stroke

LEARNING OUTCOMES

  • List the appropriate nursing actions for a patient with a Transient Ischemic Attack (TIA).
  • Define the incidence of and risk factors for stroke.
  • Define the pathophysiology of a stroke.
  • Compare and contrast the etiology and pathophysiology of ischemic and hemorrhagic strokes.
  • Differentiate among the collaborative care, drug therapy, and surgical therapy for patients with ischemic strokes and hemorrhagic strokes.
  • Explain the psychosocial impact of a stroke on the patient, caregiver, and family.

STROKE/BRAIN ATTACK: WHAT IS IT?

  • Ischemic Stroke:
    • Caused by a blockage in a blood vessel in the brain (Embolic/Thrombotic).
    • Accounts for 87% of strokes.
  • Hemorrhagic Stroke:
    • Caused by bleeding in the brain and surrounding tissue.
    • Accounts for 13% of strokes.
  • Cerebral Vascular Accident (CVA):
    • Term for a stroke, also called a brain attack which results in the death of brain cells.

STROKE FACTS

  • Major public health concern.
  • Can occur at any age.
  • Fifth leading cause of death behind heart disease and cancer.
  • Leading cause of permanent disability.
  • 87% are ischemic strokes, 13% are hemorrhagic.

MEDICAL EMERGENCY

  • The first 3-4.5 hour window following onset is critical for intervention.
  • Ischemic Stroke:
    • Characterized by a central zone of irreversible infarction surrounded by a zone of reversible ischemia, known as the ischemic penumbra.
  • Hemorrhagic Stroke:
    • Requires emergency surgical treatment which can be life-saving.
  • CT Scan:
    • Considered the gold standard for diagnosing strokes.

CLASSIC STROKE SYMPTOMS

  • Memorized with the acronym FAST:
    • Face: Sudden weakness or droopiness of the face or problems with vision.
    • Arm: Sudden weakness or numbness of one or both arms.
    • Speech: Difficulty speaking, slurred speech, or garbled speech.
    • Time: Time is critical; stroke is a medical emergency.

STROKE MIMICS

  • Conditions that may mimic stroke symptoms include:
    • Hypoglycemia
    • Seizure
    • Tumor
    • Trauma
    • Migraine
  • Diagnostic Tools:
    • Rule out mimics by checking blood glucose, conducting a CT scan, and reviewing medical history.

RISK FACTORS

NON-MODIFIABLE RISK FACTORS

  • Age: Increased risk as age increases.
  • Gender: More men experience strokes, but more women die from strokes.
  • Heredity (Race):
    • Higher risk for African Americans due to high blood pressure; Hispanic populations have increased risk due to heart disease.
  • Prior History: Previous stroke or heart attack increases risk.
  • Majority of CVAs occur in patients over 65 years of age.

MODIFIABLE RISK FACTORS

  • Atrial Fibrillation and Other Heart Disease: Responsible for 25% of all strokes.
  • Carotid Artery Disease.
  • High Blood Pressure:
    • Considered the most significant risk factor, with potential for a 50% reduction in risk through treatment.
  • Smoking:
    • Damages blood vessels and nearly doubles the risk for stroke.
  • Excessive Alcohol Consumption: Increases risk of hypertension.
  • Diabetes: Higher risk (5x) due to its effects on blood vessels in the brain.
  • High Blood Cholesterol Levels.
  • Inactive Lifestyle and Lack of Exercise.
  • Poor Diet.
  • Obesity:
  • Sleep Apnea.
  • Metabolic Syndrome.
  • Certain Blood Disorders: Including sickle cell anemia.
  • Previous History of Transient Ischemic Attack (TIA):
    • Mini strokes with no lasting effects can indicate high risk for future strokes.
  • Current or Past History of Blood Clots:
  • Medications: Such as estrogen replacement increasing risk of blood clots.

STROKE DEATH RATES

Data from 2018-2020
  • Regions:
    • Guam, Alaska, Hawaii, Northern Mariana Islands, American Samoa, Puerto Rico, US Virgin Islands.
  • Age-Adjusted Prevalence (%):
    • Ranges from 3.6% to 177.5% across different regions based on risk factors and incidents of stroke.

PATIENTS AT GREATER RISK FOR STROKE

  • Hypertension
  • Diabetes Mellitus
  • Artery Disease
  • Heart Disease (including Atrial Fibrillation)
  • High Cholesterol
  • History of Transient Ischemic Attack (TIA)

PREVENTING STROKE

  • Strategies:
    • Maintain a healthy diet, control weight, engage in regular exercise, refrain from smoking, limit alcohol intake, and schedule routine check-ups.
  • "A pound of prevention is worth an ounce of cure!"

TYPES OF STROKES

ISCHEMIC STROKE

  • Thrombotic Stroke:
    • Arteries are clogged with plaques, forming a thrombus that blocks blood flow to specific brain areas (e.g. atherosclerosis).
    • Accounts for 30-50% of TIAs.
  • Embolic Stroke:
    • A thrombus travels to the brain from another part of the body (e.g. heart) and blocks blood flow.
    • Often associated with atrial fibrillation.

HEMORRHAGIC STROKE

  • Definition:
    • A burst blood vessel that allows blood to seep into brain tissue, causing damage until clotting occurs.

TRANSIENT ISCHEMIC ATTACK (TIA)

  • Description:
    • Brief loss of neurological function that lasts less than 24 hours, typically resolving within 1 hour.
    • Caused by temporary block of blood flow to the brain (e.g., microemboli, ischemia).
    • Serves as a warning of a potential thrombotic stroke.
  • Symptoms:
    • Variable and related to the affected vessel, may include visual changes, hemiparesis, inability to speak, tinnitus, vertigo, numbness, or weakness.

TIA & STROKE PREVENTION

  • Modifiable Risk Factors:
  • Preventive Therapy:
    • Medications such as anti-platelets (ASA, Plavix), anti-coagulants (Coumadin, Xarelto, Pradaxa), and statins (Zocor, Mevacor).
  • Surgery Options:
    • Carotid Endarterectomy (removing plaque), Carotid Stenting, and Transluminal angioplasty (balloon procedure to open stenosed artery).

ATRIAL FIBRILLATION AND STROKE PREVENTION

  • Description:
    • A-fib is characterized by an irregular and often rapid heartbeat that can increase the risk of stroke.
    • Major cause of stroke disabilities/deaths worldwide.
  • Symptoms:
    • Often asymptomatic but may include general fatigue, rapid heartbeat, dizziness, shortness of breath, anxiety, weakness, faintness, and confusion.
  • Diagnosis:
    • Pulse check (heart rate
  • Statistics:
    • Approximately 1 million AF-related strokes occur annually, with patients five times more likely to experience a stroke compared to the general population.

ADULT SUSPECTED STROKE ALGORITHM

  • Steps for Management:
    • Identify signs/symptoms of stroke.
    • Activate emergency response, perform critical EMS assessments, and establish time of symptom onset.
    • Triage to stroke center and alert hospital.
    • Conduct urgent assessments including blood glucose checks, general assessment, time management for CT scan.
  • Timeline for Emergency Department (ED) Arrival:
    • 10 min for initial assessment, 25 min for initial CT scan, 45 min for treatment initiation (if applicable).

TREATMENT

ISCHEMIC STROKE

  • Emergency Treatment:
    • Use of thrombolytic agent alteplase (t-PA) within a 3 to 4.5-hour window; intra-arterial treatment must begin within 6 hours.
  • Guidelines:
    • Close monitoring in Critical Care Unit (CCU) needed.
    • Blood pressure must be maintained below 185 systolic and 110 diastolic prior to treatment; use labetalol if necessary.

NIHSS STROKE SCALE

  • Assessment Tool:
    • Scale consists of 11 components to assess the patient's level of consciousness, gaze, visual field, facial palsy, motor functions, limb ataxia, sensory responses, language, dysarthria, and inattention.
    • Score ranges from 0 (normal function) to 42 (unresponsive), detailing the extent of brain function suppression.

CONTINUED MANAGEMENT FOR ISCHEMIC STROKE

  • Post-treatment Considerations:
    • Conduct bedside swallowing screenings and consult with speech therapy.
    • Maintain NPO status until swallowing is cleared.
    • Provide bed rest with elevated head position (HOB) of 30 degrees to improve oxygenation.

HEMORRHAGIC STROKES

  • Definition:
    • Include intracerebral hemorrhages (bleeding within the brain) and subarachnoid hemorrhages (bleeding occurring on the brain's surface).
  • Causes:
    • Chronic high blood pressure, drug use (cocaine, meth), blood-thinning medications, and prior aneurysms heighten risk.

TREATMENT FOR HEMORRHAGIC STROKE

  • Actions:
    • Control the cause of bleeding, manage blood pressure, and cease medications that heighten risk of bleeding.
    • Surgical intervention may be necessary to relieve pressure in the brain.
  • Specific Treatments:
    • Administration of vitamin K for coumadin overdose and fresh frozen plasma for clotting factors.

COMMON EFFECTS OF STROKE

  • Physical and Cognitive Effects:
    • Hemiparesis or hemiplegia, one-sided neglect, visual field loss, emotional control loss, cognitive changes, behavioral alterations, dysarthria, expressive/receptive aphasia, and dysphagia.

COMMUNICATION AND APHASIA

  • Definition:
    • Aphasia is a language disorder resulting from brain injury affecting speech and communication abilities post-stroke.
  • Communication Tips for Caregivers:
    • Use simple phrases, be patient, remove distractions, utilize creative means for communication, and confirm understanding.

STROKE RECOVERY AND REHABILITATION

  • Overview:
    • Stroke recovery does not end at the six-month mark; however, this period is considered the most critical for functional and cognitive recovery.

NURSING DIAGNOSES FOR STROKE PATIENTS

  • Common Diagnoses:
    • Ineffective tissue perfusion, ineffective airway clearance, impaired physical mobility, impaired verbal communication, impaired urinary elimination, impaired swallowing, risk for aspiration.
  • Goals:
    • Improve mobility, speech, and activities of daily living (ADLs).

ACUTE INTERVENTIONS

  • Respiratory Care:
    • Monitor for atelectasis and aspiration pneumonia; utilize intubation for airway protection if necessary.
  • Musculoskeletal Care:
    • Range of motion exercises, careful positioning to avoid edema, and preventive measures for foot drop and hand contractures.
  • Integumentary Care:
    • Skin breakdown risk management; utilize appropriate measures to maintain skin integrity.
  • Nutritional Support:
    • NPO until cleared for swallowing; consult dieticians for feeding plans involving enteral access if needed.

PSYCHOSOCIAL CONSIDERATIONS

  • Emotional
    • Recognize emotional labiality and provide adequate support to patients and families affected by stroke recovery challenges.

FINAL NOTES

  • Recovery Insights:
    • Stroke recovery can be extensive and requires multidisciplinary support, education, and a tailored care plan to assist patients in regaining independence and improving their quality of life.