NSG 5130: Stroke Nursing Theory

Learning Objectives: Differentiate between ischemic and hemorrhagic strokes, describe health patterns and risk factors associated with stroke conditions, identify diagnostic tests and procedures, utilize the nursing process, and assess associated clinical manifestations. Includes nursing diagnoses, goals, and implementation (collaborative care, drug therapy, nursing care, acute and non-acute care).

Stroke (Cerebral Vascular Accident): Death of brain cells due to prolonged ischemia (lack of blood flow) or hemorrhage into the brain. This results in loss or impairment of functions including movement, sensation, and emotions controlled by the affected brain area. Severity depends on location and extent of brain involvement.
Blood flow to the brain: Affected by blood pressure, cardiac output, and blood viscosity. Without adequate blood flow, neurons cannot function. Brain needs at least 20% cardiac output. If blood flow is interrupted (e.g., cardiac arrest), neurological metabolism is altered within 30 seconds, and cellular death can occur within 5 minutes.
Canadian Statistics: Stroke is the third leading cause of death and the leading cause of serious long-term disability in Canada. About 35% of individuals who have an initial stroke die within one year. Stroke is more common in men, though women die more from stroke, often from hemorrhagic types.

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

Definition: Inadequate brain perfusion due to partial or complete occlusion of an artery. Ischemic strokes account for about 87% of all strokes.
Types:
- Transient Ischemic Attack (TIA): Transient episode of neurological dysfunction from ischemia without acute infarction. Symptoms last less than 1 hour, often less than 15 minutes. Statistics: <50% are reported, 1/3 will never have another attack, 1/3 will have another TIA, and 1/3 will have a stroke. Antiplatelet drugs (ASA, clopidogrel) are typically started for TIA patients.
- Thrombotic Stroke: A blood clot (thrombus) forms in a brain vessel, often due to injury or narrowing over time, resulting in infarction. This accounts for about 50% of all strokes. Gradual onset.
- Embolic Stroke: A detached blood clot (embolus) forms elsewhere in the body and travels to a brain vessel, blocking blood flow. This is the second most common cause of stroke, typically a single event with rapid symptom onset.

Definition: Bleeding into the brain tissue itself, the subarachnoid space, or ventricles. Hemorrhage accounts for about 15% of all strokes.
Types:
- Intracerebral Hemorrhage: Bleeding within the brain tissue, often due to ruptured blood vessel. Often a sudden onset of symptoms with progression over minutes to hours. Common cause is hypertension.
- Subarachnoid Hemorrhage: Bleeding into the subarachnoid space between the brain meninges. Frequently stemming from a cerebral aneurysm. Characteristics strongly include a very severe headache.

Definition: Permanent, localized outpouching or dilation of a blood vessel wall. Can be congenital or acquired (often due to atherosclerosis). Risk of rupture causing hypovolemia, ischemia, and infarction to other cells and organs. Surgical intervention may be required.

Motor Function: Impairment of movement, reflexes, and self-care abilities (initially flaccidity, followed by spasticity).
Communication: Aphasia (total loss of comprehension and use of language) or dysphasia (difficulty comprehending or using language), and dysarthria (impaired articulation).
Affect: Difficulty controlling emotions, exaggerated or unpredictable responses, frustration with communication and mobility limitations, and depression.
Intellectual Function: Impaired memory and judgment. Left-sided stroke is associated with specific language-related memory issues, slow and cautious movements. Right-sided stroke associated with impulsive, quick movements.
Spatial-Perceptual Alterations: Difficulties with spatial orientation and judging distance; misperception of self in space, inability to recognize objects or carry out sequential movements.
Other: Dysphagia (swallowing difficulties).

Studies done for strokes: Goal is to confirm the event is a stroke, identify the cause (ischemic vs. hemorrhagic), and rule out other medical issues. The primary diagnostic test is a CT scan, performed within 25 minutes of arrival to the ER and read within 45 minutes. Also include potentially MRI, cardiac tests, and other studies if necessary.

Addressing Risk Factors: Maintaining proper blood pressure control, controlling blood glucose levels, improving dietary habits, getting exercise, cessation of smoking, routine health assessments, and limiting alcohol consumption
ACT FAST: Educating families and individuals on the signs of stroke; being aware of symptoms allows for quicker reaction and intervention.

Goals: Preserving life, preventing further brain damage, and reducing disability.
ABCs (Airway, Breathing, Circulation): Assessing and managing airway, breathing, and circulation during the acute phase of care, including addressing altered levels of consciousness and potentially requiring intubation, ventilation, or CPR.
Comprehensive Neuro Exam: Includes level of consciousness (using the Canadian Neurological Scale), cognition, cranial nerve function, motor abilities, sensation, proprioception, cerebellar function, and deep tendon reflexes.
Managing Blood pressure: Only using medication to lower blood pressure if elevated and significant; high blood pressure after a stroke may increase mortality rates.
Managing Fluids and Electrolytes: Preventing hypervolemia and proper electrolyte balance.
Intracranial Pressure (ICP): Management potentially needed to reduce ICP; measures like cooling (blankets, IVs) to decrease metabolic demand and administer medications to reduce cerebral edema. Potential surgery if severe.
Fibrinolytic Therapy (tPA): For ischemic strokes, administered within specific time windows (3-4.5 hours after onset of symptoms) to dissolve blood clots. Stroke patients who present with hemorrhagic stroke are not candidates for tPA.

Complications: Risk for aspiration pneumonia, pressure injuries, impaired swallowing, urinary incontinence, and deep vein thrombosis (DVT) are potentially common.
Nursing and Collaborative Measures: Interventions tailored to specific complications and nursing diagnoses outlined in case studies and the 2020 Lewis text, pages 1520-1529.

Rehabilitation Strategies: Tailored to specific neurological deficits, emphasizing self-monitoring and maintaining wellness.
Goals: Techniques for self-care skills, problem-solving, and multidisciplinary approaches.
Multidisciplinary Team: Including physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and psychologists
Right-brain stroke symptoms: Difficulty with spatial awareness and judgment; tendency toward impulsiveness, disregard for limitations. Improvements best approached with verbal commands and non-verbal cues.
Left-brain stroke symptoms: Language-related memory problems, slower movements, sensitivity to environmental issues. Improvements best approached through nonverbal cues.