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Nursing Stroke 1228 Management of Patients Experiencing

Nursing

Stroke 1228
Stroke
1228

Management

of Patients

Experiencing

Nursing Stroke 1228 Management of Patients Experiencing
Nursing Stroke 1228 Management of Patients Experiencing

Stroke

A stroke occurs when the blood supply to part of your

brain is interrupted or severely reduced, depriving

brain tissue of oxygen and food. Within minutes, brain cells begin to die.

Strokes can be ischemic or hemorrhagic

Also known as a brain attack

Stroke  A stroke occurs when the blood supply to part of your brain is interrupted
Stroke  A stroke occurs when the blood supply to part of your brain is interrupted
Different STROKES for Different Folks

Different STROKES for Different Folks

Different STROKES for Different Folks
Different STROKES for Different Folks

Nursing Knowledge

Third most common cause of death in the United

States and Canada

Leading cause of serious, long-term disability

Approximately 35% of individuals who have an initial stroke die within 1 year.

Prevalence for CVA is 2X higher in AA, women account for 60% of CVA r/t deaths, killing 2X as many women as breast cancer

Hypertension is the single most important modifiable

risk factor that is often undetected and inadequately treated.

Nursing Knowledge  Third most common cause of death in the United States and Canada 
Nursing Knowledge  Third most common cause of death in the United States and Canada 
Risk Factors Non-modifiable Age  Risk increases with age  Doubles each decade after age 55
Risk Factors
Non-modifiable
Age
Risk increases with age
Doubles each decade
after age 55
Gender
Equal in men and women
Race
African Americans
Native Americans
Heredity
Family history of stroke
Prior TIA
Prior CVA

Risk Factors cont.

Modifiable risk factors

Heart disease

Hypertension

  • Most important factor

Obesity

  • Abdominal distribution in men

Oral contraceptive use

  • High dose estrogen

Physical inactivity

Substance abuse

  • Especially cocaine

 A. fib/heart murmur  hyperlipidemia Heavy alcohol consumption  >2 drinks/day Diabetes mellitus keep BS
A. fib/heart murmur
hyperlipidemia
Heavy alcohol consumption
>2 drinks/day
Diabetes mellitus
keep BS well controlled
Smoking
Metabolic syndrome
Risk Factors cont. Modifiable risk factors Heart disease Hypertension  Most important factor Obesity  Abdominal

An ounce of PREVENTION is worth a pound of cure…

 Control HTN  Reduce or control weight  Decrease sodium and fat in diet 
Control HTN
Reduce or control weight
Decrease sodium and fat in diet
Decrease alcohol consumption
Comply with medical regimen
Stop smoking
Control any existing diabetes
Regular exercise
Routine health checks and screening
An ounce of PREVENTION is worth a pound of cure…  Control HTN  Reduce or

Test Your Knowledge:

Of the following patients, the nurse recognizes

that the one with the highest risk for a

stroke is: a. an obese 45-year-old Native American. b. a 35-year-old Asian American woman who smokes.
stroke is:
a.
an obese 45-year-old Native American.
b.
a 35-year-old Asian American woman who
smokes.
c.
a 32-year-old white woman taking oral
contraceptives.
d.
a 65-year-old African American man with
hypertension.

Transient Ischemic Attack (TIA)

mini strokes‖

 Temporary, focal loss of neurologic function  Lasts less than 24 hours  Often less
Temporary, focal loss of neurologic function
Lasts less than 24 hours
Often less than 15 minutes
Most TIAs resolve within 3 hours
Microemboli that temporarily block blood flow to
brain
Considered a warning sign for impending CVA!!!
TIA - Signs and Symptoms Visual changes- blurred vision, diplopia, blindness in one eye, tunnel vision,
TIA - Signs and Symptoms
Visual changes- blurred vision, diplopia, blindness in
one eye, tunnel vision, ptosis
Transient weakness
Arm, hand, leg
Ataxic gait
Transient numbness
Face, arm, hand
Vertigo
Aphasia
Dysarthria
Dysphagia

TYPES OF STROKE

Ischemic stroke:

Inadequate blood flow to the brain Blockage may be complete or partial

Two types of ischemic strokes:

Thrombotic

Embolic

TYPES OF STROKE Ischemic stroke:  Inadequate blood flow to the brain  Blockage may be
TYPES OF STROKE Ischemic stroke:  Inadequate blood flow to the brain  Blockage may be

Ischemic Stroke

  • Thrombotic stroke

 Thrombosis occurs in relation to injury to a blood vessel wall and formation of a
Thrombosis occurs in relation to injury to a blood
vessel wall and formation of a blood clot.
Result of thrombosis or narrowing of the blood
vessel
Most common cause of stroke
30% to 50% of thrombotic strokes have been
preceded by a TIA

Ischemic Stroke

  • Embolic stroke

 Occurs when an embolus lodges in and occludes a cerebral artery  Second most common
Occurs when an embolus lodges in and occludes a
cerebral artery
Second most common cause of stroke
Commonly has a rapid occurrence of severe
clinical symptoms.
Patient usually remains conscious, although he may
have a headache.

Manifestations of Ischemic Stroke

Usually no change in LOC

Headache

Hemiplegia or hemiparesis

Dysphasia

Facial drooping

Ataxia

Some initial symptoms may improve or resolve, with remaining lesser deficits

Manifestations of Ischemic Stroke  Usually no change in LOC  Headache  Hemiplegia or hemiparesis
Manifestations of Ischemic Stroke  Usually no change in LOC  Headache  Hemiplegia or hemiparesis

Healthy vessels

Healthy vessels  A healthy artery easily carries oxygenated blood to the brain tissue.
Healthy vessels  A healthy artery easily carries oxygenated blood to the brain tissue.
  • A healthy artery easily carries oxygenated blood to the brain tissue.

Healthy vessels  A healthy artery easily carries oxygenated blood to the brain tissue.
Healthy vessels  A healthy artery easily carries oxygenated blood to the brain tissue.
Healthy vessels  A healthy artery easily carries oxygenated blood to the brain tissue.

Pathological vessels

Pathological vessels
Pathological vessels
Pathological vessels
Pathological vessels

TYPES OF STROKE

TYPES OF STROKE     Hemorrhagic stroke- Bleeding within the brain caused by rupture
TYPES OF STROKE     Hemorrhagic stroke- Bleeding within the brain caused by rupture

Hemorrhagic stroke-

Bleeding within the brain caused by rupture of a vessel

Hypertension is the most important cause.

Hemorrhage commonly occurs during periods of activity.

TYPES OF STROKE     Hemorrhagic stroke- Bleeding within the brain caused by rupture
TYPES OF STROKE     Hemorrhagic stroke- Bleeding within the brain caused by rupture
TYPES OF STROKE     Hemorrhagic stroke- Bleeding within the brain caused by rupture

The neurologic manifestations do not significantly

differ between ischemic and hemorrhagic stroke

Manifestations of Hemorrhagic Stroke

Headache Nausea and vomiting Decreased LOC (about 50% of patients) Neurologic deficits – may be severe
Headache
Nausea and vomiting
Decreased LOC (about 50% of patients)
Neurologic deficits – may be severe depending upon
what area affected
Dilated, fixed pupils
Posturing
Coma
Hemiplegia

Hemorrhagic CVA

Intracranial bleeding into cerebrospinal fluidfilled space between the arachnoid and pia mater

Commonly caused by rupture of a cerebral aneurysm

―Worst headache of one’s life‖

Hemorrhagic CVA  Intracranial bleeding into cerebrospinal fluid – filled space between the arachnoid and pia
Hemorrhagic CVA  Intracranial bleeding into cerebrospinal fluid – filled space between the arachnoid and pia
Hemorrhagic CVA  Intracranial bleeding into cerebrospinal fluid – filled space between the arachnoid and pia
Hemorrhagic CVA  Intracranial bleeding into cerebrospinal fluid – filled space between the arachnoid and pia

Treatment of Aneurysms

Goal is to stop the bleeding and relieve the pressure.

Surgical clipping of the aneurysm

Coiling Craniotomy Biologic/synthetic wrap-prevents rupture

Despite improvements in surgical techniques and

management, still a high rate of mortality and morbidity

Complications include

Rebleeding before surgery can occur

Cerebral vasospasm resulting in cerebral infarction

Treatment of Aneurysms Goal is to stop the bleeding and relieve the pressure. Surgical clipping of
Treatment of Aneurysms Goal is to stop the bleeding and relieve the pressure. Surgical clipping of

Test Your Knowledge

Information provided by the patient that

would help differentiate a hemorrhagic stroke from a thrombotic stroke includes:

  • a. sensory disturbance

  • b. a history of hypertension

  • c. presence of motor weakness

  • d. sudden onset of severe headache

A picture is worth 1,000 words…

A picture is worth 1,000 words…
A picture is worth 1,000 words…
A picture is worth 1,000 words…
A picture is worth 1,000 words…
A picture is worth 1,000 words…
A picture is worth 1,000 words…

Overall effects of stroke:

Motor

  • Cross over effect Lesion on right brain-- left side affected Lesion on left brainright side affected Impairment Mobility, respiratory function, swallowing and speech, gag reflex, self-care abilities, risk for injuries

Overall effects of stroke: Motor  Cross over effect  Lesion on right brain-- left side
Overall effects of stroke: Motor  Cross over effect  Lesion on right brain-- left side
Left sided stroke

Left sided stroke

Left sided stroke
Left sided stroke
Left sided stroke
Right sided stroke

Right sided stroke

Right sided stroke
Right sided stroke
Right sided stroke

Motor Function

  • Loss of skilled voluntary movement

  • Impairment of integration of movements

  • Alterations in muscle tone

  • Alterations in reflexes

Motor Function  Loss of skilled voluntary movement  Impairment of integration of movements  Alterations
Motor Function  Loss of skilled voluntary movement  Impairment of integration of movements  Alterations

Communication

Problems more common in left-brain stroke

Aphasia

Total loss of comprehension and/or use of language

Dysphasia Difficulty with comprehension and use of

language

Can be classified as nonfluent or fluent

Dysarthria

Poorly articulated speech, slurred speech secondary to poor muscle control

Communication Problems more common in left-brain stroke Aphasia  Total loss of comprehension and/or use of
Communication Problems more common in left-brain stroke Aphasia  Total loss of comprehension and/or use of

Affect

Depression Body image change

Loss of function physically and cognitively Loss of independence Difficulty controlling emotions Cries easily Anger, frustration common Intellectual function

Impaired memory/judgment

Affect  Depression  Body image change  Loss of function physically and cognitively  Loss
Affect  Depression  Body image change  Loss of function physically and cognitively  Loss

Spatial-perceptual alterations

  • Problems more common in right-brain stroke

Spatial-perceptual problems may be divided into four categories.

1. Incorrect perception of self and illness 2. Erroneous perception of self in space

3. Inability to recognize an object by sight, touch, or

hearing

4. Inability to carry out learned sequential movements on command

Spatial-perceptual alterations  Problems more common in right-brain stroke  Spatial-perceptual problems may be divided into
Spatial-perceptual alterations  Problems more common in right-brain stroke  Spatial-perceptual problems may be divided into

Elimination

Urinary and bowel elimination deficits usually occur

initially and are usually temporary Initially frequency, urgency, incontinence

Constipation may be lasting due to decreased mobility, weakened abdominal muscles, decreased food and fluid intake

Long-term effects often related to inability to express needs and manage clothing for toileting

Elimination Urinary and bowel elimination deficits usually occur initially and are usually temporary  Initially frequency,
Elimination Urinary and bowel elimination deficits usually occur initially and are usually temporary  Initially frequency,

Diagnostic tests

  • Confirmation that it is a stroke

  • Identify cause if possible

  • CT scan- the primary diagnostic test

 Size and location of the lesion  Differentiate between ischemic and hemorrhagic strokes  MRI
Size and location of the lesion
Differentiate between ischemic and hemorrhagic strokes
MRI
More detailed, sharper images
Can detect smaller, deeper CVAs
Further testing Blood flow tests  Ultrasound- of the neck, base of skull  Angiography-arteriogram-dye injected

Further testing

Blood flow tests

 Ultrasound- of the neck, base of skull  Angiography-arteriogram-dye injected into arteries then x-rays are
Ultrasound- of the neck, base of skull
Angiography-arteriogram-dye injected into
arteries then x-rays are taken
Electrical tests
EEG-electrical signals within the brain
Evoked response-how the brain handles
different electrical impulses related to hearing,
vision, body sensation, etc.

Drug Therapy

Thrombolytic therapy  tPA (tissue plasminogen activator) Digests fibrin and fibrinogen and thus lyses the clot
Thrombolytic therapy
tPA (tissue plasminogen activator)
Digests fibrin and fibrinogen and thus lyses the
clot
Reduces disability
Requires a consent form to be signed
Must be administered within 3 hours of the onset
of clinical signs of ischemic stroke
Timing is critical
Accurate history is critical- resent surgery?
Drug Therapy, cont. Anticoagulants  Heparin  Sub Q or IV push  Heparin drip 
Drug Therapy, cont. Anticoagulants  Heparin  Sub Q or IV push  Heparin drip 
Drug Therapy, cont.
Anticoagulants
Heparin
Sub Q or IV push
Heparin drip
Short term
Lovenox (low molecular weight heparin)
Sub Q or IV
Short term
Coumadin (warfarin)
Orally
Long term anticoagulation
Side effects: bleeding
Monitor urine, stools, epistaxis, bleeding gums, easy bruising
Caution about high risk activities

Drug Therapy, cont.

Antiplatelet drugs

Platelet inhibitors

Prevents further strokes by preventing clot formation ASA 50mg to 325mg per day Possibly baby ASA 81mg or enteric coated Ticlid, Plavix, Persantine, Aggrenox, Arixtra Teach patient to monitor for sx bleeding at home Teach dietary requirements

Drug Therapy, cont . Antiplatelet drugs  Platelet inhibitors  Prevents further strokes by preventing clot
Drug Therapy, cont . Antiplatelet drugs  Platelet inhibitors  Prevents further strokes by preventing clot
Drug Therapy, cont . Antiplatelet drugs  Platelet inhibitors  Prevents further strokes by preventing clot

Drug therapy monitoring

Baseline levels -obtain before initiating therapy

PT (PT/INR) to monitor Coumadin therapy

 Monitor daily while in acute care setting, once patient goes home and dose is stable,
Monitor daily while in acute care setting, once patient
goes home and dose is stable, weekly or monthly
Target INR is 2.0-3.0
PTT to monitor heparin therapy
Monitor every morning while on therapy in acute care
setting
 Goal is 1.5-2 times patient’s baseline PT and PTT
Drug therapy monitoring Baseline levels -obtain before initiating therapy PT (PT/INR) to monitor Coumadin therapy 

Treatment Modalities

Carotid endarterectomy

Athreromatous lesion

is removed from the

carotid artery to improve blood flow to the brain

Reduces the risk of

another CVA

Treatment Modalities  Carotid endarterectomy  Athreromatous lesion is removed from the carotid artery to improve
Treatment Modalities  Carotid endarterectomy  Athreromatous lesion is removed from the carotid artery to improve
Treatment Modalities  Carotid endarterectomy  Athreromatous lesion is removed from the carotid artery to improve

Treatment Modalities, cont.

  • Transluminal angioplasty

roto rooter‖

Insertion of a balloon to push open stenosed artery,

thus improving blood flow

Monitor patient after procedure due to risk of breaking clots loose

Treatment Modalities, cont.  Transluminal angioplasty  ― roto rooter‖  Insertion of a balloon to
Treatment Modalities, cont.  Transluminal angioplasty  ― roto rooter‖  Insertion of a balloon to
Treatment Modalities, cont.  Transluminal angioplasty  ― roto rooter‖  Insertion of a balloon to

Treatment Modalities, cont.

 
Treatment Modalities, cont.   Stenting Transvascular placement of a stent to maintain patency of artery

Stenting

Transvascular placement of a stent to maintain

patency of artery

Treatment Modalities, cont.   Stenting Transvascular placement of a stent to maintain patency of artery
Treatment Modalities, cont.   Stenting Transvascular placement of a stent to maintain patency of artery

Test Your Knowledge

A patient experiencing TIA’s is scheduled for a carotid

endarterectomy. The nurse explains that this procedure is done to:

  • a. decrease cerebral edema.

  • b. reduce the brain damage that occurs during a stroke in evolution.

  • c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow.

  • d. provide a circulatory bypass around

thrombotic plaques obstructing cranial circulation.

Acute Care

The goal is to preserve life, prevent further brain damage, and reduce the amount of disability

Maintain ABC’s

 Airway – assess patency  Decreased LOC may result in decreased/absent gag reflex, impaired swallowing
 Airway – assess patency
Decreased LOC may result in decreased/absent gag
reflex, impaired swallowing so patient should be
NPO
Administer O2, oral or nasal airway
Intubation and mechanical ventilation may be needed
Monitor pulse oximetry
Suction PRN
Position to prevent aspiration

Acute Care, cont.

Get patient to CT!!! Major priority!

 Start lab tests  Blood glucose  Treat hypoglycemia  Seizure precautions  Thrombolytic therapy
Start lab tests
Blood glucose
Treat hypoglycemia
Seizure precautions
Thrombolytic therapy for ischemic stroke – restore 02!
Manage possible increased ICP in ischemic stroke
Cerebral edema peaks in 72 hours
Brain herniation can occur
Position to improve venous drainage
Elevate HOB 30 degrees
Position head/neck in midline
Avoid hip flexion
Mannitol and Lasix may be given to decrease ICP
Acute Care, cont. Get patient to CT!!! Major priority!  Start lab tests  Blood glucose
Acute Care, cont. IV access with NS  Do not overhydrate Increases cerebral edema 1500-2000ml per

Acute Care, cont.

IV access with NS

Do not overhydrate

Increases cerebral edema 1500-2000ml per day Monitor urinary output Maintain BP

Frequently hypertensive after stroke

Compensatory mechanism to insure brain

perfusion

IV BP meds are given only if BP is markedly increased

(systolic >220)

Usually oral agents are sufficient Institute seizure precautions

Acute Care, cont. IV access with NS  Do not overhydrate Increases cerebral edema 1500-2000ml per
Acute Care, cont. IV access with NS  Do not overhydrate Increases cerebral edema 1500-2000ml per

Assessment

Neurological assessment

 Glasgow coma scale  Pupils  Extremity movement and strength Decreased LOC  Increase in
Glasgow coma scale
Pupils
Extremity movement and strength
Decreased LOC
Increase in ICP
Cardiac status should be monitored
Rhythm & rate
↑ or ↓ heart rate
Assessment Neurological assessment  Glasgow coma scale  Pupils  Extremity movement and strength Decreased LOC

Nursing Assessment

History

 Precise time of onset of S/S  Medical and surgical history including HTN, previous stroke,
Precise time of onset of S/S
Medical and surgical history including HTN,
previous stroke, TIAs (diagnosed or not), cardiac
dx, CHF, valvular dx/replacement, endocarditis,
hyperlipidemia, polycythemia, DM, and family
history of HTN, CVA
Medications
Oral contraceptives, antihypertensives,
anticoagulant agents

Nursing Assessment

Subjective Data- Person accompanying patient may need to

provide information if patient has decreased LOC or is

aphasic

Objective Data

Emotional lability, apathy, combativeness

Vital signs- tachycardia, HTN

Breath sounds- adventitious may indicate aspiration

Loss of urinary/bowel continence

Seizure

Facial drooping

Difficulty swallowing

Vertigo

Nursing Assessment  Subjective Data- Person accompanying patient may need to provide information if patient has
Nursing Assessment  Subjective Data- Person accompanying patient may need to provide information if patient has

Neurological Findings

Contralateral motor and sensory deficits

Weakness, paresis, paralysis

Unequal pupils

Unequal hand grasps

Unequal leg strength

Positive Babinski’s sign followed by increased deep

tendon reflexes

Flaccidity followed by spasticity

Amnesia

Personality change

Nuchal rigidity

      
Neurological Findings    Contralateral motor and sensory deficits Weakness, paresis, paralysis Unequal pupils Unequal

Deep Vein Thrombosis (DVT)

Increased risk of DVT after stroke due to:

 Immobility  Loss of venous tone  Decreased muscle pumping activity in legs  Especially
Immobility
Loss of venous tone
Decreased muscle pumping activity in legs
Especially on affected side
Do ROM exercises several times a day
Compression stockings
Heparin therapy
Measure calf and thigh daily
Check for pain in calf when standing
Deep Vein Thrombosis (DVT)  Increased risk of DVT after stroke due to:  Immobility 

Post-Stroke Care

  • Trochanter rolls to prevent hip rotation

  • Arm supports- slings

  • Avoid pulling patient by the arm to avoid

shoulder displacement

  • Footboards

  • Leg splints

  • High top tennis shoes to prevent foot drop

 Musculoskeletal  Maintain optimum functioning  ROM and correct positioning to prevent contractures and muscular
Musculoskeletal
Maintain optimum
functioning
ROM and correct
positioning to prevent
contractures and
muscular atrophy
Hand splints to maintain
flexibility and use of
hands
Post-Stroke Care  Trochanter rolls to prevent hip rotation  Arm supports- slings  Avoid pulling

Pharmacology Post-Stroke Care Acute & Chronic

  • Aspirin anticoagulation, s/s of GI irritation?

  • Anti-cholesterol agents why?

  • H2 Blockers reduces acid in the stomach

  • Persantine - prevent platelets from clumping with thrombus and embolus formation

 Heparin – IV or SQ requires lab monitoring  Coumadin – what lab?  Plavix
Heparin – IV or SQ
requires lab monitoring
Coumadin – what lab?
Plavix – reduces platelet
aggregation – do not take
a missed dose with the
next dose.
Mannitol – reduces
vasogenic edema
Check with HCP before
taking any herbal
medications
Pharmacology Post-Stroke Care Acute & Chronic  Aspirin – anticoagulation, s/s of GI irritation?  Anti-cholesterol

Collaborative Care

 After stroke has stabilized for 12 to 24 hours, collaborative care shifts from preserving life
After stroke has stabilized for 12 to 24
hours, collaborative care shifts from
preserving life to lessening disability and
attaining optimal functioning.
Patient may be transferred to a
rehabilitation unit, outpatient therapy, or
home care–based rehabilitation.
Post-Stroke Care Integumentary system Susceptible to breakdown Loss of sensation Decreased circulation Immobility Change positions every

Post-Stroke Care

Integumentary system

Susceptible to breakdown

Loss of sensation

Decreased circulation

Immobility

Change positions every 2 hours

Side-back-side

Only place on weak/paralyzed side X 30 min.

Special mattresses, WC cushions

Assess for redness, blanching

Do not massage damaged area

Post-Stroke Care Integumentary system Susceptible to breakdown Loss of sensation Decreased circulation Immobility Change positions every
          
Post-Stroke Care Integumentary system Susceptible to breakdown Loss of sensation Decreased circulation Immobility Change positions every

Post-Stroke Care

 Gastrointestinal  Severely affected may require enteral or parenteral nutrition  Use caution with first
Gastrointestinal
Severely affected may require enteral or parenteral
nutrition
Use caution with first attempt at oral feeding
Assess for gag reflex by gently stimulating back of
throat with tongue blade
Swallowing assessment is usually done by giving pt.
small amount of crushed ice
 Often performed by speech therapy

Post-Stroke Care

 Urinary  Bladder training  Poor bladder control program  incontinence   Promote urinary
Urinary
Bladder training
Poor bladder control
program
incontinence
Promote urinary function
Toileting Q 2 hrs during
while awake
Avoid foley catheter if
Toileting 3-4 times
possible
during night
Increases susceptibility
to UTI
Using bedpan, BSC, or
toilet
Inadequate bladder
tone
Encourage adequate
fluids-don’t restrict
Notice restlessness-may
indicate need to void
Give majority between
8am and 7pm

Test Your Knowledge

Bladder training in a male patient who has urinary incontinence after a stroke includes:

  • a. limiting fluid intake

  • b. keeping a urinal in place at all times

  • c. assisting the patient to stand to void

  • d. catheterizing the patient every 4 hours

Post-Stroke Care  Ambulation/Transfer principals  Bear weight on the unaffected (good) side  Always move

Post-Stroke Care

Ambulation/Transfer principals

Bear weight on the unaffected (good) side

Always move toward the unaffected side for easiest and safest transfers

Position chair or WC on the unaffected side and pivot

to the chair on the unaffected leg

Use a hemi-walker on the unaffected side

Always have plenty of assistance if you are uncertain

how well pt. can transfer

Post-Stroke Care  Ambulation/Transfer principals  Bear weight on the unaffected (good) side  Always move
Post-Stroke Care  Ambulation/Transfer principals  Bear weight on the unaffected (good) side  Always move

Post-Stroke Care

Instruct patient to chew on unaffected side

Prevents ―pocketing‖ of food on affected side

Constipation

Stool softener

Fluid intake 1800-2000ml per day

Fiber 25 g per day

Physical activity Assist to toilet, provide privacy

Post-Stroke Care Instruct patient to chew on unaffected side  Prevents ―pocketing‖ of food on affected
Post-Stroke Care Instruct patient to chew on unaffected side  Prevents ―pocketing‖ of food on affected
Post-Stroke Care Instruct patient to chew on unaffected side  Prevents ―pocketing‖ of food on affected

Communication

Patient may be anxious and frustrated

Speak slowly and calmly

Use simple words or sentences

Look at patient when speaking

Give patient time to respond

Ask ―yes‖ or ―no‖ questions

Communication    Patient may be anxious and frustrated Speak slowly and calmly Use simple
Communication    Patient may be anxious and frustrated Speak slowly and calmly Use simple
  
Communication    Patient may be anxious and frustrated Speak slowly and calmly Use simple

Home Care

Patient with homonymous hemianopsia has blindness in same half of each visual field

 Accommodate by placing items in correct field of vision  Self care deficit  Avoid
Accommodate by placing items in correct field of vision
Self care deficit
Avoid fatigue
Assistive devices to increase independence
Place items on unaffected side
Facilitate dressing by using clothing that is one size larger and
made of stretchy fabric
Unilateral neglect
Approach pt. from unaffected side
Instruct pt. to scan full field of vision
Talk with patient on the unaffected side
Examples of Assistive Devices

Examples of Assistive Devices

Home Care

Risk for injury

 Inability to perform familiar tasks  Misjudging distances  Spilling hot liquids  Encourage pt.
Inability to perform familiar tasks
Misjudging distances
Spilling hot liquids
Encourage pt. think through task step by step
Eliminate obstructing hazards
Pets
Rugs and clutter
 Teach sitting and balancing exercises
Patient sits or dangles on edge of bed
Next, practice transferring to chair
Place chair on the unaffected side

Additional thoughts…

Coping

 Depression, anxiety, weight loss, poor appetite, chronic fatigue, sleep disturbances are common Sexual functioning 
Depression, anxiety, weight loss, poor appetite,
chronic fatigue, sleep disturbances are common
Sexual functioning
Acceptance of physical changes takes time
Fear of rejection, another stroke, inability to
perform
Careful grooming with attractive clothing
Begin slowly and communicate
Trial and error to find optimal positioning
Experiment during peak energy times
Counseling may be needed

Additional thoughts

 Constipation/Incontinence  Related to loss of mobility, decreased intake and ability to self toilet 
Constipation/Incontinence
Related to loss of mobility, decreased intake and ability to
self toilet
Risk for low self-esteem
Feeling of dependence, loss of role function
Powerlessness
Dependence, depression & anger – physical limitations may
prevent healthy expression, inability to use ―regular‖ ways to
express emotions such as exercise, hobbies etc.
Risk for self/other directed violence
Some patients may difficulty managing emotions after
suffering a CVA – warn patients and families about potential
labiality

Community Resources for the

Stroke Patient

 The National Stroke Association  Referral services  Quarterly newsletter  The American Stroke Association
The National Stroke Association
Referral services
Quarterly newsletter
The American Stroke Association
American Heart Association
Programs and information on stroke, HTN, diet,
exercise, and assistive devices
The Easter Seal Society
Wheelchairs and assistive devices

CASE STUDY FOR HOME REVIEW

  • Stroke

Patient Profile

Suzanne, a 66-year-old white woman, awoke in the middle of the night and fell when she tried to get up and go to the bathroom. She fell because she was not able to control her left leg. Her husband took her to the hospital, where she was diagnosed

with an acute ischemic stroke. Because she had

awakened with symptoms, the actual time of onset was unknown and she was not a candidate for tPA.

CASE STUDY FOR HOME REVIEW  Stroke  Patient Profile  Suzanne, a 66-year-old white woman,
CASE STUDY FOR HOME REVIEW  Stroke  Patient Profile  Suzanne, a 66-year-old white woman,
CASE STUDY FOR HOME REVIEW  Stroke  Patient Profile  Suzanne, a 66-year-old white woman,

Subjective Data

 • Left arm and leg are weak and feel numb  • Feeling depressed and
• Left arm and leg are weak and feel numb
• Feeling depressed and fearful
• Requires help with ADLs
• Concerns regarding possibility of another stroke
• Says she has not taken her drugs for high cholesterol
for many weeks
• History of a brief episode of left-sided weakness and
tingling of the face, arm, and hand 3 months earlier,
which totally resolved and for which she did not seek
treatment

Objective Data

  • BP 180/110

  • Left-sided arm weakness (3/5) and leg weakness (4/5)

  • Decreased sensation on the left side, particularly the hand

  • Left homonymous hemianopsia

  • Overweight

  • Alert, oriented, and able to answer questions appropriately but mild slowness in responding

Objective Data  • BP 180/110  • Left-sided arm weakness (3/5) and leg weakness (4/5)
Objective Data  • BP 180/110  • Left-sided arm weakness (3/5) and leg weakness (4/5)

Critical Thinking Questions

1. How does Suzanne's prior health history put her at risk for a stroke?

2. How can the nurse address Suzanne's concerns regarding having another stroke? 3. What strategies might
2.
How can the nurse address Suzanne's concerns
regarding having another stroke?
3.
What strategies might the nurse use to help Suzanne
and her family cope with her feeling depressed?
4.
What lifestyle changes should Suzanne make to reduce
the likelihood of another stroke?
5.
How will homonymous hemianopsia affect Suzanne's
hygiene, eating, driving, and community activities?
6.
What are the priority nursing interventions for
Suzanne?

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