Nursing Care of Clients with Stroke

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Stroke: Definition, Types, Risk Factors, Prevention, Manifestations, Diagnostic Exams, Management.

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Nursing Care of Clients with Stroke

  1. 1. Stroke AKA  Cerebrovascular accident  Cerebral Infarction  Brain attack 2/13/2014 Maria Carmela Domocmat, MSN, RN
  2. 2.  Definition: decreased blood supply to the brain  Sudden loss of function resulting from a disruption of the blood supply to a part of the brain  Functional abnormality of the CNS that occurs when the blood supply is disrupted  2/13/2014 Maria Carmela Domocmat, MSN, RN
  3. 3. Incidence  700K stroke/year 500K: first attacks  200K: recurrent attacks    87% are ischemic Others: intracerebral and subarachnoid hemorrhagic strokes 2/13/2014 Maria Carmela Domocmat, MSN, RN
  4. 4. Incidence  On average, every 45 _____ seconds someone in the United States has a stroke  Who has more stroke incidence? Men or women?  Each year, about 46K more women than men have a stroke. Male:Female ratio 1.25:1  Ratio reverses after age 80   One in ____ strokes is a recurrent stroke, and the risk for a second stroke is highest during the first ____days after the first ischemic symptoms 4 30 2/13/2014 Maria Carmela Domocmat, MSN, RN
  5. 5. Phil Stat  April 2011 Stroke Deaths in Philippines reached 40,245 or 9.55% of total deaths.  #3 in the top 20 causes of death in the country  The age adjusted Death Rate is 82.77 per 100,000 of population ranks  Philippines is #106 in the world http://www.worldlifeexpectancy.com/philippines-stroke 2/13/2014 Maria Carmela Domocmat, MSN, RN
  6. 6. Mortality  Stroke accounted for about 1 of every16 deaths in the ____ United States in 2004.  About _____of stroke deaths in 2003 occurred out of hospital. 50%  When considered separately from other CVDs, stroke ranks _______among all causes of death, behind diseases of the No. 3 heart and cancer. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  7. 7. •On average, every 3 - 4 Mortality minutes someone dies of a stroke  2/13/2014 Maria Carmela Domocmat, MSN, RN Among persons 45 to 64 years of age, 8-12% of ischemic strokes and 37-38% of hemorrhagic strokes result
  8. 8.  Mortality 2/13/2014 Maria Carmela Domocmat, MSN, RN From 1994 to 2004, the stroke death rate fell 20.4%, and the actual number of stroke deaths declined 6.7%
  9. 9. Mortality From 1995 to 1998, mortality rates for subarachnoid hemorrhage, and intracerebral hemorrhage were higher among blacks than whites. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  10. 10.   Death rates from intracerebral hemorrhage were also higher among Asians/Pacific Islanders than among whites. All minority populations had higher death rates from subarachnoid hemorrhage than did whites. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  11. 11. Five classes of stroke by "severity― least to most severe  Transient Ischemic Attack (TIA), "angina" of the brain      Reversible Ischemic Neurological Deficit (RIND)     some neurological deficit, but stabilized Progressing Stroke (stroke in evolution)    similar to TIA findings last between 24 hours and three weeks usual full functional recovery within three to four weeks Partial, Nonprogressing Stroke   TIA is warning sign of stroke localized ischemic event produces neurological deficits lasting only minutes or hours full functional recovery within 24 to 48 hours deterioration of neurological status often with grand mal seizure activity has residual neurological deficits that last indefinitely Completed Stroke  2/13/2014 results from a stroke in evolution Maria Carmela Domocmat, MSN, RN
  12. 12. Two types of stroke by "cause" Ischemic 2. Hemorrhagic Stroke (bleeding) 1. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  13. 13. Brain Attack/ Stroke Ischemic Stroke Thrombotic Embolic Hemorrhagic Stroke AV amlformation Aneurysm HTN 2/13/2014 Maria Carmela Domocmat, MSN, RN
  14. 14. Ischemic  Incidence: 80% to 85%  also known as occlusive stroke (clot)  slower onset  results from inadequate blood flow leading to a cerebral infarction  caused by cerebral thrombosis or embolism within the cerebral blood vessels  most common cause: atherosclerosis 2/13/2014 Maria Carmela Domocmat, MSN, RN
  15. 15. Ischemic  caused by thrombus and embolus Thrombotic – most common  Embolic – assoc with hypercoagulability conditions   Types Large artery thrombosis  Small penetrating artery thrombosis  Cardiogenic embolism  Cryptogenic  2/13/2014 Maria Carmela Domocmat, MSN, RN
  16. 16. Manifestations of Ischemic Stroke  Symptoms depend upon the location and size of the affected area  Numbness or weakness of face, arm, or leg, especially on one side  Confusion or change in mental status  Trouble speaking or understanding speech  Difficulty in walking, dizziness, or loss of balance or coordination  Sudden, severe headache  Perceptual disturbances 2/13/2014 Maria Carmela Domocmat, MSN, RN
  17. 17. Hemorrhagic stroke (bleeding)  Incidence: 15% to 20%  abrupt onset  intracerebral hemorrhagic stroke: blood vessels rupture with a bleed into the brain  Caused by bleeding into brain tissue, the ventricles, or subarachnoid space  occurs most often in hypertensive older adults 2/13/2014 Maria Carmela Domocmat, MSN, RN
  18. 18. Hemorrhagic stroke (bleeding)  May be due to spontaneous rupture of small vessels primarily related to     2/13/2014 Hypertension subarachnoid hemorrhage due to a ruptured aneurysm or intracerebral hemorrhage related to amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants or thrombolytic therapy Maria Carmela Domocmat, MSN, RN
  19. 19. Hemorrhagic stroke (bleeding)  Brain metabolism is disrupted by exposure to blood  ICP increases due to blood in the subarachnoid space  Compression or secondary ischemia from reduced perfusion and vasoconstriction injures brain tissue 2/13/2014 Maria Carmela Domocmat, MSN, RN
  20. 20. Manifestations of Hemorrhagic stroke  Similar to ischemic stroke  Severe headache  Early and sudden changes in LOC  Vomiting 2/13/2014 Maria Carmela Domocmat, MSN, RN
  21. 21.  Subarachnoid Hemorrhage (SAH)    Epidural Bleeds    most often caused by rupture of saccular intracranial aneurysms more than 90% are congenital aneurysms cerebral arterial vessels are involved often a loss of consciousness for a short period of time called transient unconsciousness Subdural Bleeds   2/13/2014 veins are involved may not be evident until months after an initial trauma Maria Carmela Domocmat, MSN, RN
  22. 22. Transient Ischemic Attack (TIA)  Temporary neurologic deficit resulting from a temporary impairment of blood flow  ―Warning of an impending stroke‖  Diagnostic work-up is required to treat and prevent irreversible deficits 2/13/2014 Maria Carmela Domocmat, MSN, RN
  23. 23. Assessment         History and physical exam Computerized tomogram (CT) scan Magnetic resenance imaging (MRI) Doppler echocardiography flow analysis Carotid artery duplex doppler ultrasonography EEG - shows abnormal electrical activity Lumbar puncture - shows if blood is found in the cerebral spinal fluid as a result of a cerebral bleed Cerebral angiography - shows blood flow in cerebral arteries  2/13/2014 may be done with or without contrast Maria Carmela Domocmat, MSN, RN
  24. 24. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  25. 25. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  26. 26. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  27. 27. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  28. 28. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  29. 29. Intracerebral hemorrhage 2/13/2014 Maria Carmela Domocmat, MSN, RN
  30. 30. CEREBROVASCULAR ACCIDENTS The Stroke Continuum 5 Classes of stroke by severity 1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration 2. Reversible Ischemic Neurologic deficit (RIND) 3. Partial, Nonprogressing Stroke 4. Progressing Stroke (or Stroke in evolution) 4. Completed stroke 2/13/2014 Maria Carmela Domocmat, MSN, RN
  31. 31. Are you at risk?
  32. 32. RISKS FACTORS Non-modifiable • • • Age (over 55) male gender, African American race 2/13/2014 Maria Carmela Domocmat, MSN, RN
  33. 33. Risk factors  Modifiable risk factors         2/13/2014 uncontrolled Hypertension: the primary risk factor Cardiovascular disease Elevated cholesterol and triglycerides or elevated hematocrit Obesity Diabetes Oral contraceptive use Smoking and drug and alcohol abuse chronic atrial fibrillation Maria Carmela Domocmat, MSN, RN
  34. 34. RISKS FACTORS Modifiable  Hypertension  Cardio disease  Obesity  Smoking  Diabetes mellitus  Hypercholesterolemia  hypercoagulable state  illicit drug use (esp cocaine)  nonvalvular atrial fibrillation 2/13/2014 Maria Carmela Domocmat, MSN, RN
  35. 35. Risk Factors  Heart disease  AFib, Valvular Dz, MI, endocarditis  Hypertension  Smoking  Diabetes/Metabolic Syndrome  Dyslipidemia  Pregnancy  Drug Abuse/Meds  Bleeding Disorders/Anticoagulant Use 2/13/2014 Maria Carmela Domocmat, MSN, RN
  36. 36. Risk Stratification for Stroke  Highest Risk: Prior Stroke or TIA  High Risk: Any of the following Prior thromboembolism  Female >75 yo  SBP >160  Heart failure/LV dysfunction   Moderate Risk: None of above, but HTN  Low Risk: None of the above, no HTN 2/13/2014 Maria Carmela Domocmat, MSN, RN
  37. 37. Healthy lifestyle and stroke  A study of more than 37 000 women age 45 or older participating in the Women’s Health Study suggests that a healthy lifestyle consisting of abstinence from smoking, low ______ ____________________ BMI, moderate alcohol consumption, regular _________ ______________ healthy diet _____________ exercise, and _________ were associated with a significantly reduced risk of total and ischemic stroke but not of hemorrhagic stroke. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  38. 38. Prevention  avoid smoking  sedentary lifestyle  high-fat diet   increase fruits and veg  low saturated and trans fat  light to mod alcohol consumption 2/13/2014 Maria Carmela Domocmat, MSN, RN
  39. 39. Stroke Prevention: Lifestyle  People who have had a stroke or TIA can take steps to prevent a recurrence: Quit smoking.  Exercise and maintain a healthy weight.  Limit alcohol and salt intake.  Eat a healthier diet with more veggies, fish, and whole grains.  2/13/2014 Maria Carmela Domocmat, MSN, RN
  40. 40. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  41. 41. Preventive Treatment and Secondary Prevention  Modifiable risk factors: Hypertension: the primary risk factor  Cardiovascular disease  Elevated cholesterol or elevated hematocrit  Obesity  Diabetes  Oral contraceptive use  Smoking and drug and alcohol abuse  2/13/2014 Maria Carmela Domocmat, MSN, RN
  42. 42. Preventive Treatment and Secondary Prevention  Health maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease  Carotid endarterectomy  Anticoagulant therapy  Antiplatelet therapy: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid)  Statins  Antihypertensive medications 2/13/2014 Maria Carmela Domocmat, MSN, RN
  43. 43. Stroke Prevention: Medications  For people with a high risk of stroke, doctors often recommend medications to lower this risk.  Anti-platelet medicines (aspirin, clopidogrel [Plavix], Dipyridamole)  Anti-clotting drugs (warfarin)  Anti Hpn 2/13/2014 Maria Carmela Domocmat, MSN, RN
  44. 44. Stroke Test: Talk, Wave, Smile  The F.A.S.T. test helps spot symptoms. It stands for:     2/13/2014 Face. Ask for a smile. Does one side droop? Arms. When raised, does one side drift down? Speech. Can the person repeat a simple sentence? Does he or she have trouble or slur words? Time. Time is critical. Bring to hospital STAT if any symptoms are present. Maria Carmela Domocmat, MSN, RN
  45. 45. Clinical Manifestations depend on the location of the lesion 2/13/2014 Maria Carmela Domocmat, MSN, RN
  46. 46. Assessment         Transient hemiparesis Loss of speech Hemisensory loss Wernicke‟s aphasia Broca‟s aphasia Dysarthria Dysphagia Apraxia 2/13/2014  Hemianopia  Horner‟s syndrome  Agnosia  Unilateral neglect  Paresthesia  Depression  Incontinence  Proprioception Maria Carmela Domocmat, MSN, RN
  47. 47. Signs and Symptoms of Childhood Stroke:             Severe headache- this is often the first complaint Nausea and/or vomiting Warm, flushed, clammy skin Slow, full pulse – may have distended neck veins Speech difficulties- absent, slurred or inappropriate speech Eye movement problems – partial or complete blindness, blurred vision, unequal pupils Numbness – paralysis, weakness, or loss of coordination of limbs, usually on one side of the body; loss of balance Facial droop or salivary drool Urinary incontinence Seizures Brief loss of consciousness; unconscious „snoring‟ respirations May show signs of rapid recovery (TIA)
  48. 48. Glasgow Coma Scale (GCS)  most widely used scoring system to quantify level of consciousness following traumatic brain injury; scores range from 3 to 15, based on the sum of the best eye opening response, the best verbal response, and the best motor response  Eye Opening (E) 4=Spontaneous 3=To voice 2=To pain 1=None • • • • •  Verbal Response (V) 5=Normal 4=Disoriented 3=Inappropriate 2=Incomprehensible 1=None Total = E+V+M 2/13/2014 Maria Carmela Domocmat, MSN, RN Motor Response (M) 6=Normal 5=Localizes to pain 4=Withdraws to pain 3=Flexes to pain 2=Extends to pain 1=None
  49. 49. Assessment  Neurologic assessment  Cognitive changes  Motor  Sensory  CN  Cardiovas 2/13/2014 Maria Carmela Domocmat, MSN, RN
  50. 50. Cognitive changes  denial of illness spatial and proprioceptive (awareness of body position if space) dysfunction impair memory, judgment, problem-solving, decision-making decreased ability concentrate aphasia – inability to use or comprehend language alexia – reading problems  agraphia – difficulty with writing      2/13/2014 Maria Carmela Domocmat, MSN, RN
  51. 51. Motor changes     Hemiphlegia – paralysis on one side of body Hemiparesis – weakness on one side of body Hypotonia or flaccid paralysis – unable to overcome forces of gravity, and et tend to fall on one side Hypertonia or spastic paralysis – fixed positions or contractures of involves ext; ROM restricted, shoulder subluxation easily occur   a temporary, partial dislocation of the shoulder Incontinence 2/13/2014 Maria Carmela Domocmat, MSN, RN
  52. 52. Ataxia –staggering, unsteady gait unable to keep feet together; needs a broad base to stand  Dysarthria - difficulty in speaking  Aphasia - loss of speech  Dysphagia –difficulty in swallowing  2/13/2014 Maria Carmela Domocmat, MSN, RN
  53. 53. Sensory   Agnosia – is a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss. Apraxia – inability to perform a previously learned action 2/13/2014 Maria Carmela Domocmat, MSN, RN
  54. 54. Sensory     Neglect syndrome – unaware of existence of his/her paralyzed side Amaurosis fugax – is loss of vision in one eye due to a temporary lack of blood flow to the retina. Hemianopsia – blindness in one half of visual field Homonymous hemianopsia – blindness in same side of both eyes; must turn head to have complete range of vision 2/13/2014 Maria Carmela Domocmat, MSN, RN
  55. 55. Hemianopsia  loss of vision in one-half the normal visual field (usually the right or left half) of one or both eyes. http://www.wrongdiagnosis.com/bookimages/8/2608.png 2/13/2014 Maria Carmela Domocmat, MSN, RN
  56. 56. Hemianopsia  absence of vision in half of a visual field  The visual field of each eye can be divided in two vertically, with the outer half being described as temporal, and the inner half being described as nasal. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  57. 57. Hemianopsia  "Binasal hemianopsia" can be broken down as follows: bi-: involves both left and right visual fields  nasal: involves the nasal visual field  temporal: involves the temporal visual field  lateral: involves the lateral visual field  hemi-: involves half of each visual field  anopsia: blindness  2/13/2014 Maria Carmela Domocmat, MSN, RN
  58. 58. http://www.wrongdiagnosis.com/bookimages/14/4774.1.png 2/13/2014 Maria Carmela Domocmat, MSN, RN
  59. 59. Paris as seen with full visual fields 2/13/2014 Maria Carmela Domocmat, MSN, RN
  60. 60. Right homonymous hemianopsia http://upload.wikimedia.org/wikipedia/commons/thumb/0/08/Rhvf.png/300px-Rhvf.png 2/13/2014 Maria Carmela Domocmat, MSN, RN
  61. 61. Left homonymous hemianopsia 2/13/2014 Maria Carmela Domocmat, MSN, RN
  62. 62. Bitemporal hemianopsia 2/13/2014 Maria Carmela Domocmat, MSN, RN
  63. 63. Binasal hemianopsia 2/13/2014 Maria Carmela Domocmat, MSN, RN
  64. 64. Binasal hemianopsia  or Binasal hemianopia  is the medical description of a type of partial blindness where vision is missing in the inner half of both the right and left visual field. It is associated with certain lesions of the eye and of the central nervous system, such as congenital hydrocephalus. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  65. 65.  CN function   CV   chew, swallow, facial paralysis, gag reflex, tongue movement heart murmur, dysrhythmias, HTN psychosocial  emotional lability - a condition of excessive emotional reactions and frequent mood changes; is the regular occurrence of unstable, disproportionate emotional displays 2/13/2014 Maria Carmela Domocmat, MSN, RN
  66. 66.  Labs no definitive lab test confirm stroke  HCt, Hb, INR, PT, PTT, LP   Radiographic   CT, CTA other Dx  2/13/2014 MRI, MRA, ECG Maria Carmela Domocmat, MSN, RN
  67. 67. General manifestations 2/13/2014 Maria Carmela Domocmat, MSN, RN
  68. 68. Localization Middle cerebral artery:  Aphasia  Dysphagia  HEMIPARESIS on the OPPOSITE sidemore severe on the face and arm than on the legs 2/13/2014 Maria Carmela Domocmat, MSN, RN
  69. 69. Localization Anterior cerebral artery:  Weakness  Numbness on the opposite side  Personality changes  Impaired motor and sensory function 2/13/2014 Maria Carmela Domocmat, MSN, RN
  70. 70. Localization Posterior cerebral artery:  Visual field defects  Sensory impairment  Coma  Less likely paralysis 2/13/2014 Maria Carmela Domocmat, MSN, RN
  71. 71. DIAGNOSTIC tests  1. CT scan  2. MRI  3. Angiography 2/13/2014 Maria Carmela Domocmat, MSN, RN
  72. 72. Hypodense area: • Ischemic area with edema, swelling • Indicates >3 hours old • No fibrinolytics! 2/13/2014 Maria Carmela Domocmat, MSN, RN
  73. 73. (White areas indicate hyperdensity = blood) Large left frontal intracerebral hemorrhage. Intraventricular bleeding is also present No fibrinolytics! 2/13/2014 Maria Carmela Domocmat, MSN, RN
  74. 74. Acute subarachnoid hemorrhage Diffuse areas of white (hyperdense) images Blood visible in ventricles and multiple areas on surface of brain
  75. 75.  Glucose and electrolyte tests:       Hypoglycemia is the most common electrolyte abnormality that produces stroke-like symptoms Electrolyte disorders, hyperglycemia, hypoglycemia, and uremia Complete blood count: Prothrombin time (PT) and activated partial thromboplastin time (aPTT) tests Cardiac enzymes Arterial blood gas (ABG) analysis 2/13/2014 Maria Carmela Domocmat, MSN, RN
  76. 76. Carotid duplex  Carotid duplex scanning is one of the most useful tests in evaluating patients with stroke.  Increasingly, it is being performed earlier in the evaluation, not only to define the cause of the stroke but also to stratify patients for either medical management or carotid intervention if they have carotid stenoses. Patients with symptomatic critical stenoses on carotid duplex scanning may require anticoagulation before intervention is performed. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  77. 77. Angiogram  This is an angiogram of the right carotid artery showing a severe narrowing (stenosis) of the internal carotid artery just past the carotid fork. There is enlargement of the artery or ulceration in the area after the stenosis in this close-up film. Note the narrowed segment toward the bottom of the picture. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  78. 78. .
  79. 79. Time lost is Brain lost  The consequences of delaying treatment for stroke can be catastrophic.  "Time is brain" is an adage used by stroke professionals to reinforce the critical need for early and rapid intervention. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  80. 80. Every minute that the brain is deprived of oxygen, 1.9 million neurons, 14 billion synapses, and 7.5 miles of myelinated fibers are lost. After 12 minutes without treatment, a pea-sized piece of brain tissue dies. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  81. 81. Every minute that the brain is deprived of oxygen, 1.9 million neurons, 14 billion synapses, and 7.5 miles of myelinated fibers are lost. After 12 minutes without treatment, a pea-sized piece of brain tissue dies. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  82. 82. Management  to prevent or minimize the damaging effects of stroke; dependent on the type of CVA  Expected outcomes prevent or minimize the damaging effects of stoke  depends on the type of CVA  Prompt diagnosis and treatment  Assessment of stroke: NIHSS assessment tool  2/13/2014 Maria Carmela Domocmat, MSN, RN
  83. 83. Stroke: Emergency Treatment  ischemic stroke    emergency treatment focuses on medicine to restore blood flow. A clot-busting medication is highly effective at dissolving clots and minimizing long-term damage, but it must be given within three hours of the onset of symptoms. Hemorrhagic strokes   2/13/2014 are more difficult to manage. Treatment usually involves attempting to control high blood pressure, bleeding, and brain swelling. Maria Carmela Domocmat, MSN, RN
  84. 84. Treatment Occlusive stroke  Pharmacologic  thrombolytics       anticoagulant therapy: heparin, coumadin antiplatelet therapy: aspirin, dipyridamole (Persantine)   2/13/2014 Criteria for tissue plasminogen activator (tPA): see Chart 62-2 IV dosage and administration Patient monitoring Side effects: potential bleeding platelet aggregation inhibitor: clopidogrel (Plavix), ticlopidine HCL (Ticlid) steroids: dexamethasone (Decadron) Maria Carmela Domocmat, MSN, RN
  85. 85. Treatment Occlusive stroke  Elevate HOB unless contraindicated  Maintain airway and ventilation  Provide continuous hemodynamic monitoring and neurologic assessment  surgery bypass  carotid endarterectomy  2/13/2014 Maria Carmela Domocmat, MSN, RN
  86. 86. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  87. 87. Hemorrhagic stroke (ICH)  Care is primarily supportive  surgical excision of aneurysm  Prevention: control of hypertension  Bed rest with sedation  Oxygen  Treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding 2/13/2014 Maria Carmela Domocmat, MSN, RN
  88. 88. Treatment ICH  Pharmacologic  antihypertensive agents : alpha-blockers and betablockers        systemic steroids: dexamethasone (Decadron) osmotic diuretics: mannitol antifibrinolytic agents: aminocaproic acid (Amicar) vasodilators anticonvulsants Recombinant factor VIIa (rFVIIa) therapy Reverse coagulopathies  2/13/2014 Vitamin K, FFP, Platelets Maria Carmela Domocmat, MSN, RN
  89. 89. Treatment ICH  Neurosurgical ICU  Constant monitoring  Bedrest  Pain control  Reverse coagulopathies   Vitamin K, FFP, Platelets ICP control  2/13/2014 Mannitol, Induced Coma, Hyperventilation Maria Carmela Domocmat, MSN, RN
  90. 90. Treatment of SAH  Neurosurgical ICU  Constant monitoring  Bedrest  Pain control  Reverse coagulopathies  DVT Prophylaxis  Blood Pressure Management  Management of Aneurysms/AVMs 2/13/2014 Maria Carmela Domocmat, MSN, RN
  91. 91. Treatment  Common to both types of stroke care based on findings  therapies  nutritional support  physical  speech  behavioral  occupational  2/13/2014 Maria Carmela Domocmat, MSN, RN
  92. 92. NINDS Recommended Stroke Evaluation Time Benchmarks for Potential Thrombolysis Candidate Time Interval Door to doctor Access to neurologic expertise Door to CT scan completion Door to CT scan interpretation Door to treatment Admission to monitored bed 2/13/2014 Time Target 10 min 15 min 25 min 45 min 60 min 3h Maria Carmela Domocmat, MSN, RN
  93. 93. General Management of Patients With Acute Stroke Blood glucose  Blood pressure  Cardiac monitor  Intravenous fluids   Oral intake  Oxygen Temperature 2/13/2014  Treat hypoglycemia with D50 Treat hyperglycemia with insulin if serum glucose >200 mg/dL See recommendations for thrombolysis candidates and noncandidates Continuous monitoring for ischemic changes or atrial fibrillation Avoid D5W and excessive fluid administration IV isotonic sodium chloride solution at 50 mL/h unless otherwise indicated NPO initially; aspiration risk is great, avoid oral intake until swallowing assessed Supplement if indicated (Sa02 <90%, hypotensive, etc) Avoid hyperthermia, oral or rectal acetaminophen as needed Maria Carmela Domocmat, MSN, RN
  94. 94. Nursing Process—Planning Patient Recovery After an Ischemic Stroke  Major goals include:       2/13/2014 Improved mobility Avoidance of shoulder pain Achievement of selfcare Relief of sensory and perceptual deprivation Prevention of aspiration Continence of bowel and bladder       Improved thought processes Achievement of a form of communication Maintenance of skin integrity Restoration of family functioning Improved sexual function Absence of complications Maria Carmela Domocmat, MSN, RN
  95. 95. NURSING INTERVENTIONS: ACUTE 1. 2. 3. 4. 5. 6. 2/13/2014 Ensure patent airway Keep patient on LATERAL position Monitor VS and GCS, pupil size IVF is ordered but given with caution as not to increase ICP Insert NGT Medications: Steroids, Mannitol (to decrease edema), Diazepam Maria Carmela Domocmat, MSN, RN
  96. 96. In acute stage of stroke  If grand mal seizure activity note time, length, behaviors  Monitor neuro status, vital signs, LOC, GCS  Maintain adequate fluids  Position with HOB elevated 15 to 30 degrees with client turned or tilted to unaffected side  Provide activity as ordered 2/13/2014 Maria Carmela Domocmat, MSN, RN
  97. 97. In acute stage of stroke  Perform passive and/or active range of motion exercises  Maintain proper body alignment  Care for post op client as indicated  Provide care for client with increased intracranial pressure 2/13/2014 Maria Carmela Domocmat, MSN, RN
  98. 98.  A. Nonsurgical Management       Monitor (and intervene) in neurologic, ICP status Drug therapy Monitor other complications Carotid Artery Angioplasty Hypothermia Treatment B. Surgical Management      2/13/2014 Endarterectomy Extracranial-Intracranial Bypass Management of AVM Management of aneurysms Management of intracranial bleeding Maria Carmela Domocmat, MSN, RN
  99. 99. In acute stage of stroke  Monitor for potential complications : musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of increased ICP and meningeal irritation 2/13/2014 Maria Carmela Domocmat, MSN, RN
  100. 100. Long-term care of client with stroke  Monitor to facilitate normal elimination patterns  Teach/evaluate the use of supportive devices  Maintain client in a safe environment  Prevent the effects of immobility 2/13/2014 Maria Carmela Domocmat, MSN, RN
  101. 101. Long-term care of client with stroke  Support the maintenance of adequate nutrition in light of feeding and swallowing problems  Assist with eating and ADL as indicated  Provide emotional support  Provide methods of communication for client with aphasia  Focus on patient function; self-care ability, coping, and teaching needs to facilitate rehabilitation 2/13/2014 Maria Carmela Domocmat, MSN, RN
  102. 102. Nursing Diagnoses
  103. 103. Nursing Diagnoses       Impaired physical mobility Acute pain Self-care deficits Disturbed sensory perception Impaired swallowing Urinary incontinence      2/13/2014 Disturbed thought processes Impaired verbal communication Risk for impaired skin integrity Interrupted family processes Sexual dysfunction Maria Carmela Domocmat, MSN, RN
  104. 104. Nursing Diagnoses  Ineffective Tissue Perfusion (cerebral) and Potential for increased ICP r/t interruption to arterial bloodflow.  Impaired Physical Mobility, self-care deficit and potential for deep vein thrombosis or pulmonary embolism r/t neuromuscular impairment or cognitive impairment.  Disturbed Sensory Perception and risk for injury r/t altered sensory reception, transmission, and integration. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  105. 105. Nursing Diagnoses  Unilateral Neglect r/t effects of disturbed perceptual abilities or hemianopsia  Impaired Verbal Communication r/t decreased circulation in the brain  Impaired Swallowing, Risk for imbalanced nutrition: less than body requirements, constipation and risk for aspiration r/t neuromuscular impairment 2/13/2014 Maria Carmela Domocmat, MSN, RN
  106. 106. Nursing Diagnoses  Total Urinary Incontinence and Bowel Incontinence r/t neurologic dysfunction  Ineffective Coping, caregiver role strain, r/t recent change in health status, Inadequate coping method or unsatisfactory support system 2/13/2014 Maria Carmela Domocmat, MSN, RN
  107. 107. Collaborative Problems/Potential Complications  Decreased cerebral blood flow  Inadequate oxygen delivery to brain  Pneumonia 2/13/2014 Maria Carmela Domocmat, MSN, RN
  108. 108. Interventions  Focus on the whole person  Provide interventions to prevent complications and to promote rehabilitation  Provide support and encouragement  Listen to the patient 2/13/2014 Maria Carmela Domocmat, MSN, RN
  109. 109. Improving Mobility and Preventing Joint Deformities  Turn and position the patient in correct alignment every 2 hours  Use splints  Practice passive or active ROM 4 to 5 times day  Position hands and fingers  Prevent flexion contractures  Prevent shoulder abduction  Do not lift by flaccid shoulder 2/13/2014 Maria Carmela Domocmat, MSN, RN
  110. 110.  Correctly position patient to prevent contractures    2/13/2014 Place pillow under axilla Hand is placed in slight supination- ―C‖ Change position every 2 hours Maria Carmela Domocmat, MSN, RN
  111. 111. Positioning to Prevent Shoulder Abduction 2/13/2014 Maria Carmela Domocmat, MSN, RN
  112. 112. Prone Positioning to Help Prevent Hip Flexion 2/13/2014 Maria Carmela Domocmat, MSN, RN
  113. 113. Improving Mobility and Preventing Joint Deformities  Implement measures to prevent and treat shoulder problems  Perform passive or active ROM 4 to 5 times day  Encourage patient to exercise unaffected side  Establish regular exercise routine  Use quadriceps setting and gluteal exercises 2/13/2014 Maria Carmela Domocmat, MSN, RN
  114. 114. Improving Mobility and Preventing Joint Deformities  Assist patient out of bed as soon as possible: assess and help patient achieve balance and move slowly  Implement ambulation training 2/13/2014 Maria Carmela Domocmat, MSN, RN
  115. 115. Enhance self-care  Set realistic goals with the patient  Encourage personal hygiene  Ensure that patient does not neglect the affected side  Use assistive devices and modification of clothing 2/13/2014 Maria Carmela Domocmat, MSN, RN
  116. 116.  Carry out activities on the unaffected side  Prevent unilateral neglect- place some items on the affected side!!!  Keep environment organized  Use large mirror 2/13/2014 Maria Carmela Domocmat, MSN, RN
  117. 117. Improve communication Implement strategies to enhance communication  Anticipate the needs of the patient  Provide time to complete the sentence  Provide a written copy of scheduled activities  Use of communication board  Give one instruction at a time 2/13/2014 Maria Carmela Domocmat, MSN, RN
  118. 118. Care of the client with Aphasia  Say one word at a time  Identify one object at a time  Give simple commands  Anticipate needs  Allow to verbalize no matter how long it takes him  Speech therapy 2/13/2014 Maria Carmela Domocmat, MSN, RN
  119. 119. Maintain skin integrity  Use of specialty bed  Regular turning and positioning  Keep skin dry and massage NONreddened areas  Provide adequate nutrition 2/13/2014 Maria Carmela Domocmat, MSN, RN
  120. 120. Manage sensory-perceptual difficulties  Care of the client with Hemianopsia Approach from the unaffected side  Place articles on the unaffected side  Encourage the patient with visual field loss to turn his head and look to side  Teach scanning techniques. Turn head from side to side to see entire visual field  Encourage to turn the head to the affected side to compensate for visual loss  2/13/2014 Maria Carmela Domocmat, MSN, RN
  121. 121. Manage dysphagia Nutrition  Consult with speech therapist or nutritionist  Have patient sit upright to eat, preferably OOB  Use chin tuck or swallowing method  Feed thickened liquids or pureed diet 2/13/2014 Maria Carmela Domocmat, MSN, RN
  122. 122. Manage dysphagia  Provide smaller bolus of food  Place food on the UNAFFECTED side  Manage tube feedings if prescribed  Promote nutrition  2/13/2014 TPN, NGT feeding, gastrostomy feeding Maria Carmela Domocmat, MSN, RN
  123. 123. Bowel and bladder control Help patient attain bowel and bladder control  Assess and schedule voiding  Implement measures to prevent constipation: fiber, fluid, and toileting schedule  Provide bowel and bladder retraining  Promote elimination  2/13/2014 I and O; Start urinary and bowel program Maria Carmela Domocmat, MSN, RN
  124. 124. Bowel and bladder control      Intermittent catheterization in acute stage Offer bedpan on a regular schedule High fiber diet and prescribed fluid intake The best time for a bowel movement is 20 - 40 minutes after a meal, since feeding stimulates bowel activity. Some people drink warm prune juice or fruit nectar as a stimulus to bowel movements. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  125. 125.  Improve thought processes  Support patient and capitalize on the remaining strengths  Improve family coping  Help patient cope with sexual dysfunction  Provide support and encouragement 2/13/2014 Maria Carmela Domocmat, MSN, RN
  126. 126. Aneurysm Precautions     Absolute bed rest Elevate HOB 30° to promote venous drainage or keep the bed flat to increase cerebral perfusion Avoid all activity that may increase ICP or BP; implement Valsalva maneuver, acute flexion, and rotation of the neck or head Exhale through mouth when voiding or defecating to decrease strain 2/13/2014 Maria Carmela Domocmat, MSN, RN
  127. 127. Aneurysm Precautions  Nurse provides all personal care and hygiene  Provide nonstimulating, nonstressful environment: dim lighting, no reading, no TV, and no radio  Prevent constipation  Restrict visitors 2/13/2014 Maria Carmela Domocmat, MSN, RN
  128. 128. Interventions  Relieve sensory deprivation and anxiety  Keep sensory stimulation to a minimum for aneurysm precautions  Implement reality orientation  Provide patient and family teaching  Provide support and reassurance  Implement seizure precautions  Implement strategies to regain and promote self-care and rehabilitation 2/13/2014 Maria Carmela Domocmat, MSN, RN
  129. 129. Surgical Management • • • • • • Endarterectomy Extracranial-Intracranial Bypass Carotid artery angioplasty Management of AVM Management of Aneurysms Management of intracranial bleeding 2/13/2014 Maria Carmela Domocmat, MSN, RN
  130. 130. Surgical treatments of aneurysms Clipping Embolization Intra-Cranial Angioplasty and Stent (ICAS)
  131. 131. Clipping Surgical treatment of aneurysms involves placing clip on neck of aneurysm. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  132. 132. Embolization • Endovascular repair of cerebral aneurysm. • Anterior communicating artery aneurysm before and after GDC coil embolization 2/13/2014 Maria Carmela Domocmat, MSN, RN
  133. 133. Intra-Cranial Angioplasty and Stent • ICAS (Intra-Cranial Angioplasty and Stent) of Basilar Artery Stenosis 2/13/2014 Maria Carmela Domocmat, MSN, RN
  134. 134. Stent 2/13/2014 Maria Carmela Domocmat, MSN, RN
  135. 135. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  136. 136. Extracranial-intracranial bypass surgery (EC-IC bypass)   2/13/2014 is a treatment for blocked blood vessels in the brain. The purpose of the operation is to use a healthy blood vessel to bypass the block and provide an additional blood supply to areas of the brain that have been deprived of blood. Maria Carmela Domocmat, MSN, RN
  137. 137. Rehabilitation Learning to live to one’s maximum potential with a chronic impairment and it’s resultant disability  Promotes reintegration into the client’s family and community  Influenced by the client and client’s motivation  2/13/2014 Maria Carmela Domocmat, MSN, RN
  138. 138.  Goals of Rehab Prevent complications  Correction of deformities  Restoration of function to achieve maximum independence  Limitation of disability  2/13/2014 Maria Carmela Domocmat, MSN, RN
  139. 139. Goal of Stroke Rehabilitation  Most mildly impaired individuals achieve their best functional recovery in 3 weeks  While it can take up to 12 weeks for the most severe 2/13/2014 Maria Carmela Domocmat, MSN, RN
  140. 140. Elite support walker Bar Grab Pivoting for Bathrooms
  141. 141. Home Care and Teaching for the Patient Recovering From a Stroke  Prevention of subsequent strokes, health promotion, and implementation of followup care  Prevention of and signs and symptoms of complications  Medication teaching  Safety measures 2/13/2014 Maria Carmela Domocmat, MSN, RN
  142. 142. Home Care and Teaching for the Patient Recovering From a Stroke  Adaptive strategies and use of assistive devices for ADLs  Nutrition: diet, swallowing techniques, and tube feeding administration  Elimination: bowel and bladder programs and catheter use  Exercise and activities: recreation and diversion  Socialization, support groups, and community resources 2/13/2014 Maria Carmela Domocmat, MSN, RN
  143. 143. Aphasia
  144. 144. Ten Guidelines for Interacting with a Stroke Survivor © American Stroke Foundation I. Treat me the same way as you did before my stroke – I am the same person. II. Every stroke is different; therefore every stroke survivor is different. Common impairments for stroke survivors are: Vision, balance, speech, hearing, and paralyzed on one side. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  145. 145. Ten Guidelines for Interacting with a Stroke Survivor © American Stroke Foundation III. Some stroke survivors have difficulty communicating verbally as well as reading, writing, spelling, and understanding what is being said, this is called aphasia. Our brains have been rewired which affects our communication. So, we need you to: Give us enough time to respond. Talk slowly; offer at times to repeat yourself. Be patient when trying to communicate with us. It is okay to help us find a word when we are having trouble. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  146. 146. Ten Guidelines for Interacting with a Stroke Survivor © American Stroke Foundation IV. There are other ways of communication besides words. Gestures, Facial expressions, Body languages, Pictures, Pen & paper. V. Treat us like adults and not children. Speak directly to us, not our spouse or friend. Don’t talk like the stroke survivor isn’t there. Laugh with us not at us. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  147. 147. Ten Guidelines for Interacting with a Stroke Survivor © American Stroke Foundation VI. Give the stroke survivor a chance to be independent. Ask before you help them. Follow his/her instructions for initiating the help. VII. Many stroke survivors have problems with balance. A rough pat on my back, shoulder, or arm can easily set us off balance and can hurt me. Be gentle and understand that it can take a lot of concentration to walk, especially on uneven surfaces. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  148. 148. Ten Guidelines for Interacting with a Stroke Survivor © American Stroke Foundation VIII. Wheelchair and walker are extensions of us. Please respect our space. If you bump the chair, please say excuse me. Please don’t lean on a wheelchair. IX. Talk to us at eye level when possible when we are in a wheel chair. You can also back up a few feet to make it easier for a person in a wheelchair to look at you. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  149. 149. Ten Guidelines for Interacting with a Stroke Survivor © American Stroke Foundation X. When we are tired and/or frustrated, ALL of our basic skills (i.e. talking, walking, handwriting, and concentration) diminish. If we are more agitated than usual, we are probably tired or frustrated! Have patience and encourage us to rest or “take a break” when appropriate. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  150. 150. What‟s in store in the future?
  151. 151. Roles in Stroke Nursing   Nurses have responded to the challenge of making stroke systems of care a reality in recent years. Stepping into new roles, such as stroke response nurse, stroke nurse practitioner, stroke coordinator, and stroke research nurse, stroke nurses are using evidencebased practice to organize and deliver stroke services and facilitate optimal outcomes for stroke patients. 2/13/2014 Maria Carmela Domocmat, MSN, RN
  152. 152.  Clot Dissolving Substance in Vampire Bat Saliva Cell and Tissue Transplants 2/13/2014  Venom from Pit Viper   Free Radical Scavengers Maria Carmela Domocmat, MSN, RN

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