Describe the pathophysiology of a stroke.
- ischemia to part of brain
- hemorrhage into brain that results in death of brain cells
- AKA brain attack or cerebrovascular accident (CVA)
- movement, sensation, thinking, talking, emotions are lost or impaired
List the two types of strokes.
- Ischemic
- Hemorrhagic
What are the two types of ischemic strokes?
- Thrombotic (most common)
- Embolic
What causes an ischemic stroke?
Result of inadequate blood flow to brain from partial or complete occlusion of an artery
Describe an embolic stroke?
- Embolus occludes cerebral artery
- 2nd most common cause of stroke
- Emboli originate in endocardial layer of heart, rheumatic heart disease
- Atrial fibrillation
Ischemic stroke clinical manifestations?
- Artery involved and the area of the brain distal to the area of the brain supplied by the artery
- Time of onset of symptoms
- Length of period of ischemia
- *Neuro deficits: Sudden onset of dizziness, HA, one-sided facial droop, muscle weakness, slurred speech, numbness, vision loss, language disturbances, difficulty maintaining balance.
Non-modifiable risk factors of stroke (CVA)?
10% of strokes
- Age: Risk doubles each decade after 55
- Biologic sex: Biologic males > biologic females
- Heredity/family history
- History of prior stroke
Modifiable risk factors of strokes (CVA)?
90% of strokes
- Hypertension #1
- Diabetes #2
- Heart disease and dysrhythmias (atrial fibrillation)
- Hypercholesterolemia
- Hypercoagulopathy
- Obesity (lack of physical activity, poor diet)
- Sleep apnea
- Smoking
- Alcohol and drug abuse
- Some oral contraceptives (especially with smoking)
Describe acute nursing intervention for a suspected CVA.
- 1) If patient is unconscious, acute care begins with managing:
~ Airway #1
~ Breathing
~ Circulation - 2) Baseline neurologic assessment by Code FAST team
~ Noncontrast head CT/MRI STAT
~ Many patients worsen in the first 24 to 48 hours - 3) Vital signs, 12 lead EKG, and continuous EKG monitoring
~ ↑ BP common immediately after a stroke
~ Protective response to maintain cerebral perfusion
What medication is given for acute CVA?
Tissue Plasminogen Activator
What guidelines need to be followed before giving Tissue Plasminogen Activator?
- Must be given within 3 – 4.5 hours from symptom onset
- Must be at least 18
- Diagnosis of ischemic CVA with measurable neuro deficit
- NIH Stroke Scale Score ≥ 1
- BP < 185/110 mmHg
Describe some bleeding precautions for Tissue Plasminogen Activator?
- Notify nurse for signs and symptoms of bleeding
- Bloody urine, nosebleed, bloody stools, bleeding gums
- Place patient on fall precautions
- Advise patient to call for a bedpan or a urinal if needed rather than ambulating to bathroom
- Perform all invasive procedures prior to giving tPA
- No anticoagulants or antiplatelets for 24 hours
- No blood draws or IV placement for 24 hours
- No IM injections (subQ permissible)
- Prevent constipation
- Advise patient to use electric razor to shave
- Do not pluck body hair
- Use a soft-bristle toothbrush
What will stroke patients receive ~24 hours after admission?
Follow-up CT scan
Describe some post-stroke complications.
- Risk for aspiration – Swallow study f/u with speech-language pathologist prior to eating or drinking
- Risk for malnutrition – increase protein intake
- Risk for UTI – If indwelling urinary catheter is used initially, remove as soon as patient is medically and neurologically stable
- Risk for fall – Fall precautions, bed in low position
- Risk for skin breakdown
- Impaired communication
- Risk for coping or depression
- Risk for VTE – Keep the patient moving
What are diagnostic studies for Multiple Sclerosis (MS)?
- MRI of brain and spinal cord
~ Plaques, inflammation, atrophy
~ 2 or more demyelinating lesions in at least 2 different locations
What are some manifestations of Amyotrophic Lateral Sclerosis (ALS)?
- Slowly progressive weakness, fatigue, and muscle atrophy
- Spasticity, stiffness, impaired fine motor control
- Dysphagia, dysarthria, dysphonia
- Eventually affects control of the muscles needed to move, speak, eat and breathe.
What is homonymous hemianopsia?
- Blindness occurs in same half of the visual fields of both eyes.
~ Left brain stroke leads to loss of right ½ of the visual field of each eye.
~ Right brain stroke leads to loss of the left ½ of the visual field of each eye.
What are some nursing considerations for homonymous hemianopsia?
Place items on the same side that the stroke occured.
~ Ex. Place bedside table on the left side of the patient if they experienced a left brain stroke.
What is expressive aphasia?
Person may understand speech, but they have difficulty speaking fluently themselves.
How do you communicate with someone with expressive aphasia?
Give them a white board and marker for writing.
