NURS 308 - Stroke

oxygen and glucose

the brain needs a constant supply of _____ in order to function

5 minutes

when the supply of oxygen and glucose is disrupted, the brain begins to lose function very quickly. if flow is compromised completely: metabolism changes in 30 seconds, stops in 2 minutes, and cell death results in _____ – time is brain!

*cerebral autoregulation*

- systemic blood pressure

- blood viscosity

- collateral circulation

- intracranial pressure

factors affecting blood flow to the brain:

- hemiparesis (paralysis on one side of the body)

- impaired ability to walk

- assistance with ADLs

- aphasia (the inability to speak or to understand language)

- depression

common long-term disabilities of a stroke include:

aphasia

the inability to speak or to understand language

- age

- sex: higher incidence in men, but higher mortality in women

- ethnicity: higher incidence and mortality in african americans

- genetics

non-modifiable risk factors of a stroke:

- metabolic syndrome

- lack of exercise

- poor diet

- drug abuse

- migraines

- inflammatory conditions

- hypertension

- heart disease

- smoking

- excessive alcohol use

- obesity

- sleep apnea

- sickle cell anemia

*all of the same cardiovascular disease risk factors also contribute to cerebrovascular disease (except migraines are specific to stroke only)

modifiable risk factors of a stroke:

migraines

modifiable risk factor that is specific to strokes:

- hormonal contraceptive use (containing estrogen)

- preeclampsia

- menopause

- hormone replacement therapy

risk factors of a stroke in women:

transient ischemic attack (TIA)

a disruption of blood flow to the brain that resolves itself without treatment before any permanent damage is done - brain returns to normal

transient ischemic attack (TIA)

a transient episode of neurologic dysfunction: ischemia, but without acute infarction of the brain

transient ischemic attack (TIA)

*if a patient has had a TIA, they are at higher risk for having a stroke

considered a warning sign of progressive cerebrovascular disease

always seek immediate medical attention with any symptoms of a stroke, especially if they had a TIA in the past !!!!

what should we teach to patients that has had a TIA in the past?

ischemic stroke

a stroke that is caused by a blocked artery

atrial fibrillation

patients with _____ are at much higher risk for an ischemic stroke because the atrium is not pumping, therefore the blood is stasis - microemboli form in the left atrium and is pumped into the left ventricle, then out of the aorta into the carotids and up into the brain, causing a stroke

thrombotic ischemic stroke

plaque causes a clot to form, which blocks the passage of blood through an artery in the brain

thrombotic ischemic stroke

the most common cause of stroke (accounts for 60% of all strokes)

hypertension and diabetes mellitus, which accelerates atherosclerosis (narrowing of the arteries)

risk factors of thrombotic ischemic stroke:

embolic ischemic stroke

a blood clot moves from someplace else in the body and lodges in the brain

atrial fibrillation

risk factor of embolic ischemic stroke:

hemorrhagic stroke

a stroke that is caused by a ruptured artery

- high blood pressure

- overuse of anticoagulants

- abnormal formations of blood vessels (e.g., aneurysms)

risk factors of hemorrhagic strokes:

intracerebral hemorrhagic stroke

intracranial bleed within the brain itself

intracerebral hemorrhagic stroke

stroke that has a very poor prognosis: 30 day mortality rate in 40% to 80% of cases, and 50% of deaths occur within the first 48 hours

intracerebral hemorrhagic stroke

*blood pressure rises with activity

type of stroke that typically occurs during activity

- hypertension (most common)

- vascular malformations

- coagulation disorders

- anticoagulant, thrombolytic drugs

- trauma

- brain tumors

- ruptured aneurysms

risk factors of intracerebral hemorrhagic stroke:

- neurological deficits: slurred speech, paralysis, difficulty with movements, etc.

- severe headache

- nausea, vomiting

- decreased LOC

- hypertension

*neurologic deficits progress very quickly, and usually progresses to a coma

clinical manifestations of an intracerebral hemorrhagic stroke:

subarachnoid hemorrhagic stroke

intracranial bleed into the space between the arachnoid and pia mater (lining around the outside of the brain)

cerebral aneurysm

trauma

cocaine abuse

risk factors of subarachnoid hemorrhagic stroke:

- focal neurological deficits (depending on the location)

- nausea, vomiting

- seizures

- stiff neck

*symptoms are not as rapid and severe as an intracerebral hemorrhage

clinical manifestations of subarachnoid hemorrhagic stroke:

- cerebral vasospasm: with bleeding in the brain, other arteries in the body vasoconstrict in an attempt to stop the bleeding, which further impedes blood flow

- re-bleeding: the same artery starts to bleed again

complications of hemorrhagic strokes:

the area of the stroke

manifestations of a stroke are directly related to:

- motor function

- communication

- affect

- intellectual function

- spatial-perceptual alterations

- elimination

in the body, a stroke affects:

- impaired mobility

- impaired respiratory function

- impaired swallowing and speech

- absent gag reflex

- impaired self-care abilities

- akinesia (loss of skilled voluntary movements)

- impaired integration of movement

- altered muscle tone

- hyporeflexia that often progresses to hyperreflexia

motor deficits of a stroke:

akinesia

patient wants to pick up something, but they can't make their arm reach out to grab it

left

*also typically occurs when the dominant hemisphere is affected (right handed = left dominant hemisphere)

communication deficits are more common and severe for patients with a _____ sided stroke

left

which side of the brain is responsible for language skills, and affects expression and comprehension

receptive aphasia

loss of comprehension - inability to understand spoken or written words

receptive aphasia

patient doesn't understand what you are saying to them; they can hear the words but the words have no meaning

expressive aphasia

the inability to produce language

expressive aphasia

patient can understand what you are saying to them and they know what they want to say back to you, but they cannot form the words

global aphasia

total inability to communicate

anomic aphasia

can speak normally and understand speech, but cannot identify written words or pictures

anomic aphasia

patient understands language, but has difficulty with finding words - "the word is on the tip of my tongue"

dysarthria

difficulty speaking due to weakness of the muscles - pronunciation, articulation, and phonation are affected, which may cause garbled speech, slurred speech, or a monotone tone of voice

affective agnosia

an impairment in knowing how one feels emotionally

- difficulty controlling emotions

- responses may be exaggerated or unpredictable

- emotions may be very inappropriate to the situation

- patient may also get very frustrated with their mobility and communication issues, causing them to act out on that frustration

affective deficits of a stroke:

- distract the patient

- explain to the family that emotional outbursts can occur

- maintain a calm environment

- do not shame the patient or scold behavior

nursing interventions for affective defects:

- impaired memory and judgment

- cautious, careful actions (left side)

- impulsive actions, moves quickly (right side)

intellectual deficit of a stroke:

cautious, careful actions

intellectual deficit of a left hemispheric stroke:

impulsive actions, moves quickly

intellectual deficit of a right hemispheric stroke:

- hemianopia

- nystagmus

- doll's eye sign

- incorrect perception of self & illness

- neglects all input from affected side

- agnosia

- apraxia

spatial-perceptual deficits of a stroke:

hemianopia

blindness in ½ of the visual field

right

hemianopia is more common for patients with a _____ sided stroke

nystagmus

oscillation of the eyeball, the eyes cannot hold steady

doll's eye sign

indicates serious neurologic deficits

doll's eye sign

eyes deviate away from the direction of rotation (if the head is rotated to the right, the eyes will deviate to the left)

right

incorrect perception of self & illness is more common for patients with a _____ sided stroke

agnosia

the inability to recognize an object by sight, touch, and hearing

agnosia

patient cannot recognize what a fork is or what it is used for

apraxia

the inability to carry out learned sequential movements on command

apraxia

patient cannot reach out, turn the door knob, and open the door

schedule toilet time, wear clothing that is easy to remove

nursing interventions for elimination deficits of a stroke:

- paralyzed on left side: hemiplegia

- left-sided neglect

- spatial-perceptual deficits (hemianopia)

- tends to deny or minimize problems

- rapid performance, short attention span

- impulsive, quick: high risk for injury

- impaired judgment, impaired time concepts

typical clinical manifestations of a right sided stroke:

- paralyzed on right side: hemiplegia

- impaired speech

- language aphasias

- impaired right/left discrimination

- slow performance, cautious

- aware of deficits: depression, anxiety

- impaired comprehension r/t language and math

typical clinical manifestations of a left sided stroke:

carotid duplex scanning

an ultrasound of the carotid artery that can detect narrowing of the artery

echocardiogram

can identify clots in the atrium and if the heart is weak and not pumping correctly

prevention of strokes

*all patients with any risk factors for stroke should be educated on therapeutic lifestyle changes to manage their modifiable risk factors and prevent stroke

what is the main focus for a patient at risk for strokes?

fibrinolytic therapy (TPA therapy)

drug therapy used to break up and dissolve the clot, restore blood flow, and minimize permanent effects of the stroke

3-4 ½ hours

fibrinolytic therapy (TPA therapy) should be began with _____ hours of symptom onset

fibrinolytic therapy (TPA therapy)

drug therapy for the emergency phase of an ischemic stroke:

- anticoagulants: warfarin, heparin, enoxaparin (LMWH)

- antiplatelets: aspirin, clopidogrel, dipyridamole/aspirin

drug therapy for the recovery phase of an ischemic stroke:

- manage hypertension

- seizure prophylaxis

the main goal of post-hemorrhagic stroke drug therapy is:

hemorrhagic

anticoagulants and antiplatelets are contraindicated in patients with a _____ stroke, usually for the rest of their lives

TPA therapy: alteplase

the only FDA approved treatment for acute ischemic stroke, and is NOT used for hemorrhagic stroke

TPA therapy: alteplase

helps to restore blood flow to brain regions affected by a stroke, thereby limiting the risk of damage and functional impairment

before administering TPA therapy, the patient must have a head CT scan to identify if the stroke is ischemic or hemorrhagic !!!!

ONLY given to a patient with an ischemic stroke

CANNOT be given to a patient with a hemorrhagic stroke

what MUST be completed before initiating TPA therapy?

- maintain SBP < 180 and DBP < 105 for the first 24 hours

- monitor for s&s of intracranial hemorrhage (ICH) → sudden neurologic deterioration, new headache, acute hypertension, nausea, vomiting

- do NOT administer any antithrombotics for the first 24 hours post TPA therapy !!!

- if hemorrhage is suspected, STOP TPA, obtain brain CT scan, and notify neurologist

- monitor for angioedema

- avoid inserting invasive lines for 24 hours

- MUST complete a CT of the brain 24 hours post TPA administration

nursing implications for TPA therapy:

SBP < 180 and DBP < 105

during TPA therapy, the patient should maintain a blood pressure in what range for the first 24 hrs?

- sudden neurologic deterioration

- new headache

- acute hypertension

- nausea, vomiting

*it is common for patients with intracranial hemorrhage to tell you that they had the worst headache of their life

s&s of intracranial hemorrhage (ICH):

- unusual bruising

- petechiae

- nosebleeds

- bleeding gums

- blood in urine

- red or tea-colored urine

- dark stools

- blood in stools

- hematemesis

- coffee-ground emesis

- abdominal pain

- restlessness

- hypotension

- anemia

s&s of bleeding:

CT scan of the brain

what MUST be completed 24 hours post TPA administration

antithrombotics

what must NOT be administered 24 hours post TPA administration?

if hemorrhage is suspected, STOP TPA, obtain brain CT scan, and notify neurologist

DO NOT call the provider and ask if you should stop the TPA – just stop it !!

what MUST be done if the nurse suspects a patient hemorrhaging on TPA therapy

left atrial appendage occlusion (LAA)

a procedure that blocks or closes the opening to the left atrial appendage to keep blood clots from leaving there and going into the bloodstream - prevents strokes in patients with atrial fibrillation

carotid endarterectomy

a surgical procedure to remove a build-up of fatty deposits (plaque), which cause narrowing of a carotid artery

transluminal angioplasty

a procedure that can open up a blocked blood vessel using a catheter with a balloon at the end of it - when the catheter is in place, it inflates to open the blood vessel so that normal blood flow is restored

d50

for patients with an acute stroke, treat hypoglycemia with:

insulin - if serum glucose is > 200 mg/dL

for patients with an acute stroke, treat hyperglycemia with:

SBP > 220 or DBP > 120

it is recommended to use anithypertensive medication during a stroke with a blood pressure of:

- elevate the HOB at least 45 degrees, avoid dropping the HOB below the level of the heart

- prevent coughing and straining, which can increase intracranial pressure

how to prevent increased intracranial pressure

D5W

( + avoid excessive fluid administration )

what IV fluid should be avoided for patients with an acute stroke

IV isotonic sodium chloride solution at 50 mL/hr, unless otherwise indicated

what IV fluid should be administered for patients with an acute stroke

swallow test

what should be completed after a stroke in order for the patient to resume oral intake?

elevated

*avoid hyperthermia: use oral or rectal acetaminophen and cooling blankets as needed

_____ body temperatures expands the arteries and can lead to bleeding

initial symptoms

*helps to determine whether or not the patient is a candidate for TPA therapy, helps to determine if the stroke is ongoing or completed, and helps to determine which hemisphere of the brain is affected

on assessment of a patient with a potential stroke, the nurse should get a description of the patient's current illness with attention to:

NIH stroke scale

a comprehensive neurological assessment for a patient with a stroke - a 42-point scale with 6 focus areas, each one is scored from 0-7

Face – Does the face look even? Ask them to smile

Arm – Does one arm drift down? Ask them to raise both arms

Speech – Does their speech sound strange? Ask them to repeat a phrase

Time – Brain cells die with every second. Call 911 at ANY sign of a stroke!!!!!

stroke rapid assessment:

< 5

an NIH stroke scale score _____ indicates a minor stroke

> 10

an NIH stroke scale score _____ indicates a major stroke → 80% likelihood of proximal vessel occlusions