Chapter 58: Stroke management

Question 1

Non-modifiable risk factors

Answer 1

Age, gender, ethnicity/race, family history

Question 2

Modifiable risk factors

Answer 2

HTN (#1 CAUSE!!!), heart disease, smoking, diabetes, alcohol, obesity, sleep apnea, lack of exercise, poor diet, drug abuse. Most c/b atherosclerosis–> thrombus and embolus formation

Question 3

Transient episode of neurologic dysfunction c/b focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain. Sx typically last less than 1 hour. Teach the pt to seek tx for any stroke sxs, since there is no way to predict if it will resolve or if it is in fact the development of a stroke. May be d/t micro emboli that temporarily block blood flow. Warning sign of progressive cerebrovascular disease.

Answer 3

Transient ischemic attack.

Question 4

Results from inadequate blood flow to the brain from partial or complete occlusion of an artery. Nearly 80% of strokes.

Answer 4

Ischemic stroke

Question 5

Occurs from injury to a blood vessel wall and formation of a blood clot. The lumen of the blood vessel becomes narrowed and, if it becomes occluded, infarction occurs. Thrombosis develops readily where atherosclerotic plaques have already narrowed blood vessels.Account for about 60% of stroked. 2/3 are associated with HTN, DM, or both. Usually have had some TIAs.
S/S: no decrease in LOC, sx progress for 72 hours

Answer 5

Thrombotic stroke

Question 6

Occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel. Second most common cause of a stroke. Severe clinical sx that occur suddenly. Warning signs less common than with thrombotic. Often occurs rapidly, giving little time to accommodate by developing collateral circulation. Pt usually remains conscious although they may have a headache. Prognosis r/t the amt of brain tissue deprived of its blood supply. Usually have a cardiac hx. Recurrence is common.
S/S: sudden onset of sx, usually remain conscious

Answer 6

Embolic stroke

Question 7

Results from bleeding into the brain tissue itself (intracerebral or intraparenchymal) or into the subarachnoid space or ventricles.

Answer 7

Hemorrhagic stroke

Question 8

Bleeding within the brain c/b a rupture of a vessel. Prognosis is poor. HTN is the most common cause. Sudden onset of sx with progression over minutes to hours because of ongoing bleeding. Initially, pts experience a severe headache with N/V. Weakness of one side, slurred speech, deviation of the eyes. Progression- hemiplegia, fixed and dilated pupils, abnormal body posturing, coma.
S/S: Neurological deficits, headache, nausea, vomiting, decreased LOC, and HTN.

Answer 8

Intracerebral hemorrhage

Question 9

Intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain. C/b rupture of a cerebral aneurysm. Other causes can be trauma and illicit drug (cocaine) abuse. Pt may have warning sx if the ballooning artery applies pressure to brain tissue, or minor warning sx may result from leaking of an aneurysm before major rupture. Viewed as the “silent killer,” since individuals do not have warning signs of an aneurysm until rupture has occurred. Loss of consciousness may or may not occur. Pt’s LOC may range from alert to comatose. Neurological deficit, nausea, vomiting, seizures, and stiff neck.

Answer 9

Subarachnoid hemorrhage

Question 10

FAST for strokes

Answer 10

Facial droop, uneven smile
Arm numbness, arm weakness
Slurred speech, difficulty speaking or understanding
Time- call 911 and get to the hospital immediately

Question 11

Sx: slow, cautious; depressed; anxious; slow speech; right paralysis; impaired right/left discrimination; aware of deficits; impaired comprehension r/t language, math.

Answer 11

Left sided stroke

Question 12

Sx: impulsive; denies problems; talks fast; safety risks; left paralysis; left side neglect.
Short attention span; impaired judgement; impaired time concepts

Answer 12

Right sided stroke

Question 13

Motor function and stroke

Answer 13

Motor deficits are the most obvious effects of a stroke. Loss of skilled voluntary movement (akinesia), impairment of integration of movements, alterations in muscle tone, and alterations in reflexes. The initial hyporeflexia (depressed reflexes) progresses to hyperreflexia for most. A lesion on one side of the brain affects motor function on the opposite side of the body (contralateral).. The arms and legs of the affected side may be weakened or paralyzed to different degrees depending on which part of and to what extent the cerebral circulation was compromised. An initial period of flaccidity may last from days to several weeks and is r/t nerve damage. Spasticity of muscles, which follows the flaccid stage, is r/t interruption of upper motor neuron influence.

Question 14

Communication and stroke

Answer 14

Left hemisphere is dominant for language skills in right-handed persons and in most left-handed persons. Pt may experience aphasia (receptive- loss of comprehension; expressive- inability to produce language; global- total inability to communicate). Aphasia often occurs when a stroke damages the dominant hemisphere of the brain.
Dysphagia refers to impaired ability to communicate. Patterns of aphasia may differ, since the stoke affects different portions of the brain. Nonfluent aphasia- minimal speech activity with slow speech that requires obvious effort. Fluent aphasia- speech is present but contains little meaningful communication.
Dysarthia- a disturbance in the muscular control of speech. Does not affect the meaning of communication or the comprehension of language, but it does affect the mechanics of speech.

Question 15

Affect and stroke

Answer 15

May have difficulty controlling their emotions. emotional responses may be exaggerated of unpredictable. Depression and feelings associated with changes in body image and loss of function can make this worse. Pts may also be frustrated by mobility and communication problems.

Question 16

Intellectual function and stroke

Answer 16

Memory and judgement may be impaired as a result of stroke. These impairments can occur with strokes affecting either side of the brain. A left-brain stroke is more likely to result in memory problems r/t language. Pts with left-brain stroke often are cautious in making judgements. PT with a right-brain stroke tends to be impulsive and move quickly.

Question 17

Spatial-perceptual alterations

Answer 17

Pts with right-sided stroke are more likely to have problems with spatial-perceptual orientation. Can occur in left too. Damage to parietal lobe-incorrect perception of self and illness (may deny illnesses or their own body parts). Pt neglects all input from the affected side (erroneous perception of self in space. May be worsened by homonymous hemianopsia- blindness occurs in the same half of the visual fields of both eyes. Difficulty with spatial orientation, such as judging distances). Agnosia- the inability to recognize an object by sight, touch, or hearing. Apraxia- inability to carry out learned sequential movements on command.
Pts may or may not be aware of their spatial-perceptual alterations

Question 18

Elimination and stroke

Answer 18

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 excellent. At least partial sensation for bladder filling remains, and voluntary urination is present. Initially, pt may experience frequency, urgency, and incontinence.
Pts are frequently constipated (associated with immobility, weak abdominal muscles, dehydration, and diminished response to the defecation reflex).
Urinary and bowel elimination problems may also be r/t inability to express needs and to manage clothing.
Urinary temporary, constipation long-term

Question 19

Most important test in dx of stroke. Provides visualization of cerebral blood vessels. Can be performed after or at the same time as a noncontrast. Can provide an estimate of perfusion and detect filling defects in the cerebral arteries.

Answer 19

CT angiography (CTA)

Question 20

Can detect vascular lesions and blockages, similar to CTA

Answer 20

Magnetic resosnance angiography (MRA)

Question 21

Two tests that can rapidly distinguish between ischemic and hemorrhagic stroke and help determine the size and location of the stroke

Answer 21

CT/MRI

Question 22

Noninvasive study that measures the velocity of blood flow in the major cerebral arteries. Effective in detecting micro emboli and vasospasm and is ideal for the pt suspected of having an SAH.

Answer 22

Transcrainal Doppler (TCD) ultrasonography

Question 23

Measures brain oxygenation and temperature. Dx tool to evaluate the progression of a stroke

Answer 23

LICOX

Question 24

Preventative therapy

Answer 24

Health promotion for a healthy lifestyle and management of modifiable risk factors. Health promotion focuses on 1) health diet, 2) weight control, 3) regular exercise, 4) no smoking, 5) limitation on alcohol consumption, and 6) routine health assessments. Pts with known risk factors such as DM, HTN, obesity, high serum lipids, or cardiac dysfunction require close management. It having TIAs, look for causes.

Question 25

Preventative drug therapy

Answer 25

Measure to prevent the development of a thrombus or an embolus are used in pts with TIAs, since they are at high risk for a stroke. Anti platelet drugs are usually the chosen tx to prevent stroke in pts who have had a TIA. ASA is the most frequently used anti platelet agent. Also clopidogrel (Plavix).
For pts with a-fib, oral anticoagulation can include warfarin (Coumadin) among others.

Question 26

Surgical therapy for TIA and stroke prevention

Answer 26

Surgical interventions for the pt with TIAs d/t carotid disease include carotid endarterectomy (CEA. atheromatous lesion is removed from the carotid artery to improve blood flow), transluminal angioplasty (insertion of a balloon to open a stenosed after in the brain and improve blood flow. Balloon is threaded up to the carotid artery via a catheter inserted in the femoral artery), stenting (intravascular placement of a stent in an attempt to maintain patency of the artery. Can in inserted during an angioplasty. System can be used with a tiny filter that opens like an umbrella that catches and removes the debris that is stirred up during the stenting procedure before it floats to the brain, which can trigger a stroke), and extra cranial-intracranial (EC-IC) bypass (involves anastomosing [surgically connecting] a branch of an extra cranial artery to an intracranial artery beyond an area of obstruction with the goal of increasing cerebral perfusion). Generally reserved for pts who do not benefit from other forms of therapy Post op care involves neurovascular assessments, BP management, assessment of stent occlusion or retroperitoneal hemorrhage as cs, and minimization of cx at the inserting site by keeping the pt’s leg straight for the prescribed time.

Question 27

Acute care for ischemic stroke

Answer 27

Single most important point in the pt’s hx is the time of onset of sx. Managing circulation, airway, and breathing. Pts may have difficulty keeping an open and clear airway b/c of a decreased LOC or decreased or absent gag and swallowing reflexes. Baseline neurologic assessment. Elevated BP is common immediately after a stroke and may be a protective response to maintain cerebral perfusion, but can also be detrimental. Fluid and electrolyte balance (keep pt hydrated to promote perfusion and decrease further brain injury); Overhydration may compromise perfusion by increasing cerebral edema. IV solutions with glucose and water are avoided because they are hypotonic and may further increase cerebral edema and ICP.
Management of increased ICP: Elevate HOB, maintaining head and neck alignment and avoiding hip flexion. Management of hyperthermia, drug therapy to prevent seizures, pain management, avoidance of hypervolemia, management of constipation. CSF may be drained.
Prevent hypoxia, hypercapnia (because can increase ICP)

Question 28

Drug therapy for ischemic stroke

Answer 28

Fibrinolytic therapy should not be delayed. tPA is used to produce localized fibrinolysis by binding to the fibrin in the thrombi. The finbinolytic action of tPA occurs as the plasminogen is converted to plasmin, whose enzymatic action then digests fibrin and fibrinogen, and thus lyses the clot.
tPA is administered IV to reestablish blood flow through a blocked artery to prevent cell death in pts with acute onset of ischemic stroke. Must be administered within 3-4.5 hours of the onset of clinical signs. Pts are screened carefully before tPA is given (non contrast CT or MRI to rule out hemorrhagic). If tPA is expected as a treatment option, insert a urinary catheter, nasogastric tube, and multiple IVs before. Closely monitor the pts vitals and neuro status to assess for improvement or for potential deterioration r/t intracerebral hemorrhage. Control of BP (maintained blow 180/105 for at least 24 hrs after tPA). is critical during tx and for 24 hours following. No anticoagulants (i.e. heparin) in the emergency phase. ASA within 24-48 hours after the onset.

Question 29

Drug therapy for hemorrhagic stroke

Answer 29

Anticoagulants and platelet inhibitors are contraindicated. Main drug therapy for pts with hemorrhagic stroke is the management of HTN. Oral and IV agents may be used to maintain BP within a normal to high-normal range (systolic BP less than 160. Nimotop to decrease vasospasm). Seizure prophylaxis in the acute period after intracerebral and subarachnoid hemorrhages is situation specific and should be discussed with the collaborative care team.

Question 30

Surgical therapy for hemorrhagic stroke

Answer 30

Immediate evacuation of aneurysm-induced hematoma or cerebellar hematoma larger than 3 cm. Surgical resection and/or radio surgery (i.e. gamma knife). Tx of an aneurysm involves clipping (places a metallic clip on the neck of the aneurysm to block blood flow and prevent rupture; clip remains in place for life) or coiling (metal coil is inserted into the lumen of the aneurysm via interventional neuroradiology; provides immediate protection against hemorrhage by reducing blood pulsations within the aneurysm. Thrombus eventually forms within the aneurysm and the aneurysm becomes sealed off from the parent vessel by the formation of an endothelialized layer of connective tissue) the aneurysm to prevent rebleeding.
Subarachnoid and intracerebral hemorrhage can involve bleeding into the ventricles of the brain. This situation produces hydrocephalus, which further damages brain tissue from increased ICP. Insertion of a ventriculostomy for CSF drainage can dramatically improve these situations.

Question 31

Respiratory system intervention

Answer 31

During the acute phase after a stroke, management of the resp. system is a nursing priority. Stoke pts are particularly vulnerable to resp. problems. Advancing age and immobility increase the risk of atelectasis and pneumonia. Risk for aspiration pneumonia is high b/c of impaired consciousness or dysphagia. Airway obstruction can occur b/c of problems with chewing and swallowing, food pocketing, and the tongue falling back. An oropharyngeal airway may be used in comatose pts to prevent the tongue from falling back and obstructing the airway and to provide access for suctioning.
Frequently assessing the airway patency and function, providing oxygenation, suctioning, promoting pt mobility, positioning the pt to prevent aspiration, encouraging deep breathing.

Question 32

Neuro acute interventions

Answer 32

NIH stroke scale- measures stroke severity
Mental status, pupillary responses, and extremity movement and strength. Closely monitor VS. A decreasing LOC may indicate increasing ICP.

Question 33

CV acute interventions

Answer 33

Maintaining homeostasis. Many pts have decreased cardiac reserves 2* to cardiac disease. Monitor VS, monitor cardiac rhythms; calculate I&O, noting imbalances; regulating IV infusions; adjusting fluid intake to individual pt needs; monitoring lung sounds for crackles and rhonchi indicating pulmonary congestion; monitoring heart sounds for murmurs or for S3 or S4 heart sound.
HTN is sometimes seen after a stroke as the body attempts to increase cerebral blood flow. Monitor for orthostatic hypotension before ambulating with pt for the first time.
Pt is at risk for VTE, especially in the wake or paralyzed lower extremity. Keep pt moving (ROM exercises) and usually preventions.

Question 34

Musculoskeletal interventions

Answer 34

Maintain optimal function by preventing joint contractors and muscular atrophy. ROM exercises and positioning. Muscle atrophy 2* to lack of innervation and activity can develop, so exercise is an important intervention for rehab and recovery. Paralyzed or weak side needs special attention when the pt is positioned. Position each joint higher than the joint proximal to it to prevent dependent edema.
Nursing interventions: trochanter roll at the gip to prevent external rotation; hand cones (not rolled washcloths) to prevent hand contractors; arm supports with slings and lap boards to prevent shoulder displacement; avoidance of pulling the pt by the arm to avoid shoulder displacement; posterior leg splints, footboards, or high-top tennis shoes to prevent foot drop; hand splints to reduce spasticity.

Question 35

Integumentary system interventions

Answer 35

Skin of the pt with a stroke is particularly susceptible to breakdown r/t loss of sensation, decreased circulation, and immobility.
Nursing interventions: pressure relief by position changes, special mattresses, or wheelchair cushions; good skin hygiene; emollients applied to dry skin; early mobility. Do not massage damaged area b/c can cause additional damage. Control of pressure is the single most important factor in both the prevention and tx of skin breakdown. Pillows can be used under lower extremities to reduce pressure on the heels. Vigilance and good nursing care are required to prevent pressure sores.

Question 36

GI system interventions

Answer 36

Most common problem is constipation. Pts may be prophylactically placed on stool softeners and/or fiber. If pt has liquid stools, check for impaction. Physical activity also promotes bowel function. Laxatives, suppositories, or additional stool softeners may be ordered if the pt does not respond to increased fluid and fiber. Enemas are used only in suppositories and digital stimulation are inneftive b/c they cause vagal stimulation and increase ICP.
Bowel retraining may be needed and continues into the rehab phase.

Question 37

Urinary system interventions

Answer 37

In the acute stage of stroke the 1* urinary problem is poor bladder control, resulting in incontinence. Take steps to promote normal bladder function and avoid the use of indwelling catheter. Bladder retraining program.

Question 38

Nutritional interventions

Answer 38

Speech therapy to assess swallowing ability. Keep upright. Assess gag reflex. Initially offer only crushed ice or water. Pureed diet is too smooth and too bland. Use Thick-It. Chin turk and double swallow. Watch for pocketing. Put food on unaffected side. Give good mouth care.

Question 39

Communication interventions

Answer 39

Ask yes or no questions. May not be able to read words. Give plenty of time to respond. Speak in normal volume and tone. Picture boards.
Communicating frequently and meaningfully; allowing time for the pt to comprehend and answer; using simple, short sentences; using visual cues; structuring conversation so that it permits simple answers by the pt; praising the pt honestly for improvements with speech

Question 40

Sensory-perceptual interventions

Answer 40

Pts with a stroke on the right side of the brain usually have difficulty judging position, distance, and rate of movement. These pts are often impulsive and impatient and tend to deny problems. They may fail to correlate spatial-perceptual problems with the inability to perform activities, such as guiding a wheelchair through the doorway. Pt with a right-sided stroke is at higher risk for injury because of mobility difficulties. Directions for activities are best given verbally for comprehension. Environmental control, such as removing clutter and obstacles and using good lighting, aids in concentration and safer mobility. 
Pts with left-sided strong commonly are slower in organization and performance tasks, tend to have impaired spatial discrimination. Behaviors are cautious and slow. Nonverbal cues and instructions are helpful for comprehension. 
Homonymous hemianopsia (blindness in the same half of each visual field) is a common problem. Arrange the environment within the pt's perceptual field, such as arranging a food tray so that all foods are on the right or left side. 
Diplopia treated with an eyepatch.

Question 41

Coping interventions

Answer 41

Explanations to the pt about what has happened and about diagnostic and therapeutic procedures should be clear and understandable. Give the caregiver and family a careful, detailed explanation of what has happened.
Clearly communicate, repeat teaching often. Help with arranging follow-up care. Depression can be common.
Tone, demeanor, and touch may also be used to convey support. Speak in a normal volume and tone, keep questions simple, and present one thought or idea at a time. To decrease frustration, always let the pt speak without interruption and make use of gestures. Do not forget to use writing and communication boards.

Question 42

Musculoskeletal home interventions

Answer 42

If muscles are still flaccid several weeks after the stroke, the prognosis for regaining function is poor and care focuses on preventing additional loss. Balance training is the initial step and begins with the pt sitting up in bed or dangling the legs over the bed. Evaluate tolerance by noting dizziness or syncope c/b vasomotor instability.
Supportive or assistive equipment, such as canes, walkers, and leg braces, may be needed on a short- or long-term basis for mobility. The PT usually selects the most appropriate supportive device(s) to meet individual needs and instructs the pt regarding use.
Constraint-induced movement therapy (CIMT) encourages the pt to use the weakened extremity by restricting movement of the normal extremity.

Question 43

Bowel/bladder home interventions

Answer 43

Prevent constipation. Bowel retraining.
Tend to have functional incontinence. Regular voiding schedule (q2hr). No fluid restriction, but give most fluids between 7a and 7p. Try not to cath unless there is incomplete emptying.

Question 44

A pt with a stroke has dysphagia. Before allowing him to eat, which action should you take first?

a) Check the pts gag reflex.
b) Request a soft diet with no liquids
c) Place the pt in high-Fowler’s position
d) Test the pt’s ability to swallow with a small amount of water

Answer 44

a) check the pt’s gag reflex