Stroke PDF

❑A stroke or cerebrovascular accident is 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. OR ❑ It is the clinical designation for a rapidly developing loss of...

❑A stroke or cerebrovascular accident is 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. OR ❑ It is the clinical designation for a rapidly developing loss of brain function due to a disturbance in the blood vessels supplying blood to the brain. OR ❑ A stroke can be 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 that occurs when there is an interruption in blood supply to a part of the brain, leading to cell death and loss of function in the affected area.  Stroke occurs when there is ischemia (inadequate blood flow) to a part of the brain or hemorrhage into the brain that results in death of brain cells. ❑"Transient Ischaemic Attack (TIA) is often called a "mini-stroke" and occurs when there's a temporary reduction in blood flow to part of the brain. This reduction in blood flow results in stroke-like symptoms that typically last for a few minutes to a few hours but do not cause permanent damage 1. Causes: TIAs are often caused by blood clots or other blockages that briefly obstruct blood flow to the brain. 2. Symptoms: Symptoms are similar to those of a stroke and can include sudden numbness or weakness (especially on one side of the body), trouble speaking or understanding speech, confusion, vision disturbances, and difficulty walking. 3. Duration: Symptoms resolve within 24 hours (usually within minutes to hours). 4. Risk of Stroke: A TIA is a warning sign for potential future strokes. People who experience a TIA have a higher risk of experiencing a full stroke in the future. ❑The brain requires a continuous supply of blood to provide the oxygen and glucose that neurons need to function. ❑ Blood flow must be maintained at 750 to 1000 mL/min (55 mL/100 g of brain tissue), or 20% of the cardiac output, for optimal brain functioning. If blood flow to the brain is totally interrupted (e.g., cardiac arrest), neurologic metabolism is altered in 30 seconds, metabolism stops in 2 minutes, and cellular death occurs in 5 minutes ❖Factors that affect blood flow to the brain include:  systemic BP,  cardiac output, and  blood viscosity.  The terms brain attack and cerebrovascular accident (CVA) are also used to describe stroke. The term brain attack communicates the urgency of recognizing the clinical manifestations of a stroke and treating this as a medical emergency, as would be done with a heart attack ❑Apoplexy, from the Greek word meaning "struck down with violence,” ❑Stroke is a medical emergency and can cause permanent neurological damage, complications and death if not promptly diagnosed and treated. ❑The most common motor dysfunction is hemiplegia (paralysis of one side of the body) due to a lesion of the opposite side of the brain. Hemiparesis, or weakness of one side of the body, is another sign. Risk Factors ❑The risk factors for stroke is categorised in to: nonmodifiable and modifiable. ❑The nonmodifiable factors are ones that cannot be changed by the individual and include: ❖Increasing age. A person's risk of stroke doubles each year after age 55. ❖Race. Strokes occur approximately twice as often in blacks and Hispanics as they do in whites. ❖Gender. Men have a 50% higher chance of stroke than women do. ❖Family history of stroke or transient ischemic attack (TIA). ❑Modifiable risk factors are those that can be changed These factors include: ❖High blood pressure ❖ Smoking ❖High blood pressure (major risk factor) ❖Diabetes ❖High cholesterol ❖ Physical inactivity ❖ Obesity ❖ Excessive alcohol consumption ❖ Heart disease (especially atrial fibrillation) ❖Sickle cell anemia, ❖ High cholesterol levels in the blood, ❖Atrial fibrillation, an abnormal heart rhythm ❖Drug abuse ❖Hormone replacement therapy (HRT). ❖Use of birth control pills, or oral contraceptives  Types and causes of stroke 1. Ischaemic Stroke: In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction and necrosis of the brain tissue in that area. Nearly 80% of strokes are ischemic. A TIA attack is usually a precursor to ischemic stroke. The causes of this stroke include: ❖ Thrombosis (obstruction of a blood vessel by blood clot forming locally)- Thrombotic stroke Thrombosis develops readily where atherosclerotic plaques have already narrowed blood vessels.  Thrombotic stroke is the most common cause of stroke, accounting for about 60% of strokes.  Two thirds of thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate atherosclerosis.  In 30% to 50% of individuals, thrombotic strokes are preceded by a TIA. ❖ Embolism (idem due to a blood clot from elsewhere in the body.Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel). ❖ Embolism is the second most common cause of stroke, accounting for about 24% of strokes. ❖ Most emboli originate in the endocardial (inside) layer of the heart, with plaque breaking off from the endocardium and entering the circulation. ❖Systemic hypoperfusion (general decrease in blood supply e.g. in shock, decrease cardiac output.) ❖Cryptogenic (no known cause) 2. Hemorrhagic stroke- Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. Hemorrhagic strokes account for 15% to 20% of cerebrovascular disorders. ❑ Intracerebral hemorrhage ❑ Subarachnoid hemorrhage ▪ Cerebral aneurysm ▪ Arteriovenous malformation Intracerebral Hemorrhage. ❖ Intracerebral hemorrhage is bleeding within the brain caused by a rupture of a vessel and accounts for about 10% of all strokes.  The prognosis of patients with intracerebral hemorrhage is poor,  Fifty percent of the deaths occur within the first 48 hours. Hypertension is the most common cause of intracerebral hemorrhage.  Other causes include: ❖ Vascular malformations, ❖ Coagulation disorders, ❖ Anticoagulant and thrombolytic drugs, ❖ Trauma, ❖ Brain tumors, and ❖ Ruptured aneurysms..  Pathophysiology of Stroke In an ischemic stroke, a blood clot or blockage in an artery prevents oxygen-rich blood from reaching brain cells, leading to tissue death. In a hemorrhagic stroke, blood leaking into brain tissue or spaces around the brain compresses structures and disrupts blood supply, causing cell death and increased intracranial pressure.  Sign and Symptoms ❖Weakness of one side of the body including the face ❖Inability to rise up from a sitting or lying position ❖Sudden fall ❖Loss of speech ❖Difficulty walking, dizziness, or loss of balance or coordination ❖Unconsciousness in some patients ❖Seizures ❖ Paralysis of a limb and/or the face ❖ Initial flaccidity, but spasticity and exaggerated reflexes occur later ❖ Loss of one-half of 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 haemorrhage) ❖ Severe headache and/or neck pain (subarachnoid haemorrhage) Communication Loss ❖Dysarthria (difficulty in speaking), caused by paralysis of the muscles responsible for producing speech ❖Dysphasia (impaired speech) or aphasia (loss of speech), which can be expressive aphasia, receptive aphasia, or global (mixed) aphasia ❖Apraxia (inability to perform a previously learned action), as may be seen when a patient makes verbal substitutions for desired syllables or words : Emotional Deficits include ❖Loss of self-control ❖ Emotional lability ❖ Decreased tolerance to stressful situations ❖ Depression ❖ Withdrawal or feelings of isolation ❖ Fear, hostility, and anger  Investigations ❖ CT Scan: Often first-line to distinguish between ischemic and hemorrhagic stroke. ❖ MRI: More sensitive in detecting early ischemic changes and small infarcts. ❖ Blood tests: To rule out other causes, assess clotting and check for underlying conditions. ❖ Angiography: Visualizes blood vessels in the brain and identifies blockages or hemorrhages. ❖ Echocardiogram: Assesses the heart, especially if embolic sources are suspected. ❖ Electrocardiogram (ECG): To detect cardiac arrhythmias like atrial fibrillation. ❖ FBC, ESR ❖ Blood glucose ❖ Serum lipid profile ❖ Blood urea, electrolytes and creatinine ❖ Uric acid ❖ Chest X-ray ❖ Complete physical and neurologic examination ❖ Clinical manifestations ❖ Lumbar puncture may be performed  Treatment Treatment objectives ❖To limit the progression area of brain damage ❖To protect patients from the dangers of unconsciousness and immobility ❖To treat the underlying cause if possible ❖To institute measures to improve functional recovery ❖To support and rehabilitate patients who survive with residual disability ❖To prevent recurrence of cerebrovascular lesions  Non-pharmacological treatment ❖Admit and monitor patient`s vital signs and neurological signs frequently ❖Establish adequate airway in unconscious patients. ❖Nurse in the lateral position with suctioning where necessary ❖Prevent pressure sores by regular turning (every 2 hours) in bed. ❖Maintain adequate hydration ❖Insert nasogastric tube as early as possible for feeding and medications in unconscious patients or those with swallowing difficulties ❖Insert urethral/condom catheter to keep patient clean and dry. ❖Early physiotherapy as soon as practicable  Pharmacological treatment Haemorrhagic strokes ❖Antihypertensive medications. Reduce blood pressure gradually over several days. ❖Control diabetes and other co-morbidities  Ischaemic strokes ❖Aspirin, oral, 75 mg daily ❖Atorvastatin, oral, 10-40 mg daily Or ❖Rosuvastatin, oral, 5-10 mg daily Or ❖Simvastatin, oral, 20 mg daily irrespective of lipid levels NURSING MANAGEMENT  VISUAL PROBLEM ❑ Place objects within intact field of vision so that patient can see. ❑ Approach the patient from side of intact field of vision to enable him see you ❑ Instruct/remind the patient to turn head in the direction of visual loss to compensate for loss of visual field. ❑ Encourage the use of eyeglasses if available for better sight. ❑When teaching the patient, do so within patient’s intact visual field for him to see you and enhance understanding.. ❑Encourage the use of a cane or other object to identify objects in the periphery of the visual field. ❑Explain to the patient the location of an object when placing it near the patient. ❑Consistently place patient care items in the same location for easy access.  Management paralysed site ❑Place objects within the patient’s reach on the non-affected side for easy access. ❑Instruct the patient to exercise and increase the strength on the unaffected side. ❑Encourage the patient to provide range-of-motion exercises to the affected side. ❑Provide immobilization as needed to the affected side. ❑Maintain body alignment in functional position. ❑Support patient during the initial ambulation phase to prevent falls and injuries. ❑Provide supportive device for ambulation (walker, cane). ❑Instruct the patient not to walk without assistance or supportive device.  Communication ❑ Provide the patient with alternative methods of communicating such as providing a bell to call when necessary ❑ Allow the patient sufficient time to respond to verbal communication. ❑ Support patient and family to alleviate frustration related to difficulty in communicating. ❑ Encourage patient to repeat sounds of the alphabet. ❑ Explore the patient’s ability to write as an alternative means of communication. ❑Speak slowly and clearly to assist the patient in forming the sounds. ❑Use simple words and short sentences to avoid overwhelming patient with verbal stimuli. ❑ Explore the patient’s ability to read as an alternative means of communication. ❑ Speak clearly and in simple sentences; use gestures or pictures to enhance communication. ❑ Reorient patient to time, place, and situation frequently. ❑Match visual tasks with a verbal cue; holding a toothbrush, simulate brushing of teeth while saying, “I would like you to brush your teeth now.” ❑Minimize distracting noises and views when teaching the patient. ❑Repeat and reinforce instructions frequently. ❑ Involve the speech therapist in patient’s care ❑Perform prescriptive speech-language therapies during informal interactions with patient to reinforce prescribed therapies. ❑Listen attentively to convey the importance of patient’s thoughts and to promote a positive environment for learning. ❑ Provide positive reinforcement and praise to build self- esteem and confidence. ❑Provide verbal prompts and reminders to help patient to express self.  Nutrition ❑Test the patient’s pharyngeal reflexes before offering food or fluids to prevent chocking. ❑Assist the patient with meals if he cannot feed himself. ❑Place food on the unaffected side of the mouth to enhance chewing and swallowing. ❑Allow patient ample time to eat and avoid rushing him because of the difficulties in chewing and swallowing. ❑Serve patient food in bits but at frequent intervals to meet his nutritional needs. ❑Give well nourishing light diet as patient can tolerate and gradually shift to normal diet as condition improves ❑Serve low salt and fatty diet if patient is hypertensive ❑Pass NG Tube and feed if patient is unconscious and cannot swallow. ❑Plan diet with patient and provide his choice of meal if not contraindicated ❑Maintain oral hygiene to promote appetite ❑Serve patient food attractively and coax him to eat ❑Place patient’s meal at the unaffected side to enable patient see ❑Avoid serving hot meals to prevent burns ❑Administer prescribed iv fluids eg dextrose 5%  Swallowing Therapy ❑ Collaborate with other members of health care team (e.g., occupational therapist, speech pathologist, dietitian) to provide continuity in patient’s rehabilitative plan. ❑Assist patient to sit in an erect position (as close to 90 degrees as possible) for feeding/exercise to provide optimal position for chewing and swallowing without aspirating. ❑Assist patient to position head in forward flexion in preparation for swallowing (“chin tuck”). ❑Assist patient to maintain sitting position for 30 min after completing meal to prevent regurgitation of food. ❑Instruct patient or caregiver on emergency measures for choking to prevent complications in the home setting. ❑Check mouth for pocketing of food after eating to prevent collection and putrefaction (decay)of food and/or aspiration. ❑Provide mouth care as needed to promote comfort and oral health.  Psychological Care ❑Reassure patient and relatives of competent staff, availability potent drugs and possible outcome of condition to allay anxiety ❑ Support patient during uncontrollable outbursts of emotion ❑ Discuss with the patient and family that the outburst are due to the disease process. ❑ Encourage patient to participate in group activity ❑Control stressful situations, if possible. ❑Encourage patient to express feelings and frustrations related to disease process. ❑Involve patient family in his care to make him feel at home ❑Encourage friends, family members and religious leader if patient so wish to visit him and give social supports  Urinary Habit Training  Keep a continence specification record for 3 days to establish voiding pattern and plan appropriate interventions.  Establish interval of initial toileting schedule (based on voiding pattern and usual routine) to initiate process of improving bladder functioning and increased muscle tone.  Assist patient to toilet and prompt to void at prescribed intervals to assist patient in adapting to new toileting schedule.  Teach patient to consciously hold urine until the scheduled toileting time to improve muscle tone.  Discuss daily record of continence with staff to provide reinforcement and encourage compliance with toileting schedule.  Give positive feedback or positive reinforcement to patient when he or she voids at scheduled toileting times, and make no comment when patient is incontinent, to reinforce desired behavior. ❑Other nursing management: ❑Rest and sleep ❑Observation ❑Personal hygiene ❑Education THANK YOU