What are the risk factors for stroke using the mnemonic “Strokes Happen”? And what risk factors are not covered by this mnemonic?
- Rhythm changes (AFib)
- Oral Contraceptives
- Kin (family history)
- Excessive weight
- Senior citizens
- Physical inactivity
- Previous TIA
- Elevated glucose (DM)
- Aneurysm (brain)
- This mnemonic covers all the risk factors except age, gender, ethnicity, sleep apnea, metabolic syndrome, poor diet, and drug/alcohol abuse
What causes ischemic stroke?
Disruption of blood flow to the brain due to a thrombus and emboli within a cerebral artery
What causes hemorrhagic stroke?
Disruption of blood flow to the brain due to bleeding into the brain tissue, ventricles, or subarachnoid space
What type of ischemic stroke is the most common?
What type of stroke is caused by a clot that narrows the lumen of blood vessels?
What type of stroke is caused by a moving blood clot that occludes the cerebral artery?
What type of stroke is caused by a bleed inside the brain, usually from a ruptured blood vessel?
Primary Intracerebral Hemorrhage (ICH)
What type of stroke is caused by a bleed in the space of arachnoid and pia mater, between the brain and the skull?
Subarachnoid Hemorrhage (SAH)
Explain the signs and symptoms progression with thrombotic strokes
s/s develop slowly, there is some improvement, then recurrence in 20-25% of survivors
Explain the signs and symptoms of progression with embolic strokes
s/s develop quickly, there is some improvement, then a recurrence is common without aggressive treatment of the underlying disease or cause
Explain the signs and symptoms of progression with primary intracerebral hemorrhage
- Headache precedes 25% of cases and is precipitated most often by activity
- Progression over 24 hours
- Poor prognosis and fatality are more likely with presence of a coma
Explain the signs and symptoms of progression with subarachnoid hemorrhage
- Commonly caused by aneurysms in the brain with a severe headache being the most common sign and symptom
- Often caused by activity with sudden onset
- Most commonly related to head trauma
- Usually a single sudden event
- Fatality is more likely with presence of a coma
What causes a brain aneurysm?
Dilation of the walls of cerebral arteries that develop from weakness in the arterial wall
What causes arteriovenous malformations and what are they?
- Usually caused from abnormality in embryonal development
- Tangles of arteries and veins that lack a capillary bed
What can brain aneurysms and arteriovenous malformations put you at risk for?
What are the basic clinical manifestations of a stroke?
- Numbness or weakness of the face, arm, or leg – especially on one side of the body
- Confusion or change in mental status
- Trouble speaking or understanding speech
- Trouble seeing or vision changes or disturbances (differences in perception)
- Difficulty walking or loss of balance and coordination
- Dizziness and perceptual disturbances
- Sudden severe headache
- Heart rate increase or decrease
- Respiratory distress
- Unequal pupils
- Facial drooping on affected side
- Difficulty swallowing
- Bladder or bowel incontinence
- Nausea and vomiting
What are the clinical manifestations of left hemisphere stroke?
- Paralysis or weakness on the right side of the body
- Right visual field deficits
- Impaired right/left discrimination
- Altered intellectual ability and comprehension related to language and math
- Slow, cautious behavior
- Aware of deficits which can cause depression, anxiety and anger
What are the clinical manifestations of right hemisphere stroke?
- Paralysis or weakness on left side of the body
- Left visual field deficit
- Tends to deny or minimize problems
- Short attention span
- Spatial-perceptual deficits
- Increased distractibility and impulsive behavior making them accident prone and risk for injury
- Impaired judgement and lack of awareness of deficits
- Impaired time concepts
- Left-sided neglect
What are the neurological deficits of stroke regarding motor function?
- Hemiplegia (weakness)
- Hemiparesis (paralysis)
What are the neurological deficits of stroke regarding communication loss?
- Dysarthria – disturbance with muscle control (mouth won’t move to make words)
- Dysphasia – difficulty speaking
- Aphasia – unable to speak
- Receptive – cannot understand what is being said
- Expressive – know what they want to say, but cannot get it out
- Global – both receptive and expressive
- Apraxia – cognitive; cannot do something they previously knew how to do (e.g., brush hair)
What are the neurological deficits of stroke regarding perceptual disturbances?
- Hemianopsia – side of affected body, vision will be cut in half
- If they have a right-side stroke, then they will have hemianopsia in the left eye
What are the neurological deficits of stroke regarding sensory loss?
- Agnosia – can’t name or recall something they knew
- Calls a cup a bowl
What are the neurological deficits of stroke regarding cognitive impairments?
- Higher cortical intellectual function
What are the neurological deficits of stroke regarding psychological effects?
- Emotional liability – all over the place emotionally; patient may laugh or cry inappropriately
What diagnostic studies are used to diagnose a stroke including the extent of involvement?
- CT scan
- CT angiography (CTA)
- Magnetic resonance angiography (MRA)
- CT/MRI perfusion and diffusion imaging
What diagnostic studies are used to show cerebral blood flow in the diagnosis of a stroke?
- Cerebral angiography
- Carotid angiography
- Digital subtraction angiography
- Transcranial doppler ultrasonography
- Carotid duplex scanning
What diagnostic studies are used to perform cardiac assessment in the diagnosis of a stroke?
- Chest x-ray
- Cardiac markers (troponin, creatine kinase-MB)
- Echocardiography (transthoracic, transesophageal)
What additional studies may be performed when diagnosing a stroke?
- Complete blood count (including platelets) and glucose
- Coagulation studies: prothrombin time, activated partial thromboplastin time
- Electrolytes, blood glucose
- Renal and hepatic studies
- Lipid profile
- Cerebrospinal fluid analysis (a lumbar puncture to obtain cerebrospinal fluid is avoided if increased intracranial pressure is suspected)
What can patients do to prevent strokes or reduce the risk of having a stroke?
- Reduce salt and sodium intake.
- Maintain a normal body weight.
- Maintain a normal BP.
- Increase level of physical exercise.
- Avoid cigarette smoking or tobacco products.
- Limit consumption of alcohol to moderate levels.
- Follow a diet that is low in saturated fat, total fat, and dietary cholesterol and high in fruits and vegetables (e.g., Mediterranean diet).
What drugs can be given as preventative therapy for stroke prevention?
- Antiplatelets (ASA, ticlopidine, clopidogrel, dipyridamole)
- Anticoagulants (warfarin, rivaroxaban, dabigatran, apixaban)
What is the therapeutic range for INR when receiving warfarin?
What precautions must be taken with warfarin therapy?
- Patients have to be careful about foods they eat and have to have blood work frequently
- Avoid increased intake of dark green leafy vegetables
What drug is given to prevent clots in patients with AFib?
What surgical procedures can be done to help prevent stroke?
- Carotid endarterectomy (CEA)
- Transluminal angioplasty
- Carotid stenting
What is carotid endarterectomy (CEA)?
- Removal of plaque in the carotid artery
- RISK FOR STROKE
What is transluminal angioplasty?
Can open up stenosed veins to improve blood flow
What are the initial nursing interventions which should be performed in the emergency management of a stroke?
- If unresponsive, assess circulation, airway, and breathing
- If responsive, monitor airway, breathing, and circulation
- Call stroke code or stroke team
- Remove dentures
- Perform pulse oximetry
- Maintain adequate oxygenation (SaO2 >95) with supplemental O2, if necessary
- Establish IV access with normal saline
- Maintain BP according to guidelines
- Remove clothing
- Obtain CT scan or MRI immediately
- Perform baseline lab tests including blood glucose immediately and treat if hypoglycemic
- Position head in midline
- Elevate head of bed 30 degrees if no symptoms of shock or injury
- Institute seizure precautions
- Anticipate thrombolytic therapy for ischemic stroke
- Keep patient NPO until swallow reflex evaluated
What is tPA?
- Tissue plasminogen activator
- Dissolves the clot that is blocking blood flow to decrease the size of the stroke and improve functional outcomes
What are the strict criteria that must be met for the administration of tPA?
- Must be administered within 3 to 4 ½ hours of onset of symptoms
- CT/MRI to rule out hemorrhagic stroke
- Blood tests for glucose level and coagulation disorders
- Screening for recent history of GI bleed, stroke, or head trauma within the past 3 months
- Any major surgery within the last 14 days
- Any recent active internal bleeding within the last 22 days
What are the goals of management in the acute care of hemorrhagic stroke?
- Allow the brain to recover from the initial bleed
- Prevent or minimize the risk of rebleeding
- Prevent or treat any complications
What drug therapy is used in the acute care of hemorrhagic stroke patients?
- Manage HTN
- Nimodipine – given for SAH to decrease effects of vasospasm and minimize edema
- Analgesic agents to treat headache or other pain
- Treat any fever or hyperglycemia
What can be done surgically for a hemorrhagic stroke?
- Craniotomy to remove blood
- Neuro-interventional radiology for aneurysm coiling/clipping
What are the nursing interventions for aneurysm precautions?
- Non-stimulating environment
- HOB elevated 15-30 degrees unless otherwise ordered
- Avoid anything that increases BP or ICP (Valsalva maneuver, straining, forceful sneezing, pushing up in bed, flexion or rotation of the head, cigarette smoking, enemas)
- Anti-embolism stockings or SCDs
- Keep client well informed
What are the immediate complications of hemorrhage?
- Extension of bleeding causing increased ICP
- Acute hydrocephalus
- Potential for herniation
- Secondary brain injury
- Cerebral hypoxia and decreased blood flow
- Vasospasms and rebleeding
What are the nursing interventions for a stroke patient?
- Report any evidence of deterioration and increased ICP
- Focus on ABCs and LOC
- Ongoing GCS evaluation
- Monitor pulse oximetry
- Increase HOB 30 degrees
- Monitor sedation
- Watch for aspiration – NPO until screened
- Prep for: anticoagulant reversal, hyperventilation, placement of ventricular catheter for CSF drainage, administer mannitol
- Turn q 2 hours
- Improve mobility and prevent joint deformities
- Prevent shoulder pain
- Enhance self-care
- Managing sensory-perceptual difficulties
- Assisting with nutrition
- Attainting bowel and bladder control
- Improving thought processes
- Improving communication
- Maintain skin integrity
- Improving family coping
- Improve coping ability with sexual dysfunction
- Providing patient education and preparing patient for home
When performing nursing interventions for stroke patients, what can be done to improve mobility and prevent joint deformities?
- Prevent shoulder adduction
- Proper position of hand and fingers
- Change position at least every 2 hours
- Establish an exercise program
- Prepare for ambulation as soon as possible
When performing nursing interventions for stroke patients, what can be done to prevent shoulder pain?
- Use care when positioning the patient and moving the affected arm to prevent painful shoulder
- Shoulder slings can be used to prevent dislocation which cause shoulder subluxation or incomplete dislocation
When performing nursing interventions for stroke patients, what are some of the sensory and perceptual difficulties experienced by patients who experienced a stroke in the right hemisphere and what can we do to manage some of those difficulties?
- patients usually have difficulty judging position, distance, and rate of movement
- often impulsive/impatient, deny problems r/t stroke
- higher risk for injury because of mobility difficulties
- directions for activities are best given verbally for comprehension, broken into simple steps for ease of understanding
- non-slip socks at all times
- one sided neglect is common – remind to dress weak/paralyzed side or shave the forgotten side of the face
When performing nursing interventions for stroke patients, what are some of the sensory and perceptual difficulties experienced by patients who experienced a stroke in the left hemisphere and what can we do to manage some of those difficulties?
- Slower in organization and performance of tasks
- Impaired special discrimination
- Behaviors slow and cautious
- Nonverbal cues and instructions are helpful for comprehension
When performing nursing interventions for stroke patients, what is homonymous hemianopsia and what can we do to manage the sensory and perceptual difficulties associated with homonymous hemianopsia?
- Homonymous hemianopsia is blindness in the same half of each visual field – common problem after stroke
- Persistent disregard of objects in part of the visual field should alert you to this possibility
- Initially help patient compensate by arranging environment within patients’ perceptual field (arrange all food on right or left to accommodate field of vision)
- Later patient learns to compensate by consciously attending to or scanning neglected side
When performing nursing interventions for stroke patients, what must be assessed before assisting with nutrition?
- Gag reflex must be assessed
- First oral feeding must be carefully planned
When performing nursing interventions for stroke patients, what can be done to assist in attainment of bowel and bladder control?
- The bladder can become atonic which leads to the inability to feel when the bladder is full. Patient may need foley/intermittent catherization
- Constipation is common. Patient may need stool softeners prophylactically. Check for impaction if patient has liquid stools
What are the guidelines for communicating with a patient with aphasia?
Decrease environmental stimuli that may be distracting and disrupting to communication efforts
- Treat the patient as an adult
- Speak with normal volume and tone
- Present one thought or idea at a time
- Keep questions simple or ask questions that can be answered with “yes” or “no”
- Let the person speak. Do not interrupt. Allow time for the individual to complete thoughts
- Make use of gestures or demonstration as an acceptable alternative form of communications Encourage this by saying, “show me…” or “Point to what you want”
- Do not pretend to understand the person if you do not. Calmly say you do not understand and encourage the use of nonverbal communication, or ask the person to write out what he or she wants
- Give the patient time to process information and generate a response before repeating a question or statement
- Allow body contact (clast of a hand, touching) as much as possible. Realize that touching may be the only way the patient can express feelings
- Organize the patient’s day be preparing and following a schedule (the more familiar the routine, the easier it will be)
- Do not push communication if the person is tired or upset. Aphasia worsens with fatigue and anxiety
- Teach communication techniques to caregiver and family members
How can you provide assistance to the patient, caregiver, and family who need help coping with the losses associated with stroke?
- Supporting communication between the patient and family
- Discussing lifestyle changes resulting from stroke deficits
- Discussing changing roles and responsibilities within the family
- Being an active listener to allow the expression of fear, frustration, and anxiety
- Including the family and patient in short- and long-term goal planning and patient care
- Supporting family conferences
- Identifying support groups and referrals as needed
What are the 3 aspects of the patient’s behavior that caregivers and family members must cope with?
- Recognition of behavioral changes resulting from neurologic deficits that are not changeable
- Responses to multiple losses by both the patient and family
- Behaviors that may have been reinforced during the early stages of stroke as continued dependency