Nursing Care of Clients with Stroke

Stroke
AKA
 Cerebrovascular accident
 Cerebral Infarction
 Brain attack

2/13/2014

Maria Carmela Domocmat, MSN, RN



Definition:
decreased blood supply to the brain
 Sudden loss of function resulting from a
disruption of the blood supply to a part of
the brain
 Functional abnormality of the CNS that
occurs when the blood supply is disrupted


2/13/2014


Incidence


700K stroke/year
500K: first attacks
 200K: recurrent attacks





87% are ischemic
Others: intracerebral and subarachnoid
hemorrhagic strokes

2/13/2014


Incidence


On average, every 45
_____ seconds someone in the United
States has a stroke



Who has more stroke incidence? Men or women?



Each year, about 46K more women than men have a stroke.
Male:Female ratio 1.25:1
 Ratio reverses after age 80





One in ____ strokes is a recurrent stroke, and the risk for a
second stroke is highest during the first ____days after the
first ischemic symptoms
4

30

2/13/2014


Phil Stat


April 2011 Stroke Deaths in Philippines
reached 40,245 or 9.55% of total deaths.
 #3 in the top 20 causes of death in the
country
 The age adjusted Death Rate is 82.77
per 100,000 of population ranks
 Philippines is #106 in the world
http://www.worldlifeexpectancy.com/philippines-stroke
2/13/2014


Mortality


Stroke accounted for about 1 of every16 deaths in the
____
United States in 2004.



About _____of stroke deaths in 2003 occurred out of hospital.
50%



When considered separately from other CVDs, stroke ranks
_______among all causes of death, behind diseases of the
No. 3
heart and cancer.

2/13/2014


•On average,
every 3 - 4
Mortality
minutes
someone dies
of a stroke



2/13/2014


Among
persons 45 to
64 years of
age, 8-12% of
ischemic
strokes and
37-38% of
hemorrhagic
strokes result



Mortality

2/13/2014


From 1994 to
2004, the
stroke death
rate fell 20.4%,
and the actual
number of
stroke deaths
declined 6.7%

Mortality

From 1995 to 1998, mortality rates for subarachnoid
hemorrhage, and intracerebral hemorrhage were
higher among blacks than whites.
2/13/2014






Death rates from intracerebral hemorrhage were
also higher among Asians/Pacific Islanders
than among whites.
All minority populations had higher death
rates from subarachnoid hemorrhage than did
whites.

2/13/2014


Five classes of stroke by "severity―
least to most severe


Transient Ischemic Attack (TIA), "angina" of the brain







Reversible Ischemic Neurological Deficit (RIND)






some neurological deficit, but stabilized

Progressing Stroke (stroke in evolution)





similar to TIA
findings last between 24 hours and three weeks
usual full functional recovery within three to four weeks

Partial, Nonprogressing Stroke




TIA is warning sign of stroke
localized ischemic event
produces neurological deficits lasting only minutes or hours
full functional recovery within 24 to 48 hours

deterioration of neurological status often with grand mal seizure activity
has residual neurological deficits that last indefinitely

Completed Stroke


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results from a stroke in evolution


Two types of stroke by "cause"
Ischemic
2. Hemorrhagic Stroke (bleeding)
1.

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Brain Attack/ Stroke

Ischemic Stroke

Thrombotic

Embolic

Hemorrhagic
Stroke

AV
amlformation

Aneurysm

HTN

2/13/2014


Ischemic


Incidence: 80% to 85%
 also known as occlusive stroke (clot)
 slower onset
 results from inadequate blood flow leading
to a cerebral infarction
 caused by cerebral thrombosis or embolism
within the cerebral blood vessels
 most common cause: atherosclerosis
2/13/2014


Ischemic


caused by thrombus and embolus
Thrombotic – most common
 Embolic – assoc with hypercoagulability
conditions




Types
Large artery thrombosis
 Small penetrating artery thrombosis
 Cardiogenic embolism
 Cryptogenic


2/13/2014


Manifestations of Ischemic Stroke


Symptoms depend upon the location and
size of the 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
2/13/2014


Hemorrhagic stroke (bleeding)


Incidence: 15% to 20%
 abrupt onset
 intracerebral hemorrhagic stroke: blood
vessels rupture with a bleed into the brain
 Caused by bleeding into brain tissue, the
ventricles, or subarachnoid space
 occurs most often in hypertensive older
adults
2/13/2014




May be due to spontaneous rupture of
small vessels primarily related to






2/13/2014

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 or
thrombolytic therapy




Brain metabolism is disrupted by
exposure to blood
 ICP increases due to blood in the
subarachnoid space
 Compression or secondary ischemia
from reduced perfusion and
vasoconstriction injures brain tissue

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Manifestations of Hemorrhagic
stroke


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

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

Subarachnoid Hemorrhage (SAH)





Epidural Bleeds





most often caused by rupture of saccular
intracranial aneurysms
more than 90% are congenital aneurysms
cerebral arterial vessels are involved
often a loss of consciousness for a short period of
time called transient unconsciousness

Subdural Bleeds



2/13/2014

veins are involved
may not be evident until months after an initial
trauma

Transient Ischemic Attack (TIA)


Temporary neurologic deficit resulting
from a temporary impairment of blood
flow
 ―Warning of an impending stroke‖
 Diagnostic work-up is required to treat
and prevent irreversible deficits

2/13/2014


Assessment












History and physical exam
Computerized tomogram (CT) scan
Magnetic resenance imaging (MRI)
Doppler echocardiography flow analysis
Carotid artery duplex doppler ultrasonography
EEG - shows abnormal electrical activity
Lumbar puncture - shows if blood is found in the
cerebral spinal fluid as a result of a cerebral bleed
Cerebral angiography - shows blood flow in cerebral
arteries


2/13/2014

may be done with or without contrast


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Intracerebral hemorrhage

2/13/2014


CEREBROVASCULAR ACCIDENTS
The Stroke Continuum
5 Classes of stroke by severity
1. TIA- transient ischemic attack, temporary
neurologic loss less than 24 hours duration
2. Reversible Ischemic Neurologic deficit
(RIND)
3. Partial, Nonprogressing Stroke
4. Progressing Stroke (or Stroke in evolution)
4. Completed stroke
2/13/2014


RISKS FACTORS
Non-modifiable
•

•
•

Age (over 55)
male gender,
African American race

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Risk factors


Modifiable risk factors












2/13/2014

uncontrolled Hypertension: the primary risk
factor
Cardiovascular disease
Elevated cholesterol and triglycerides or
elevated hematocrit
Obesity
Diabetes
Oral contraceptive use
Smoking and drug and alcohol abuse
chronic atrial fibrillation

RISKS FACTORS
Modifiable
 Hypertension
 Cardio disease
 Obesity
 Smoking
 Diabetes mellitus
 Hypercholesterolemia
 hypercoagulable state
 illicit drug use (esp cocaine)
 nonvalvular atrial fibrillation
2/13/2014


Risk Factors


Heart disease


AFib, Valvular Dz, MI, endocarditis



Hypertension
 Smoking
 Diabetes/Metabolic Syndrome
 Dyslipidemia
 Pregnancy
 Drug Abuse/Meds
 Bleeding Disorders/Anticoagulant Use

2/13/2014


Risk Stratification for Stroke


Highest Risk: Prior Stroke or TIA
 High Risk: Any of the following
Prior thromboembolism
 Female >75 yo
 SBP >160
 Heart failure/LV dysfunction




Moderate Risk: None of above, but HTN
 Low Risk: None of the above, no HTN
2/13/2014


Healthy lifestyle and stroke


A study of more than 37 000 women age 45 or
older participating in the Women’s Health Study
suggests that a healthy lifestyle consisting of
abstinence from smoking, low ______
____________________ BMI, moderate alcohol
consumption, regular _________ ______________
healthy diet
_____________ exercise,
and _________ were associated with a
significantly reduced risk of total and ischemic
stroke but not of hemorrhagic stroke.

2/13/2014


Prevention


avoid
smoking
 sedentary lifestyle
 high-fat diet




increase fruits and veg
 low saturated and trans fat
 light to mod alcohol consumption

2/13/2014


Stroke Prevention: Lifestyle


People who have had a stroke or TIA
can take steps to prevent a recurrence:
Quit smoking.
 Exercise and maintain a healthy weight.
 Limit alcohol and salt intake.
 Eat a healthier diet with more veggies, fish,
and whole grains.


2/13/2014


Preventive Treatment and
Secondary Prevention


Modifiable risk factors:
Hypertension: the primary risk factor
 Cardiovascular disease
 Elevated cholesterol or elevated hematocrit
 Obesity
 Diabetes
 Oral contraceptive use
 Smoking and drug and alcohol abuse


2/13/2014


Preventive Treatment and
Secondary Prevention


Health maintenance measures including a
healthy diet, exercise, and the prevention
and treatment of periodontal disease
 Carotid endarterectomy
 Anticoagulant therapy
 Antiplatelet therapy: aspirin, dipyridamole
(Persantine), clopidogrel (Plavix), and
ticlopidine (Ticlid)
 Statins
 Antihypertensive medications
2/13/2014


Stroke Prevention: Medications


For people with a high risk of stroke,
doctors often recommend medications to
lower this risk.
 Anti-platelet medicines (aspirin,
clopidogrel [Plavix], Dipyridamole)
 Anti-clotting drugs (warfarin)
 Anti Hpn

2/13/2014


Stroke Test: Talk, Wave, Smile


The F.A.S.T. test helps spot symptoms. It
stands for:







2/13/2014

Face. Ask for a smile. Does one side droop?
Arms. When raised, does one side drift down?
Speech. Can the person repeat a simple
sentence? Does he or she have trouble or slur
words?
Time. Time is critical. Bring to hospital STAT if
any symptoms are present.


Clinical Manifestations
depend on the location of the lesion

2/13/2014


Assessment











Transient
hemiparesis
Loss of speech
Hemisensory loss
Wernicke‟s aphasia
Broca‟s aphasia
Dysarthria
Dysphagia
Apraxia
2/13/2014



Hemianopia
 Horner‟s
syndrome
 Agnosia
 Unilateral
neglect
 Paresthesia
 Depression
 Incontinence
 Proprioception


Signs and Symptoms of
Childhood Stroke:

















Severe headache- this is often the first complaint
Nausea and/or vomiting
Warm, flushed, clammy skin
Slow, full pulse – may have distended neck veins
Speech difficulties- absent, slurred or inappropriate speech
Eye movement problems – partial or complete blindness,
blurred vision, unequal pupils
Numbness – paralysis, weakness, or loss of coordination of
limbs, usually on one side of the body; loss of balance
Facial droop or salivary drool
Urinary incontinence
Seizures
Brief loss of consciousness; unconscious „snoring‟
respirations
May show signs of rapid recovery (TIA)

Glasgow Coma Scale (GCS)


most widely used scoring system to quantify level of
consciousness following traumatic brain injury; scores
range from 3 to 15, based on the sum of the best eye
opening response, the best verbal response, and the best
motor response



Eye Opening (E)
4=Spontaneous
3=To voice
2=To pain
1=None

•
•
•
•

•



Verbal Response (V)
5=Normal
4=Disoriented
3=Inappropriate
2=Incomprehensible
1=None

Total = E+V+M

2/13/2014


Motor Response (M)
6=Normal
5=Localizes to pain
4=Withdraws to pain
3=Flexes to pain
2=Extends to pain
1=None

Assessment


Neurologic assessment
 Cognitive changes
 Motor
 Sensory
 CN
 Cardiovas

2/13/2014


Cognitive changes



denial of illness
spatial and proprioceptive (awareness of body
position if space) dysfunction
impair memory, judgment, problem-solving,
decision-making
decreased ability concentrate
aphasia – inability to use or comprehend
language
alexia – reading problems



agraphia – difficulty with writing








2/13/2014


Motor changes






Hemiphlegia – paralysis on one side of body
Hemiparesis – weakness on one side of body
Hypotonia or flaccid paralysis – unable to
overcome forces of gravity, and et tend to fall on
one side
Hypertonia or spastic paralysis – fixed positions
or contractures of involves ext; ROM restricted,
shoulder subluxation easily occur




a temporary, partial dislocation of the shoulder

Incontinence

2/13/2014


Ataxia –staggering, unsteady gait unable
to keep feet together; needs a broad
base to stand
 Dysarthria - difficulty in speaking
 Aphasia - loss of speech
 Dysphagia –difficulty in swallowing


2/13/2014


Sensory




Agnosia – is a loss of ability to recognize
objects, persons, sounds, shapes, or smells
while the specific sense is not defective nor is
there any significant memory loss.
Apraxia – inability to perform a previously
learned action

2/13/2014


Sensory






Neglect syndrome – unaware of existence of
his/her paralyzed side
Amaurosis fugax – is loss of vision in one eye
due to a temporary lack of blood flow to the
retina.
Hemianopsia – blindness in one half of visual
field
Homonymous hemianopsia – blindness in
same side of both eyes; must turn head to
have complete range of vision

2/13/2014


Hemianopsia


loss of vision in
one-half the
normal visual
field (usually the
right or left half)
of one or both
eyes.

http://www.wrongdiagnosis.com/bookimages/8/2608.png

2/13/2014


Hemianopsia


absence of vision in half of a visual field
 The visual field of each eye can be
divided in two vertically, with the outer
half being described as temporal, and
the inner half being described as nasal.

2/13/2014


Hemianopsia


"Binasal hemianopsia" can be broken
down as follows:
bi-: involves both left and right visual fields
 nasal: involves the nasal visual field
 temporal: involves the temporal visual field
 lateral: involves the lateral visual field
 hemi-: involves half of each visual field
 anopsia: blindness


2/13/2014


http://www.wrongdiagnosis.com/bookimages/14/4774.1.png

2/13/2014


Paris as seen with full visual fields

2/13/2014


Right homonymous hemianopsia

http://upload.wikimedia.org/wikipedia/commons/thumb/0/08/Rhvf.png/300px-Rhvf.png

2/13/2014


Left homonymous hemianopsia

2/13/2014


Bitemporal hemianopsia

2/13/2014


Binasal hemianopsia

2/13/2014


Binasal hemianopsia


or Binasal hemianopia
 is the medical description of a type of
partial blindness where vision is missing
in the inner half of both the right and left
visual field. It is associated with certain
lesions of the eye and of the central
nervous system, such as congenital
hydrocephalus.
2/13/2014




CN function




CV




chew, swallow, facial paralysis, gag reflex, tongue
movement
heart murmur, dysrhythmias, HTN

psychosocial


emotional lability - a condition of excessive
emotional reactions and frequent mood changes; is
the regular occurrence of unstable, disproportionate

emotional displays
2/13/2014




Labs
no definitive lab test confirm stroke
 HCt, Hb, INR, PT, PTT, LP




Radiographic




CT, CTA

other Dx


2/13/2014

MRI, MRA, ECG


General manifestations

2/13/2014


Localization
Middle cerebral artery:
 Aphasia
 Dysphagia
 HEMIPARESIS on the OPPOSITE sidemore severe on the face and arm than
on the legs

2/13/2014


Localization
Anterior cerebral artery:
 Weakness
 Numbness on the opposite side
 Personality changes
 Impaired motor and sensory function

2/13/2014


Localization
Posterior cerebral artery:
 Visual field defects
 Sensory impairment
 Coma
 Less likely paralysis

2/13/2014


DIAGNOSTIC tests


1. CT scan
 2. MRI
 3. Angiography

2/13/2014


Hypodense area:
• Ischemic area with
edema, swelling
• Indicates >3 hours old
• No fibrinolytics!

2/13/2014


(White areas indicate
hyperdensity = blood)

Large left frontal
intracerebral
hemorrhage.

Intraventricular

bleeding
is also present
No fibrinolytics!

2/13/2014


Acute subarachnoid
hemorrhage
Diffuse areas of white
(hyperdense) images

Blood visible in
ventricles

and multiple areas on
surface of brain



Glucose and electrolyte tests:









Hypoglycemia is the most common electrolyte abnormality
that produces stroke-like symptoms

Electrolyte disorders, hyperglycemia,
hypoglycemia, and uremia
Complete blood count:
Prothrombin time (PT) and activated partial
thromboplastin time (aPTT) tests

Cardiac enzymes
Arterial blood gas (ABG) analysis

2/13/2014


Carotid duplex


Carotid duplex scanning is
one of the most useful tests in
evaluating patients with stroke.
 Increasingly, it is being
performed earlier in the
evaluation, not only to define
the cause of the stroke but
also to stratify patients for
either medical management or
carotid intervention if they have
carotid stenoses. Patients with
symptomatic critical stenoses
on carotid duplex scanning
may require anticoagulation
before intervention is
performed.

2/13/2014


Angiogram


This is an angiogram of
the right carotid artery
showing a severe
narrowing (stenosis) of
the internal carotid artery
just past the carotid fork.
There is enlargement of
the artery or ulceration in
the area after the
stenosis in this close-up
film. Note the narrowed segment toward the
bottom of the picture.

2/13/2014


Time lost is Brain lost


The consequences of
delaying treatment for
stroke can be
catastrophic.



"Time is brain" is an
adage used by stroke
professionals to reinforce
the critical need for early
and rapid intervention.

2/13/2014


Every minute
that the brain is
deprived of oxygen,
1.9 million neurons,
14 billion synapses,
and 7.5 miles of
myelinated fibers
are lost.
After 12 minutes
without treatment,
a pea-sized piece of
brain tissue dies.
2/13/2014


Management


to prevent or minimize the damaging
effects of stroke; dependent on the type
of CVA


Expected outcomes
prevent or minimize the damaging effects of
stoke
 depends on the type of CVA


Prompt diagnosis and treatment
 Assessment of stroke: NIHSS assessment
tool


2/13/2014


Stroke: Emergency Treatment


ischemic stroke





emergency treatment focuses on medicine to
restore blood flow.
A clot-busting medication is highly effective at
dissolving clots and minimizing long-term
damage, but it must be given within three hours
of the onset of symptoms.

Hemorrhagic strokes



2/13/2014

are more difficult to manage.
Treatment usually involves attempting to
control high blood pressure, bleeding, and brain
swelling.

Treatment Occlusive stroke


Pharmacologic


thrombolytics









anticoagulant therapy: heparin, coumadin
antiplatelet therapy: aspirin, dipyridamole
(Persantine)




2/13/2014

Criteria for tissue plasminogen activator (tPA): see Chart
62-2
IV dosage and administration
Patient monitoring
Side effects: potential bleeding

platelet aggregation inhibitor: clopidogrel (Plavix),
ticlopidine HCL (Ticlid)

steroids: dexamethasone (Decadron)


Treatment Occlusive stroke


Elevate HOB unless contraindicated
 Maintain airway and ventilation
 Provide continuous hemodynamic
monitoring and neurologic assessment
 surgery
bypass
 carotid endarterectomy


2/13/2014


Hemorrhagic stroke (ICH)


Care is primarily supportive
 surgical excision of aneurysm
 Prevention: control of hypertension
 Bed rest with sedation
 Oxygen
 Treatment of vasospasm, increased ICP,
hypertension, potential seizures, and
prevention of further bleeding
2/13/2014


Treatment ICH


Pharmacologic


antihypertensive agents : alpha-blockers and betablockers












systemic steroids: dexamethasone (Decadron)
osmotic diuretics: mannitol
antifibrinolytic agents: aminocaproic acid (Amicar)
vasodilators
anticonvulsants
Recombinant factor VIIa (rFVIIa) therapy
Reverse coagulopathies


2/13/2014

Vitamin K, FFP, Platelets


Treatment ICH


Neurosurgical ICU
 Constant monitoring
 Bedrest
 Pain control
 Reverse coagulopathies




Vitamin K, FFP, Platelets

ICP control


2/13/2014

Mannitol, Induced Coma, Hyperventilation

Treatment of SAH


Neurosurgical ICU
 Constant monitoring
 Bedrest
 Pain control
 Reverse coagulopathies
 DVT Prophylaxis
 Blood Pressure Management
 Management of Aneurysms/AVMs
2/13/2014


Treatment


Common to both types of stroke
care based on findings
 therapies


nutritional support
 physical
 speech
 behavioral
 occupational


2/13/2014


NINDS Recommended Stroke Evaluation Time
Benchmarks for Potential Thrombolysis
Candidate

Time Interval
Door to doctor
Access to neurologic expertise
Door to CT scan completion
Door to CT scan interpretation
Door to treatment
Admission to monitored bed

2/13/2014

Time Target
10 min
15 min
25 min
45 min
60 min
3h


General Management of Patients With
Acute Stroke
Blood glucose



Blood pressure



Cardiac monitor



Intravenous
fluids





Oral intake


Oxygen
Temperature
2/13/2014



Treat hypoglycemia with D50
Treat hyperglycemia with insulin if serum glucose
>200 mg/dL
See recommendations for thrombolysis candidates
and noncandidates
Continuous monitoring for ischemic changes or
atrial fibrillation
Avoid D5W and excessive fluid administration
IV isotonic sodium chloride solution at 50 mL/h
unless otherwise indicated
NPO initially; aspiration risk is great, avoid oral
intake until swallowing assessed
Supplement if indicated (Sa02 <90%, hypotensive,
etc)
Avoid hyperthermia, oral or rectal acetaminophen
as needed

Nursing Process—Planning Patient
Recovery After an Ischemic Stroke


Major goals include:







2/13/2014

Improved mobility
Avoidance of shoulder
pain
Achievement of selfcare
Relief of sensory and
perceptual deprivation
Prevention of
aspiration
Continence of bowel
and bladder








Improved thought
processes
Achievement of a form
of communication
Maintenance of skin
integrity
Restoration of family
functioning
Improved sexual
function
Absence of
complications


NURSING INTERVENTIONS:
ACUTE
1.
2.

3.
4.

5.
6.

2/13/2014

Ensure patent airway
Keep patient on LATERAL position
Monitor VS and GCS, pupil size
IVF is ordered but given with caution as not
to increase ICP
Insert NGT
Medications: Steroids, Mannitol (to decrease
edema), Diazepam


In acute stage of stroke


If grand mal seizure activity note time,
length, behaviors
 Monitor neuro status, vital signs, LOC, GCS
 Maintain adequate fluids
 Position with HOB elevated 15 to 30
degrees with client turned or tilted to
unaffected side
 Provide activity as ordered
2/13/2014




Perform passive and/or active range of
motion exercises
 Maintain proper body alignment
 Care for post op client as indicated
 Provide care for client with increased
intracranial pressure

2/13/2014




A. Nonsurgical Management








Monitor (and intervene) in neurologic, ICP status
Drug therapy
Monitor other complications
Carotid Artery Angioplasty
Hypothermia Treatment

B. Surgical Management







2/13/2014

Endarterectomy
Extracranial-Intracranial Bypass
Management of AVM
Management of aneurysms
Management of intracranial bleeding




Monitor for potential complications :
musculoskeletal problems, swallowing
difficulties, respiratory problems, and
signs and symptoms of increased ICP
and meningeal irritation

2/13/2014


Long-term care of client with stroke


Monitor to facilitate normal elimination
patterns
 Teach/evaluate the use of supportive
devices
 Maintain client in a safe environment
 Prevent the effects of immobility

2/13/2014


Long-term care of client with stroke


Support the maintenance of adequate
nutrition in light of feeding and swallowing
problems
 Assist with eating and ADL as indicated
 Provide emotional support
 Provide methods of communication for
client with aphasia
 Focus on patient function; self-care ability,
coping, and teaching needs to facilitate
rehabilitation
2/13/2014


Nursing Diagnoses








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








2/13/2014

Disturbed thought
processes
Impaired verbal
communication
Risk for impaired
skin integrity
Interrupted family
processes
Sexual dysfunction


Nursing Diagnoses


Ineffective Tissue Perfusion (cerebral) and
Potential for increased ICP r/t interruption to
arterial bloodflow.



Impaired Physical Mobility, self-care deficit and
potential for deep vein thrombosis or pulmonary
embolism r/t neuromuscular impairment or
cognitive impairment.



Disturbed Sensory Perception and risk for injury
r/t altered sensory reception, transmission, and
integration.

2/13/2014


Nursing Diagnoses


Unilateral Neglect r/t effects of disturbed
perceptual abilities or hemianopsia



Impaired Verbal Communication r/t decreased
circulation in the brain



Impaired Swallowing, Risk for imbalanced
nutrition: less than body requirements,
constipation and risk for aspiration r/t
neuromuscular impairment

2/13/2014


Nursing Diagnoses


Total Urinary Incontinence and Bowel
Incontinence r/t neurologic dysfunction



Ineffective Coping, caregiver role strain, r/t
recent change in health status, Inadequate
coping method or unsatisfactory support
system

2/13/2014


Collaborative Problems/Potential
Complications


Decreased cerebral blood flow
 Inadequate oxygen delivery to brain
 Pneumonia

2/13/2014


Interventions


Focus on the whole person
 Provide interventions to prevent
complications and to promote
rehabilitation
 Provide support and encouragement
 Listen to the patient

2/13/2014


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
2/13/2014




Correctly position patient to prevent
contractures




2/13/2014

Place pillow under axilla
Hand is placed in slight supination- ―C‖
Change position every 2 hours


Positioning to Prevent Shoulder
Abduction

2/13/2014


Prone Positioning to Help Prevent
Hip Flexion

2/13/2014


Joint Deformities


Implement measures to prevent and treat
shoulder problems
 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
2/13/2014


Joint Deformities


Assist patient out of bed as soon as
possible: assess and help patient
achieve balance and move slowly
 Implement ambulation training

2/13/2014


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

2/13/2014




Carry out activities on the unaffected
side
 Prevent unilateral neglect- place some
items on the affected side!!!
 Keep environment organized
 Use large mirror

2/13/2014


Improve communication
Implement strategies to enhance
communication
 Anticipate the needs of the patient
 Provide time to complete the sentence
 Provide a written copy of scheduled
activities
 Use of communication board
 Give one instruction at a time
2/13/2014


Care of the client with Aphasia


Say one word at a time
 Identify one object at a time
 Give simple commands
 Anticipate needs
 Allow to verbalize no matter how long it
takes him
 Speech therapy
2/13/2014


Maintain skin integrity


Use of specialty bed
 Regular turning and positioning
 Keep skin dry and massage NONreddened areas
 Provide adequate nutrition

2/13/2014


Manage sensory-perceptual
difficulties


Care of the client with Hemianopsia
Approach from the unaffected side
 Place articles on the unaffected side
 Encourage the patient with visual field loss
to turn his head and look to side
 Teach scanning techniques. Turn head from
side to side to see entire visual field
 Encourage to turn the head to the affected
side to compensate for visual loss


2/13/2014


Manage dysphagia
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

2/13/2014


Manage dysphagia


Provide smaller bolus of food
 Place food on the UNAFFECTED side
 Manage tube feedings if prescribed
 Promote nutrition


2/13/2014

TPN, NGT feeding, gastrostomy feeding


Bowel and bladder control
Help patient attain bowel and bladder
control
 Assess and schedule voiding
 Implement measures to prevent
constipation: fiber, fluid, and toileting
schedule
 Provide bowel and bladder retraining


Promote elimination


2/13/2014

I and O; Start urinary and bowel program

Bowel and bladder control








Intermittent catheterization in acute stage
Offer bedpan on a regular schedule
High fiber diet and prescribed fluid intake
The best time for a bowel movement is 20 - 40
minutes after a meal, since feeding stimulates
bowel activity.
Some people drink warm prune juice or fruit
nectar as a stimulus to bowel movements.

2/13/2014




Improve thought processes


Support patient and capitalize on the
remaining strengths



Improve family coping
 Help patient cope with sexual
dysfunction
 Provide support and encouragement

2/13/2014


Aneurysm Precautions







Absolute bed rest
Elevate HOB 30° to promote venous
drainage or keep the bed flat to increase
cerebral perfusion
Avoid all activity that may increase ICP or
BP; implement Valsalva maneuver, acute
flexion, and rotation of the neck or head
Exhale through mouth when voiding or
defecating to decrease strain

2/13/2014


Aneurysm Precautions


Nurse provides all personal care and
hygiene
 Provide nonstimulating, nonstressful
environment: dim lighting, no reading, no
TV, and no radio
 Prevent constipation
 Restrict visitors

2/13/2014


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
self-care and rehabilitation
2/13/2014


Surgical Management
•
•
•
•

•
•

Endarterectomy
Extracranial-Intracranial Bypass
Carotid artery angioplasty
Management of AVM
Management of Aneurysms
Management of intracranial bleeding

2/13/2014


Surgical treatments of aneurysms
Clipping
Embolization
Intra-Cranial Angioplasty and Stent (ICAS)

Clipping

Surgical
treatment of
aneurysms
involves placing
clip on neck of
aneurysm.

2/13/2014


Embolization
• Endovascular
repair of cerebral
aneurysm.
• Anterior
communicating
artery aneurysm
before and after
GDC coil
embolization
2/13/2014


Intra-Cranial Angioplasty and Stent
• ICAS (Intra-Cranial Angioplasty and Stent)
of Basilar
Artery Stenosis

2/13/2014


Stent

2/13/2014


Extracranial-intracranial bypass surgery
(EC-IC bypass)



2/13/2014

is a treatment for blocked
blood vessels in the brain.
The purpose of the
operation is to use a
healthy blood vessel to
bypass the block and
provide an additional blood
supply to areas of the brain
that have been deprived of
blood.


Rehabilitation
Learning to live to one’s maximum
potential with a chronic impairment and
it’s resultant disability
 Promotes reintegration into the client’s
family and community
 Influenced by the client and client’s
motivation


2/13/2014




Goals of Rehab
Prevent complications
 Correction of deformities
 Restoration of function to achieve maximum
independence
 Limitation of disability


2/13/2014


Goal of Stroke Rehabilitation


Most mildly impaired individuals achieve
their best functional recovery in 3 weeks
 While it can take up to 12 weeks for the
most severe

2/13/2014


Elite support
walker

Bar Grab
Pivoting for
Bathrooms

Home Care and Teaching for the
Patient Recovering From a Stroke


Prevention of subsequent strokes, health
promotion, and implementation of followup care
 Prevention of and signs and symptoms
of complications
 Medication teaching
 Safety measures

2/13/2014


Home Care and Teaching for the
Patient Recovering From a Stroke


Adaptive strategies and use of assistive
devices for ADLs
 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
2/13/2014


Ten Guidelines for Interacting with a Stroke
Survivor © American Stroke Foundation
I. Treat me the same way as you did before my stroke – I
am the same person.

II. Every stroke is different; therefore every stroke survivor
is different. Common impairments for stroke survivors
are: Vision, balance, speech, hearing, and paralyzed on
one side.

2/13/2014



III. Some stroke survivors have difficulty communicating
verbally as well as reading, writing, spelling, and
understanding what is being said, this is called aphasia.
Our brains have been rewired which affects our
communication. So, we need you to: Give us enough
time to respond. Talk slowly; offer at times to repeat
yourself. Be patient when trying to communicate with
us. It is okay to help us find a word when we are having
trouble.

2/13/2014


IV. There are other ways of communication besides
words. Gestures, Facial expressions, Body
languages, Pictures, Pen & paper.

V. Treat us like adults and not children. Speak directly to
us, not our spouse or friend. Don’t talk like the stroke
survivor isn’t there. Laugh with us not at us.

2/13/2014


VI. Give the stroke survivor a chance to be
independent. Ask before you help them. Follow his/her
instructions for initiating the help.

VII. Many stroke survivors have problems with balance. A
rough pat on my back, shoulder, or arm can easily set us
off balance and can hurt me. Be gentle and understand
that it can take a lot of concentration to walk, especially
on uneven surfaces.

2/13/2014


VIII. Wheelchair and walker are extensions of us. Please
respect our space. If you bump the chair, please say
excuse me. Please don’t lean on a wheelchair.

IX. Talk to us at eye level when possible when we are in a
wheel chair. You can also back up a few feet to make it
easier for a person in a wheelchair to look at you.

2/13/2014



X. When we are tired and/or frustrated, ALL of our basic
skills (i.e. talking, walking, handwriting, and
concentration) diminish. If we are more agitated than
usual, we are probably tired or frustrated!
Have patience and encourage us to rest or “take a
break” when appropriate.

2/13/2014


What‟s in store
in the future?

Roles in Stroke Nursing




Nurses have responded to the challenge of
making stroke systems of care a reality in
recent years.
Stepping into new roles, such as stroke
response nurse, stroke nurse practitioner,
stroke coordinator, and stroke research
nurse, stroke nurses are using evidencebased practice to organize and deliver stroke
services and facilitate optimal outcomes for
stroke patients.

2/13/2014




Clot Dissolving
Substance in
Vampire Bat Saliva
Cell and Tissue
Transplants

2/13/2014



Venom from Pit
Viper





Free Radical
Scavengers


Nursing Care of Clients with Stroke

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