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

Stroke = Cerebral Vascular Accident

• A stroke is the death of brain cells caused by prolonged ischemia or hemorrhage in a part of the brain.
• Functions lost or impaired include movement, sensation, and emotions controlled by the affected brain area.
• Stroke severity varies based on the location and extent of brain involvement.

Stroke = Cerebral Vascular Accident - Blood Flow

• Blood flow to the brain is affected by: blood pressure (BP), cardiac output, and blood viscosity.
• Without adequate blood flow (oxygen and glucose), neurons cannot function.
• Brain needs at least 20% cardiac output.
• If blood flow is interrupted (cardiac arrest), neurological metabolism is altered within 30 seconds, metabolism stops in 2 minutes, and cellular death occurs within 5 minutes.

Stroke - Canadian Statistics

• Stroke is the third most common cause of death in Canada.
• It is behind cancer and heart disease.
• Approximately 35% of individuals with initial strokes die within one year.
• Men are more likely to have thrombolytic or embolic strokes, while women die more from hemorrhagic strokes.

Risk Factors

• Non-Modifiable: Age, Gender, Ethnicity and race, and Heredity/family history.
• Modifiable: Hypertension, Diabetes (4-5x risk), Heart disease, Heavy alcohol consumption, Oral contraceptive use (estrogen), Physical inactivity, and Smoking (2x risk).

Ischemic Strokes

• Inadequate perfusion due to partial or complete artery occlusion (87% of all strokes).
• Types: Transient Ischemic Attack (TIA), Thrombotic Stroke, and Embolic Stroke.

Ischemic Stroke: Transient Ischemic Attack (TIA)

• A transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.
• Symptoms last less than 1 hour, most often less than 15 minutes.
• Statistics: about half of TIA patients have another TIA while a third never have another TIA and a third will have a stroke.
• Treatment: antiplatelet drugs (aspirin, clopidogrel), and statins to reduce cholesterol.

Ischemic Stroke: Thrombotic Stroke

• Thrombosis (formation of a blood clot) occurs in a brain vessel in relation to injury or narrowing of the blood vessel (often over time).
• Plaque build-up in blood vessels causes injury, which results in thrombosis.
• Most common stroke type (50% of all strokes). Symptoms progress step-wise as ischemia increases. A common warning sign is TIA.

Ischemic Stroke: Embolic Stroke

• An embolus (blood clot or other debris) formed elsewhere in the body lodges in and occludes a cerebral artery.
• Most often originate from the heart.
• Results in infarction (tissue death) and edema in the area supplied by the involved vessel.
• Second most common stroke cause. Symptoms typically develop quickly.
• Often no prior warning symptoms.

Hemorrhagic Strokes

• Account for approximately 15% of all strokes.
• Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles. Common types: Intracerebral Hemorrhage and Subarachnoid Hemorrhage.

Intracerebral Hemorrhage

• Bleeding within the brain due to vessel rupture, increasing intracranial pressure.
• Hypertension is the most common cause.
• Symptoms include sudden onset, with progression over minutes to hours. Common warning signs include headache, nausea, and vomiting.

Subarachnoid Hemorrhage

• Intracranial bleeding from a vessel outside the brain, into the cerebrospinal fluid.
• Commonly caused by ruptured cerebral aneurysms.
• Warning sign: very severe headaches.
• Associated with higher stroke mortality.

Aneurysm

• A permanent, localized, outpouching or dilation of the vessel wall.
• Can be congenital or acquired.
• Risk of rupture.
• May require surgical intervention.

Clinical Manifestations - Include

• Motor Function: Impaired mobility, respiratory function, swallowing and speech difficulties, gag reflex, and self-care issues.
• Communication: Aphasia (total loss of language comprehension and use), dysphasia (difficulty with language comprehension or use), and dysarthria (disturbance in muscular control of speech) related to muscular control difficulties such as pronunciation, articulation, or phonation. Comprehension is usually still present.
• Affect: Difficulty controlling emotions. Emotional responses may be exaggerated or unpredictable, frustration due to communication and mobility limitations may be expressed, and depression is observed in the first post-stroke year.
• Intellectual function: Problems with memory and judgment. Left-brain stroke often correlates with memory problems and slow, cautious movements. Right-brain stroke may result in impulsive movements and poor safety measures.
• Spatial-Perceptual Alterations: Difficulties in spatial-perceptual orientation. Right-sided brain strokes are more prone to these alterations. Patients might deny injury, misjudge distances or space, and have difficulty recognizing objects, leading to problems with sequential motor tasks.

Diagnostics

• When stroke symptoms occur, diagnostic studies are performed to confirm it as stroke or determine the cause (ischemic or hemorrhagic).
• CT scan is the main diagnostic test, performed within 25 minutes of arrival to the ER and report within 45 minutes to confirm the presence of a stroke. MRI, and cardiac tests rule out other concerns and check for associated risk factors.

Prevention

• Blood pressure (BP) control.
• Blood glucose control.
• Diet and exercise.
• Smoking cessation.
• Limiting alcohol consumption.
• Teaching families about ACT FAST!

ACT FAST!

• Face: Is it drooping?
• Arms: Can you raise both?
• Speech: Is it slurred or jumbled?
• Time: To call 9-1-1.

Stroke Management - Acute Care

• Aims to preserve life, prevent further brain damage, and reduce disability.
• Patient history of stroke onset time is crucial.
• Managing ABCs (Airway, Breathing, Circulation).
• Altered Level of Consciousness (LOC).
• Hypoxia and prevention.
• Intubation and Mechanical Ventilation (severe cases).
• Cardiovascular support (CPR if needed).
• Comprehensive neuro exam.
• Level of consciousness (using Canadian Neurological Scaling).
• Cognition, cranial nerve function, motor, sensory, proprioception, cerebellar function, and deep tendon reflexes.
• Reducing intracranial pressure (ICP) with cooling measures (e.g., blankets, intravenous fluids), mannitol or 3% saline to reduce edema, and pain control measures.
• Hypertension management.
• Fluid and electrolyte balance.
• Avoid hypervolemia.

Stroke Management - Acute Care - Fibrinolytic/Hemorrhagic

• Ischemic (thrombotic/embolic) Stroke: Fibrinolytic therapy STAT (tPA) is frequently given in acute phase cases, potentially including surgical treatment.
• Hemorrhagic Stroke: Focus on managing hypertension, and preventing surgical intervention and seizures.

Stroke Management - Nursing Management

• Complications of stroke are varied.
• Nurses must address potential risks for patients (e.g., aspiration pneumonia, injury/falls, impaired skin integrity, DVT, and urinary/GI complications).
• Collaborative/Multidisciplinary interventions are essential to address patient needs and complications.

Rehabilitation

• Stroke rehabilitation begins 12–24 hours after stroke stabilization.
• Goals include learning self-monitoring techniques to maintain physical wellness.
• Demonstrating self-care skills, problem-solving skills with self-care, and multidisciplinary approach (physician, nurse, physiotherapist, occupational therapist, speech-language pathologist, psychologist).

Rehabilitation Strategies

• Patients with right-brain stroke often have difficulty judging spatial relationships, distance, and movement. They may be impulsive, impatient, and insensitive. Verbal directions are often best suited for these patients.
• Patients with left-brain stroke may have speech or language difficulties. They may be fearful and anxious, and responding to nonverbal cues may be better suited.

Recovery from a Stroke

• Focus on the impact of stroke on the brain and the types of therapy involved in recovery.

Related Nursing Diagnoses and Complications

• Various nursing diagnoses and complications can arise from stroke events.
  • Risk for Injury/Falls
  • Risk for Impaired Skin Integrity
  • Risk for Aspiration Pneumonia
  • Risk for Imbalanced Nutrition: Less Than Body Requirements
  • Impaired Swallowing/Feeding Self-Care Deficit
  • Impaired Communication
  • GI/Urinary (e.g., constipation, urinary incontinence)
  • Risk for DVT (Deep Venous Thrombosis)

Other Important Considerations

• Positioning: Proper positioning for patients with stroke is essential. Different positioning strategies may be necessary, based on the side of the brain affected by the stroke.
• Adaptive/Assistive Technology: Adaptive tools, splints, and/or equipment (e.g., walkers or wheelchairs) may be recommended.
• Communication: Communication strategies are helpful to address communication deficits. Simple questions, yes/no options, lists of words, and/or visuals may be used frequently to help facilitate more effective communication.

Test your knowledge on the critical aspects of stroke, including the differences between ischemic and hemorrhagic strokes. This quiz covers health patterns, risk factors, and the nursing process involved in client care. Assess your understanding of nursing implications related to diagnostic tests and patient management pre, during, and post-stroke.