What is stroke? CVA? Brain Attack?

Occurs when there is ischemia (inadequate blood flow) or hemorrhage into the brain that results in brain cell death Major public health concern Approx 700,000 persons annually in the U.S. suffer a stroke 3rd most common cause of death in U.S. 25% of individuals who have an initial stroke die within 1 year Also a leading cause of serious, long-term disability

Modifiable Non-modifiable Health Promotion Cerebral blood flow Atherosclerosis Carotid Doppler's

Temporary loss of neurologic function caused by ischemia Lasts < 24 hours, sometimes <15 minutes Most resolve within 3 hours Warning sign of progressive cerebral vascular disease Tinnitis, vertigo, darkened or blurred vision, diplopia, ptosis, dysarthria, dysphagia, ataxia, numbness and weakness Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain Diagnosis Treatment

Aspirin (81-325 mg) when given within 48 hours after ischemic stroke, resulted in a small but statistically significant reduction in death and disability. Plavix Persantine Ticlid Slight risk of hemorrhagic stroke after aspirin

Strokes are classified on the basis of underlying pathophysiologic findings.

Ischemic Hemorrhagic

TIME IS BRAIN!!! 1. Cellular death occurs in 4-6 minutes if blood flow is interrupted to the brain 2. More than pts with chest pain arrived at hospital within 4 hours 3. Average time between onset of stroke symptoms and initiation of medical care = 24 hours 4. People over 70 took longer to arrive People living alone took longer to arrive

When symptoms of a stroke occur, diagnostic studies are done to

Confirm that it is a stroke Identify the likely cause of the stroke

CT is the primary diagnostic test used after a stroke. Other studies

CTA MRI, MRA Cerebral angiography Digital subtraction angiography Transcranial Doppler ultrasonography Lumbar puncture LICOX system Electrocardiogram Chest x-ray Cardiac enzymes Echocardiography Holter monitor

For cardiac assessment

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PREVENTION ACUTE CARE: INITIAL Ongoing Rehabilation

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Carotid endarterectomy is performed to prevent impending cerebral infarction. A, A tube is inserted above and below the blockage to reroute the blood flow. B, Atherosclerotic plaque in the common carotid artery is removed. C, Once the artery is stitched closed, the tube can be removed. A surgeon may also perform the technique without rerouting the blood flow.
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. Brain stent used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant the stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery and then inflated. The stent expands due to the inflation of the balloon. C, The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery open and improving the flow of blood.
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The MERCI retriever removes blood clots in patients who are experiencing ischemic strokes. The retriever is a long, thin wire that is threaded through a catheter into the femoral artery. The wire is pushed through the end of the catheter up to the carotid artery. The wire reshapes itself into tiny loops that latch onto the clot and the clot can then be pulled out. To prevent the clot from breaking off, a balloon at the end of the catheter inflates to stop blood flow through the artery.
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Clipping of aneurysms.
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GDC coil. A, A coil is used to occlude an aneurysm. Coils are made of soft, springlike platinum. The softness of the platinum allows the coil to assume the shape of irregularly shaped aneurysms while posing little threat of rupture of the aneurysm. B, A catheter is inserted through an introducer (small tube) in an artery in the leg. The catheter is threaded up to the cerebral blood vessels. C, Platinum coils attached to a thin wire are inserted into the catheter and then placed in the aneurysm until the aneurysm is filled with coils. Packing the aneurysm with coils prevents the blood from circulating through the aneurysm, reducing the risk of rupture.
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ASSESSMENT NURSING DIAGNOSES GOALS OR PLANNING NURSING IMPLEMENTATION

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Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemianopsia Shows that food on the left side is not seen and thus is ignored.
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Fig. 58-12. Loss of postural stability is common after stroke. When the nondominant hemisphere is involved, walking apraxia and loss of postural control are usually apparent. The patient is unable to sit upright and tends to fall sideways. Appropriate support with pillows or cushions should be provided.
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Fig. 58-13. Assistive devices for eating. A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips and swivel handles are helpful for some persons. B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the other. C, Plate guards help keep food on the plate. D, Cup with special handle.
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Charles is a 77 year-old male who presented to the ED today with an acute onset of right sided weakness in his arm and leg and garbled speech. He has a history of a-fib, HTN and lung cancer. His wife is with him and is very worried that he may die. His V/S are: 182/100 37.2 92 24 O2 sat 91%

What are some variables that may have contributed to his condition? What diagnostic tests might the provider order for him? What medications might be ordered? How will you decrease his wife anxieties? What additional information would you obtain?

Question 1
A patient with right-sided paresthesias and hemiparesis is hospitalized and diagnosed with a thrombotic stroke. Over the next 72 hours, the nurse plans care with the knowledge that the patient:

1. Is ready for aggressive rehabilitation. 2. Will show gradual improvement of the initial neurologic deficits. 3. May show signs of deteriorating neurologic function as cerebral edema increases. 4. Should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits.
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Answer: 3 Rationale: Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.

Question 2
While performing health screening at a health fair, the nurse identifies which of the following individuals at greatest risk for experiencing a stroke? 1. A 46-year-old white female with hypertension and oral contraceptive use for 10 years. 2. A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dL. 3. A 42-year-old African American female with diabetes mellitus who has smoked for 30 years. 4. A 62-year-old African American male with hypertension who is 35 pounds overweight.
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Answer: 4 Rationale: Option 4: This individual has five risk factors: age, African American, male, hypertension, and overweight. Option 1: This individual has two risk factors: hypertension and oral contraception use. Option 2: This individual has two risk factors: male and increased cholesterol level. Option 3: This individual has three risk factors: African American, diabetes mellitus, and smoking. Nonmodifiable risk factors include age, gender, ethnicity/race, and family history/heredity. Stroke risk increases with age, doubling each decade after 55 years of age. Two thirds of all strokes occur in individuals >65 years. Strokes are more common in men, but more women die from stroke than men. Because women tend to live longer than men, they have more opportunity to suffer a stroke. African Americans have a higher incidence of stroke, as well as a higher death rate from stroke than whites. A family history of stroke, a prior transient ischemic attack, or a prior stroke also increases the risk of stroke. Modifiable risk factors are those that can potentially be altered through lifestyle changes and medical treatment, thus reducing the risk of stroke. Modifiable risk factors include hypertension, increased cholesterol, elevated blood lipid levels, heart disease, smoking, excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, and drug abuse. Early forms of birth control pills that contained high levels of progestin and estrogen increased a womans chance of experiencing a stroke, especially if she also smoked heavily. Newer, low-dose oral contraceptives have lower risks for stroke except in those individuals who are hypertensive and smoke. Other conditions that may increase stroke risk include migraine headaches, inflammatory conditions, and hyperhomocysteinemia. Sickle cell disease is another known risk factor for stroke.

Question 3
A patient with a stroke has dysphagia. Before allowing the patient to eat, which of the following actions should the nurse take first? 1. Check the patients gag reflex. 2. Request a soft diet with no liquids. 3. Place the patient in high-Fowlers position. 4. Test the patients ability to swallow with a small amount of water.

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Answer: 1 Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding, and begin exercises to stimulate swallowing. To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated), and give the patient a small amount of crushed ice or ice water to swallow.

73-year-old man was admitted to the hospital with right-sided paresis and expressive aphasia. He had been experiencing periods of confusion, right-sided weakness, and slurred speech for the past several weeks. These episodes were brief and resolved completely within an hour. No treatments were sought. History of COPD, MI 15 years prior, and atrial fibrillation Over the first 24 hours of admission, his neurologic deficits gradually progressed. By day 2 of admission, he had right-sided flaccid paralysis and global aphasia.
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1.

2.
3.

4.

What is probably the cause of his stroke? Could this stroke have been prevented? What are the priority nursing interventions for him? What teaching will you need to do for him and his family?

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With his history of atrial fibrillation, he could have had an embolic stroke. He also has risk factors for a thrombotic stroke. He also could have been having transient ischemic attacks. 2. There are preventable risk factors that could have been modified, such as hypertension. The atrial fibrillation should have been treated with anticoagulants. 3. Preventing any complications related to immobility. Helping him adjust and cope with the results of the stroke. 4. Discuss what changes they can expect to see as a result of the stroke. Then the focus should be on rehabilitation.
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60-year-old male suffered a left cerebral hemispheric stroke involving the middle cerebral artery. Transcranial Doppler ultrasonography demonstrated 80% stenosis bilaterally. He was advised to undergo bilateral carotid endarterectomy. He has a history of hypertension, MI 2 years previous, COPD, and rheumatic arthritis. He has a 40-year history of smoking, hyperglycemia, hypercholesterolemia, and steroid dependency secondary to treatment of RA. 5 days after his stroke, he is discharged from the hospital to recuperate.
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1.

2.

3.

What were his risk factors for a stroke? What important patient teaching should be performed before he is discharged? What challenges will he face once he gets home?

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1. Age,

smoking, hypertension, diabetes, high cholesterol. 2. The importance of lowering his modifiable risk factors to prevent future strokes. 3. 3. It depends on the degree of disability. Common problems are related to walking, eating, communication, and urinary and bowel function.

Which of the following modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A) Hypertension B) Hyperlipidemia C) Alcohol consumption D) Oral contraceptive use

Answer: A Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated.

The nurse would expect to find which of the following clinical manifestations in a patient admitted with a left-brain stroke? A) Impulsivity B) Impaired speech C) Left-side neglect D) Short attention span

Answer:B Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language aphasias, impaired right/left discrimination, and slow and cautious performance. The other options are all manifestations of right-sided brain damage.

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which of the following medications might the nurse expect to provide discharge instructions (select all that apply)? A) Clopidogrel (Plavix) B) Enoxaparin (Lovenox) C) Dipyridamole (Persantine) D) Enteric-coated aspirin (Ecotrin) E) Tissue plasminogen activator (tPA)

Answer: A,C,D Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke, not prevent TIAs.

Which of the following nursing interventions is most appropriate when communicating with a patient suffering from aphasia poststroke? A) Present several thoughts at once so that the patient can connect the ideas. B) Ask open-ended questions to provide the patient the opportunity to speak. C) Use simple, short sentences accompanied by visual cues to enhance comprehension. D) Finish the patients sentences so as to minimize frustration associated with slow speech.

Answer: C When communicating with a patient with aphasia, the nurse should present one thought or idea at a time; ask questions that can be answered with a yes, no, or simple word; use visual cues; and allot time for the individual to comprehend and respond to conversation.

Computed tomography of a 68-year-old male patients head reveals that he has experienced a hemorrhagic stroke. Which of the following is a nursing priority intervention in the emergency department? A) Maintenance of the patients airway B) Positioning to promote cerebral perfusion C) Control of fluid and electrolyte imbalances D) Administration of tissue plasminogen activator (tPA)

Answer: A Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke, and supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 2 weeks earlier. How should the nurse best promote the health of the patients integumentary system? A) Position the patient on her weak side the majority of the time. B) Alternate the patients positioning between supine and side-lying. C) Avoid the use of pillows in order to promote independence in positioning. D) Establish a schedule for the massage of areas where skin breakdown emerges.

Answer: B A position change schedule should be established for stroke patients. An example is side-backside, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

Which of the following sensory-perceptual deficits is associated with left-brain stroke (right hemiplegia)? A) Overestimation of physical abilities B) Difficulty judging position and distance C) Slow and possibly fearful performance of tasks D) Impulsivity and impatience at performing tasks

Answer: C Patients with a left-brain stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-brain stroke.

Mrs. P. is a 72-year-old white woman who was admitted 2 days ago to the medical unit with a stroke. She has left-sided hemiparesis. Her first CT scan, about 2 hours after the onset of symptoms, was negative. A second CT scan, 12 hours later, was positive for an ischemic area in the right hemisphere. Objective Data Physical Examination Pupils equal, round, reactive to light and accommodation Decreased sensation in left lower extremity, no sensation in left upper extremity, normal sensation to right upper and lower extremity 0/5 strength left upper extremity, 1+/5 left lower extremity, 5/5 right upper and lower extremity Left facial droop Slurred speech Expressive aphasia but nods appropriately to yes/no questions Diagnostic Studies A barium swallow study has been ordered for 1300

Why was the first CT scan negative? What is the difference between an ischemic and a hemorrhagic stroke? What are the different manifestations of right-sided versus left-sided stroke? Why was the barium swallow study ordered? Based on assessment findings, what are the priority nursing diagnoses? What nursing interventions can be used to address the risk for falls? What nursing interventions can be used to address the impaired communication?

1. If the stroke is less than 3 hours old and is ischemic in nature, the CT will appear normal because the brain structures with or without blood flow appear the same in a noncontrast CT scan. An ischemic stroke results from inadequate blood flow to the brain from partial or complete occlusion of an artery. A hemorrhagic stroke results from bleeding into the brain tissue itself or into the subarachnoid space or ventricles. 2. Manifestations of right-sided brain damage include a paralyzed left side, left-sided neglect, spatial-perceptual deficits, patient tends to deny or minimize problems, rapid performance, short attention span, impulsivity, safety problems, impaired judgment, and impaired time concepts. Manifestations of left-sided brain damage include a paralyzed right side, impaired speech and language aphasia, impaired right-left discrimination, slow performance, decreased awareness of deficits, depression, anxiety, and impaired comprehension related to language and math. 3. The barium swallow will assist in determining Mrs. P.s risk for aspiration and her ability to eat and drink so that her diet can be adjusted accordingly. 4. Priority nursing diagnoses include impaired swallowing, impaired physical mobility (total), selfcare deficit, imbalanced nutrition: less than body requirements, risk for aspiration, risk for falls, and impaired verbal communication. 5. Place Mrs. P. in a room near the nurses station. Use a wheelchair for mobility. Use a bed alarm. 6. 6. Place frequently used objects near the bed on the right side. Encourage family to stay with patient as necessary. Communicate in simple, yes/no statements. Consider restraints if necessary. 7. Implement use of a communication or picture board; encourage the use of gesturing if the patient is able.