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Acute Stroke Injury

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Nicole H

on 3 November 2013

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Transcript of Acute Stroke Injury

Acute Stroke Injury
Chapter 17

What is a stroke?
It is a acute neurologic deficit that occurs when impaired blood flow to a localized area of the brain results in injury to brain tissue
Classifications of Stroke
Types of Ischemic Strokes
Thrombotic Stroke
Caused by a blood clot that obstructs arterial blood flow to an area of the brain
Are more common in older adults and are usually associated with atherosclerotic plaque
Risk Factors: HTN, smoking, high cholesterol, DM, & atherosclerosis
Characteristics: may have TIAs, develop during sleep or on awakening, mild headache,
Embolic Stroke
Occurs when an embolus lodges in & occludes a cerebral artery
Most emboli originate from a thrombus in the heart that develops with certain heart conditions
Usually occur suddenly when the person is awake & active
Risk Factors: cardiac abnormalities: A Fib, valvular heart disease, carotid plaque or thrombosis
Characteristics: no warning, sudden attack, symptoms vary with location, usually occur during daytime
Transient Ischemic Attack
A temporary focal loss of neurologic function caused by ischemia
Usually resolve in a few minutes or hours & don't cause permanent brain injury
TIAs are a warning sign of progressive cerebrovascular disease
Hemorrhagic Strokes
Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles
Occurs with brain trauma, aneurysms, arteriovenous malformations, or HTN
Types of Hemorrhagic Strokes
Intracerebral Hemorrhage
Occurs when a cerebral blood vessel accumulates in brain tissue
Often occurs in older adults with sustained HTN
Risk Factors: chronic hypertension & anticoagulant therpay
Characteristics: usually no warning, gradual development, headache, N/V, photophobia, HTN, bloody CSF, decreased LOC, motor-sensory deficits of face, arm, leg
Subarachnoid Hemorrhage
Intracranial bleeding into cerebrospinal fluid-filled space between the arachnoid and pia mater
Usually due to a rupture of an aneurysm
Occurs in young, middle-aged adults
Risk Factors: ruptured aneurysms, arteriovenous malformation, brain tumor
Characteristics: usually no warning, sudden attack, severe headache "the worst headache of my life", N/V, photophobia, HTN, decreased LOC
Which of the following are the major classifications of stroke?
A. Subarachnoid and intracranial hemorrhage
B. Thrombotic and embolic
C. Ischemic and hemorrhage
D. TIA and embolic

which conditions are associated with emboli formation?
A. Myocardial infarction
B. Atrial fibrillation
C. Brain trauma
D. Endocarditis

Pathophysiology of Stroke
The majority of strokes result from ischemic infarction & inadequate blood flow
Cerebral ischemia can be focal (localized) or global (widespread)
Refusion is undertaken within the first hour of injury (the "golden hour")
The goal of medical treatment is to restore cerebral blood flow & limit the size & extension of the infarcted zone
Risk Factors for Stroke
Modifiable Risk Factors
Blood Pressure
the single most important modifiable risk factor, implicated in both ischemic & hemorrhagic strokes.
Cardiac Disease
coronary heart disease, heart failure, left ventricular hypertrophy, or dysrhythmias (A-Fib)
Diabetes Mellitus
accelerated atherosclerosis, HTN, dyslipidemia & macrovacular disease.
Smoking
increases platelet activation & injures endothelium, thereby increasing the risk for thrombus formation; plays an important role in development & progression of atherosclerosis
Dyslipidemia
risk factor for atherosclerosis; treatment with statins
Nonmodifiable Risk Factors
Age
for each successive decade after 55 years, the stroke rate more than doubles
Gender
men are at greater risk for stroke than women until the age of 75 At about 84 and older, women are at greater risk for stroke than men.
Race
Hispanics, American Indiana/Alaska Natives, & African Americans have a higher risk for stroke than Asian or non-Hispanic whites
Genetics
a direct link between a single gene & strokes has not yet been proven
What is the most important modifiable risk factor for stroke?
A. Age
B. Hypertension
C. Atrial fibrillation
D. Diabetes mellitus

Which modifiable risk factors are associated with increased risk of stroke (select all that apply)
A. Cigarette smoking
B. Heavy use of alcohol
C. Physical inactivity
D. Urban living

Assessment & Diagnosis of Stroke
It is recommended that the patient be diagnosed & have a treatment plan in place within 60 minutes of arrival to the ED
Strokes are commonly classified by cause as either
ischemic
or
hemorrhagic
Diagnosis
Is based on a complete H&P with a focused neurologic exam
The goal of the exam is to quickly determine whether the stroke is ischemic or hemorrhagic
Important info to obtain includes any reports of recent medical or neurologic events & medication history
Diagnostic Tests & Procedures
Imaging studies (CT scan or MRI) help determine the type, extent, & location of the injury
Lumbar puncture may be performed to detect blood in the CSF to R/O subarachnoid hemorrhage
TEE identifies cardiac sources of embolic ischemic stroke
A CBC including PT, INR, PTT, & fibrinogen are evaluated to detect any coagulopathies & establish a baseline for therapy
Serum electrolytes & blood glucose levels may be ordered to help R/O other conditions
ABGs, drug screen, & a serum alcohol level may be ordered if indicated
What is the most common manifestation of stroke?
A. Numbness & weakness of the face & arms
B. Monocular vision loss
C. Aphasia
D. Hemineglect

Which diagnostic test may be used to detect cardiac & aortic causes of embolism?
A. CT scan
B. MRI
C. Transesophageal echocardiography
D. Lumbar puncture

Acute Stroke Management
Medical Management of Strokes
Thrombolytic Therapy
IV tissue plasminogen activator (tPA) is strongly recommended for patients with acute ischemic stroke who meet specific criteria & who can be treated within three hours of onset of ischemic stroke
These patients are usually admitted to the ICU
During & after tPA infusion, the nurse performs frequent neurological assessments & evaluates the patient's B/P
If during the infusion the patient develops N/V, severe headache, or acute hypertension, the infusion is D/C'd & the physician is notified immediately
Other Priority Interventions
Oxygenation
It is important to maintain oxygen saturation at > 92%. It is also important to elevate HOB to 30 degrees and evaluate the patient's ability to swallow before offering them anything PO
Serum Glucose
Stress hyperglycemia is common & should be managed with rapid-acting insulin. Hyperglycemia of 155 mg/dL or greater has been associated with higher mortality & worse outcomes.
Blood Pressure
Large fluctuations in B/P has been shown to increase patient morbidity & mortality. For this reason, permissive hypertension may be allowed during the early phase of treatment. The blood pressure is lowered slowly & by no more than 15% within the first 24 hours of stroke onset. Hypotension should also be avoided
Fever
Increase cerebral oxygen consumption, which can increase ischemia & injury. fevers must be monitored frequently & managed aggressively in the acute stroke patient.
Dysrhythmias
All patients admitted with acute stroke should have an admission ECG & continuous cardiac monitoring
Invasive Procedure
&
Surgical Management of Strokes
Angioplasty & Stent Placement
These techniques use a balloon catheter to mechanically dilate vessels
Catheters are introduced via the femoral artery and directed to the major arteries at the base of the brain
Risks: intracerebral hemorrhage, injury to the vessel wall, & distal embolization
Following the procedure, nursing assessments for neurologic & vital sign changes are done frequently until the patient is neurologically stable
Craniotomy
This surgical procedure is indicated for brainstem infarction or hemorrhage with s/sx of brainstem compression & increased ICP
Aneurysm Clipping
This surgical procedure is performed within 72 hours of the bleed & involves opening the cranium & inserting a metal clip around the aneurysm to prevent rebleeding
A mojor postoperative complication is cerebral vasospam. It is prevented & treated with "triple H therapy": hypervolemia, hypertension, & hemodilution
Carotid Endarterectomy
A surgical procedure to remove exposed occlusive atherosclerotic plaque from the carotid artery.
Postoperative nursing care: position patient on nonoperative side with HOB at 30 degrees, maintain head & neck alignment, observe for complications (hemorrhage, respiratory distress, cranial nerve impairment, & alterations in B/P)
Nursing Management
Initial Priorities
ABCs are assessed
Impaired airway clearance may result from hemiplegia, dysphagia, a weak cough reflex, & immobility
Continuous monitoring of breath sounds, breathing patterns, oxygen saturation, skin color, & ABGs is important
Cardiovascular assessment includes frequent vital signs (B/P & HR) until the patient is stable
Activity
activity level should slowly increase & PT should be started for strengthening, ROM, & early mobilization to prevent joint contractures & muscle atrophy
Nutrition
nutritional support & adequate fluid balance is important. Ensure the patient's caloric needs are met & evaluate the ability to swallow before initiation of oral food or fluids
Preventing
Infection
Pneumonia & UTIs are two of the most common infections that complicate stroke recovery
Preventing Complications
Acute ischemic stroke or TIA
160-325mg of ASA
Acute ischemic stroke &
restricted mobility
LMWH or heparin between days 2 & 4 following admin of tPA
Embolic stroke
from a cardiac source
chronic anticoagulation therapy with warfarin or ASA
Non-cardiac related
embolic stroke
long-term antiplatelet regimen with ASA (81-325mg/daily) within 48 hours of stroke onset
During administration of tPA how frequently should neurological assessments initially be made?
A. 12 hours
B. 6 hours
C. 1 hour
D. 15 minutes
Hospital Management & Secondary Prevention in the Acute Phase
Risk for Ineffective Peripheral Tissue Perfusion
This is a priority nursing diagnosis & results from immobility
Stroke patients are at high risk for venous thromboembolism (VTE), which includes DVT & pulmonary embolism (PE)
Impaired Physical Mobility
Is related to motor & sensory deficits
Rehabilitation begins early after a stroke in an effort to increase independence
Maintaining functional abilities in the acute phase is an important component of patient care
To help prevent contractures: active/passive ROM exercises at least 3-4 times a day & proper body alignment
Imbalanced Nutrition: Less than Body Requirements
During acute stroke, metabolic demands become greater at a time when oral intake is often restricted
Clinically, the patient may manifest a decrease in serum protein leading to compromised immune state, weight loss, muscle weakness, & atrophy, increased risk for pressure ulcers, higher morbidity & mortality & longer hospital stay
Impaired Urinary Elimination
May be related to impaired mobility, cognitive impairment, aphasia, & preexisting elimination problems
After the acute phase has passed, the indwelling catheter is removed & an intermittent catheterization program is implemented (Q4 hours) to ensure that the urine volume doesn't exceed 400mL
As can establish a voiding schedule
When possible, briefs and indwelling urinary catheter should be avoided
Risk for Impaired Skin Integrity
Sensation & skin integrity may be altered due to loss of the sense of touch, pressure, temperature, & sensation; or motor or vascular tone loss.
The loss of primary sensations or paresthesias places the patient at risk for burns, bruises, & other forms of injury
Loss of proprioception or position sense may lead to falls
To protect the patient from injury and to maintain skin integrity: the skin should be inspected for adequate capillary refill, pallor, & hyperemia; & pressure should be avoided; reposition the patient Q2 hours; and teach the patient and family about what to assess
Unilateral Neglect
The patient falls to respond to stimuli presented to the side contralateral to the brain lesion; that side is ignored but can be used if attention is drawn to it
These patients can be assisted by increasing their awareness of their surroundings & by alleviating apprehension
The patient should be approached from the unaffected side, positioned so that the intact visual field is toward the action, personal items are arranged within the field of vision, & taught to scan the environment
As the patient's apprehension decreases, their awareness & attention can be stimulated by placing items towards the affected side to encourage awareness of & attention to that side
Impaired Verbal Communication
Aphasia
a total inability to understand or formulate language
Dysphasia
refers to difficulty with comprehending, speaking, or writing
Wernicke's
Aphasia
a receptive aphasia; patient recieves & comprehends auditory input but verbal responses are inappropriate; aware of what to say but can't say it correctly. Keep the conversation on one defined subject with one question at a time & avoiding multiple choices
Broca's
Aphasia
expressive aphasia; patient is unable to comprehend language; reading, writing, speech, & naming objects are impaired. The goal of the patient is to establish reliable language output to express needs. This may be accomplished by asking the patient "yes-no" questions
Global
Aphasia
combination of Broca's & Wernicke's aphasia with a almost complete loss of comprehension & expression of speech. The goal for the patient is to improve the ability to communicate. The patient is taught to enhance communication with nonverbal gestures & facial expressions
Dysathria
an impairment of the muscles that control speech. The goal of therapy isto strengthen the speech muscles in order to speak more clearly & fluently.
Ineffective Coping
The potential for ineffective coping is related to abrupt change in lifestyle, loss of roles. dependency, & economic insecurity
Clergy, friends, & family support groups may help assist the patient in coping & may provide comfort for both the patient & the family
Informing the patient that most recovery takes up to 6 months may be helpful in preventing unrealistic expectations for recovery
A positive body image is reinforced when the nurse focuses on the function that is left & not on that which is lost
Use terms such as affected and unaffected rather than good & bad
Other Sensory & Motor Deficits
Agnosia
is a cortical impairment that results in the inability to recognize or interpret familiar sensory information although there is no impairment of sensory input or dementia. These patients will work with OT
Apraxia
is the inability to carry out a purposeful movement although movement, coordination, & sensation are intact. For these patients, repetition, consistency, avoidance of distractions, & visual motor coordination exercises are helpful
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