Stroke and Hemiplegia Quiz

Stroke/Apoplexy/Brain Attack (CVA)

• Stroke is a medical emergency, a rapidly developing focal or global disturbance of cerebral function lasting 24 hours or longer, or leading to death, with no apparent cause other than a vascular origin.
• Stroke is also defined as a sudden global or focal neurological deficit resulting from spontaneous haemorrhage or infarction of the central nervous system, with objective evidence of an infarction or haemorrhage, irrespective of the duration of clinical symptoms.
• Stroke is a medical emergency where blood supply to part of the brain is interrupted, causing cell death and loss of function.
• Stroke arises from ischemia (inadequate blood flow) or hemorrhage into the brain, leading to brain cell death.
• Transient Ischemic Attack (TIA), sometimes called a "mini-stroke," involves a temporary reduction in blood flow to part of the brain.
• TIA symptoms resemble strokes, lasting minutes to hours but not causing permanent damage.
• TIA causes are often blood clots or other blockages temporarily obstructing blood flow to the brain.
• TIA symptoms include numbness, weakness, especially on one side of the body, speech difficulties, confusion, vision issues, and walking problems.
• Typical TIA symptoms resolve within 24 hours (usually within minutes to hours).
• TIA is a warning sign for future strokes, increasing the risk of full-blown stroke.
• The brain needs a constant blood supply (750-1000 mL/min) to provide oxygen and glucose for neuron function.
• If blood flow is completely cut off (e.g., cardiac arrest), neurological metabolism is immediately affected, ceasing in 2 minutes, and cellular death occurring within 5 minutes.
• Factors affecting brain blood flow include systemic blood pressure, cardiac output, and blood viscosity.
• Brain attack, and cerebrovascular accident (CVA) are additional terms used for stroke to highlight the urgency of recognizing and responding to the medical situation as one would for a heart attack.
• Apoplexy is another term for stroke, deriving from the Greek word for "struck down with violence".
• Stroke results in permanent neurological damage and potential complications or death without prompt diagnosis and treatment.
• Common motor dysfunction in stroke is hemiplegia (paralysis of one side of the body), caused by a lesion on the opposite side of the brain; hemiparesis (weakness on one side of the body) is also a potential sign.

Risk Factors

• Non-modifiable: Increasing age (risk doubles annually after 55), race (higher in blacks and Hispanics), gender (men have a 50% higher risk), and family history of stroke or TIA.
• Modifiable: High blood pressure (a major risk factor), smoking, diabetes, high cholesterol, physical inactivity, obesity, excessive alcohol consumption, heart disease (especially atrial fibrillation), sickle cell anemia, high cholesterol levels in the blood, drug abuse, hormone replacement therapy (HRT), and use of birth control pills/oral contraceptives.

Types and Causes of Stroke

• Ischemic stroke: Blood supply to a part of the brain is reduced, leading to brain tissue dysfunction and necrosis; TIA is a precursor to ischemic stroke.
• Ischemic Stroke Causes: Thrombosis (blood clot forms locally), atherosclerotic plaques narrowing blood vessels, hypertension or diabetes (accelerating atherosclerosis), and an embolus lodging in a cerebral artery; thrombosis is the most frequent cause (about 60%).
• Embolic stroke: An embolus (blood clot) travels to and blocks a cerebral artery, causing infarction and edema in the supplied area. It accounts for approximately 24% of strokes. Most emboli originate inside the heart with a plaque breaking off from the endocardium.
• Systemic hypoperfusion: A general decrease in blood supply (e.g., in shock, decreased cardiac output).
• Cryptogenic stroke: Stroke with no identifiable cause.

Hemorrhagic Stroke

• Intracranial hemorrhage where blood accumulates within the skull; it accounts for 15-20% of cerebrovascular disorders.
• Intracerebral hemorrhage: Bleeding within the brain caused by a ruptured blood vessel. A poor prognosis, with 50% of deaths occurring within the first 48 hours, commonly caused by hypertension.
• Subarachnoid hemorrhage: Bleeding into the space surrounding the brain; causes include cerebral aneurysm and arteriovenous malformation.

Pathophysiology of Stroke

• Ischemic stroke: A blood clot or blockage prevents oxygen-rich blood from reaching brain cells, resulting in tissue death.
• Hemorrhagic stroke: Leaking blood into brain tissue or surrounding spaces compresses structures, disrupts blood supply, and increases intracranial pressure, causing cellular death.

Signs and Symptoms

• Weakness on one side of the body, including the face.
• Inability to rise from a sitting or lying position.
• Sudden fall.
• Loss of speech.
• Difficulties with walking, dizziness, loss of balance, or coordination.
• Unconsciousness in some patients.
• Seizures.
• Paralysis of a limb or face.
• Initial flaccidity, but later spasticity and exaggerated reflexes.
• Loss of half the visual field (homonymous hemianopsia).
• Hemiplegia (paralysis of one side of the body) caused by a lesion of the opposite side of the brain.
• Neck stiffness (in subarachnoid hemorrhage).
• Severe headache and/or neck pain (in subarachnoid hemorrhage).
• Communication loss (dysarthria, dysphasia or aphasia, or apraxia).
• Emotional deficits (loss of self-control, emotional lability, decreased tolerance to stress, depression, withdrawal, fear, hostility, and anger).

Investigations

• CT scan: Distinguishes between ischemic and hemorrhagic stroke.
• MRI: More sensitive in detecting early ischemic changes and small infarcts.
• Blood tests: Ruling out other causes, assessing clotting, and checking for underlying conditions.
• Angiography: Visualizing blood vessels, identifying blockages or hemorrhages.
• Echocardiogram: Assessing the heart, especially if an embolic source is suspected.
• ECG: Detecting cardiac arrhythmias like atrial fibrillation; FBC, ESR, Serum Glucose, lipids, blood urea, electrolytes, creatinine, uric acid, chest x-ray, complete physical and neurologic examination, lumbar puncture.

Treatment

• Objectives: Limiting brain damage progression, protecting from unconsciousness and immobility, treating the underlying cause if possible, improving functional recovery, supporting and rehabilitating survivors with disabilities, preventing recurrence.

Non-Pharmacological Treatment (Nursing Management)

• Monitoring vital signs, neurological signs frequently.
• Establishing an adequate airway in unconscious patients.
• Lateral positioning with suctioning where needed.
• Preventing pressure sores by regular turning (every 2 hours).
• Maintaining adequate hydration.
• Inserting a nasogastric tube for feeding/medications in unconscious/swallowing-impaired patients.
• Inserting urethral/condom catheter for hygiene.
• Early and ongoing physiotherapy.

Pharmacological Treatment

• Hemorrhagic stroke: Antihypertensive medications to gradually reduce blood pressure over several days. Controlling diabetes and comorbidities.
• Ischemic stroke: Aspirin (oral, 75 mg daily).
• Ischemic stroke: Statins (such as Atorvastatin, 10-40 mg daily, Rosuvastatin, 5-10 mg daily, or Simvastatin, 20 mg daily).

Nursing Management

• Visual Problems: Ensuring objects are within the patient's intact field of vision, approaching from the side of the intact field, instructing head turning to compensate for loss, and encouraging use of eyeglasses when needed. Ensuring patient safety when moving around in and out of bed and other activities.
• Using a cane or other peripheral cues to aid in visual guidance.
• Placing items consistently in the same location.
• Paralysed Site Management: Managing affected side reach, exercising unaffected side, performing range-of-motion exercises on the affected side, and providing immobilization as needed.
• Maintainting body alignment in functional position.
• Assisting during initial ambulation, implementing falls prevention strategies, and determining appropriate assistive devices (walkers, canes).
• Avoiding patient ambulation without assistance or a supportive device.
• Communication: Providing alternative communication methods (bells, communication boards, etc.), giving sufficient time to respond, supporting patients and families, encouraging repetition of sounds of the alphabet, encouraging written communication if applicable, expressing in short, simple sentences, use of gestures or pictures to enhance communication, and reorienting the patient frequently to time, place, and situation.
• Visual/Verbal Tasks: Matching visuals with verbal instructions (e.g., brushing teeth).
• Reducing distractions when teaching.
• Encouraging reinforcement of instructions and speech therapy involvement.
• Encouraging patient to perform prescribed speech/language therapies.
• Actively listening and conveying the importance of patient's thoughts, providing positive reinforcement to support self-esteem and confidence.
• Providing reminders to assist patients in expressing themselves.

Nutrition

• Testing pharyngeal reflexes before offering food/fluids to prevent choking.
• Assisting with meals if needed.
• Placing food on the unaffected side of the mouth for better chewing/swallowing.
• Allowing ample eating time to avoid rushing.
• Serving food in small portions but at frequent intervals to meet nutritional needs.
• Providing a light, nutritious diet that can be gradually transitioned to a standard diet as condition improves.
• A low-salt, low-fat diet for hypertensive patients if appropriate.
• Passing nasogastric tubes and feeding if the patient is unconscious and cannot swallow.
• Encouraging the patient's food choices, if not contraindicated.
• Maintaining oral hygiene for improved appetite and avoiding burning foods to prevent injuries. Providing prescribed intravenous fluids (e.g., dextrose 5%). Serving food attractively and encouraging eating.

Swallowing Therapy

• Collaborating with other healthcare team members to ensure comprehensive rehabilitation.
• Positioning patient in an erect position for feeding/exercise (as close to 90 degrees as possible), emphasizing optimal chewing and swallowing positions to avoid aspiration.
• Positioning patient's head in forward flexion ("chin tuck") during eating to assist in swallowing.
• Maintaining sitting position for 30 minutes after meals to prevent food regurgitation.
• Instructing the patient or caregiver on emergency choking measures.
• Checking the mouth for food pocketing to prevent decay or aspiration.
• Providing mouth care as needed.

Psychological Care

• Reassuring patients and their families about treatment, staff competence, drug availability, and potential outcomes to alleviate anxiety.
• Supporting patients during emotional outbursts and discussing that such outbursts are related to the disease process.
• Encouraging participation in group activities, controlling stressful situations, and encouraging expression of feelings & frustrations about the disease process.
• Involving family in patient care to create a "home-like" environment.
• Encouraging friends, family members and/or religious leaders to visit and offer support, if desired by the patient.

Urinary Habit Training

• Keeping a continence record for 3 days to understand the voiding pattern and plan appropriate interventions.
• Establishing an initial toileting schedule based on the patient's pattern and routine to improve bladder function and muscle tone.
• Assisting the patient to the toilet and prompting voiding at regular intervals.
• Teaching the patient to consciously hold urine until the toileting time.
• Discussing the daily continence record with staff.
• Providing positive reinforcement for toileting success and no comment for incontinence, reinforcing desired behaviors.

Other Nursing Management

• Addressing rest and sleep needs.
• Providing routine observations.
• Maintaining personal hygiene.
• Offering education about the disease and recovery process.