STROKE

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STROKE 101
Third leading cause of death in America,

behind heart disease and cancer Kills 160,000 people each year Leading cause of adult disability About 750,000 strokes will occur this year, 500,000 of those strokes could be prevented Costs the nation $62.7 billion in direct and indirect costs

POINTS TO CONSIDER
2,000,000 brain cells die every minute during

stroke, increasing risk of permanent brain damage, disability or death. Recognizing symptoms and acting fast to get medical attention can save life and limit disabilities.

STROKE
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A stroke is a medical emergency in which

the blood supply to any portion of the brain is interrupted or reduced. Alternative names: Cerebrovascular accident/ disease (CVA), Cerebral infarction, Cerebral hemorrhage.
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PROGNOSIS
The results of a stroke vary depending on

the size and location, the presence of any associated medical problems, and the likelihood of recurring strokes. Dysfunctions correspond to the area in the brain that had been damaged.

THE HUMAN BRAIN

DIRECT CAUSES OF STROKE

Cerebral thrombosis a blood clot or plaque

blocks an artery that supplies a vital brain center Cerebral hemorrhage or aneurysm an artery in the brain bursts, weakens the aneurysm wall; severe rise in BP causing hemorrhage and ischemia Cerebral embolism a blood clot breaks off from a thrombus elsewhere in the body, lodges in a blood vessel in the brain and shuts off blood supply to that part of the brain

ACT F.A.S.T.
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F = Face
Ask the person to smile. Does one side of the face droop?

A = Arms
Ask the person to raise both arms. Does one arm drift

downward?

S = Speech
Ask the person to repeat a simple sentence. Does the speech

sound slurred or strange?

T = Time
Call 911 immediately!

TYPES OF STROKE:

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TYPES OF STROKE
Ischemic stroke - when arteries are blocked by blood clots or by

gradual build up of plaque and other fatty deposits.

Almost 85% of strokes are ischemic.

Hemorrhagic stroke when a blood vessel in the brain breaks

leaking blood into the brain.

About 15% of all strokes but responsible for 30% of stroke deaths

RISKS
TIA CAD High Blood Pressure High Cholesterol Smoking Excessive alcohol

consumption
Family History Age Sex Race Obesity

Heart Disease
Diabetes

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PREVENTION
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Control high Blood Pressure

Lower cholesterol
Quit smoking Control diabetes Maintain healthy weight Exercise Manage stress Eat a healthy diet

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COMMON STROKE SYMPTOMS

Weakness or paralysis Numbness, tingling, decreased

sensation
Vision changes
Speech problems Swallowing difficulties or drooling Loss of memory

Vertigo (spinning sensation)

Loss of balance and coordination Personality changes Mood changes (depression, apathy)

Drowsiness, lethargy, or loss of

consciousness
Uncontrollable eye movements or

eyelid drooping

MAJOR EFFECTS OF STROKE

Hemiplegia - most common result of CVA

Paralysis of one side of the body

May affect other functions, such as hearing, general sensation

and circulation
The degree of impairment depends on the part of the brain

affected
Stages: Flaccid numbness and weakness of affected side Spastic muscles contracted and tense, movement hard

Recovery therapy and rehab methods successful

 Aphasia and Dysphasia Brain Damage extent of brain damage determines chances of

recovery
Hemianopsia blindness in half of the visual field of one or both

eyes
Pain usually very little; injection of local anesthetic provides

temporary relief
Autonomic Disturbances Such as perspiration or goose flesh above the level of

paralysis
May have dilated pupils, high or low BP or headache Treated with atropine-like drugs Personality Changes either functional or organic

THE SYMPTOMS OF A STROKE ARE DEPENDENT ON WHAT PORTION OF THE BRAIN IS DAMAGE.

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TYPES OF PARALYSIS

ABNORMAL VISUAL FIELDS

TESTS

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Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Cerebral Angiography: identify responsible

blood vessel Electrocardiogram (ECG): underlying heart conditions Echocardiogram: blood clot from heart Carotid Duplex: carotid artery stenosis Heart monitors, blood work and many more tests!!

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ISCHEMIC STROKE:
A blood vessel

becomes blocked and the blood supply to that part of your brain is blocked. Types of Ischemic strokes:
Thrombotic Stroke Embolic Stroke

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 Symptoms depend upon the location and size of the

MANIFESTATIONS OF ISCHEMIC STROKE

affected area

Numbness or weakness of face, arm, or leg, especially on

one side
Confusion or change in mental status Trouble speaking or understanding speech

Difficulty in walking, dizziness, or loss of balance or

coordination
Sudden, severe headache Perceptual disturbances

PREVENTIVE TREATMENT AND SECONDARY PREVENTION

Health maintenance measures including a healthy

diet, exercise, and the prevention and treatment of periodontal disease Anticoagulant therapy Antiplatelet therapy: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid) Statins Antihypertensive medications

TREATMENTS
Tissue plasminogen activator (tPA) can be

given within three hours from the onset of symptoms.

In addition to being used to treat strokes, the following can also be used as preventative measures.
Anticoagulants/Antiplatelets Carotid Endarterectomy Angioplasty/Stents

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MEDICAL MANAGEMENT DURING ACUTE PHASE OF STROKE

Prompt diagnosis and treatment

Assessment of stroke: NIHSS

assessment tool
Thrombolytic therapy
Criteria for tissue plasminogen activator (tPA) IV dosage and administration Patient monitoring Side effects: potential bleeding

MEDICAL MANAGEMENT DURING ACUTE PHASE OF STROKE (CONT.)

Elevate HOB unless contraindicated Maintain airway and ventilation Provide continuous hemodynamic

monitoring and neurologic assessment

NURSING PROCESSASSESSING THE PATIENT RECOVERING FROM AN ISCHEMIC STROKE

Acute phase Ongoing/frequent monitoring of all systems including

vital signs and neurologic assessment: LOC and motor, speech, and eye symptoms
Monitor for potential complications including

musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of increased ICP and meningeal irritation After the stroke is complete Focus on patient function; self-care ability, coping, and teaching needs to facilitate rehabilitation

NURSING PROCESSDIAGNOSIS OF THE PATIENT RECOVERING FROM AN ISCHEMIC STROKE

Impaired physical mobility

Acute pain
Self-care deficits Disturbed sensory perception Impaired swallowing Urinary incontinence

NURSING PROCESSDIAGNOSIS OF THE PATIENT RECOVERING FROM AN ISCHEMIC STROKE (CONT.)

Disturbed thought processes

Impaired verbal communication

Risk for impaired skin integrity Interrupted family processes Sexual dysfunction

NURSING PROCESSPLANNING PATIENT RECOVERY AFTER AN ISCHEMIC STROKE Major goals include:
Improved mobility
Avoidance of shoulder pain Achievement of self-care Relief of sensory and perceptual

deprivation Prevention of aspiration Continence of bowel and bladder

NURSING PROCESSPLANNING PATIENT RECOVERY AFTER AN ISCHEMIC STROKE (CONT.)

Major goals include (cont):
Improved thought processes Achievement of a form of communication

Maintenance of skin integrity

Restoration of family functioning Improved sexual function

Absence of complications

IMPROVING MOBILITY AND PREVENTING JOINT DEFORMITIES

Turn and position the patient in correct alignment every 2

hours
Use splints Practice passive or active ROM 4 to 5 times day Position hands and fingers

Prevent flexion contractures

Prevent shoulder abduction Do not lift by flaccid shoulder Implement measures to prevent and treat shoulder

problems

IMPROVING MOBILITY AND PREVENTING JOINT DEFORMITIES

Perform passive or active ROM 4 to 5 times

day Encourage patient to exercise unaffected side Establish regular exercise routine Use quadriceps setting and gluteal exercises Assist patient out of bed as soon as possible: assess and help patient achieve balance and move slowly Implement ambulation training

INTERVENTIONS
Focus on the whole person

Provide interventions to prevent

complications and to promote rehabilitation

Provide support and encouragement

Listen to the patient

INTERVENTIONS
Enhance self-care
Set realistic goals with the patient Encourage personal hygiene Ensure that patient does not neglect the affected side Use assistive devices and modification of clothing

Provide support and encouragement Implement strategies to enhance communication Encourage the patient with visual field loss to turn his head

and look to side

INTERVENTIONS (CONT.)
Nutrition Consult with speech therapist or nutritionist Have patient sit upright to eat, preferably OOB Use chin tuck or swallowing method Feed thickened liquids or pureed diet Bowel and bladder control Assess and schedule voiding Implement measures to prevent constipation: fiber, fluid, and toileting schedule Provide bowel and bladder retraining

HEMORRHAGIC STROKE:
A small blood vessel

in the brain becomes weak and ruptures. Types of hemorrhagic stroke:

Intracerebral hemorrhage

(ICH)
Subarachnoid hemorrhage

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HEMORRHAGIC STROKE
Caused by bleeding into brain tissue, the

ventricles, or subarachnoid space

May be due to spontaneous rupture of small

vessels primarily related to hypertension; subarachnoid hemorrhage due to a ruptured aneurysm; or intracerebral hemorrhage related to amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants

MANIFESTATIONS
Similar to ischemic stroke Severe headache Early and sudden changes in LOC Vomiting

TREATMENT
Surgery is often required to remove pooled blood from the

brain and to repair damaged blood vessels.

Prevention:
An obstruction is introduced to prevent rupture and bleeding

of aneurysms and arteriovenous malformations (AVM).

Surgical Intervention Endovascular Procedures

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MEDICAL MANAGEMENT
Prevention: control of hypertension

Diagnosis: CT scan, cerebral angiography, and lumbar

puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage

Care is primarily supportive Bed rest with sedation Oxygen

Treatment of vasospasm, increased ICP, hypertension,

potential seizures, and prevention of further bleeding

NURSING PROCESSASSESSMENT OF THE PATIENT WITH A HEMORRHAGIC STROKE/CEREBRAL ANEURYSM Complete an ongoing neurologic assessment: use
neurologic flow chart
Monitor respiratory status and oxygenation Monitor ICP Monitor patients with intracerebral or subarachnoid

hemorrhage in the ICU

Monitor for potential complications Monitor fluid balance and laboratory data Reported all changes immediately

NURSING PROCESS
DIAGNOSIS OF THE PATIENT WITH A HEMORRHAGIC STROKE/ CEREBRAL ANEURYSM

Ineffective tissue perfusion (cerebral)

Disturbed sensory perception

Anxiety

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Vasospasm

Seizures
Hydrocephalus Rebleeding Hyponatremia

NURSING PROCESS
PLANNING CARE OF THE PATIENT WITH A HEMORRHAGIC STROKE/CEREBRAL ANEURYSM

Goals may include:

Improved cerebral tissue perfusion Relief of sensory and perceptual deprivation Relief of anxiety Absence of complications

ANEURYSM PRECAUTIONS (CONT.)

Nurse provides all personal care and hygiene

Provide nonstimulating, nonstressful

environment: dim lighting, no reading, no TV, and no radio

Prevent constipation Restrict visitors

INTERVENTIONS
Relieve sensory deprivation and anxiety Keep sensory stimulation to a minimum for

aneurysm precautions Implement reality orientation Provide patient and family teaching Provide support and reassurance Implement seizure precautions Implement strategies to regain and promote selfcare and rehabilitation

HOME CARE AND TEACHING FOR THE PATIENT RECOVERING FROM A STROKE
Prevention of subsequent strokes, health

promotion, and implementation of follow-up care Prevention of and signs and symptoms of complications Medication teaching Safety measures Adaptive strategies and use of assistive devices for ADLs

HOME CARE AND TEACHING FOR THE PATIENT RECOVERING FROM A STROKE (CONT.)
Nutrition: diet, swallowing techniques, and tube

feeding administration Elimination: bowel and bladder programs and catheter use Exercise and activities: recreation and diversion Socialization, support groups, and community resources

TRANSIENT ISCHEMIC ATTACK (TIA)

Blood supply to the brain is only briefly interrupted Symptoms do not last long Warning Stroke- steps should be taken to prevent future stroke.

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