stroke management Flashcards
what age group does majority of stroke occur in?
over 65
after six months what things can still be challenging for a person who had stroke?
cannot walk indoors
need help to dress
need to be fed
need help with toileting
common symtpoms of stroke?
Right side of mouth drooping, drooling saliva
Able to raise left arm, but not right arm or active right leg
Difficulty communicating and finding words: expressive dysphasia
Right homonymous hemianopia (visual field defect)
why is scan essential before treating stroke patient?
exclude haemorrhage so thrombolysis can be given
what is given if swallowing is seen to be unsafe?
NG tube
what weakness is caused by stroke?
Contralateral weakness of limbs –>Extent of stroke determines degree of arm and leg weakness
Weakness and incoordination of oropharyngeal muscles:
Dysarthria: slurred, indistinct speech
Incoordination of swallowing
what are the language problems involved in speach? In right handed patients
If Broca’s areas damage then –> Flow of speech: stilted, difficult + Expressive dysphasia.
Reading, writing and comprehension relatively intact
If Wernicke’s area damaged then –> speech is fluent but Neologisms (“made up” words)
Comprehension, reading and writing impaired
Antihypertensive treatment is not recommended after acute stroke, unless?
Intracerebral haemorrhage with systolic BP >200,
Hypertensive encephalopathy/ nephropathy/ cardiomyopathy
Aortic dissection
Eclampsia/ pre-eclampsia (a condition of pregnancy:
what is hypertensive nephropathy?
the high blood pressure damages the kidney
what is hypertensive cardiomyopathy?
damage to the heart due to high blood pressure
when is oxygenation recommended?
Supplemental oxygen is recommended if saturations fall below 95% on air
what is system used to help set goals for rehabilitation after a stroke?
SMART: Specific, Measurable, Achievable, Relevant, Time-limited
Set within 5 days of admission, review regularly
what is the assessment for swallowing?
Position patient correctly, ensure they are alert 1) Give a single teaspoon of water 2) Give 2 further teaspoons of water 3) 50ml water SAFE SWALLOW Allow normal diet and fluids
what actions will make the patient fail the swallowing assessment and what will be the outcome?
Drooling from mouth?
Coughing or choking?
Wet voice or cough?
UNSAFE SWALLOW –>Keep Nil By Mouth +Feed by NG tube
why is DVT caused in hospital, how can it be prevented and treatment?
Risk factors include immobility and sepsis ( Stasis of blood in leg veins leads to thrombosis)
Prevention: Consider injections of low molecular weight heparin
Treatment: warfarin for 6 months
what is the risk factors of pressure ulcers and how is it caused?
Risk factors
Immobility, malnutrition, diabetes, smoking, terminal illness, sensory impairment
Pathogenesis
Sustained pressure, often over bony prominence
Friction and shear forces when moving patient
Moisture: incontinence, sweating
why might shoulder subluxation occur after a stroke? How is it managed?
Weakness of rotator cuff muscles on stroke side
Neglect of affected limb (in right hemisphere stroke only)
Management: optimise positioning, support shoulder
what pre-conditions can be exacerbate due to overuse of one side of the body?
Chronic back pain
Osteoarthritis
Rheumatoid arthritis
what occurs in post stroke pain?
Damage to sensory cortex leads to contralateral sensory disturbance
Negative phenomena
Decreased sensation in one or more modalities
Positive phenomena:
Paraesthesia, burning, shooting pains
Dysaesthesia: altered perception (e.g. soft touch felt as prickly pain
what type of drugs don’t work on post stroke pain
analgesic drugs
what drugs will patients reply to when having post stroke pain?
Pregabalin or Gabapentin: anti-epileptic agents
Amitriptyline: a type of antidepressant
after a stroke what might be the causes of incontinence?
Communication Immobility: can’t reach toilet in time Constipation with overflow Medication: on laxatives, diuretics Other medical problems: diabetes mellitus (polyuria), urinary tract infection, prostatic hypertrophy
what is the management of incontinence?
General:
Communication strategies to allow him to summon help when needed
Bowels:
Regular toileting
Managed bowel regimen: use suppositories to open bowels at predictable intervals
Bladder:
Is he able to manipulate bottles?
Convene: sheath as opposed to indwelling catheter
Long term catheter
what factors might make a person depressed aftera stroke? How common is it
adjustment to disability financial problems medical condition relationship with family/partner communication Up to 50% of people
assessment and mangement of depression post stroke patient?
Assessment
History
Observation of behaviour: crying, withdrawal
Standardised assessments: some suitable for use in dysphasic patients
DON’T FORGET SUICIDE RISK ASSESSMENT!
Management:
Counselling: supported conversation approach
Drugs: (selective serotonin reuptake inhibitors) second line
what recoverys occurs in the first few days after stroke? physiologically
natural recovery
Resolution of oedema
Reperfusion of ischemic penumbra
what recoverys occurs in the weeks and months after stroke? physiologically
Neuronal plasticity, cortical remodelling
Dendrite sprouting, synaptic remodelling
in what type of stroke does neglect take place in?
Neglect is a feature of RIGHT hemisphere stroke
what occurs in neglect post stroke?
May be visual or somatosensory
Problem of attention: failure to attend to/ monitor left side
what is Agnosias?
Modality-specific inability to access semantic knowledge of an object
what happens in visual agnosias?
Unable to recognise common object by sight alone. May be able to do so when allowed to use other modalities, e.g. touch
what is Prosopoagnosia
inability to recognise faces
what is DVLA regulations for driving?
Absolute ban for one month post stroke
Driving absolutely barred:Seizure within past year, visual neglect, visual field defect, Cognitive impairment
Limb weakness: may be able to control adapted vehicle
what is Dyspraxia?
loss of ability to conceptualise, plan, and execute complex sequence of motor actions
what difficulties might a patient with dyspraxia have?
Identifying and knowing how to use objects
Copying drawings
Tasks such as walking, dressing
what anatomical lesion can cause dyspraxia?
Left inferior parietal lobe
Supplementary motor area
what is required when planning discharge?
Planning a care package requires information on:
The patient’s abilities: what assistance do they need?
Are any family or friends willing to provide care?
Any foreseeable and modifiable risks?
The environment they will be discharged to:Accessibility, need for adaptations, hazards
what occurs in Spastic hemiparetic gait?
Stiff legged
Short, slow steps
Risk of falls
what is the mangement of Spastic hemiparetic gait?
Splints to correct foot drop, physiotherapy, manage spasticity, walking aides
what is Spasticity?
is a condition in which certain muscles are continuously contracted.
consequence of spasticity?
Loss of function: impaired balance, manual dexterity
Unable to maintain skin hygiene in flexures
Pain
management of spasticity?
Physiotherapy and splinting to maintain joint range of movement
Drugs: botulinum toxin injections (local), baclofen (systemic)
