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Stroke

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Janet Adanty

on 13 November 2016

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Transcript of Stroke

Nursing Interventions
Venous thromboembolism prophylaxis
62
ECG
bpm
Thank You!
WHAT IS A STROKE?
"A clinical syndrome characterized by an acute loss of focal brain function lasting for more than 24 hours" (Kearney, 2014, p. 9)
INCIDENCE & PREVALENCE
CT scans are often the first tests done to diagnose a stroke. The images can reveal whether the stroke was caused by a blood clot (ischemic stroke) or uncontrolled bleeding (hemorrhagic stroke).

Works by taking a series of images of the brain in “slices” to show details of the brain. In some cases, a dye is injected to define the tissues and vessels for the images. (Heart and Stroke Foundation, 2015; Besson et, al, 1995)
Stroke Stats
By:
Janet Adanty
Kwesi Asamoah

Kaitlin Fernandes
Afnan Tahlil

Stroke
RISK FACTORS
PREVENTION
Smoking Cessation
Moderate Alcohol Use
Increase Physical Activity
Weight Loss
Dietary Sodium Reduction
ACE inhibitors & ARBs [anti-hypertensives]
High-dose atorvastatin has been shown to reduce the risk of stroke [dyslipidemic]
CLINICAL MANIFESTATIONS
TREATMENT
REHABILITATION
Nursing Interventions
Cannulate and take blood samples
Electrogram
Neurological observations every 15 minutes
Emergency computed tomography (CT) scan
Support family and friends
Contact GP (general practitioner) for details of medication
"Thought to be due to spontaneous hemorrhage (...) or inadequate blood supply to a part of the brain as a result of low blood flow, thrombosis, or embolism" (Kearney, 2014, p. 9)
TYPES
HEMORRHAGIC

ISCHEMIC
Weakness
Trouble Speaking (dysarthria)
Vision Problems
Headache
Dizziness
Motor Weakness (Paresis)
Sudden blindness in one or both eyes or double vision
(McCallum & Leonard, 2013, p. 21, 24)
Non-Modifiable
Age
Ethnicity
(Sander, 2013, p. 35)
Chobanian's work (as cited in Bergman 2011).
Modifiable
Hypertension
Smoking
Diabetes
Atrial Fibrillation
Dyslipidemia
Diet
Physical Inactivity
Obesity
Goldstein et al's work (as cited in Sander 2013)
Common in men
Oral contraceptives & pregnancy
Positive family history
Low-Birth Weight
(Goldstein et al. 2011, p. 519-520)
RECOGNIZE
F
: Face
A
: Arms
S
: Speech
T
: Time
National Institute for Health and Care Excellence work (as cited in Sander, 2013)
Providing a good supply of oxygen to the damaged brain is vital. Singhal et al's work (as cited in Sander, 2013).
Oral assessment is mandatory before food, fluid or medication is given orally (Sander, 2013).
Involve a speech and language therapist who will give a small amount of water to see if the patient coughs or the voice changes , suggesting water in the larynx, or if fluids pools in the mouth. National Institute for Health and Care Excellence work

(as cited in Sander, 2013).
Pay close attention to mouth care
Catangui and Slark's work (as cited in Sander, 2013)
(Sander, 2013, p.36).
“About 315,000 Canadians are living with the effects of stroke (PHAC, 2011c).” (“Heart and Stroke”, 2012).
The goals of rehabilitation after a stroke include preventing complications and maximizing recovery (Norman, 2014)
Positioning is key in preventing complications. Care must be taken by the nurse when positioning a client these ways: - the side-lying position (for the affected and unaffected side) - sitting upright in bed - sitting out in a chair
The hemiplegic shoulder must be protected from injury and but also encouraged for use (Norman, 2014)
REFERENCES
Bergman, D. (2011). Preventing recurrent cerebrovascular events in
patients with stroke or transient ischemic attack: The current data.
Journal Of The American Academy Of Nurse Practitioners,
23(12), 659-666. doi:10.1111/j.1745-7599.2011.00650.x
Goldstein, L., Bushnell, C., Adams, R., Appel, L., Braun, L., Chaturvedi, S.,
& ... Pearson, T. (2011). Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
Stroke (00392499),
42(2), 517-584. doi:10.1161/STR.0b013e3181fcb238
Kearney, P. M. (2014). Stroke: Frameworks for understanding. Part 1.
Journal Of The
Australasian Rehabilitation Nurses' Association (JARNA),
17(1), 8-13.

McCallum, C., & Leonard, M. (2013). The connection between neurosciences and
dialysis: A quick neurological assessment for hemodialysis nurses.
CANNT Journal
, 23(3), 20-28.
Sander, R. (2013). Prevention and treatment of acute ischaemic
stroke.
Nursing Older People
, 25(8), 34-39. doi:10.7748/nop2013.10.25.8.34.e438
Besson, G., Robert, C., Hommel, M., & Perret, J. (1995). Is It Clinically
Possible to Distinguish Nonhemorrhagic Infarct From Hemorrhagic Stroke?.
American Heart Association,
26, 1205-1209, doi: 10.1161/01.STR.26.7.1205
Heart and Stroke Foundation. (2008).
Stroke Diagnosis
. Retrieved January 27,
2015 from http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483941/k.A2B1/Stroke__Tests.htm
Heart and Stroke Foundation. (2015, January 12).
Recognize The Signs of Stroke FAST – Victim
.
[Video file] Retrieved from http://www.heartandstroke.com/site/c.ikIQLcMWJtE
/b.2796497/k.BF8B/Home.htm?gclid=CLXy3MC3t8MCFQmNaQodbI4Aaw.
REFERENCES
Wallace, A. N., Dinesm J. N., Zipfel, G. J., & Derdeyn, C. P. (2013). Yield of
Catheter Angiography After Computed Tomography Negative, Lumbar Puncture Positive Subarachnoid Hemorrhage.
American Heart Association
, 44, 1729-1731, doi: 10.1161/STROKEAHA.113.001234
Registered Nurses’ Association of Ontario (2005).
Stroke
Assessment Across the Continuum of Care.
Retrieved January 27, 2015 from http://rnao.ca/sites/rnao-ca/file Stroke_Assessment_Across_the_Continuum_of_Care.pdf
CT Scans
Cerebral or carotid angiography or arteriography

Takes pictures of the blood flowing in the neck and brain due to a dye injected that will show up on X-rays. This shows the size and location of any blockages.

Carotid Ultrasound
Sound waves are used to examine the blood flow in the carotid arteries and detect potential blockages or narrowing.


Echocardiogram

Uses ultrasound to show a picture of the heart. This test is done if a stroke is suspected due to a heart condition. It also shows if there are potential blood clots in the heart.

Uses magnetic field and radio waves to get clear 3-D pictures of the inside of the brain and detect bleeding, tumors or stroke. Also detects smaller strokes or strokes in the back of the brain. (Heart and Stroke Foundation, 2015)
Magnetic Resonance Imaging (MRI)
Vital Signs
Temperature

Hyperthermia can occur within 72 hours of stroke
Pulse, Respirations and Blood Pressure

Arrhythmias, SOB and HTN can occur post stroke. Irregularities in the heart can also identify atrial fibrillation
Blood Glucose
Baseline blood glucose levels should be assessed. Hyperglycemia can initiate anerobic metabolism, lactic acidosis and free radical production in damaged brain tissue which is irreversible.

(RNAO, p. 29-33, 2005)
Magnetic Resonance Angiography (MRA)
Used to detect any blocking or narrowing of the arteries in the neck and brain. Information about a stroke can be drawn from 3-D images of specific veins and arteries. (Heart and Stroke Foundation, 2015).
Lumbar Puncture
Is performed to detect presence of RBCs in the cerebral spinal fluid (CSF), if a subarachnoid hemorrhage is suspected. (Wallace et al., 2013)
Neurological Exam
Canadian Neurological Scale, National Institutes of Health Stroke Scale or Glasgow Coma Scale assess: Level of consciousness, orientation, Motor (strength, pronator drift, balance and coordination), pupils, speech/language
Neurological assessment
helps to identify any neurological deterioration
Assessment of Coordination
clients who have experienced brainstem/cerebellar/posterior hemispheric strokes will experience limb or gait ataxia, motor or sensory loss, dysarthria, amnesia, visual field deficits, and/or nystagmus.

Simple coordination and gait testing can identify deficits in these areas:
-Finger-nose-finger test
-Heel-shin test
-Tandem gait
Assessment of strength

Patient performs the pronator drift test for 45 seconds
Pupil size and reaction
“About 80% of strokes are ischemic caused by the interruption of blood flow to the brain due to a blood clot. About 20% of strokes are hemorrhagic caused by uncontrolled bleeding in the brain.” (“Heart and Stroke”, 2012).
“There are estimated 50,000 strokes in Canada each year. That’s one stroke every 10 minutes (Hakim, Silver, & Hodgson, 1998).” (“Heart and Stroke”, 2012).
“Each year, over 14,000 Canadians die from stroke (Statistics Canada, 2012).” (“Heart and Stroke”, 2012).

Statistics - Heart and Stroke Foundation of Canada. (2012).
Retrieved February 2, 2015, from http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistics.htm
Norman, L. (2014). Stroke rehabilitation promoting
physical recovery.
Nursing & Residential Care
, 16(12). 699-702.
Miller, T. S., Levitt, A. H., & Brook, A. L. (2013). Emerging role of endovascular and
acute ischemic stroke treatments.
Applied Radiology,
42(6), 17-23
.

"Hemorrhagic strokes are caused by uncontrolled bleeding in the brain. This bleeding interrupts the normal blood flow in the brain and kills brain cells either by flooding at the leakage site or by shortage of blood supply beyond the leakage" (Heart and Stroke, 2014, para. 1).

Heart and Stroke Foundation. (2014).
Hemorrhagic Stroke.
Retrieved Febuary 7th,
2015 from
http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3484153/k.7675/Stroke__Hemorrhagic_stroke.htm
"
Thrombotic
stroke is caused by a blood clot that forms in an artery directly leading to the brain" (Heart and Stroke Foundation, 2014, para. 2).
"
Embolic
stroke occurs when a clot develops somewhere else in the body and travels through the blood stream to the brain" (Heart and Stroke, Foundation, 2014, para 3).


TYPES OF ISCHEMIC STROKE
"Ischemic stroke occurs when a region of the brain does not receive adequate blood supply for a time period sufficient to cause cell death" (Miller, Levitt & Brook, 2013, p. 17).
TYPES OF HEMORRHAGIC STROKE
"
Subarachnoid
hemorrhage is uncontrolled bleeding on the surface of the brain, in the area between the brain and the skull" (Heart and Stroke Foundation, 2014, para. 2).
"
Intracerebral

hemorrhage occurs when an artery deep within the brain ruptures" (Heart and Stroke, 2014, para. 3).
Heart and Stroke Foundation. (2014).
Ischemic Stroke.
Retrieved Febuary 7th,
2015 from http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3484151/k.7916/Stroke__Ischemic_stroke.htm
TRANSIENT ISCHEMIC ATTACK
“A
brief episode
of neurological dysfunction caused by a disturbance of brain or retinal ischemia, with clinical symptoms typically lasting less than 1 h, without evidence of infarction” Albers et al., work (as cited in Bergman 2014).

Diagnostic Tests
Stroke Rehabillitation. Adapted from “Ask Doctor K”, Ask Doctor K. Retrieved February 7, 2015, from http://www.askdoctork.com/what-is-stroke-rehabilitation-201207132220
Warning signs that’s apply to TIA and Stroke. Adapted from “Mail Online”, Daily Mail Reporter. Retrieved February 7, 2015, from http://www.dailymail.co.uk/health/article-2224590/Thousands-miss-early-warning-signs-stroke.html
Computed Tomography-CT Screening Exams. Adapted from “Norwalk Radiology and Mammography Center”. Retrieved February 7, 2015, from http://www.norwalkradiology.com/ct_computed_tomography.html
Example of iodine-based contrast in cerebral angiography. Adapted from “Wikipedia”. Retrieved February 7, 2015, from http://en.wikipedia.org/wiki/Digital_subtraction_angiography
Time-of-flight MRA at the level of the Circle of Willis. Adapted from “Wikipedia”. Retrieved February 7, 2015, from http://en.wikipedia.org/wiki/Magnetic_resonance_angiography
Prevention Therapy
Emergency Treatment -
Ischemic Stroke

Drug Therapy
Emergency Treatment -
Hemorrhagic Stroke

-Anticoagulants & Antiplatelets are contraindicated (Broderick et al., 2007).
Antiplatelet drugs
Asprin :
81 to 325 mg/day
(Healey et al., 2008)
clopidogrel (Plavix)
dipyridamole (Persantine)
combined dipyridamole
(Furie et al., 2011)

Oral anticoagulation
Warfarin (for patients with AF who have had a TIA) (Furie et al., 2011).

Statins (simvastatin [Zocor], lovastatin [Mevacor]) for TIA patients(Furie et al., 2011).


Emergency Treatment -
Ischemic Stroke

Surgical therapy
Mechanical embolus removal in cerebral ischemia (MERCI) retriever
Restores cerebral perfusion within 8 hours of stroke symptom onset (Smith, 2006, pg.1)


Drug Therapy
-Management of hypertension- - systolic BP <160 mm Hg)
--- Oral or IV ( Metoprolol (Lopressor) (Broderick et al., 2007).
Emergency Treatment -
Hemorrhagic Stroke

Surgical Therapy
Removal of the blood clot
Repair blood vessels
Surgery may be needed to remove the hematoma and relieve the pressure on the brain (Heart&stroke foundation, 2008, pg.1).
Aneurysms

Which drug is used for stroke prevention:
a.Ranitidine
b.Lasix
c.Aspirin
d.Sodium bicarbonate

http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483937/k.86D8/Stroke__Stroke_signs.htm
REHABILITATION
AVM
Surgery is performed to repair the ruptured blood vessels (Heart&stroke foundation, 2008).
An abbreviated neurological assessment
by the nurse should include: LOC, orientation, speech and language, motor movement, pupils (McCallum & Leonard, 2013, p. 22).
MORTALITY
"Stroke is the third leading cause of death in Canada. Six percent of all deaths in Canada are due to stroke" (Statistics Canada, 2012).


"Each year, over 14,000 Canadians die from stroke" (Statistics Canada, 2012) (“Heart and Stroke”, 2012).
Treatment. Adapted from ‘comomeningitis’. Retrieved February 12, 2015, from http://www.comomeningitis.org/facts-about-meningitis/treatment/
Brain hematoma. Adapted from ‘connecttoresearch’. Retrieved February 12, 2015, from http://www.connecttoresearch.org/publications/91
Clipping treatment for cerebral aneurysm. Adapted from ‘hopkinsmedicine’. Retrieved February 12, 2015, from http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/cerebral_aneurysm_85,P08772/
AVM (Arteriovenous Malformation). Adapted from ‘avminfo’. Retrieved February 12, 2015, from http://avminfo.com/
Treatment. Adapted from ‘comomeningitis’. Retrieved February 12, 2015, from http://www.comomeningitis.org/facts-about-meningitis/treatment/

Dedicated to Quality EMS Education ( 2008, Aug 1). MERCI clot retreival catheter for ischemic stroke. Retrieved from
Recombinant tissue plasminogen activator (tPA)
Indication:

Dissolves clot (Adams et al., 2007).
Route: IV or Intra-arterial infusion (Adams et al., 2007).
Time range:
3 to 4.5 hours (del Zoppo, Saver, Jauch, & Adams, 2009).
Screening:
-A non contrast CT or MRI to eliminate hemorrhagic stroke
-Blood work for coagulation disorders
-Recent history of gastrointestinal bleeding, stroke, or head trauma within the past 3 months
major surgery within 14 days (Adams et al., 2007).

Possible complication:
Bleeding ( intracranial bleeding) (Adams et al., 2007)
Aspirin
Indication:

Route:

Oral
Dose:
325 mg
Time range:
24-48 hours
Possible Complications:
GI Bleeding
(Hegge, 2008)

Nursing Interventions
Continence
:
All stroke patients should be screened for urinary incontinence and retention, fecal incontinence, and constipation
(Canadian Stroke Network & Heart and Stroke Foundation, 2010, p.89)
High risk
patients include those who are unable to move one or both lower limbs and those who are unable to mobilize independently; a history of venous thromboembolism; dehydration; and comorbidities such as malignant disease (Canadian Stroke Network & Heart and Stroke Foundation, 2010, p.88)


A.Early mobilization(within 24 hours) and adequate hydration
(CSN/HSF, 2010, p.89)
Some contraindications to early mobilization include, but may not
be restricted to, unstable medical conditions, low oxygen saturation, and lower limb fracture or injury (CSN/HSF, 2010, p.88)

B. Venous thromboembolism prophylaxis immediately.
Low molecular weight heparin should be considered for patients with acute ischemic stroke at high risk of venous thromboembolism; or unfractionated heparin for patients with renal failure (CSN/HSF, 2010, p.88)

Temperature should be monitored regularly as part of vital signs and particularly every four hours for first
48
hours (CSN/HSF, 2010, p.88).
Interventions:
Assessing the stroke patient for urinary tract infections to determine a possible transient cause of urinary retention
Excellent pericare and infection prevention strategies should be implemented to minimize risk of infections
A bladder-training program should be implemented in patients who are incontinent of urine, including timed and prompted toileting on a consistent schedule
A bowel management program should be implemented for stroke patients with persistent constipation or bowel incontinence
Nutrition
:
nutritional and hydration status of stroke patients should be screened within the first 48 hours of admission using a valid screening tool
(CSN/HSF, 2010, p.89-90)
Nursing Interventions
Oral Care:
Upon or soon after admission, all stroke patients should have an oral/dental assessment, including screening for signs of dental disease, level of oral care, and appliances
(CSN/HSF, 2010, p.90)
Interventions:
referral to a dietitian for further assessment and ongoing management of nutritional and hydration status
consideration of enteral nutrition support (tube feeding) within seven days of admission for patients who are unable to meet their nutrient and fluid requirements orally. This decision should be made collaboratively with the interprofessional team, the patient, and the caregivers and family
For temperature greater than
37.5°
Celsius:
Increase frequency of monitoring

Suspect possible infection such as pneumonia or urinary tract infection

Initiate temperature reducing measures ( antipyretic and antimicrobial therapy as required) (CSN/HSF, 2010, p.88).
Temperature Management
Interventions:
Interventions:
For patients wearing a full or partial denture it should be determined if they have the neuromotor skills to safely wear and use the appliance
The oral care protocol should be consistent with the Canadian Dental Association recommendations, and should address areas such as frequency of oral care (twice per day or more); types of oral care products (toothpaste, floss, and mouthwash); and management for patients with dysphagia
If concerns with implementing an oral care protocol are identified, consider consulting a dentist, occupational therapist, speech-language pathologist, and/or a dental hygienist
Interventions:
Nursing Interventions
Nursing Interventions
(CSN/HSF, 2010, p.89)
(CSN/HSF, 2010, p.89-90)
(CSN/HSF, 2010, p.90)
Canadian Stroke Strategy—Canadian best practices recommendations for stroke care:
Update 2010. (2010). Retrieved February 3, 2015, from http://www.strokebestpractices.ca/wp-content/uploads/2011/04/2010BPR_ENG.pdf
-Seizure prophylaxis measures are recommend
Prevention Therapy
Drug Therapy
Carotid angioplasty and stenting
Coiling aneurysms
For aneurysms that have not ruptured yet

Coils are placed into place by a catheter that is threaded through the blood vessels (Heart&stroke foundation, 2008, pg.1).
A balloon-like device to open a clogged artery. Then, a small metal stent is put in place to aid keep the artery open (Heart&stroke foundation, 2008, pg.1).
In coronary arteries of the heart
Angioplasty. Adapted from ‘topnews’. Retrieved February 14, 2015, from http://www.topnews.in/health/angioplasty-stents-better-bypass-surgery-low-risk-heart-patients-212544
Coling anyresum. Adapted from ‘mayfieldclinic’. Retrieved February 14, 2015, from http://www.mayfieldclinic.com/PE-Coiling.htm
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