Stroke: Nursing Management

1. Stroke: Nursing Management ZoyaMinasyan, RN, MSN-Edu

2. Structures and Functions of Nervous System Left hemisphere of cerebrum, lateral surface, showing major lobes and areas of the brain.

3. Structures and Functions of Nervous System Structural features of neurons: dendrites, cell body, and axons.

4. Structures and Functions of Nervous System Major divisions of the central nervous system (CNS).

5. Structures and Functions of Nervous System The cranial nerves are numbered according to the order in which they leave the brain.

6. Structures and Functions of Nervous System Arteries of the head and neck. Brachiocephalic artery, right common carotid artery, right subclavian artery, and their branches. The major arteries to the head are the common carotid and vertebral arteries.

7. Structures and Functions of Nervous System Arteries at the base of the brain. The arteries that compose the circle of Willis are the two anterior cerebral arteries joined to each other by the anterior communicating cerebral artery and to the posterior cerebral arteries by the posterior communicating arteries.

8. Structures and Functions of Nervous System The vertebral column (three views).

9. Stroke • Stroke occurs when ischemia or hemorrhage into the brain results in death of brain cells. • Also known as a brain attack • Functions are lost or impaired • Such as movement, sensation, or emotions that were controlled by the affected area of the brain • Severity of the loss of function varies according to the location and extent of the brain involved.

10. Risk Factors • Most effective way to decrease the burden of stroke is prevention. • Risk factors can be divided into non modifiable and modifiable risks.

11. Risk Factors • Modifiable • Hypertension • Metabolic syndrome • Heart disease • Heavy alcohol consumption • Poor diet • Drug abuse • Sleep apnea • Obesity • Physical inactivity • Smoking • Non modifiable • Age • Gender • Race • Heredity/family history

12. Types of Stroke • Strokes are classified on the basis of underlying pathophysiologic findings. • Ischemic • Thrombotic • Embolic • Hemorrhagic

13. Major Types of Stroke

14. Ischemic Stroke • Ischemic strokes result from • Inadequate blood flow to the brain from partial or complete occlusion of an artery • 80% of all strokes are ischemic strokes. • Ischemic strokes can be • Thrombotic • Embolic

15. Ischemic Stroke • Thrombotic stroke • 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 • Lacunar strokes • a stroke from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue. • thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate atherosclerosis

16. Pathogenesis of Atherosclerosis A, Damaged endothelium. B, Diagram of fatty streak and lipid core formation. C, Diagram of fibrous plaque. Raised plaques are visible: some are yellow, others are white. D, Diagram of complicated lesion: thrombus is red, collagen is blue. Plaque is complicated by red thrombus deposition.

17. Pathogenesis of Atherosclerosis • Developmental stages: • Fatty streaks • Earliest lesions • Characterized by lipid-filled smooth muscle cells • Potentially reversible • Fibrous plaque • Beginning of progressive changes in the arterial wall • Lipoproteins transport cholesterol and other lipids into the arterial intima. • Fatty streak is covered by collagen, forming a fibrous plaque that appears grayish or whitish. • Result = Narrowing of vessel lumen • Complicated lesion • Continued inflammation can result in plaque instability, ulceration, and rupture. • Platelets accumulate and thrombus forms. • Increased narrowing or total occlusion of lumen

18. Ischemic Stroke • Embolic stroke • Occurs when an embolus lodges in and occludes a cerebral artery • Results in infarction and edema of the area supplied by the involved vessel • Second most common cause of stroke • Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms. • Onset of embolic stroke is usually suddenand may or may not be related to activity. • Patient usually remains conscious, although he may have a headache.

19. Ischemic Stroke • Transient ischemic attack • Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain • Symptoms last <1 hour • Most TIAs resolve • encourage patients to go to the emergency room at symptom onset since once a TIA starts, one does not know if it will persist and become a true stroke, or if it will resolve. • In general, one third of individuals who experience a TIA will not experience another event, one third will have additional TIAs, and one third will progress to stroke.

20. Hemorrhagic Stroke • Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles • Often a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding • Intracerebral hemorrhage • Bleeding within the brain caused by rupture of a vessel • Hypertension is the most important cause. • Hemorrhage commonly occurs during periods of activity.

21. Hemorrhagic Stroke Massive hypertensive hemorrhage rupturing into a lateral ventricle of the brain.

22. Hemorrhagic Stroke • Intracerebral hemorrhage • Manifestations • Neurologic deficits • Headache • Nausea and/or vomiting • Decreased levels of consciousness • Hypertension

23. Hemorrhagic Stroke • Subarachnoid hemorrhage • Intracranial bleeding into cerebrospinal fluid–filled space between the arachnoid and pia mater • Commonly caused by rupture of a cerebral aneurysm • Majority of aneurysms are in the circle of Willis. • “Worst headache of one’s life” • Other causes of subarachnoid hemorrhage include trauma and illicit drug (cocaine) abuse. • people who have a hemorrhagic stroke due to a ruptured aneurysm can die during the first episode or die from subsequent bleeding. • increases with age, • higher in women than men. • Loss of consciousness may or may not occur. • focal neurologic deficits (including cranial nerve deficits), nausea, vomiting, seizures, and stiff neck. Most frequent surgical procedure to prevent re bleeding is clipping of the aneurysm.

24. Clinical Manifestations • Affects many body functions • Motor activity • Elimination • Intellectual function • Spatial-perceptual • Personality • Affect • Sensation • Communications

25. Clinical ManifestationsMotor Function • Most obvious effect of stroke • Include impairment of • Mobility • Respiratory function • Swallowing and speech • Gag reflex • Self-care abilities • Loss of skilled voluntary movement • Alterations in muscle tone • Alterations in reflexes

26. Clinical ManifestationsMotor Function • An initial period of flaccidity • (also known as hypotonicity is a condition characterized by a decrease or loss of normal muscle tone due to the deterioration of the lower motor nerve cells). • May last from days to several weeks • Related to nerve damage • Spasticity of the muscles follows the flaccid stage. • (an abnormal increase in muscle tension and a reduced ability of a muscle to stretch) • Related to interruptions in upper motor neuron influence

27. Clinical ManifestationsCommunication • Patient may experience aphasia when a stroke damages the dominant hemisphere of the brain. • Aphasia is the total loss of comprehension and use of language. • Dysphasia refers to difficulty related to the comprehension or use of language and is due to partial disruption or loss.

28. Types of Aphasia • Broca’s • Damage to frontal lobe, speak in short phrases that makes sense but with great effort. “Walk doge””Book –book table”. They are aware of it and become frustrated. • Wernicke’s • Left temporal lobe damage. Long sentences with no meaning, difficult to understand the meaning of the speech. They are not aware of it. • Global • Severe communication difficulties, limited in ability to speak. • A massive stroke may result in global aphasia, in which all communication and receptive function are lost.

29. Clinical ManifestationsCommunication • Many patients experience dysarthria. • Disturbance in the muscular control of speech • Dysarthria does not affect the meaning of communication or the comprehension of language, but it does affect the mechanics of speech. • Some patients experience a combination of aphasia and dysarthria. • Impairments may involve • Pronunciation • Articulation • Phonation

30. Clinical ManifestationsAffect • Patients who suffer a stroke may have difficulty controlling their emotions. • Depression and feelings associated with changes in body image and loss of function can make this worse. • Patients may also be frustrated by mobility and communication problems. • Emotional responses may be exaggerated or unpredictable. • An example of unpredictable affect is as follows: • A well-respected lawyer has returned home from the hospital following a stroke. During meals with his family, he becomes frustrated and begins to cry because of difficulty getting food into his mouth and chewing, something that he was able to do easily before his stroke.

31. Clinical ManifestationsIntellectual Function • Both memory and judgment may be impaired as a result of stroke. • A left-brain stroke is more likely to result in memory problems related to language.

32. Clinical ManifestationsSpatial–Perceptual Alterations • Stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation. • However, this may occur with left-brain stroke. • An example of behavior with right-brain stroke is the patient who tries to rise quickly from a wheelchair without locking the wheels or raising the footrests. • The patient with a left-brain stroke would move slowly and cautiously from the wheelchair.

33. Clinical ManifestationsSpatial-Perceptual Alterations • Spatial-perceptual problems may be Incorrect perception of self and illness perception of self in space Inability to recognize an object by sight, touch, or hearing Inability to carry out learned sequential movements on command A stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation, although this can also occur with left-brain stroke as well.

34. Clinical ManifestationsElimination • Most problems with urinary and bowel elimination occur initially and are temporary. • When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is intact • partial sensation of bladder and voluntary urination is present • Initially, the patient may experience frequency, urgency, and incontinence. • Constipation is associated with immobility, weak abdominal muscles, dehydration, and diminished response to the defecation reflex.

35. Diagnostic Studies • When symptoms of a stroke occur, diagnostic studies are done to • Confirm that it is a stroke • Identify the likely cause of the stroke • CT is the primary diagnostic test used after a stroke. • A CT scan can rapidly distinguish between ischemic and hemorrhagic stroke and help determine the size and location of the stroke. Serial CT scans may be used to assess the effectiveness of treatment and to evaluate recovery.

36. Diagnostic Studies • CTA • CT angiography (CTA) provides visualization of cerebral blood vessels • MRI, MRA • MRI is used to determine the extent of brain injury • Angiography may detect vascular lesions and blocksges • Cerebral angiography • Angiography can identify cervical and cerebrovascular occlusion, atherosclerotic plaques, and malformation of vessels • Digital subtraction angiography • Intraarterial digital subtraction angiography (DSA) reduces the dose of contrast material, uses smaller catheters, and shortens the length of the procedure compared with conventional angiography • Transcranial Doppler ultrasonography • Transcranial Doppler (TCD) ultrasonography is a noninvasive study that measures the velocity of blood flow in the major cerebral arteries. • Lumbar puncture • LICOX system • The LICOX system may be used as a diagnostic tool for evaluating the progression of stroke, brain O2 and temperature, page 1432

37. LICOX catheter The LICOX brain tissue oxygen system involves a catheter inserted through an intracranial bolt , placed in white matter of the brain. (A). The system measures oxygen in the brain (PbtO2), brain tissue temperature, and intracranial pressure (ICP) (B).

38. Diagnostic Studies of Nervous System Normal images of the brain. A, CT scan. B, MRI. 38

39. Diagnostic Studies of Nervous System Cerebral angiogram illustrating an arteriovenous malformation (arrow).

40. Collaborative CarePrevention • Goals of stroke prevention include • Health promotion • Education and management of modifiable risk factors • Patients with known risk factors require close management. • Diabetes mellitus • Hypertension • Obesity • High serum lipids • Cardiac dysfunction

41. Collaborative CarePrevention • Antiplatelet drugs are usually the chosen treatment • Aspirin is the most frequently used as antiplatelet agent. • Common dose for aspirin is 81 to 325 mg/day. • Other drugs include ticlopidine (Ticlid), clopidogrel(Plavix), dipyridamole (Persantine), and combined dipyridamole and aspirin (Aggrenox). • Oral anticoagulation using warfarin is the treatment of choice for individuals with atrial fibrillation.

42. Collaborative CarePrevention • Surgical interventions • Carotid end-arterectomy(tube inserted above and below the blockage, remove the plaque, stitch the artery close, remove the tube) • Transluminal angioplasty (insertion of balloon to open artery in the brain and to improve blood flow) • Stenting (inflate the balloon cath, imlpant the stent, deflate the balloon and remove, leave the stent permanently in place holding the artery open to improve the blood flow) • Extracranial-intracranial bypass (EC-IC) anastomosing (surgically connecting) external artery to internal artery-superficial temporal to middle cerebral artery

43. Carotid End-arterectomy Carotid endarterectomy is performed to prevent impending cerebral infarction. A,A tube is inserted above and below the blockage to reroute the blood flow. B,Atherosclerotic plaque in the common carotid artery is removed. C, Once the artery is stitched closed, the tube can be removed. A surgeon may also perform the technique without rerouting the blood flow.

44. Brain Stent Brain stent used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant the stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery and then inflated. The stent expands due to the inflation of the balloon. C, The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery open and improving the flow of blood.

45. Collaborative CareAcute Care • Goals for collaborative care during the acute phase are • Preserving life • Preventing further brain damage • Reducing disability • Begins with managing the ABCs • Airway • Breathing • Circulation

46. Collaborative CareAcute Care • Causes • Sudden vascular compromise causing disruption of blood flow to the brain • Thrombosis • Trauma • Aneurysm • Embolism • Hemorrhage

47. Collaborative Care:Acute Care • Assessment findings • Altered level of consciousness • Weakness, numbness, or paralysis • Speech or visual disturbances • Severe headache • ↑ or ↓ heart rate • Respiratory distress • Unequal pupils • Hypertension • Facial drooping on affected side • Difficulty swallowing • Seizures • Bladder or bowel incontinence • Nausea and vomiting • Vertigo

48. Collaborative CareAcute Care • Interventions • Ensure patent airway. • Call stroke code or stroke team. • Remove dentures. • Perform pulse oximetry. • Maintain adequate oxygenation. • Obtain IV access. • Maintain BP. • Obtain CT scan immediately. • Perform baseline laboratory tests. • Position head midline. • Elevate head of bed 30 degrees if no symptoms of shock or injury occur. • Institute seizure precautions. • Anticipate thrombolytic therapy for ischemic stroke.

49. Collaborative CareAcute Care • Watch for hypertension post stroke. • Drugs to lower BP are used only if BP is markedly increased. (metoprolol, cardene) • Fluid and electrolyte balance must be controlled carefully. • Adequate hydration promotes perfusion and decreases further brain injury. • Adequate fluid intake during acute care via oral, intravenous (IV), or tube feedings should be 1500 to 2000 mL/day. • Overhydration may compromise perfusion by increasing cerebral edema.

50. Collaborative CareAcute Care • Interventions • Monitor vital signs and neurologic status. • Level of consciousness • Monitor sensory function • Pupil size and reactivity • O2 saturation • Cardiac rhythm