is a abrupt loss of function resulting from disrupted blood supply to a part of the brain.
Five Types according to causes:
Large artery thrombosis – are due to atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction.
Small penetrating artery thrombosis – affects one or more vessels and are the most common type of ischemic stroke.
- also known as Lacunar strokes because of the cavity that is created once the infracted brain tissue disintegrates.
Cardiogenic embolic strokes – are associated with cardiac dysrhythmias, usually atrial fibrillation. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting in a stroke. Emboli stroke may be prevented by the use of anticoagulant therapy in patients with atrial fibrillation.
Cryptogenic stroke – iatrogenic.
other strokes – from the use of cocaine, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.
Stroke Continuum: Time Course Classification
Transient Ischemic Attack
- may serve as a warning of approaching strokes
- greatest incidence is in the first month following the first attack.
- temporary episodes of neurologic dysfunction manifested by a sudden loss of motor, sensory, or visual function.
- last for a few seconds or minutes but no longer than 24 hours.
Reversible Ischemic Neurologic Deficit
- sign and symptoms are consistent but more distinct than a TIA
- last for more than 24 hours
- symptoms revolve in days without permanent neurologic deficits.
Stroke in Evolution
- worsening of neurologic sign and symptoms over several minutes or hours.
- Progressing stroke
- stabilization of the neurologic signs and symptoms
- indicates no further progression of hypoxic insult to the brain from this particular ischemic event.
Risk Factors 10. Drug abuse 9. Excessive alcohol consumption 8. Smoking 7. Use of Oral Contraceptive 6. Diabetes Mellitus 5. Elevated hematocrit 4. Genetics 4. Obesity 3. Race 3. High cholesterol levels 2. Sex 2. Cardiovascular diseases 1. Age 1. Hypertension Uncontrollable Risk Factors Controllable Risk Factors
Pathophysiology Occlusion of artery Dec blood flow Dec oxygenation and nutrition of brain Dec energy stores
Pathophysiology Open Ca channels Inc Ca, Na and Cl Dec K Inc cell death Inc glutamine and aspartate
Cognitive Impairment and Psychological Effects
- Cognitive impairment
- Psychological problems
Cooperation of Left and Right Hemispheric Stroke Lack of awareness of deficits Impulsive behavior and poor judgment Slow, cautions behavior Increase distractibility Altered intellectual ability Spatial-perceptual deficits Aphasia (expressive, receptive, or global) Left visual field loss Right visual field deficit Paralysis or weakness on left side of the body Paralysis or weakness on right side of the body Right Hemispheric Stroke Left Hemispheric Stroke
Non Contrast Computed Tomography scan
12-lead electrocardiogram –standard test
Carotid ultrasound – standard test
Transcranial Doppler flow studies
Transthoracic or transesophageal echocardiography
Magnetic resonance imaging
Single photon emission CT
Digital subtraction angiography
Warfarin Sodium (Coumadin)
- most cost effective
- 50 mg/d
- 400 mg/d
Therapy for patients with ischemic stroke not receiving t-PA
Criteria for t-PA Administration
18 years of age or older
NIH stroke scale of 22
Time of onset of stroke known and is 3 hours or less
BP systolic < 185; diastolic of < 110
Not a minor stroke or rapidly resolving stroke
No seizure at onset of stroke
Not taking warfarin
Prothrombine time < 15 second or INR < 1.7
Not receiving heparin during the past 48 hours with elevated partial thromboplastin time
Platelet count of > 100,000
Blood glucose level between 50 and 400 mg/dL
No acute myocardial infarction
No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm
No major surgical procedures within 14 days
No stroke or serious head injury within 3 months
No gastrointestinal or urinary bleeding within last 21 days
Not lactating or postpartum within last 30 days.
Dosage and administration of t-PA administration
Weight the patient
Minimum dose is 0.9 mg/kg; maximum of 90 mg.
Load the 10% of the dose and is administered over 1 minute
The remaining dose is administered over 1 hour via a infusion pump
After infusion is completed, flush the line with 20 ml of normal saline solution.
Monitor the vital signs every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, then every hours for 16 hours.
Bleeding at the insertion site of IVF, urinary catheter. ET tube, NGT, urine, stool, emesis, and etc.
Therapy for patients with ischemic stroke not receiving t-PA
Administer osmotic diuretics
Maintaining PCO2 within the range of 30-35 mmHg
Elevate the head of the bed
Intubation with an endotracheal tube, if necessary
Continuous hemodynamic monitoring
used to manage TIAs
most frequently performed peripheral vascular procedure
removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral artery.
Post operative Nursing management for Endarterectomy
Maintain adequate blood pressure
Close cardiac monitoring
Assess neurologic status
Assess the cranial nerves VI, X, XI, and XII.
Observe fro swelling and hematoma formation.
Managing potential complication
Maintain cardiac output
Decrease cerebral blood flow due to increase ICP
Inadequate oxygen delivery to the brain
NURSING PROCESS: The Patient Recovering from an Ischemic Stroke
Change in the level of consciousness or responsiveness as evidenced by movement, resistance to change of position and response to stimulation; orientation to time, place, and person.
Presence or absence of voluntary and involuntary movements of the extremities; muscle tone; body posture; and position of the head.
Stiffness or flaccidity of the neck
Eye opening, comparative size of pupil and papillary reactions to light and ocular position
Color of the face and extremities; temperature and moisture of the skin
Quality and rates of pulse and respiration; arterial blood gas values as indicated, body temperature, and arterial pressure
Ability to speak
Input and output q 24 hours
Presence of bleeding
Maintain blood pressure within the desire parameters.
Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
Acute pain (painful shoulder) related to hemiplegia and disuse
Self-care deficits (hygiene, toileting, grooming, and feeding) related to stroke sequelae
Disturbed sensory perception related to altered sensory reception, transmission, and/or integration.
Incontinence related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating
Disturbed thought processes related to brain damages, confusion, or inability to follow instructions
Impaired verbal communication related to brain damages
Risk for impaired skin integrity related to hemiparesis/hemiplegia, or decreased mobility
Interrupted family processes related to catastrophic illness and care giving burdens
Sexual dysfunction related to neurologic deficits or fear of failure
Planning and Goals
For the patient to improve mobility
Avoidance of shoulder pain
Achievement of self-care
Relief of sensory and visual deprivation
Prevention of aspiration
Continence of bowel and bladder
Improvement of thought process
Achieving a form of communication
Maintain skin integrity
Restore family functioning
Improvement in sexual functions
Absence of complication
Improving mobility and preventing joint deformities
a. Preventing shoulder adduction
Assist in maintaining body alignment and prevent compressive neuropathies
Applying a posterior splint during sleep at night to the affected extremity.
Place a pillow in the axilla when there is a limited external rotation of the shoulder.
b. Positioning the hand and fingers
The hand is placed in slight supination. (palms facing upward)
If upper extremity is flaccid, use a volar resting splint If the extremity is spastic, use a dorsal wrist splint, instead of hand roll
c. Changing position
Change position q2 hours.
Place the patient in a lateral position, a pillow is placed between the legs before the patient is turned.
If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day.
d. Establishing an exercise program
Passive exercise and put through a full range in motion 4 or 5 times a day .
Quadriceps muscle setting and gluteal setting exercises are started early in
e. Preparing for ambulation
Use a tilt table, which slowly brings the patients.
Chair should be low enough
Use of parallel bars. A chair or wheelchair should be available if the patent suddenly becomes fatigue.
A three or four pronged cane
f. Preventing shoulder pain
The nurse should never lift the patient by flaccid shoulder or pull on the affected arm or shoulder.
The flaccid arm is positioned on a table or with pillows while the patient is seated.
The patient is instructed to interlace the finger, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward.
Pushing the heel of the hand firmly down on a surface is useful
Amitriptyline hydrochloride (Elavil)
2. Enhancing self-care
As soon as the patient can sit up, personal hygiene activities are encourage.
Use of assistive devices
The family are instructed to bring clothing that are size larger than that normally worn
Clothing fitted with front or fide fasteners or Velcro Closure is most suitable.
The patient is dressed better in a seated position.
Keep the environment organized and uncluttered.
The clothing are placed on the affected side in the order in which the garments are to be put on.
Use a large mirror while dressing
3. Managing sensory-perceptual difficulties
Approached on the side where visual perception is intact
All visual stimuli should be placed on this side. E.g. clock, calendar and television)
The patient can be taught to turn the head in the direction of the defective visual field
The nurse should make eye contact with the patient and draw his or her attention to the affected side
Stand at a position that encourage the patient
Increase the natural or artificial lighting in the room and provide eyeglasses.
Constantly remind the patient about the other side of the body.
Place the extremities where the patient can see them.
4. Managing dysphagia
Advice to take smaller boluses of food, and taught about which foods are easier to swallow
The patient is initially started on a thick liquid or purred diet.
Having the patient sit upright position
Instruct to him or her to tuck the chin toward the chest as he or she swallow to prevent aspiration.
5. Managing Tube feeding
Elevate the head of the bed at least 30 degrees
Check the position of the tube before feeding, ensuring the cuff of the tracheotomy tube is inflated.
Give the tube feeding slowly
Aspirate periodically to ensure that the feeding are passing through the gastrointestinal tract.
6. Attaining bowel and bladder control
Upright posture and standing position are helpful for male patients during this aspect of rehabilitations
7. Improving thought processes
Review the neuropsychological testing
Observes the patient’s performance and progress, gives feedback
8. Improving communication
A consistent schedule, routines, and repetitions help the patient to function despite significant deficits.
A written copy of daily schedule, a folder of personal information, checklists, and an audiotape list help improve the patient’s memory and concentration.
The patient’s attention, speak slowly and keep the language of instruction consistent.
One instruction at a time and time to allow the patient to process what has been said.
9. Maintaining Skin integrity
Frequent assessment of the skin with the emphasis on the bony areas.
Use specialty bed
Regular timing and positioning schedule
10. Improving family coping
They are given information about the expected outcomes
Counseled the family to avoid doing for the patient those things that he or she can do.
Inform the family that the rehabilitation of the hemiplegic patient requires progress may be slow.
The family can help by approaching the patient with supportive and optimistic attitude, focusing on the abilities that remains,
The family should be prepared to expect occasional episodes of emotional lability.
Explain to the family that patient’s laughter does not necessarily mean happiness, as well as crying does not reflect sadness.
11. Helping the patient cope with sexual dysfunction
Providing information, education, reassurance, how to adjust to the medication, providing counseling regarding coping skills and suggesting about alternative positions to the patient and the partner about
The patient expected outcome may include:
1. Achieve improved mobility
Avoids deformities (contractures and footdrop)
Participates in prescribed exercise program
Achieves sitting balance
Uses unaffected side to compensate for loss of function of hemiplegics side
Participates in turning and positioning activities
10. Family members demonstrate a positive attitude and coping mechanism
Encourage patients in exercise programs
Take an active part in rehabilitation process
Contact respite care programs or arrange for other family members to assume some responsibilities for care
11. Has positive attitude regarding alternative approaches to sexual expression
are caused of bleeding in the brain tissue, the ventricles, or the subarachnoid space.
Types of Hemorrhagic Stroke
Primary intracerebral hemorrhage
is from spontaneous rupture of small vessels accounts for approximately 80%
caused by uncontrolled hypertension
Secondary intracerebral hemorrhage
associated with arteriovenous malformations, intracranial aneurysms or certain medications.
most common in patients with hypertension and cerebral atherosclerosis because degenerative changes from these diseases caused by rupture vessel.
also due to certain types of arterial pathology, brain tumor, and the use of medication.
bleeding usually is arterial in origin and most commonly in the cerebral lobes, basal ganglia, thalamus, brain stem and cerebrum.
most fatal if the bleeding cause intraventricular hemorrhage
Intracranial (Cerebral) Aneurysms
dilatation of the walls of the cerebral artery that develops as a result of weakness in the arterial wall.
Most commonly affected by an aneurysm:
Internal carotid artery
Anterior cerebral artery
Anterior communicating artery
Posterior communicating artery
Posterior cerebral artery
Middle cerebral artery
abnormality in embryonal development that leads to a tangle of arteries and veins in the brain without a capillary bed.
most common in young people.
may occur as a result of arteriovenous malformations
Pathophysiology Hypertension Inc pressure to the vessels Rupture of the blood vessels Bleeding
Pathophysiology Compression of the adjacent to the brain tissue Neuronal dysfunction
sudden severe headache
often loss of consciousness
visual disturbances such as diplopia, ptosis, visual loss
Cerebral angiography – confirms the diagnosis
Use of Hunt-Hess Classification of systems
Hunt-Hess Classification of systems Modified classification adds the following No acute meningeal/brain reaction, but with fixed neurological deficit Ia Unrupture aneurysm 0 Deep coma, decerebrate rigidity, moribund appearance Add one grade for serious systemic disease or severe vasospasm on angiography V Stupor, moderate to severe hemiparesis, early decerebrate rigidity IV Mild focal deficit, lethargy, or confusion III Cranial nerve palsy, abducens, moderate-to-severe headache, nuchal rigidity II Asymptomatic, or mild headache and slight nuchal rigidity I
1. Cerebral Hypoxia and Decrease Blood Flow
a. administering oxygen
b. maintaining the hemoglobin and hematocrit level
c. adequate hydration through IV fluids
d. avoid extreme hypertension or hypotension
e. treat seizures
a. surgery to clip aneurysm
b. Calcium-Channel blocker through IV administration
c. Endovascular technique
3. Increase ICP
a. lumbar punctured
b. ventricular catheter drainage
c. diuretics (mannitol)
4. Systemic Hypertension
a. antihypertensive therapy
- labetalol (Normodyne)
- nicardipine (Cardene)
- nitroprusside (Nitropress)
b. Hemodynamic monitoring
c. Anti-seizure agents
c. Stool softener
5. Surgical Management
a. extracranial-intracranial arterial bypass
Postoperative internal artery occlusion
Fluid and electrolyte disturbances
NURSING PROCESS: The patient with a Hemorrhagic Stroke
altered level of consciousness – early sign
sluggish pupillary reaction
motor and sensory dysfunction
cranial nerve deficits
speech difficulties and visual disturbances
headache and nuchal rigidity
Ineffective cerebral tissue perfusion related to bleeding
Disturbed sensory perception related to medically imposed restrictions
Anxiety related to illness and/or medically imposed restrictions
Planning and Goals
Improve cerebral tissue perfusion
Relief of sensory and perceptual deviation
Relief of anxiety
Absence of complication
1. Optimizing Cerebral Tissue Perfusion
Monitor neurologic deterioration
Check hourly the blood pressure, pulse, LOC, papillary responses and motor function. And any changes should be reported immediately
2. Implementing Aneurysm Precaution
Provide a nonstimulating environment
Prevent further increase in ICP pressure
Provide quiet, nonstressful environment
Visitor are restricted (except for the family)
Elevate head in 15-30 degrees
Avoid sudden increase in blood pressure
Avoid vasalva maneuver, straining, forceful sneezing, pushing up in bed, acute flexion or rotation of the head and neck and cigarette smoking
Instruct the patient to exhale through the mouth during voiding or defecation
No enema are permitted
Coffee and tea, unless contraindicated
Thigh-high elastic compression stockings or sequential compression boots
The nurse administers all personal care
External stimuli are keep in minimum.
3. Relieving Sensory Deprivation and Anxiety
Keeping the patient well informed of the plan of care
Provide information and support to the family
Managing Potential Complications:
Fluid volume expanders
Maintaining the airway
Drug of choice: phenytoin (Dilantin)
Any change in patients responsiveness are reported immediately
Monitor for initial signs of hemorrhage usually after 2 weeks of after hemorrhage
Administer anti-fibrinolytic agents (epsilon-aminocaproic acid) as prescribed to delay the lysis of the clot surrounding the rupture
The patient is expected outcome:
Demonstrates intact neurologic status and normal vital signs and respiratory patterns
Is alert and oriented to time, place and person
Demonstrates normal speech patterns and intact cognitive processes
Demonstrate normal and equal strength, movement, and sensation of all four extremities
Exhibits normal deep tendon reflexes and papillary responses
Demonstrates normal sensory perceptions
States rationale for aneurysm precaution
Exhibits clear thought process
Exhibits reduced anxiety level
Is less restless
Exhibits absence of physiologic indicators of anxiety
Is free of complication
Exhibits absence of vasospasm
Exhibits normal vital signs and neuromuscular activity without seizures
Verbalizes understanding of seizure precautions
Exhibits normal mental status and normal motor and sensory status