes).
• Types: Transient Ischemic Attack (TIA), Thrombotic Stroke, Embolic Stroke.

Ischemic Stroke: Transient Ischemic Attack (TIA)

• A brief episode of neurological dysfunction caused by temporary ischemia in the brain.
• Symptoms last less than one hour, frequently less than 15 minutes.
• Approximately 50% of TIA patients are not reported to healthcare professionals.
• One-third of TIA patients experience no further episodes, another one-third have another TIA, and one-third have a stroke.
• Antiplatelet drugs (like aspirin and clopidogrel) are common for TIA.

Ischemic Stroke: Thrombotic Stroke

• A blood clot forms from narrowed vessel injury, damaging its walls over time.
• Most prevalent cause of stroke (~50% of all strokes).
• Symptoms progressively increase with increasing ischemia.
• Warning sign can include TIA.

Ischemic Stroke: Embolic Stroke

• Caused by an embolus (blood clot, air, or other debris) traveling from elsewhere and lodging in a brain artery, leading to immediate infarction and edema in the involved vessel.
• Second most prevalent cause of stroke (~10-15% of all strokes).
• Symptoms typically develop rapidly after the initial event.

Hemorrhagic Strokes

• Caused by bleeding into the brain tissue itself or into the subarachnoid space or ventricles..
• Account for about 15% of all strokes.
• Types: Intracerebral hemorrhage and subarachnoid hemorrhage

Intracerebral Hemorrhage

• Bleeding within the brain due to ruptured blood vessels, often caused by hypertension and impacting during activity.
• Characterized by a sudden onset of symptoms that worsen over minutes to hours as bleeding continues.
• Common warning signs can include headaches, nausea, and vomiting.

Subarachnoid Hemorrhage

• Bleeding into the cerebrospinal fluid surrounding the brain.
• Commonly caused by ruptured cerebral aneurysms.
• Characterized by extremely severe headaches.

Aneurysm

• A permanent localized outpouching or dilation of the arterial wall.
• May be congenital or acquired (often due to atherosclerosis).
• Can rupture, leading to hypovolemia, ischemia, or infarction of other cells and organs.
• Stroke risk factors related to aneurysms are worth considering medically.

Brain Aneurysm

• Clinical manifestations of unruptured aneurysm include: pain behind the eye, changes in vision or double vision.
• Ruptured aneurysm = hemorrhagic stroke

Clinical Manifestations

• Motor Function: Loss of skilled voluntary movements, impairments in muscle tone and reflexes.
• Communication: Aphasia (total loss), Dysphasia (partial loss, often associated with left-sided stroke), Dysarthria (impaired articulation).
• Affect: Difficulty controlling and unpredictable emotional responses, frustration related to communication and mobility.
• Intellectual Function Impaired memory and judgment
• Spatial-Perceptual Alterations Difficulty with spatial orientation, and denial of injury
• Other Considerations: Stroke on right side of brain more likely to cause impaired spatial-perceptual orientation, those with left-sided stroke likely to exhibit slow, cautious movements.

Diagnostics

• When stroke symptoms present, diagnostic tests to definitively identify cause (ischemic vs. hemorrhagic).
• Primary test: CT scan of the brain to be performed within 25 minutes of arrival at the ER.
• MRI, cardiac tests, to rule out other potential concerns and check for risk factors.

Prevention

• Key factors: Blood pressure control, blood glucose management, diet and exercise, smoking cessation, limiting alcohol consumption, and routine health assessment.
• Educate families on recognizing warning signs and ACT FAST (Face, Arm, Speech, Time).

Stroke Management - Acute Care

• Goals: Preserve life, prevent further brain damage, reduce disability.
• Treatment: Treatment plans differ according to stroke type and patient status.
• Important historical information: Time of onset of symptoms.
• Initial treatment: Manage ABCs (Airway, Breathing, Circulation) and altered level of consciousness (LOC)
• Comprehensive Neuroexamination: Includes level of consciousness (using Canadian Neurological Scale), motor abilities, cranial nerve function, sensation, proprioception, cerebellar function (gait, Romberg's, coordination), deep tendon reflexes.
• Blood Pressure & ICP: Immediately after stroke, control hypertension. Manage increased intracranial pressure (ICP).

Stroke Management - Nursing Management

• Complication risks: Respiratory, cardiac, musculoskeletal, gastrointestinal, urinary, neurological, nutritional, and affect.
• Nursing considerations: Assessment and management of complications (e.g., risk for aspiration pneumonia, risk for DVT).
• Nursing interventions: Specific prevention strategies to be reviewed in case studies.
• Nursing interventions are based on associated complications and nursing diagnoses.

Rehabilitation

• Rehabilitation begins 12–24 hours post-stroke stabilization.
• Goals: Learn self-monitoring and physical wellness techniques, self-care skills, problem-solving skills.
• Approach: Multidisciplinary (physician, nurse, physiotherapist, occupational therapist, speech-language pathologist, psychologist).
• Treatment Strategies: Based on the side of the brain affected (Right side: difficulty with judgment and movement, impulsive; left side: slower organization and responses, respond well to nonverbal cues).

Recovery from Stroke

• Neurological recovery following a stroke is variable and influenced by a range of factors.
• The impact of stroke on the brain and types of therapy involved during recovery can be a factor in assessing recovery.

Related Nursing Diagnoses and Complications

• Risk for Injury/Falls: Clear directions, environmental control (clutter removal), nonslip footwear, lighting, call bells, appropriate ambulatory aids.
• Risk for Impaired Skin Integrity: Prevention for pressure injuries.
• Risk for Aspiration Pneumonia: Based upon dysphagia.
• Risk for Imbalanced Nutrition: Nutritional requirements, using feeding assist tools.
• Impaired Swallowing: Assessment, communication, and feeding self-care strategies.
• Impaired Communication: Strategies to assess and enhance communication (e.g. facial exercises, simple questions).
• GI/Urinary: Constipation, poor bladder control, incontinence, and catheter use avoidance.
• Optimize Musculoskeletal Function: Strategies to prevent contractures and improve mobility.
• Risk for DVT: Patient movement to improve venous tone and muscle activity.

Other Related Topics

• Assessment/Rehabilitation: Collaboration with other healthcare professionals is necessary.
• tPA (Tissue Plasminogen Activator): Thrombolytic therapy to break down blood clots; must be administered within 3 to 4.5 hours of stroke onset. Careful screening of patients for suitability for tPA.
• Include information related to specific conditions and interventions (i.e. facial and tongue exercises, simple questions).

This quiz focuses on Level III Nursing Theory related to stroke, covering both ischemic and hemorrhagic strokes. It explores the health patterns, risk factors, and the nursing process involved in client care before, during, and after a stroke. Enhance your understanding of diagnostic tests and their significance in stroke management.