Stroke: Nursing Management

Ischemia
inadequate blood flow
Stroke
Ischemia to a apart of the brain that results in death of brain cells. Functions are lost of impaired. Severity of loss of function varies accordingly to the location and extent of brain tissue involvement.
Cerebral autoregulation
Compensation to keep blood supply to the brain. Regulates the diameter of blood vessels. Collateral circulation helps maintain cerebral perfusion as there is more than one way for blood supply if there is a blockage
Stroke facts
3rd most common cause of death in US and Canada, leading cause of disability, 35% of people with an initial stroke die within one year
Stroke risk factors
Modifiable: HTN (most significant), diabetes (5x risk), heart disease-atrial fib (causes 20%), smoking, heavy alcohol consumption

Non-modifiable: age, gender, race, heredity, family history

Stroke prevention
Smoking cessation, limiting excessive alcohol intake, healthy diet, weight control

Antiplatelet drugs with TIA pts., ASA

Close management and control of diabetes mellitus, HTN, obesity, high serum lipids, cardiac dysfunction

Stroke classifications
TIA: transient ischemic attack-neurologic deficits, resolve in 24 hours

Stroke or CVA: 2 main categories-ischemic (clot blocks O2 to area of brain) and hemorrhagic (bleeding in brain tissue)

TIA
-Temporary focal loss of neurological function (s/s depend on blood vessels involved and are of brain that is ischemic)
-Caused by ischemia
-Warning sign of progressive CVA (showing blockage somewhere)
Stroke diagnostics
-CT of brain without contrast to indicate location and size of lesion and differentiate between ischemic and hemorrhagic stroke
-CT within 25 minutes of arrival to ER-within 45 minutes reading completed and treatment begins
Ischemic stroke
Partial of complete occlusion of an artery
80% of all CVA’s
Subarachnoid hemorrhagic stroke
-Caused from ruptured aneurysm, AV malformation (abnormal connection b/w arteries and veins-weakening in wall), and tumors

-Bleeding into CSF-filled space between layers of membrane on surface of the brain

-Young and middle age adults

-Sudden severe headache, N/V, photophobia, HTN

Intracerebral hemorrhagic stroke
-Caused by chronic HTN, anticoagulant therapy, aneurysms

-Affects elderly population

-Characterized by gradual development and headache, N/V, LOC changes

s/s of stroke
-Affects many bodily functions
-Motor activity
-Elimination
-Intellectual function
-Most common sign-numbness and weakness in arm or face
-Altered LOC
-Speech or visual disturbances
-Severe headache
-Increased or decreased respirations
-Respiratory distress
Right brain damage
Left body effects
-left weakness/neglect
-spatial-perceptual deficits
-minimizes problems, safety problems
-impulsive, impaired judgment, short attention span
-rapid performance
Left brain damage
Right body effects
-right weakness/neglect
-speech language aphasias (use yes/no ?’s)
-Aware of deficits, depression, and anxiety
-Cautious, impaired comprehension (math, language)
-slow performance
Stroke Acute care goals
-preserve life
-prevent further brain damage
-reduce disability
-treatment differs according to the type of CVA, and as patient changes
Acute care collaborative care
-Begin with ABC’s (priority for first 24 hours)
-Neuro assessment (LOC, numbness/weakness, paralysis, difficulty swallowing, N/V, incontinence, increased or decreased HR, BP, respiratory distress, unequal pupils)
-Maintain oxygenation
-IV fluids with normal saline
-Maintain BP
-HOB 30 degrees if no s/s shock of injury
-Institute seizure precautions
-Anticipate thrombolytic therapy for ischemic strokes
HTN acute care
-In ischemic stroke, lower BP only if markedly increased (systolic blood pressure >220, MAP >130 use metoprolol)
-Protective mechanism to keep blood to brain and help cerebral perfusion pressure
-Do not use with hemorrhagic stroke
Fluid and electrolyte interventions
-Adequate hydration
-Individualized-based on ICP, electrolytes, CVP
-I&O
-Avoid glucose and water (hypotonic)-ca increase ICP
ICP interventions
-Monitor ICP (peak 72 hours after stroke)
-Pain management
-Avoid hypervolemia
-Avoid constipation
-CSF drainage
-Diuretic (Manitol and Lasix if increased)
Drug interventions
-Ischemic stroke within 3-4.5 hours of s/s-recombinant tissue plasminogen activator (tPA)
-watch for s/s of intracranial hemorrhage
-no antiplatelets or anticoagulants for 24 hours after tPA
-If wake up in AM with s/s of stroke do not give tPA (don’t know when s/s started)

-Thrombus and embolus stroke pt.
-platelet inhibitors
-aspirin (81-325mg/day)
-ticlid
-plavix
-persantine

-Thrombus and embolus stroke pt after stabilization
-anticoagulants: IV heparin replaced by coumadin
-INR 2-3x normal, watch for hemorrhage
-Vitamin K warfarin antidote, Protamine sulfate heparin antidote

Hemorrhagic stroke
-NO anticoagulants or platelet inhibitors
-Calcium channel blocker: Nimotop to prevent cerebral vasospasm and improve cerebral perfusion
Stroke surgery
-Aneurysm clip/coil to prevent hemorrhagic
-carotid endarterectomy or angioplasty/stenting for ishemic
Stroke nursing diagnoses
-Altered tissue perfusion
-Impaired physical mobility
-Disturbed sensory perception
-Impaired communication
-Impaired swallowing
-Risk for impaired skin integrity
-Altered urinary elimination
Musculoskeletal interventions
-Positioning
-position on weak or paralyzed side for only 30 minutes
-turn every 2 hours
-position with pillows
-good skin care with emollients
-special care mattress/cushions
-prevent pressure sores-do not massage areas of redness
Activity post CVA care
-Up as soon as possible when patient has a sense of balance
-Splints, braces for contractures-avoid traditional slings
-Get patient up on strong side
-Start with strengthening, balance, then ambulation
GI system interventions
-Constipation, most common problem
-Assess for gag reflex (tongue blade)
-Speech/OT for swallowing exercises
-High fowler’s 30 minutes after feeding to prevent aspiration
-Food in unaffected side of mouth (watch for pocketing of food in affected side)
-1800-2000 mL o fluid
-25 g per day of fiber
-Use of assistive devices for eating
Impaired urinary elimination interventions
-Initially have flaccid bladder then functional incontinence related to communication, mobility, and dressing difficulties

-Clear path, loose clothing, commode or urinal, scheduled toileting

-Assess for bladder distention, toilet every 2 hours in the day and every 4 at night, focus intake 08-1900, use clothing easy to manipulate

-Avoid foleys (intermittent cath if retention)

Sensory perception interventions
-Diplopia (eye patch)
-Ptosis/drooping (no treatment)
-Corneal reflex loss (artificial tears, eye shield at bedtime)
-Homonymous hemianopsia (blindness same half of visual field-approach from the side they can see, tray on visual side, put things in field of vision, teach “visual sweep”)
Communication interventions
-Decrease environmental distractions
-Treat pt as an adult-if don’t understand, tell them
-Use normal tone and volume
-Yes/no questions, stay on same topic
-Communication board
-Give patient time to process and finish words they’re saying
-Use gestures and facial expressions and teach patient to do same, use body contact as appropriate
-Aphasia worsens with tiredness and anxiety-work on communication when pt rested
Affect interventions
-Distract client when they become suddenly emotional
-Explain to client and family reasons for suddenly having emotional outbursts
-Maintain calm environment
-Avoid shaming/scolding during emotional outburst
Coping interventions
-Losses
-Family/pt goes through grief and mourning associated with losses
-Long term depression: anxiety, weight gain, loss of energy, poor appetite, sleep disturbances
-Support communication between patient and the family
-Discuss lifestyle changes resulting from the CVA
-Discuss changing roles/responsibilities within the family
-Active listener (allow expression of fear, frustration, anxiety)
-Support family conferences
-Include pt, family in ST and LT goal setting
-Behavioral changes from the CBA not changeable (permanent loss of brain tissue)
-Responses to the multiple losses
-Support groups
-Spiritual needs
-Family therapy