Untitled Quiz

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/procedures, and utilize nursing process for patient care (pre, during, post-stroke). Assessment should include associated clinical manifestations, nursing diagnoses, goals, and implementation (collaborative care, drug therapy, acute/non-acute care, and health promotion).

Stroke = Cerebral Vascular Accident

• Stroke is the death of brain cells due to prolonged ischemia (lack of blood flow) or hemorrhage (bleeding) into the brain.
• Functions lost or impaired include movement, sensation, and emotions controlled by the affected brain area.
• Severity of function loss depends on the location and extent of brain involvement.
• Blood flow to the brain is affected by blood pressure, cardiac output, and blood viscosity.
• Without adequate blood flow (oxygen, glucose), neurons cannot function.
• Brain needs at least 20% of cardiac output.
• If blood flow is interrupted (e.g., 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 leading cause of death in Canada, behind cancer and heart disease.
• It's the leading cause of serious, long-term disability.
• Approximately 35% of individuals who experience an initial stroke die within one year.
• Stroke is more common in men than women, though women die more frequently from strokes (likely more from hemorrhagic).

Risk Factors

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

Ischemic Strokes

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

Transient Ischemic Attack (TIA)

• Short-term neurological dysfunction not causing brain cell death.
• Symptoms last less than 1 hour, usually less than 15 minutes.
• Statistics: <50% are reported to healthcare providers, 1/3 never have another TIA, 1/3 have another TIA, and 1/3 have a stroke.
• Treatment: Antiplatelet drugs (ASA, clopidogrel), possibly statins to reduce cholesterol.

Thrombotic Stroke

• Thrombosis (clot formation) in a brain vessel due to injury to blood vessel wall or narrowing.
• Usually develops over time (slow).
• Often a stepwise progression of increasing ischemia.
• Warning sign: TIA.

Embolic Stroke

• Embolus (blood clot or other debris) formed elsewhere and lodges in a cerebral artery.
• Typically a single/sudden event, symptoms develop quickly.
• Often a rapid and severe clinical presentation.
• Often has no obvious warning signs.

Hemorrhagic Strokes

• Bleeding into the brain tissue, subarachnoid space, or ventricles.
• Approximately 15% of all strokes.
• Two types: Intracerebral Hemorrhage, and Subarachnoid Hemorrhage.

Intracerebral Hemorrhage

• Bleeding within the brain from a ruptured blood vessel.
• Often caused by hypertension.
• Commonly occurs during periods of activity and often presents with a sudden onset of symptoms.
• Warning signs include headache, nausea, and vomiting.

Subarachnoid Hemorrhage

• Bleeding from a ruptured cerebral aneurysm into cerebrospinal fluid.
• Requires awareness of aneurysms.
• Characterized by a very severe headache.
• Associated with higher stroke mortality rates.

Aneurysm

• Permanent, localized outpouching or dilation of a blood vessel wall.
• Can be congenital or acquired (often due to atherosclerosis that weakens the vessel wall).
• Can lead to risks of rupture, hypovolemia, and ischemia/infarction to other cells/organs.
• May require surgical intervention.

Brain Aneurysm

• **Congenital or acquired:**Genetic component.
• Screening recommended.
• Clinical manifestations of unruptured brain aneurysm: Pain behind the eye, changes in vision or double vision.
• **Ruptured:**Hemorrhagic stroke.

Clinical Manifestations - General

• Manifested in the part of the brain where the stroke is located, impacting various functions (motor, communication, sensation, intellectual, spatial-perceptual, and affect).
• Motor Function: Loss of skilled voluntary movement, impairment of integration of movements, alterations in muscle tone, reflexes, and self-care abilities are impacted.
• Communication: Aphasia/dysphasia, dysarthria, affecting language comprehension and expression.
• Affect: Difficulty controlling emotions; exaggerated or unpredictable emotional responses; frustration (communication & mobility limitations); depression is common.
• Intellectual Function: Impaired memory and judgment result from the impact on different areas of the brain.
• **Spatial-Perceptual Alterations:**Problems in spatial-perception and orientation along with denial of injury/stroke and difficulties judging distances are common.

Clinical Manifestations - Specific (Left/Right Hemisphere)

• Differences in clinical manifestations exist between left-vs.-right-side CVA affecting various functions.
• Left-sided CVA usually presents with memory/language difficulties.
• Right-sided CVA often shows impulsivity, difficulty judging distances and problems in recognizing/orientating to surroundings.

Clinical Manifestations - Diagnostics

• Goal is to confirm it's a stroke and determine cause (ischemic vs. hemorrhagic).
• CT scan is the primary diagnostic test done within 25 minutes of arrival to ER and read within 45minutes.
• Magnetic resonance imaging (MRI), cardiac tests, used as additional diagnostics to rule out other concerns and check for risk factors.

Prevention is Key!

• Blood pressure control.
• Blood glucose control.
• Diet and exercise.
• Smoking cessation.
• Limiting alcohol consumption.
• Routine health assessments.
• Teach families 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 immediately.

Stroke Management - Acute Care

• Preserving life, preventing further brain damage.
• Treatment differs based on stroke type and patient changes.
• Single most important assessment is the time of stroke onset.
• Initiates by managing ABC (airway, breathing, and circulation).
• Comprehensive neuro examination, level of consciousness assessment (Canadian Neurological Scale), cognition, motor abilities, cranial nerve function, sensation, proprioception, cerebellar function, and deep tendon reflexes.

Stroke Management - Acute Care (continued)

• Hypertension management (only if increase is significant).
• Fluids & electrolyte management (avoid hypervolemia).
• Management of Increased Intracranial Pressure (ICP) (e.g., cooling measures, mannitol/3% saline, pain/constipation management).
• May require surgery in severe cases (remove bone flap).

Stroke Management - Acute Care (ischemic vs. hemorrhagic)

• Ischemic (thrombotic/embolic): Fibrinolytic therapy immediately (tPA - tissue plasminogen activator).

• **Hemorrhagic:**Manage hypertension, surgical intervention, seizure prevention

Feeding Self-care Deficit

• Assessment/Rehabilitation therapy with OT involves no distractions, use adaptive tools, strength training, encouraging patient to look towards the affected side, placing food on the stronger side of the mouth.

Complications of Stroke

• Respiratory
• Cardiovascular
• Musculoskeletal
• Gastrointestinal/urinary
• Neuro/sensory
• Nutritional
• Affect

• Risk for aspiration/pneumonia, impaired skin integrity, impaired swallowing, feeding self-care deficit and impaired communication are common.
• GI/Urinary: Constipation is the most common bowel problem; poor bladder control results in incontinence.

Optimization of Musculoskeletal Function

• Positioning strategies (adjusting positioning with pillows, using appropriate positioning equipment) and use of splints/support devices.

Rehabilitation

• Begins 12-24 hours post-stroke stabilization.
• Goals include learning techniques to self-monitor and maintain physical wellness.
• Demonstrate self-care skills and exhibit problem-solving skills in self-care.
• Multidisciplinary approach:Physician, nurse, physiotherapist, occupational therapist, speech-language pathologist, and psychologist are involved.

Rehabilitation - Strategies

• Patients with right-sided stroke (often) display impulsivity, impatience, and inability to recognize problems; best respond to verbal directions.
• Patients with left-sided stroke may be cautious/slower in motor tasks; respond best to nonverbal cues.

Other Important Considerations

• Recovery from a stroke: Understanding the impact of stroke on the brain and the types of therapy involved in recovery.
• Related Nursing Diagnoses and Complications: Includes risk for injury/falls, risk for impaired skin integrity, risk for aspiration pneumonia, risk for DVT (deep vein thrombosis), and risk for imbalanced nutrition (deficient).

Glossary of Terms

• Includes terms relevant to stroke (e.g., aphasia, dysphasia, agnosia, dysarthria, apraxia, etc.)