NSG 5130: Nursing Theory - Stroke Overview

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 diagnostic tests and procedures for both ischemic and hemorrhagic strokes, and use the nursing process to discuss client care pre, during, and post-stroke. Sub-topics include assessment of associated clinical manifestations, nursing diagnoses, goals, implementation, collaborative care, drug therapy, nursing care, acute care, and health promotion/management.

• Learning Resources: 2019 edition of Lewis, et al.'s Medical-Surgical Nursing in Canada, chapter 60.

Stroke = Cerebral Vascular Accident

• A stroke is the death of brain cells caused by prolonged ischemia or hemorrhage.
• Functions controlled by the affected area of the brain are lost or impaired.
• Stroke severity varies based on location and extent of brain involvement.

Blood Flow to the Brain

• Blood flow to the brain is affected by blood pressure (BP), cardiac output, and blood viscosity.
• Insufficient oxygen and glucose due to inadequate blood flow leads to neuronal dysfunction.
• Brain requires at least 20% cardiac output.
• Interrupted blood flow (e.g., cardiac arrest) results in neurological metabolism alteration within 30 seconds, metabolism stops in 2 minutes, and cellular death within 5 minutes.

Stroke - Canadian Statistics

• Stroke is the third leading cause of death in Canada, following cancer and heart disease.
• Approximately 35% of stroke patients die within the first year.
• Stroke is more common in men but women have a higher risk of death from stroke.
• Those with their initial stroke tend to have either thrombolytic or embolic strokes, while women are more likely to have hemorrhagic strokes.

Risk Factors

• 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 (estrogen), physical inactivity, smoking (2 times higher risk).

Ischemic Strokes

• Account for 87% of all strokes.
• Caused by inadequate perfusion due to partial or complete blockage of an artery.
• Sub-types include transient ischemic attack (TIA), thrombotic stroke, and embolic stroke.

Ischemic Stroke: Transient Ischemic Attack (TIA)

• A temporary episode of neurological dysfunction from focal brain, spinal cord, or retinal ischemia, without infarction.
• Symptoms last less than 1 hour, most often less than 15 minutes.
• Statistics show that ~50% of TIA patients report to healthcare professionals, with a 1/3 chance of not having another TIA, 1/3 chance of having another TIA, and 1/3 chance of having a stroke.
• Treatment includes antiplatelet drugs (aspirin, clopidogrel [Plavix]) and possibly statins to reduce cholesterol, if appropriate.

Ischemic Stroke: Thrombotic Stroke

• Aka cerebral infarction, resulting from thrombosis in a brain vessel due to injury to the blood vessel wall
• Clots often develop over time due to plaque buildup, which causes narrowing of the blood vessel and subsequently impedes blood flow to the brain area supplied by the vessel.
• Accounts for ~50% of all strokes.
• Characterized by a stepwise progression of symptoms as ischemia increases.
• TIA can be a warning sign of a potential thrombotic stroke.

Ischemic Stroke: Embolic Stroke

• Caused by an embolus (blood clot or other debris) formed elsewhere in the body that lodges in and occludes a cerebral artery.
• Most often related to a cardiac origin(plaque).
• Results in infarction and edema in the area supplied by the involved vessel.
• Stroke symptoms typically appear quickly as a singular event.
• A warning sign can be TIA.

Hemorrhagic Strokes

• Account for ~15% of strokes.
• Result from bleeding into the brain tissue itself, subarachnoid space, or ventricles.
• Sub-types include intracerebral hemorrhage and subarachnoid hemorrhage.

Intracerebral Hemorrhage

• Bleeding within the brain from a ruptured blood vessel.
• Causes increased intracranial pressure
• Commonly occurs during periods of activity.
• Symptoms include sudden onset and progressive symptoms over minutes to hours.
• Warning signs include severe headache, nausea, and vomiting.

Subarachnoid Hemorrhage

• Intracranial bleeding from a ruptured vessel just outside the brain.
• Commonly associated with rupture of a cerebral aneurysm.
• Often a very severe headache is the warning sign.
• Associated with a higher risk of stroke mortality.

Aneurysm

• A permanent localized outpouching or dilation of a blood vessel wall.
• Can be congenital or acquired (often related to atherosclerosis).
• Rupture can lead to hypovolemia and ischemia/infarction to other cells and organs.
• Surgical intervention may be required.

Brain Aneurysm

• Aneurysm can be congenital, be acquired due to atherosclerosis.
• Screening is recommended.
• Clinical manifestation of an unruptured brain aneurysm includes pain behind the eye, changes in vision, or double vision.

Clinical Manifestations

• Motor Function: Includes mobility, respiratory function, swallowing, speech, gag reflex, and self-care abilities. Impairment may include flaccidity (lasting days to weeks, related to nerve damage), and subsequent spasticity (related to interruptions in upper motor neuron influence).
• Communication: Can involve aphasia (total loss of comprehension and use of language) or dysphasia (difficulty with comprehension or use of language). Dysarthria (impaired articulation) due to disturbance in muscle control could also occur, but comprehension may remain intact.
• Affect: Patients may experience difficulty controlling emotions, with responses possibly exaggerated or unpredictable, and related frustration due to communication or mobility limitations. Depression is also commonly encountered following stroke.
• Intellectual Function: Memory and judgment may be impaired. Left side strokes are more likely to cause memory problems related to language, resulting in slower/cautious movements. Right side strokes may result in impulsive/quick movements and ignoring safety mechanisms.
• Spatial-Perceptual Alterations: Right side strokes more often cause problems in spatial-perceptual orientation, with the patient showing erroneous perception of self in space or difficulty with judging distance and recognizing objects.

Diagnostics

• When stroke symptoms occur, diagnostic studies are conducted to determine if it's a stroke, identify its cause (ischemic vs. hemorrhagic), and complete related assessments. A CT scan within 25 minutes of arrival to the emergency room (ER) is the primary test. A CT scan should be read within 45 minutes of arrival.

Prevention is Key

• BP control, blood glucose control, diet and exercise, smoking cessation, limiting alcohol consumption, and teaching families about ACT FAST, are key prevention methods to implement.

Act FAST!

• A mnemonic (Face, Arms, Speech, Time) to easily assess stroke symptoms to quickly aid those who may be experiencing a stroke.

Stroke Management

• Acute Care: Begins with managing ABC's (airway, breathing, and circulation). Comprehensive neuro examination, and managing vital signs, especially blood pressure and fluid/electrolyte balance and possible increased intracranial pressure (ICP).
• Nursing Management: Focuses on managing stroke complications. Addressing risks such as respiratory compromise, skin impairment, impaired swallowing, and communication.
• Complications of Stroke: Complications include respiratory compromise or aspiration pneumonia, cardiac issues, muscular skeletal concerns, GI and urinary problems, neurological concerns, nutritional issues, and emotional affects.
• Nursing and Collaborative Measures: Interventions (like medication adjustments) depend on the patient's associated complications and nursing diagnoses. Case studies and comprehensive nursing management from reference material are essential for specific action plans.
• Rehabilitation: Stroke rehabilitation starts within 12-24 hours post-stroke stabilization. Techniques for self-monitoring and maintenance of physical well-being, problem-solving, and self-care skills are learned. A multidisciplinary approach involving speech therapy, physical therapy, occupational therapy, physicians, and a psychologist is essential.

Recovery From a Stroke

• Recovery involves understanding the impact of stroke on the brain, and recognizing therapy options.

Related Nursing Diagnoses and Complications

• Risk for Injury/Falls: The risk factors include poor orientation, environment hazards, and mobility issues, but these can be minimized via clear instructions, environmental control, nonslip socks, good lighting, and appropriate placement of call bells to promote independence.
• Risk for Impaired Skin Integrity: The risk is associated with immobility, and needs proactive interventions to prevent skin impairment, and also should involve avoiding pressure on one-side of the body for too long or any immobility for extended periods.
• Risk for Aspiration Pneumonia: Stroke patients risk aspiration pneumonia because of their potential for difficulty swallowing. Intervention strategies to help prevent this should be addressed in an individualized manner.
• Risk for Imbalanced Nutrition: Nutritional needs require quick assessment and treatment, and may include IV infusions to maintain fluid and electrolyte balance.
• Impaired Swallowing: Intervention strategies can be supported by therapy. Treatment plan may include no distractions in the eating area, adaptive tools like adaptive utensils, strength training, encouraging the patient to look towards the affected side, and placing food towards the non-affected oral side.
• Impaired Communication: Aphasia/Dysphasia (and dysarthria) are addressed via communication strategies with simple verbal communication approaches, lists of words/phrases that can be practiced (via communication therapy), and questions that utilize simple "yes" or "no" responses.
• Gastrointestinal/Urinary System: Issues like constipation and bladder control problems have preventative measures like physical activity promotion, stool softeners, and avoiding catheters if possible.
• Optimize Musculoskeletal Function: Prevent contractures with hand splints, arm supports, leg splints, and footboards. Don't pull at one limb. Careful attention should paid to positioning in terms of joint placement and support to avoid edema from dependency. Using transfer belts, wheelchairs and walkers when necessary can also aid in safety measures.
• Positioning: A proper positioning method should be used depending on the patient's stroke, and involves the use of pillows for comfort, as well as avoiding pressure sores.
• Risk for Deep Vein Thrombosis (DVT): Preventing immobility and using proactive preventative measures can help reduce the risk factors related to stroke. This will be reviewed later in the lecture.

Additional Information

• Tissue Plasminogen Activator (tPA): A thrombolytic therapy used to break up clots. tPA is administered within 3 to 4.5 hours of stroke symptom onset.
• Medication Orders: Nurses need to question any orders if they are unsure, and should communicate any concerns to the healthcare provider.
• Clinical Judgement: Nurses need demonstrated clinical judgement and knowledge to assess a patient.

Glossary Of Frequently Used Terms In Stroke

• Terms and definitions for terminology in the content of concern.

References

• Heart and Stroke Foundation of Canada (2020)
• Lewis et al. (2019), Medical-Surgical Nursing in Canada(4th Canadian Edition)
• McMillan (2020), Altered Consciousness Part 2 (PowerPoint slides).

This quiz evaluates knowledge on ischemic and hemorrhagic strokes, including assessment, diagnosis, and nursing care. It is based on Chapter 60 from Lewis' Medical-Surgical Nursing in Canada. Test your understanding of stroke conditions and their management throughout the nursing process.