Stroke Fall 24 Outline PDF

**Cerebrovascular Disorders CH 46** - **Incidence** - More common in older men - African Americans, Asians, and Pacific Islander have a higher incidence Southeast US have a higher incidence "stroke belt" - **Review stroke performance measures (All you need to know is that...

**Cerebrovascular Disorders CH 46** - **Incidence** - More common in older men - African Americans, Asians, and Pacific Islander have a higher incidence Southeast US have a higher incidence "stroke belt" - **Review stroke performance measures (All you need to know is that it is part of your assessment)** - NIH Stroke scale - Ischemic - DVT - Ischemic & Hemorrhagic - Discharged on antithrombotic therapy - Ischemic - Discharged on anticoagulation for pt with A-Fib - Ischemic - Thrombolytic therapy administration - Ischemic - Antithrombotic medication by the end of hospital day 2 - Ischemic - Discharged on cholesterol-reducing medications - Ischemic - Stroke education - Ischemic & Hemorrhagic - Assessed for rehabilitation - Ischemic & Hemorrhagic - **7 D's** - Detection - Detection of the onset of S&S - Dispatch - 911 - Delivery - Brought to stroke center - Door - At the door of the hospital Pt should undergo neurologic assessment. - Data - CT, serial neuro exams, review of pt file for potential tPA exclusions. - Decision - Review risk and benefits with pt and family if pt remains a candidate for tPA - Drug Administration - As appropriate and post administration monitoring. - **TYPES OF STROKES** - Ischemic - Core infarct- cell death at the site of occlusion. Ischemic Penumbra-surrounding area of brain tissue in which blood flow has been reduced. This tissue may be saved with early intervention - Causes - Large-artery thrombosis - Small, penetrating artery thrombosis - Cardiogenic embolic - Cryptogenic (no known cause) - Other - Main presenting symptoms - Numbness or weakness of the face, arm, or leg, especially on one side of the body. - Additional symptoms - Slurred speech, or difficulty with word finding or comprehension. - Hemorrhagic - Causes - Intracerebral hemorrhage - Subarachnoid hemorrhage - Cerebral aneurysm - Arteriovenous malformation - Main presenting symptoms - Exploding headache, decreased LOC - Additional symptoms - N&V, Visual changes, Seizures - **TIA** - Warning signs - Temporary (less than 24 hr) - Signs/Symptoms - Blurred vision - Diplopia (double vision) - Blindness in one eye - Tunnel vision - Weakness - Ataxia (gait disturbance) - Numbness - Vertigo - Aphasia - Dysarthria (slurred speech) - Diagnostics - CT with and without contrast - MRI (magnetic resonance imaging) - MRA (Magnetic resonance angiography) - Carotid US - TCD (Transcranial Doppler) - Cerebral Angiography - **TIA Nursing care** - TEACHING!!!!! - Hypertension - Diabetes Mellitus - Anticoagulants - Lifestyles changes - RISK FACTORS FOR STROKE - Non-modifiable - Age - Gender- male - Family Hx - Race- African American - Hx of heart attack (MI) - Hx of migraine - Prior stroke - Sickle Cell - Modifiable - HTN - Dyslipidemia - TIA's - CV disease-a fib - DM - Clotting disorders - Sleep Apnea - Smoking - Substance abuse - Obesity - Sedentary lifestyle - Oral contraceptives - Alcohol - **ASSESSMENTS** - History - Don't waste time talking through history rapid assessment -transfer pt to a stroke center - Activity when symptoms began, hemorrhagic usually starts during activity Progression of symptoms -- abrupt (hemorrhagic) or gradual (thrombotic) - May need to question family as pt is not responsive - **Clinical Manifestations** - Left and Right Hemispheric Strokes - Be alert for the following signs and symptoms: - Left hemispheric stroke: - Paralysis or weakness on right side of body - Right visual field deficit - Aphasia (expressive, receptive, or global) - Altered intellectual ability - Slow, cautious behavior - Right hemispheric stroke: - Paralysis or weakness on left side of body - Left visual field deficit - Spatial-perceptual deficits - Increased distractibility - Impulsive behavior and poor judgment - Lack of awareness of deficits - Aphasia- inability to use/comprehend language - Dysarthria- diff articulating speech - Apraxia- unable to carry out purposeful movement - Agraphia- difficulty writing - Hemiplegia- paralysis on 1 side of body - Hemiparesis- weakness on 1 side (most common) - Ataxia- gait disturbance - Agnosia- unable to use object correctly - Diplopia - Hyper/hypotonia- problems with muscle tone - Unilateral neglect- unaware of the paralyzed side - Hemianopsia- blindness in half of the visual field - Dysphagia- difficulty chewing or swallowing - Emotional lability - **ASSESSMENTS/DIAGNOSTICS** - Baseline CBC, PT/PTT/INR - CT to rule out hemorrhagic stroke - Toxicology screen - MRI (magnetic resonance imaging) - MRA (Magnetic resonance angiography) - Carotid US - TCD (Transcranial Doppler) - Cerebral Angiography - **INTERVENTIONS** - Improving cerebral perfusion - Embolization or removal of AVM's - Clipping of aneurysms - Carotid stent - Carotid endarterectomy- removes plaque from the carotid artery - Monitor neuro changes- frequent neuro checks - Bedrest in quiet environment - HOB elevated; 30 degrees - Ischemic tissue can be saved with timely intervention by administering t-PA (tissue plasminogen activator) which dissolves the blood clot and restores circulation **must occur within 3 hours of symptom onset**; not given to pts on anticoagulants, BP \> 185/110, prior intracranial hemorrhage, recent surgery, head injury, GI/GU bleeding, or postpartum - Pt is managed in the ICU; frequent VS and neuro checks - Bleeding is the most common side effect - Embolectomy- inject fibrinolytic directly into clot or remove mechanically - Monitor for increased ICP - Monitor for hydrocephalus- may occur due to impeded circulation of CSF- sudden onset of stupor/coma, or gradual onset of drowsiness and behavioral changes; managed with a ventriculostomy drain or ventriculoperitoneal shunt - Monitor for vasospasm- increased neuro deficits that fluctuate - Monitor for re-bleeding- severe headache, N/V, neuro deficits; manage BP, prevented by clipping aneurysm - **Drug therapy** - tPA - Blood pressure - Anticoagulants - Antiseizure - Stool softeners - Pain control (Tylenol or maybe mild sedative) - Anxiety - **Improving mobility/preventing deformities** - Upper extremity - Place a pillow in the axilla - Lower extremity - Keep legs straight - Positioning - Turn every 2 hr - Splinting - Flex fingers, passive ROM - OOB - Get them in a chair - **Managing dysphagia** - NPO - Speech therapy - Feeding tubes - **Bowel/bladder control** - intermittent catheterization (due to bladder becomes atonic with impaired sensation) - problems with bowel control, particularly constipation. Unless contraindicated, a high-fiber diet and adequate fluid intake (2--3 L/day) should be provided, and a regular time (usually after breakfast) should be established for toileting. - **Preventing shoulder pain** - Place a pillow in the axilla when there is limited external rotation - Never lift the Pt by the flaccid shoulder or pull the affected arm or shoulder. - **Enhancing self-care** - As soon as the Pt can sit up. - Personal hygiene - Comb hair, brushing teeth, shaving (electric razor), bathing, and eating. - **Managing sensory-perceptual difficulties** - Patients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (e.g., clock, calendar, television) should be placed on this side. - The patient can be taught to turn the head in the direction of the defective visual field to compensate for this loss. - The nurse should make eye contact with the patient and draw their attention to the affected side by encouraging the patient to move the head. - The nurse may also want to stand at a position that encourages the patient to move or turn to visualize who is in the room. - Increasing the natural or artificial lighting in the room and providing eyeglasses are important aids to increasing vision. - **Improving thought processes** - Supportive - Positive feedback - Convery an attitude of confidence and hope. - **Improving communication** - strategies to make the atmosphere conducive to communication. - being sensitive to the patient's reactions and needs and responding to them in an appropriate manner. - A consistent schedule, routines, and repetition - A written copy of the daily schedule, a folder of personal information (birth date, address, names of relatives), checklists, and an audio-taped list help improve the patient's memory and concentration. - The patient may also benefit from a communication board, which has pictures of common needs and phrases. - When talking with the patient, it is important for the nurse to gain the patient's attention, speak slowly, and keep the language of instruction consistent. - One instruction is given at a time, and time is allowed for the patient to process what has been said. - The use of gestures may enhance comprehension. - In working with the patient with aphasia, the nurse must remember to talk to the patient during care activities. - **Maintaining skin integrity** - Turning schedule at least every 2 hours. - Minimize shear and friction forced that may tear the skin. - Keep skin clean and dry - Gentle massage - Adequate nutrition - **Improving family coping** - The family needs to be informed that the rehabilitation of the hemiplegic patient requires many months and that progress may be slow. - The gains made by the patient in the hospital or rehabilitation unit must be maintained. - All caregivers should approach the patient with a supportive and optimistic attitude, focusing on the patient's remaining abilities. - The rehabilitation team, the medical and nursing team, the patient, and the family must all be involved in developing attainable goals for the patient at home. - **Cope with sexual dysfunction** - Nurses in the rehabilitation setting play a crucial role in beginning a dialogue between the patient and their partner about sexuality after a stroke. - In-depth assessments to determine sexual history before and after the stroke should be followed by appropriate interventions. - Interventions for the patient and partner focus on providing relevant information, education, reassurance, adjustment of medications, counseling regarding coping skills, suggestions for alternative sexual positions, and a means of sexual expression and satisfaction. - **Promoting home care** - OT - PT - Modifications may need to be made. - Shower instead of taking a bath. - Long handle bath brush - Could place a stool in the tub if shower is not available. - Special utensils for eating