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1

ISCHAEMIC STROKE

- Blockage of blood vessels supplying the brain
- 4 out of 5 strokes are ischaemic
- Embolic: clot forms and travels to the brain
- Thrombotic: Plaques form

Transient Ischemic Attack: (Mini stroke)
- Temporary blockage of blood vessels supplying the brain
- Can be precursor to a stroke. ⅕ will have a major stroke within the next 3 months→ don’t ignore
- Strokes are the 3rd leading cause of death in Australia

2

HAEMORRHAGIC STROKE

- Blood vessel rupture causing bleeding into the brain
- 1 out of 5 strokes are hemorrhagic
- Intracerebral haemorrhage
- Subarachnoid haemorrhage

3

STROKE AND THE ELDERLY

- Cerebral amyloidosis- amyloid deposits (70’s)
- Atherosclerotic changes
- Decrease in function of baroreceptors (heart rate and blood pressure)
- Ageing and wear and tear
- Neurological loss and shrinkage, loss of synapses (connections between neurons)
- Reduction in new neuronal growth- reduce the ability to recover from insult
- Reduction in neurotransmitters
- Decreased cerebral blood flow and cerebral metabolic rate (more than 25% by 80’s)
- Decreased pathways, procession speed

4

STROKE RISK FACTORS: NO CONTROL

- Age
- Gender
- Family history

5

STROKE RISK FACTORS:

- TIA
- AF- Atrial fibrillation
- Diabetes
- Fibromuscular dysplasia

6

STROKE RISK FACTORS:

- Hypertension
- Hyperlipidemia
- Smoking
- Obesity/ Inactivity
- Alcohol intake

7

STROKE PREVENTIONS (FAST)

- 80% of strokes can be prevented

F.A.S.T→Signs and symptoms
- Facial drooping
- Arm weakness
- Speech difficulties
- Time to call 000

8

STROKE PROCEDURAL: ISCHARMIC

- Thrombolysis
- Endovascular clot retrieval
- Carotid endarterectomy

9

STROKE PROCEDURAL: HAEMORRHAGIC

- Craniotomy and repair of vascular abnormality
- Endovascular repair of vascular abnormality

10

STROKE PROCEDURAL: THROMBOLYSIS- TISSUE PLASMINOGEN ACTIVATOR (TPA)

- Intravenous alteplase should be administered as early as possible (within the first few hours) after stroke onset but may be used up to 4.5 hours after onset

Contraindicated
- Haemorrhagic stroke
- Large area of ischaemic stroke on imaging (>⅓)
- Active bleeding, recent history of trauma or surgery
- Coagulopathy, decreased platelet count , Increased INR
- Anticoagulants within 48hrs

11

MEDICATION MANAGEMENT: ISCHAEMIC

- Antiplatelet
- Antihypertensive
- Anticoagulants
- Statins

12

MEDICATION MANAGEMENT: HAEMORRHAGIC

Antihypertensive

13

NURSING CONSIDERATIONS: REMEMBER THE ANATOMY

- Swallow deficits (dysphagia) high aspiration risk- swallow assessment within 4 hours or prior to oral intake
- Oral hygiene
- High falls risk, decreased morbidity
- Risk of VTE- immobility
- Spasticity and contractures
- Early hydration/nutrition assessment support where required
- Communication deficits- aphasia
- Fatigue/depression
- Adherence to preventive pharmacotherapy

14

INDICATIONS FOR URINARY CATHETERISATION

- Relieve urinary retention acute/chronic
- To empty the bladder prior to surgery/investigations
- To instil medication
- Determine residual volume in the absence of u/sound equipment
- Irrigate the bladder
- To keep the perineal area dry to assist healing
- Determine accurate fluid balance
- To collect a sterile specimen of urine
- For investigations of the lower urinary tract. E.g. Urodynamics
- Management of intractable incontinence
- Instrument delivery
- To allow healing following lower urinary tract surgery
- Comfort for the terminally ill

15

FEMALE URINARY CATHERTIRISATION: EQUIPMENT

- Gloves (clean and sterile)
- Light source (if needed)
- Catheter pack
- Catheter (size)
- Waterproof sheet (bluey)
- Adhesive tape, scissors
- Drainage system
- Goggles, apron
- Waste bag

16

FEMALE URINARY CATHERTIRISATION: PROCEDURE

- Washes hands, cleans trolley and gathers equipment for catheterisation
- Establishes sterile field without contamination
- Dons apron, goggles and places bluey under patient, drapes patient, organises position and drainage system
- Invasive procedure hand wash, dons sterile gloves
- Prepares equipment on sterile field, tests balloon
- Cleans inner vulva and urinary meatus
- Inserts urinary catheter without any contamination
- Inflates balloon
- Attaches drainage system and secures
- Drains perineal area, repositions patient, ensures comfort
- Disposes of equipment appropriately
- Washes hands
- Documents relevant information

17

DYSPHAGIA

- A disorder/ symptom that can be caused by structural, physiological and/or neurological impairment→ affects preparatory, oral, pharyngeal and/or esophageal stages
- Any difficulty moving food from mouth to stomach

Impacts→
- Aspiration pneumonia
- Malnutrition and dehydration
- Increased length of hospital stay
- Increased mortality and disability
- Higher chance of going to residential care at discharge
- Very common in acute stroke→ patients should be screened for swallowing deficits before being given food/drink/oral medication

18

PHASES OF NORMAL SWALLOW: (4)

1) Oral preparatory phase (Voluntary)
2) Oral phase (Voluntary)
3) Pharyngeal phase (Involuntary)
4) Oesophageal Phase (Involuntary)

19

PHASES OF NORMAL SWALLOW: Oral preparatory phase (Voluntary)

- Prepares the mouth for the bolus and fluid
- The larynx and pharynx are relaxed
- Airway is open
- Requires senses of taste, temperature and touch for formation of a bolus to the right size and consistency

20

PHASES OF NORMAL SWALLOW: Oral phase (Voluntary)

- Begins with placement of food in the mouth
- Lips/Cheeks seal- food is chewed, mixed with saliva and gathered to form the bolus
- Soft palate rests against back of tongue
- The larynx and pharynx are at rest and the airway is open
- Initiated when the tongue begins to move the bolus towards the pharynx
- Once the bolus reaches the pharynx the oral stage of the swallow is terminated

21

PHASES OF NORMAL SWALLOW: Pharyngeal phase (Involuntary)

- Begins with the triggering of the swallow reflex
- Breathing is suspended
- Soft palate meets pharyngeal wall
- Larynx elevates and airway seals
- Bolus squeezed through oropharynx
- Upper esophageal sphincter opens to allow food into oesophagus

22

PHASES OF NORMAL SWALLOW: Oesophageal Phase (Involuntary)

- Closure of upper esophageal sphincter to prevent regurgitation
- The hyoid bone is released and moves back to its resting position
- The individual breaths out
- Food moves down toward stomach

23

ORAL DYSPHAGIA

- Reduced awareness of the bolus/ Poor bolus control and formation
- Lip weakness
- Slow and laboured chewing
- Oral residue

24

PHARYNGEAL DYSPHASIA

- Delayed or absent swallow reflex
- Premature spillage into pharynx
- Penetration into the larynx
- Pharyngeal pooling
- Reduced laryngeal excursion

25

ASPIRATION

- Refers to the passing of food or fluid below the level of the vocal folds toward the lungs
- Commonly occurs from impairment in the swallow function
- Can be overt or silent
- May result in aspiration pneumonia → infection of the lungs and bronchial tubes→ caused by aspiration of foreign material such as food, fluid or saliva

26

PRINCIPLES OF PERSON CENTRED CARE (4)

- Know the patient as a person
- Share the power and responsibility in care
- Make services accessible and flexible
- Enrich the care environment

27

PRINCIPLES OF PERSON CENTRED CARE: Know the patient as a person

- Build a relationship with the person and their family/carer
- Getting to know the person beyond their diagnosis

28

PRINCIPLES OF PERSON CENTRED CARE: Share the power and responsibility in care

- Respect preferences
- Treat the person and their family/carer as partners when setting goals, planning care and making decisions about care, treatment and outcomes

29

PRINCIPLES OF PERSON CENTRED CARE: Make services accessible and flexible

- Meet the person’s individual needs by acknowledging their values, preferences and needs
- Whilst giving the accurate and appropriate info, so they can make informed choices about their care

30

PRINCIPLES OF PERSON CENTRED CARE: Enrich the care environment

- Identify the relationships between the human and physical environments and the older person’s health behaviour and actions
- Adjust the physical, organisational and socio-cultural environment to enable staff to be person centred in the way they work