Stroke Flashcards
Cerebrovascular accident CVA
Sudden onset of neurological deficit
Results from a sudden interruption in the blood supply to an area of the brain
Depriving the affected area of oxygen
Causing death of brain tissue
Ischaemic stroke
Form of CVD, 9% attributed to cerebral infarction
Due to mechanical blockage of blood flow in a cerebral blood vessel
Caused by atherosclerosis and blood clot formation
Embolic: blood clot formed elsewhere in the body, causes a blockage in the smaller vessels of the brain
Thrombotic: formation of thrombosis within the cerebral artery blocking blood flow and oxygen supply
Haemorrhagic stroke
Results from the rupture of weakened or damaged blood vessels (15% of all cases)
Bleeding within the brain (intracerebral)
Causes are mainly hypertension
Bleeding around the brain (subarachnoid)
Causes- ruptured aneurysm, anteriovenouz malformation, head trauma
Can be managed surgically
Transient ischaemic attack (TIA)
Small temporary blockages to blood vessels
Resolve within 24 hours
Characterised by dizzy spells
Cause small, cumulative amounts of brain change
High risk of later stroke
Risk factors age, hypertension, smoking, dyslipidaemia, excessive alcohol, diabetes, CVD
Primary prevention of stroke
Management of hypertension
Smoking cessation
Reduce cardiovascular risk:
Reducing weight
Avoid excessive sodium consumption <2.3g
Increasing oily fish
Moderation of alcohol intake - male <14 units; female <9 units
Increasing physical activity 30-60 x 4-7
Increasing fruit and veg intake
Secondary prevention of stroke
Lifestyle advice as for primary prevention, focus on behaviour change
Antihypertensive therapies
Aim bp <140/90
Anticoagulation (ischaemic stroke or TIA)
Antiplatelet therapy (ischaemic stroke or TIA)
Cholesterol reduction (statins)
Diabetes management
Consequences of stroke
Weakened/ paralysis of muscles (50-80%)
Altered levels of consciousness (30-40%)
Speech, communication difficulties (30%)
Dysphasia (swallowing) difficulties (30%)
Impaired visions (7%)
Impaired cognitive function
Incontinence
Emotional instability
Right sided stroke
Left Hemiplegia
Problems with spariL and perceptual ability eg misjudge distances (leading to a fall), unable to guide hands to pick up and object etc
Behavioural judgement difficulties. Act impulsively and unaware of impairments
Left side neglect
Short term memory problems
Left sided stroke
Right hemiplegia
Aphasia: speech and language problems
Development of slow and cautious behaviour eg require frequent instruction and feedback to finish tasks
Memory problems- shortened retention spans, difficulty in learning new info
Cerebellum stroke
Cerebellum plays an important role in motor control Abnormal reflexes of the head and torso Coordination and balance problems Dizziness Nausea and vomiting
Brain stem stroke
Brain stem controls all involuntary functions
Breathing rate, bp and heart beat
Abilities such as eye movements, hearing, speech and swallowing
Paralysis in one or both sides of the body
Nutritional management
Should take place within 24-48 hours
Assess nutritional requirements and premorbid status eg underweight person treated differently to normal, active person or morbidly obese
Prescribe dietary intervention as indicated by:
- the degree of dysphagia
- any impairment to self feeding
Ensure nutrient and fluid requirements are met
Glycaemic control
Glucose intolerance after stroke is common (25%)
Prevalence of undetected diabetes ranges from 16-24%
Hyperglycaemia linked to higher stroke recurrence
Patients with hyperglycaemia should have their blood glucose levels monitored and appropriate glycaemic therapy instituted to ensure euglycaemia, especially if patient is diabetic
Hypoglycaemia should be avoided
Energy and protein requirements
May be increased due to hypermetabolism and in the frail elderly with preexisting undernutrition
Metabolic responses to injury induced hypermetabolism and catabolism
- increased energy requirements
- increased nitrogen requirements
- insulin resistance and glucose intolerance
- fluid and electrolyte imbalance
- acute effects can persist for 4-8 weeks
Energy- Schofield
Injury / stress factor %
CVA: 1.05 (5%)
Cerebral haemorrhage: 1.3 (30%)
Limited activity factor: 1.1 (10%) in bed and immobile
Protein range 1-1.3g/kg/d
If overweight, would calculate using ideal body weight range.
If BMI over 35-75% of body weight, over 40- 60% of body weight
Avoid using ranges for stress factors which are too high
If multitude of stress factors, use clinical judgement to determine realistic goal- needs to be in line with ability to eat, avoid feeding non-metabolic tissue (fat)
Malnutrition
Need to make an assessment 8-34% will be malnourished on admission Malnourished patients more likely to: Develop pneumonia and other infections Develop pressure areas Exhibit poor functional performance Have increased rage of mortality
Dysphagia
Occurs in up to 50% of all stroke patients
Increased risk of pneumonia and chest infections through aspiration
Higher risk of nutritional depletion and dehydration
Oral stage, problems with;
Bolus formation in mouth due to poor lip seal
Poor tongue movement
Poor jaw movement and chewing
Pocketing of food in cheeks
Pharyngeal stage;
Complex stage where bolus is transferred towards the oesophagus with simultaneous closure of the larynx and pause in respiration
Up to 8% of cases persist for up to six months. Need mod texture diets to meet nutrient and fluid requirements
Oral feeding contra indication
IV fluid during initial stabilisation (24-48 hours)
Alternative nutrition support (eg nasogastric feeding) is generally initiated when it is anticipated patient will be NBM >1-2 days
PEG insertion when long term significant dysphagia is predicted (>4 weeks). Consider patient Qol- other comorbidities, advanced care planning if in place
Texture mod diets
Required to minimise risk of choking and aspiration
Reduce amount of chewing and prevent fatigue during eating
Grades alterations in food and fluid consistency
Foods and fluids modified to a consistency which provides the best control over the rate at which foods and liquids pass through the pharynx
Texture A soft
Soft pieces of may be cooked or cut to alter texture
Can be chewed but not necessarily bitten
Food should be moist or served with a sauce or gravy to increase moisture content
Minimal cutting required- easily broken up with a fork
Eg. Most dairy, naturally soft fruit, well cooked veg, soft desserts, tender meat
Texture B- minced and moist
Should easily form a ball
Individual uses tongue rather than teeth to break the small lumps in this texture
Should easily be mashed with a fork
May be presented as thick purse with obvious lumps in it
Lumps are soft and rounded, not sharp or hard
Eg. Soggy breakfast cereal, mashed fruit, mince meat, scrambled eggs, most dairy
Smooth puréed
No lumps or bumps but may have grainy quality
Moist and cohesive enough to hold its shape on a spoon
Food could be moulded, layered or piped
Eg lump free cereal, pureed veg, pureed fruit, most dairy, pureed meat
These need to be supplemented because of high fluid content
Mildly thick
Level 150 nectar thick
Thicker than naturally thick fluids such as fruit nectar, but not as thick as a thick shake
Steady to fast flow
Pours quickly from a cup but slower than regular unmodified fluids
May leave coating film of residue in the cup after being poured
Drink this fluid thickness from a cup
Moderately thick
Level 400- honey thick Similar to thickshake or honey Slow flow rate Cohesive and pours slowly Possibly to drink directly from cup although fluid flows very slowly Difficult to drink using a straw Spooning may be best
