stroke presentation Flashcards
stroke signs and symptoms,
post stroke deficits
Headache, visual disturbance, photophobia, vomiting, cervical stiffness.
Loss of consciousness
Attention, concentration, memory issues
Motor deficits – loss of power, hemiplegia, facial droop
Sensory deficits – neglect, inattention
Speech problems
Visual disturbance
Visuo-spatial issues
Cognitive impairment
Other issues – nutrition, continence, breathing, circulation,
motor system
Hemiparesis Weakness Paralysis Loss of voluntary motor control Spasticity Increased reflexes
weakness ‘hemiparesis’
Upper limb 50% Lower limb 45% Both limbs Face 40% Trunk muscles Implications - immobility, ADL, functional mobility & weight transfer
hemiparesis/ hemiplegia
Hemiplegia is a paralysis that affects one side of the body. It’s often diagnosed as either the right or left hemiplegia, depending on which side of the body is affected.
abnormal tone
Initial - Cerebral shock – low tone, hypotonia.
Hypertonia – increased tone, spasticity (typical patterns).
Evaluate tone (Ashworth scale).
Use of positioning charts
Liaise with ward staff
Prevent - adaptive changes - deformity / contracture
sensory impairment. Hemiaesthesia
Lesion - sensory cortex / thalamus. Impaired sensation - hemisensory loss. Tests clinical & largely subjective. Course of recovery. Implications for management. Role for sensory re-education
balance
Loss of balance control Loss of automatic postural adjustments Posture - large base of support \+/- ataxia Increased risk of falls
Loss of consciousness
LOC/Coma – may or may not be present, may be terminal.
15% - first few days post stroke
Average coma – 1 hour
Cause of coma – cerebral shock
Eyes are deviated to side of lesion in comatose patient i.e. R side lesion, eyes to the R, L sided hemiplegia.
Prognostic variable
Haemorrhagic stroke, SAH, brainstem compression
Assessment – Glasgow Coma Scale (GCS)*
attention and concentration
Lesion prefrontal, posterior parietal, ventral temporal, thalamus, brainstem.
Impaired attention & concentration.
Implications for rehabilitation.
Neuropsychology input.
memory
Medial temporal lobe & thalamus.
Factor in natural decline in memory with age.
Other diseases/co-morbidities e.g. dementia.
Failure to register new information – how might this affect rehabilitation.
communication
Broca’s area Expressive/motor dysphasia Wernicke’s area Receptive/sensory dysphasia Aphasia motor+sensory dysphasia Reading & writing Numeracy
visual deficits
Receive, transmit & interpret visual information
Concomitant disease - visual acuity, glaucoma diabetic retinopathy, cataract
Stroke related
Homonymous hemianopia
Visual field defect
Visual inattention
visuospatial deficits
Damage non-dominant posterior parietal lobe.
Somatognosia
Lack of awareness of body structure and failure to recognise one’s parts and their relationship to one another.
Anosognosia
Severe form of neglect - patient fails to recognise paralysis or deficits
Unilateral neglect
Inability to integrate and use perceptions from one side of the body /environment. Ignores one half of body. Bumps into objects.
Right / left discrimination
Inability to understand concepts of right
and left.
Apraxia
Inability to perform skilled movements in the absence of loss of motor power, sensation or co-ordination
Agnosia
Lack of recognition of familiar objects.
Body image
Visual & mental memory image of one’s body.
Body scheme
The position of different parts of the body to each other.
visuospatial deficits: tests
Tests Clock drawing Line Bissection test Cancellation tasks Clinical psychology and OT
Implications in rehabilitation
swallow problems - dysphagia
45% acute stage.
Bedside swallow test in first 7hr, screening & NPO.
Formal SLT assessment first 24hr.
Risk of aspiration pneumonia.
Dehydration / malnutrition.
Video fluoroscopy Management Swallow technique Modify food consistency Nursing staff/nutritionist Positioning Involve carers
complications after stroke
Seizure- 2-4% Delirium – 28% Nutrition Incontinence Pain - Musculoskeletal pain – 30% Psychological issues - Depression – 30% Circulation - Deep Vein Thrombus (DVT) – 6% Breathing issues
Infection – 20% Aspiration pneumonia – 40% Urinary tract infection (UTI) – 40% Hospital acquired infection Falls – 25% Pressure Ulcer – 3% Fractures Limb oedema
nutrition
Malnutrition common in elderly.
Weakness (implications for rehab).
Clinical Nutritionist
Appetite stimulants
Supplemental nutrition NG tube PEG
Hydration
Involve SLT/Family & Carer.
incontinence
Urinary & faecal.
33 - 66% acute stage urinary incontinence.
Severe stroke poor prognosis > 7 - 10 days.
Risk of pressure areas.
Communication difficulties.
Spontaneous recovery 1 - 2 weeks.
Nursing Continence protocols.
pain following stroke - causes
Spasticity
Consequence of immobility
Shoulder hand syndrome
Painful shoulder
Thalamic syndrome
Central Post Stroke Pain Syndrome
Result of a Fall
psychological impact
Prevalence of depression of 33% at any time after stroke (17 – 61%)
Less participation in rehabilitation
Less compliance with medications
Poorer recovery than non-depressed
SSRI’s – ischaemic stroke
Screening e.g. Hospital Anxiety & Depression Scale
Anxiety
Emotional lability
Impact on quality of life, activity levels and social reintegration
breathing and circulation
Breathing Central sleep apnoea Cheyne Stokes breathing Lesion Medulla (brainstem) Circulation Severe brainstem lesion Massive haemorrhage Pulmonary embolism Deep vein thrombosis
prevention of DVT/PE
Ischaemic stroke & symptomatic proximal deep vein thrombosis (DVT) or pulmonary embolism, receive anticoagulation treatment in preference to treatment with aspirin unless there are other contraindications to anticoagulation.
Haemorrhagic stroke & symptomatic deep vein thrombosis or pulmonary embolism should have treatment to prevent the development of further pulmonary emboli using either anticoagulation or vena cava filter.
infection management
Aspiration Pneumonia 1/3 of stroke patients History of dysphagia Semi-upright position nursing Good dental hygiene & oral care Swallow Screening Modified diet/fluids Urinary Tract Infection 11% of stroke patients Avoid urinary catheters Urinary retention (>600mls) Bladder scan Hydrate Management: bladder care/bowel care/ pressure area care
Falls
Prevalence 25% (serious injury 5%)
Cognitive impairment, inattention, anosognosia, balance, co-ordination, muscle weakness, sensory loss, visual disturbance.
Falls risk assessment
Management
Minimise sedative medications or psychoactive drugs
Use of hip protectors advised if manageable
Calcium/Vitamin D
