3. Overview of Stroke
About 85% of strokes are ischemic, and
about 15% are hemorrhagic.
Approximately 795,000 strokes occur each
year.
Stroke is the 3rd leading cause of death in the
US, and the first cause of death worldwide.
Stroke is a leading cause of adult disability.
4. History of Stroke
Hippocrates-2,400 yrs ago
Names for Stroke
Most commonly known today
Brain Attack
5. Demographics of Stroke
Women have about 60,000 more strokes
than men.
Native Americans have highest prevalence.
African Americans have almost twice the
rate compared to Caucasians.
Hispanics have slightly higher rates
compared to non-Hispanic whites.
Modifiable risk factors must be addressed in
our aging population with the propensity to
stroke.
6. Definition
Ischemic stroke
Caused by a blocked blood vessel in
the brain.
Hemorrhagic Stroke
Caused by a ruptured blood vessel in
the brain.
7. Nursing and Stroke
Nurses play a pivotal role in the care
of stroke patients.
Nursing care directed in two phases
of the acute stroke experience:
The emergent or hyper-acute phase
The acute phase
8. Nursing Care of the Stroke
Patient
Stroke is a complex disease requiring
the efforts and skills of the
multidisciplinary team.
Nurses are often responsible for the
coordination of that care.
Coordinated care can result in:
improved outcomes, decreased LOS,
translating to decrease costs.
9. Etiology of Ischemic Strokes
20% caused by large vessel athero-
thrombotic causes (intracranial or
carotid artery)
25% caused by small vessel disease
(penetrating artery disease)
20% caused by cardiac sources (cardio-
embolism)
30% from unknown causes
10. Risk factors for Ischemic
Stroke
Hypertension
Diabetes
Heart Disease
Smoking
High Cholesterol
Male gender
Age
Ethnicity/Race
12. Ischemic Stroke
Most patients with ischemic stroke do
not have a decreased level of
consciousness in the first 24 hours
May progress in the first 72 hours
13. Embolic stroke
Majority of emboli originate in the inside
layer of the heart, with plaque breaking off
from the endocardium and entering the
circulation
Patient with an embolic stroke commonly
has a rapid occurrence of severe clinical
symptoms
14. Transient Ischemic Attack (TIA)
Transient ischemic attack (TIA) is
a temporary focal loss of
neurologic function caused by
ischemia
Most TIAs resolve within 3 hours
TIAs are a warning sign of
progressive cerebrovascular
disease
15. Caused by a primary either intra-
cerebral hemorrhage or
subarachnoid hemorrhage.
Etiology of Hemorrhagic Stroke
SAH 3%
ICH 10%
21. Blood supply by arteries
Blood is supplied to the brain by
two major pairs of arteries
Internal carotid arteries
Vertebral arteries
22. Blood supply by arteries
Carotid arteries branch to supply
most of the
Frontal, parietal, and temporal lobes
Basal ganglia
Part of the diencephalon
Thalamus
Hypothalamus
23. Blood supply by arteries
Vertebral arteries join to form the
basilar artery, which supply the
Middle and lower temporal lobes
Occipital lobes
Cerebellum
Brainstem
Part of the diencephalon
26. Clinical Manifestations
Affects many body functions
Motor activity
Elimination
Intellectual function
Spatial-perceptual alterations
Personality
Affect
Sensation
Communication
27. The 5 Key Stroke Syndromes:
Classic Signs Referable to
Different Cerebral Areas
Left (Dominant
Hemisphere)
Left gaze preference
Right visual field deficit
Right hemiparesis
Right hemisensory loss
Right (Nondominant
Hemisphere)
Right gaze preference
Left visual field deficit
Left hemiparesis
Left hemisensory loss
neglect (left hemi-
inattention)
28. The 5 Key Stroke Syndromes:
Classic Signs Referable to
Different Cerebral Areas
Brainstem
Nausea and/or vomiting
Diplopia, dysconjugate
gaze, gaze palsy
Dysarthria, dysphagia
Vertigo, tinnitus
Hemiparesis or
quadriplegia
Sensory loss in hemibody
or all 4 limbs
Decreased consciousness
Hiccups, abnormal
respirations
Cerebellum
Truncal/gait ataxia
Limb ataxia neck
stiffness
29. Clinical Manifestations
Motor Function
Most obvious effect of stroke
Include impairment of
Mobility
Respiratory function
Swallowing and speech
Gag reflex
Self-care abilities
30. Clinical Manifestations
Motor Function
An initial period of flaccidity may last
from days to several weeks and is
related to nerve damage
Spasticity of the muscles follows the
flaccid stage and is related to
interruption of upper motor neuron
influence
31. Clinical Manifestations
Communication
Patient may experience aphasia when
a stroke damages the dominant
hemisphere of the brain
Aphasia is a total loss of
comprehension and use of language
32. Clinical Manifestations
Communication
Dysphasia refers to difficulty related to
the comprehension or use of language
and is due to partial disruption or loss
Dysphasia can be classified as
nonfluent or fluent
34. Clinical Manifestations
Affect
Patients who suffer a stroke may have
difficulty controlling their emotions
Emotional responses may be
exaggerated or unpredictable
35. Clinical Manifestations
Intellectual Function
Both memory and judgment may be
impaired as a result of stroke
A left-brain stroke is more likely to
result in memory problems related to
language
39. Clinical Manifestations
Elimination
Most problems with urinary and bowel
elimination occur initially and are
temporary
When a stroke affects one hemisphere
of the brain, the prognosis for normal
bladder function is excellent
40. Emergent Stroke Workup
All patients
Non-contrast brain CT or brain MRI
Blood glucose
Serum electrolytes/renal function tests
ECG
Markers of cardiac ischemia
Complete blood count, including platelet
count
Prothrombin time/INR
aPTT
Oxygen saturation
41. Emergent Stroke Workup
Selected patients
Hepatic function tests
Toxicology screen
Blood alcohol level
Pregnancy test
Arterial blood gas tests (if hypoxia is
suspected)
Chest radiography (if lung disease is
suspected)
Lumbar puncture (if SAH is suspected and
CT scan is negative for blood)
EEG (if seizures are suspected)
42. Collaborative Care
Prevention
Goals of stroke prevention include
Health management for the well
individual
Education and management of
modifiable risk factors to prevent a
stroke
43. Collaborative Care
Prevention
Antiplatelet drugs are usually the
chosen treatment to prevent further
stroke in patients who have had a
TIA
Aspirin is the most frequently used
anti-platelet drug
44. Collaborative Care
Prevention
Surgical interventions for the patient
with TIAs from carotid disease
include
Carotid endarterectomy
Transluminal angioplasty
Stenting
Extracranial-intracranial bypass
45. Once a potential stroke is suspected,
EMS personnel and nurses must
determine the time at which the
patient was last known to be well
(last known well time).
This time is the single most
important determinant of treatment
options during the hyperacute
phase.
Collaborative Care
Hyperacute Care
46. From the Field to the ED:
Stroke Patient Triage and Care
EDs should establish standard operating procedures and
protocols to triage stroke patients expeditiously.
Standard procedures and protocols should be established for
benchmarking time to expeditiously evaluate and treat
eligible stroke patients with rtPA.
Target treatment with rtPA should be within 1 hour of the
patient’s arrival in the ED.
Eligible patients can be treated between the 3-4.5 hour
window when carefully evaluated carefully for exclusions to
treatment.
47. EMERGENCY NURSING INTERVENTIONS IN
THE EMERGENCY/HYPERACUTE PHASE OF
STROKE:
The First 24 Hours
Stroke symptoms can evolve over
minutes to hours.
Nurses should be aware of unusual stroke
presentations.
ED assessments include: Neurological
assessment, vital signs + temperature,
and should be done not less than every
30 minutes.
48. Intensive Monitoring
30% of patients will deteriorate in the first
24 hours.
Intensive monitoring by nurses trained in
stroke is very important
Trained in neurological assessment
Trained in monitoring of bleeding
complications (major and minor)
Ongoing management of blood pressure,
temperature, oxygenation, and blood
glucose
49. Collaborative Care
Acute Care
Assessment findings
Altered level of consciousness
Weakness, numbness, or paralysis
Speech or visual disturbances
Severe headache
↑ or ↓ heart rate
Respiratory distress
Unequal pupils
50. Collaborative Care
Acute Care
Interventions – Initial
Ensure patient airway
Remove dentures
Perform pulse oximetry
Maintain adequate oxygenation
IV access with normal saline
Maintain BP according to guidelines
51. Collaborative Care
Acute Care
Interventions – Initial
Remove clothing
Obtain CT scan immediately
Perform baseline laboratory tests
Position head midline
Elevate head of bed 30 degrees if no
symptoms of shock or injury
52. Collaborative Care
Acute Care
Interventions – Ongoing
Monitor vital signs and
neurologic status
Level of consciousness
Motor and sensory function
Pupil size and reactivity
O2 saturation
Cardiac rhythm
53. Collaborative Care
Acute Care
Recombinant tissue plasminogen
activator (tPA) is used to
Reestablish blood flow through a
blocked artery to prevent cell death
in patients with acute onset of
ischemic stroke symptoms
54. Collaborative Care
Acute Care
Thrombolytic therapy given
within 3 hours of the onset of
symptoms
↓ disability
But at the expense of ↑ in deaths
within the first 7 to 10 days and ↑
in intracranial hemorrhage
55. Collaborative Care
Acute Care
Surgical interventions for stroke
include immediate evacuation of
Aneurysm-induced hematomas
Cerebellar hematomas (>3 cm)
56. Nursing Management during the
Acute Phase of CVA
Objectives of care during the acute phase:
(a) Keep the patient alive.
(b) Minimize cerebral damage by providing
adequately oxygenated blood to the brain.
Support airway, breathing, and circulation.
57. 3. Maintain neurological flow sheet with frequent
observations of the following:
(a) Level of consciousness.
(b) Pupil size and reaction to light.
(c) Patient's response to commands.
(d) Movement and strength.
(e) Patient's vital signs--BP, pulse,
respirations & temperature.
(f) Be aware of changes in any of the above.
Deterioration could indicate progression of the
CVA.
Nursing Management during the Acute
Phase of CVA
58. Nursing Management during the Acute
Phase of CVA
4. Continually reorient patient to person, place,
and time (day, month) even if patient remains in
a coma. Confusion may be a result of simply
regaining consciousness, or may be due to a
neurological deficit.
5. Maintain proper positioning/body alignment.
(a) Prevent complications of bed rest.
(b) Apply foot board, sand bags, trochanter rolls,
and splints as necessary.
(c) Keep head of bed elevated 30º, or as
ordered, to reduce increased intracranial
pressure.
(d) Place air mattress or alternating pressure
mattress on bed and turn patient every two
hours to maintain skin integrity.
59. Nursing Management during the Acute
Phase of CVA
6. Ensure adequate fluid and electrolyte balance.
(a) Fluids may be restricted in an attempt to reduce
intracranial pressure (ICP).
(b) Intravenous fluids are maintained until patient's
condition stabilizes, then naso-gastric tube feedings or
oral feedings are begun depending upon patient's
abilities.
7. Administer medications, as ordered
(a) Anti hypertensives.
(b) Antibiotics, if necessary.
(c) Seizure control medications.
(d) Anticoagulants.
(e) Sedatives and tranquilizers are not given because
they depress the respiratory center and obscure
neurological observations.
60. Nursing Management during the Acute
Phase of CVA
8. Maintain adequate elimination
(a) A Foley catheter is usually inserted during the
acute phase; bladder retraining is begun during
rehabilitation.
(b) Provide stool softeners to prevent
constipation. Straining at stool will increase
intracranial pressure.
9. Include patient's family and significant others
in plan of care to the maximum extent possible.
(a) Allow them to assist with care when feasible.
(b) Keep them informed and help them to
understand the patient's condition.
61. Rehabilitation of the patient
with CVA
Process of setting goals for rehabilitation must
include the patient. This increases the likelihood
of the goals being met.
62. Rehabilitation of the patient
with CVA
General rehabilitative tasks faced by the patient
include:
*Learning to use strength and abilities that are
intact to compensate for impaired functions.
*Learning to become independent in activities of
daily living (bathing, dressing, eating).
*Developing behavior patterns that are likely to
prevent the recurrence of symptoms.
*Taking prescribed medications.
*Stopping smoking.
*Reducing day-to-day stress.
*Modifying diet.
63. Rehabilitation CVA
Specific teaching, encouragement, and support are
needed.
Individualized exercise program involving both affected
and unaffected extremities is required.
Speech therapy, as indicated by patient's condition, may
be necessary.
Continuous revaluation of goals and patient's ability to
meet the goals is required to maintain a realistic plan of
care.
Counseling and support to family is an integral part of
the rehabilitation process.
-Both family and patient need direction and support
in coping with intellectual and personality impairment.
-Instruct family to expect some emotional lability
such as inappropriate crying, laughing, or outbursts of
temper.