Stroke

1. Stroke by Ann Van Eerden April, 2011

2. Navigation of this Tutorial Click to advance to the next slide Click to go to the previous slide Click to return to Table of Contents Click to return to the last slide you viewed Click on underlined words and blue boxes throughout the tutorial for more information.

3. Learning Outcomes Learner will define CVA Learner will distinguish the causes of CVA Learner will state risk factors for CVA Learner will recognize clinical manifestations of a stroke Learner will identify the nursing diagnosis “at risk for falls.” Learner will discern conditions related to risk for falls Learner will develop nursing outcomes and interventions

4. Table of Contents Welcome to Your Clinical What is a Stroke? Causes of Stroke Risk Factors Clinical Manifestations “At Risk for Falls” Conditions Related to “At Risk for Falls” References

5. Yes! No, I think I am going to drop this class. Welcome to the first day at your new clinical site! You learn that the patient you have been assigned for the day has a medical diagnosis of stroke, more specifically, a left sided cerebrovascular accident. Would you like to continue?

6. Before you make that decision, please stay for awhile; you’ll feel much better after this tutorial!

7. Yes, please! No thanks, I’ve decided to change my major. Your instructor greets you and introduces you to the night nurse who immediately begins giving you report. This is your first time on a medical unit. Your mind is racing; you are trying to recall everything that you remember about stroke, and nothing comes to mind. Would you like a review?

8. Ha! Ha! But, before you make that official, you might feel better if you take a few minutes to review stroke with this tutorial.

9. A Thrombus You are correct! Is there anything else? An Embolism You are correct! Is there anything else? A Hemorrhage You are correct! Is there anything else? A stroke is a BRAIN ATTACK! It means that there is an interrupted flow of blood to the brain. What do you think might cause this interruption?

10. A thrombus is the most common cause of stroke. It accounts for 60% of all strokes. It occurs more often in men. The onset is usually during or after sleep. The signs and symptoms develop slowly. (Lewis, 2004, p. 1528)

11. An embolic stroke occurs when an embolus occludes a cerebral artery. It occurs more often in men. The onset is rapid. It is a single event. (Lewis, 2004, p. 1529) (Used with permission of Emily Gillis)

12. Hemorrhagic strokes are either an intracerebral hemorrhage or a subarachnoid hemorrhage. An intracerebral hemorrhage has a sudden onset and a very poor prognosis. A subarachnoid hemorrhage is caused by an aneurysm and often follows strenuous activity. (Lewis, 2004, p. 1529) (Used with permission of Emily Gillis)

13. Okay! The night nurse has left and its time for you to take over. Mr. C. V. Accident is still sleeping and a nursing assistant offers to get his breakfast tray, so you have time to get organized. Let’s use the nursing process.

14. Do you remember the process? ASSESS DIAGNOSE PLAN IMPLEMENT EVALUATE Click on each box below for a review.

15. Mr. C.V. Accident’s Chart Mr. C.V. Accident is a 72 year old African- American with a history of hypertension. He is overweight, does not exercise, and smokes one pack of cigarettes per day. His wife died last year and since her death his diet consists primarily of fast food.

16. There are a number of risk factors that contribute to stroke. Some are modifiable, others are not. Click here to review the modifiable risk factors. Click here to review the non-modifiable risk factors.

17. Modifiable Risk Factors Atrial fibrillation Carotid stenosis Cigarette smoking Diabetes Heavy alcohol consumption Hypercoagulability Hyperlipidemia Hypertension Obesity Oral contraceptive use Physical inactivity Sickle cell disease (Lewis, 2004, p. 1526)

18. Non-Modifiable Risk Factors Age Gender Race Family history Prior stroke, TIA, or heart attack (Lewis, 2004, p. 1525)

19. Hypertension is the most important modifiable risk factor. Hypertension is a sustained elevation in blood pressure.It is defined as a systolic blood pressure equal to or greater than 140 mm Hg OR a diastolic blood pressure equal to or greater than 90 mm Hg for extended periods of time.Would you like to review what happens with hypertension? (Lewis, 2004, p.779) Yes No thanks.

20. Hypertension Flow Chart Increased Blood Pressure What does high blood pressure do to the blood vessels? Injury to vessels What happens to injured vessels? Inflammation Do you remember what happens to the inflamed vessels? Plaque develops and leads to atherosclerosis And what does atherosclerosis lead to? Risk of thrombus and emboli and INCREASED RISK FOR STROKE

21. Atherosclerosis is often described as hardening and thickening of the arteries.How does this lead to stroke?

22. Lipids in the arteries develop into PLAQUE Plaque leads to narrowing and thickening of the arteries PLAQUE may break off and occlude the artery and ultimately cause STROKE! PLAQUE narrows arteries and can lead to hypertension and ultimately STROKE!

23. Other factors affect these processes.They are:AgingGeneticsInflammationStress

24. Contribution of Aging Aging What does aging do to the aorta and arteries? Aorta and arteries decrease in elasticity What does this do to blood pressure? Increase in systolic blood pressure Increased risk for stroke

25. Contribution of Genetics Sickle cell disease What do the sickle cells adhere to? Sickles adhere to endothelium What happens to the vessel lining? Vessel lining becomes inflamed What else do these sickle cells promote? Increased coagulation What is the risk associated with increased coagulation? Increased risk of thrombus Increased risk for stroke

26. Contribution of Inflammation Injury to Endothelial Cell Do you remember what happens to an injured cell? Inflammatory cells migrate to injury What do these cells do? Contribute to development of atherosclerotic plaques What is this plaque build up called in the vessels? Atherosclerosis What modifiable risk factor does this contribute to? Hypertension Increased risk for stroke

27. Contribution of the Stress Response Stress What does stress do to the sympathetic nervous system? Sympathetic Nervous System releases epinephrine and norepinephrine What happens to your blood pressure? Increased blood pressure and increased mechanical stress Do you remember what this does to the cells? Endothelial Cell Injury And this leads to hardening of the arteries, also known as? Atherosclerosis Do you remember which risk factor develops because of this? Hypertension Increased risk for stroke

28. What Are Modifiable Risk Factors that Contributed to Mr. C.V. Accident’s Stroke? Age No, this is not modifiable. Hypertension Yes, this is correct. Race No, race is not modifiable. Weight Yes, this is modifiable. Activity Level Yes, this is modifiable. Family History No, this is not modifiable. Diet Yes, this is modifiable. Sex No, this is not modifiable. Height This is not a risk factor. Profession This is not a risk factor. Smoking Yes, this is modifiable. Hair Color This is not a risk factor.

29. Mr. C. V. Accident’s history indicates that while he was at church with his daughter, the right side of his face started drooping. Suddenly, he was unable to lift his right arm, and his speech became slurred. His daughter acted quickly and immediately called 9-1-1.

30. Mr. C.V. Accident had an ischemic stroke. Because he got to the hospital in LESS THAN THREE HOURS from the onset of his symptoms and a CT scan excluded the diagnosis of hemorrhagic stroke, Mr. C. V. Accident received recombinant tissue-type plasminogen activator (tPA), a thrombolytic agent.How does tPA work?

31. Here is how tPA works: Tissue plasminogen activator (tPA) targets thethrombus and catalyzes the conversion of plasminogen to plasmin resulting in thrombolysis.

32. Mr. C.V. Accident is diagnosed with a left sided cerebral accident. This means that the left side of his brain has been damaged and that the right side of his body will be impaired. Damage to the right side of his brain would result in impairment to the left side of his body.(Used with permission of Emily Gillis)

33. In your assessment, what are some of the clinical manifestations you might see with Mr. C.V. Accident? (Remember he has a left sided CVA.) Right sided hemiplegia Yes, you are correct! Left sided weakness No, not with a left sided CVA. Homonymous hemianopsia Yes, this is the loss of the visual field at the vertical midline of both eyes and is true of all strokes! Impaired speech and language Yes, this is true! Impaired concept of time No, this is true for right sided strokes. Impulsivity No, this is true for right sided strokes. Right sided neglect Yes, this is true for left sided brain damage. Difficulty in learning new information Yes, this is true for any stroke!

34. Your assessment is complete, now, its time for a nursing diagnoses for Mr. C.V. Accident.Do you think Mr. C.V. Accident is at risk for falls? YES MAYBE NO

35. Falls are one of the most common medical complications after stroke. 7% incidence first week after stroke 25%-37% incidence between one and six months post-stroke 40%-50% incidence six to twelve months after stroke 55%-73% incidence one year after stroke (Verheyden, 2010) (Microsoft Clip Art)

36. So, Mr. C.V. Accident isAT RISK FOR FALLS related to Balance Impairment Hemi-neglect Self-care deficit Cognitive impairment Hemiparesis Hemianopsia

37. At risk for falls related to balance impairment Encourage Mr. C.V. Accident to use walking aids when ambulating. Yes! You are correct! Monitor Mr. C.V. Accident’s fluid intake. This may be valuable for other reasons, but it will not decrease the risk of falls related to balance impairment. Outcome: Mr. C.V. Accident will remain free from falls Which nursing intervention would you use? (Microsoft Clip Art)

38. At risk for falls related to hemi-neglect Offer Mr. C.V. Accident frequent reminders to be aware of his left side. You are correct! Assess Mr. C.V. Accident’s pain level. While this may be a great intervention if Mr. C.V. Accident exhibits signs of pain, this will not help him address his hemi-neglect. Outcome: Mr. C.V. Accident will remain free from falls Which nursing intervention would you use?

39. At risk for falls related to self care deficit Monitor Mr. C.V. Accident’s vital signs every four hours. While vital signs are important, this will not keep Mr. C.V. Accident from falling while dressing himself. Assist Mr. C.V. Accident with dressing. Hooray! You are correct! Outcome: Mr. C.V. Accident will remain free from falls Which nursing intervention would you use? (Microsoft Clip Art)

40. At risk for falls related to cognitive impairment Orient Mr. C.V. Accident to his environment. Include the location and way to use his call button. Correct! Assess neurological status with the Glasgow coma scale. This is appropriate if Mr. C.V. Accident exhibits an altered level of consciousness, but it will not keep him free from falls. Outcome: Mr. C.V. Accident will remain free from falls Which nursing intervention would you use? (Microsoft Clip Art)

41. At risk for falls related to hemiparesis Perform neurological assessment every four hours. Sorry! This will not prevent Mr. C.V. Accident from falling. Encourage Mr. C.V. Accident to use assistive devices for walking. Hooray! You are correct! If he uses his assistive devices, the risk for falls will be decreased. Outcome: Mr. C.V. Accident will remain free from falls Which nursing intervention would you use? (Microsoft Clip Art)

42. At risk for falls related to hemianopsia Place items in Mr. C.V. Accident’s field of vision. Correct! You are doing a great job! Encourage Mr. C.V. Accident to increase his fluid intake. While fluids are important, this will not prevent falls. Click here to help Mr. C.V. Accident find the knife. Outcome: Mr. C.V. Accident will remain free from falls Which nursing intervention would you use? (Microsoft Clip Art)

43. Wow! Mr. C.V. Accident’s care plan is done! Its time to implement the nursing interventions, and evaluate them as the day goes on. This first clinical is almost over and it is going very well!

44. References Centers for Disease Control and Prevention (n.d.). Stroke Facts. Retrieved from http://www.cdc.gov/stroke/facts.htmm. Lewis, S.M., Heitkemper, M. M., & Dirksen, S. Medical surgical nursing: assessment and management of clinical problems, ed 6, St. Louis, 2004, Mosby. Microsoft Clip Art Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott. Verheyden, G., Weerdesteyn, V., Pickering, R., Hyndman, D., Lennon, S., Geurts, A., & Ashburn, A. (2010). Interventions for preventing falls in people after stroke.