9- stroke hemorrhagic and ischemic 9.pptx

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Cerebrovascular Disorders
Functional abnormality of the CNS that occurs when
the blood supply to the brain is disrupted
Stroke is the primary cerebrovascular disorder and
the fifth leading cause of death in the United States
Stroke is the leading cause of serious long-term
disability in the United States
Financial impact is profound

Risk Factors
 Nonmodifiable risk factors
o Age, gender, ethnicity
 Modifiable risk factors
o Hypertension is the primary risk factor
o Cardiovascular disease
o Elevated cholesterol or elevated hematocrit
o Obesity
o Diabetes
o Oral contraceptive use
o Smoking and drug and alcohol abuse

Stroke
“Brain attack”
Sudden loss of function resulting from a disruption
of the blood supply to a part of the brain
Types of stroke:
o Ischemic
o Hemorrhagic

Ischemic Stroke
Disruption of the blood supply caused by an
obstruction, usually a thrombus or embolism, that
causes infarction of brain tissue
Types
o Large artery thrombosis
o Small penetrating artery thrombosis
o Cardiogenic embolism
o Cryptogenic
o Other

Pathophysiology

Manifestations of Ischemic Stroke
Symptoms depend on 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

Signs and symptoms
Hemiplegia
Hemiparesis
Dysarthria
Aphasia
o Expressive aphasia
o Receptive aphasia
Hemianopsia
Agnosia

Comparison between right and left side
stroke
Left hemispheric stroke Right hemispheric stroke
 Paralysis or weakness on right side of
body
 Right visual field deficit
 Aphasia (expressive, receptive, or
global)
 Altered intellectual ability
 Slow, cautious behavior
 Paralysis or weakness on left
side of body
 Left visual field deficit
 Spatial-perceptual deficits
 Increased distractibility
 Impulsive behavior and poor
judgment
 Lack of awareness of deficits

Transient Ischemic Attack (TIA)
Temporary neurologic deficit resulting from a
temporary impairment of blood flow
“Warning of an impending stroke”
Diagnostic workup is required to treat and prevent
irreversible deficits

prevention
Primary prevention is the best method to avoid
hemorrhagic and ischemic stroke through
management of modifiable risk factors including:-
o controlling hypertension
o consuming alcohol in moderation
o exercise
o no smoking
o and managing diabetes.

Preventive Treatment and Secondary
Prevention of TIA and Stroke
Carotid endarterectomy for carotid stenosis
Anticoagulant therapy for atrial fibrillation
Antiplatelet therapy
“Statins for atherosclerosis
Antihypertensive medications

Carotid Endarterectomy

Prompt diagnosis of stroke is very
important
 Any patient with neurologic deﬁcits needs a careful history and a complete
physical and neurologic examination.
 The initial diagnostic test for a stroke is a noncontrast computed tomography
(CT) scan performed emergently to determine if the event is ischemic or
hemorrhagic (which determines treatment).
 Further diagnostic workup for ischemic stroke involves attempting to identify
the source of the thrombi or emboli.
 A 12-lead electrocardiogram

Medical Management: Acute Phase of
Stroke
 Elevation of the head of the bed to promote venous drainage
and to lower increased ICP unless contraindicated
 Intubation with an endotracheal tube to establish a patent
airway, if necessary
 Continuous hemodynamic monitoring.
 Thrombolytic therapy if patient is a candidate for it
 Continuous neurologic assessment to determine if stroke is
recovering or complications develop.

Eligibility Criteria for t-PA Administration
 Age 18 years or older
 Clinical diagnosis of stroke
 Time of onset of stroke known and is 3 hours or less
 BP systolic ≤ 185; diastolic ≤ 110
 No seizure at onset of stroke
 Not taking warfarin (Coumadin) or heparin
 Prothrombin time ≤ 15 seconds or INR ≤ 1.7
 Platelet count ≥ 100,000
 Blood glucose level between 50 and 400 mg/dL
 No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or
aneurysm, No major surgical procedures within 14 day, No stroke or serious head
injury within 3 months

Hemorrhagic Stroke
 Caused by bleeding into brain tissue, the ventricles, or
subarachnoid space
 May be caused by spontaneous rupture of small vessels
primarily related to hypertension; subarachnoid hemorrhage
caused by a ruptured aneurysm; or intracerebral hemorrhage
related to amyloid angiopathy, arterial venous malformations
(AVMs), intracranial aneurysms, or medications such as
anticoagulants
 Brain metabolism is disrupted by exposure to blood
 ICP increases caused by blood in the subarachnoid space
 Compression or secondary ischemia from reduced perfusion
and vasoconstriction causes injury to brain tissue

Manifestations of Hemorrhagic Stroke
 Similar to ischemic stroke
 Severe headache
 Early and sudden changes in Level of Consciousness (LOC)
 Vomiting
 Bleeding

Medical Management of Hemorrhagic
Stroke
Diagnosis: CT scan, cerebral angiography, lumbar
puncture if CT is negative and ICP is not elevated to
confirm subarachnoid hemorrhage
Care is primarily supportive
Bed rest with sedation
Oxygen
Treatment of vasospasm, increased ICP,
hypertension, potential seizures, and prevention of
further bleeding

Stroke algorithm

Stroke algorithm continued

Nursing Management of Ischemic Stroke:
Acute Phase
 Ongoing, frequent monitoring of all systems, including vital
signs and neurologic assessment
 LOC
 Motor symptoms
 Speech
 Pupil changes
 I & O
 Blood pressure maintenance
 Bleeding
 Oxygen saturation

Assessment of the Patient Recovering
from an Ischemic Stroke
After the acute phase:
o Mental status
o Sensation/perception
o Motor control
o Swallowing ability
o Nutritional and hydration status
o Skin integrity
o Activity tolerance
o Bowel and bladder function

Collaborative Problems and Potential
Complications of the Patient Recovering from
an Ischemic Stroke
Decreased cerebral blood flow
Inadequate oxygen delivery to brain
Pneumonia

Nursing Interventions for the Patient
Recovering from an Ischemic Stroke
Improving mobility and preventing joint deformities
o Prevent shoulder abduction
o Position the hands and fingers
o Change positions—every 2 hours
o Establish an exercise program
 Passive or active ROM four or five times day
o Prepare for ambulation
 Assist patient out of bed as soon as possible
Preventing shoulder pain

 Enhancing self-care
o Use of assistive devices such as Raised toilet seat, Long-handled bath sponge)
o Ensure the patient does not neglect the affected side.
o Return of functional ability is important to the patient recovering after a stroke.
o clothing is preferably a size larger than that normally worn.
o the nurse can take steps to keep the environment organized and uncluttered.
o The clothing is placed on the affected side.
o Using a large mirror while dressing .
o Support and encouragement are provided to prevent the patient from becoming
overly fatigued and discouraged.

 Adjusting to physical changes
 Assisting with nutrition
o Consult with speech therapy or nutritional services
o Have patient sit upright, preferably out of bed, to eat
o Chin tuck or swallowing method
o Use of thickened liquids or pureed diet

 Managing Sensory-Perceptual Difficulties
o All visual stimuli (clock, calendar, and television) should be placed on
affected side.
o make eye contact with the patient and draw his or her attention to the
affected side.
o stand at a position that encourages the patient to move to visualize who is in
the room.
o Increasing the natural or artiﬁcial lighting in the room and providing
eyeglasses are important in increasing vision.
o It is important for the nurse to constantly remind the patient of the other side
of the body, to maintain alignment of the extremities if possible, to place the
extremities where the patient can see them.

Recovering from an Ischemic Stroke #3
 managing dysphagia
o Advise to take smaller boluses of food, and taught about which
foods are easier to swallow.
o The patient may initially be started on a thick liquid or puréed
diet because these foods are easier to swallow than thin liquids.
o Having the patient sit upright, preferably out of bed in a chair,
and instructing him or her to tuck the chin toward the chest as
he or she swallows, will help prevent aspiration.
o The diet may be advanced as the patient becomes more
proﬁcient at swallowing.
o If the patient cannot resume oral intake, a gastrointestinal
feeding tube will be placed for ongoing tube feedings.

 Attaining Bowel And Bladder Control
o intermittent catheterization with sterile technique is carried
out.
o The voiding pattern is analyzed and the urinal or bedpan
offered on this pattern or schedule.
o The upright posture and standing position are helpful for
male patients during this aspect of rehabilitation.
o Unless contraindicated, a high-ﬁber diet and adequate ﬂuid
intake (2 to 3 L per day)
o Bedpain should be provided and a regular time established
(usually after breakfast) for toileting.

 Improving Communication
o Face the patient and establish eye contact.
o Speak in a normal manner and tone.
o Use short phrases and pause between phrases to allow the
patient
o time to understand what is being said.
o Limit conversation to practical and concrete matters.
o Use gestures, pictures, and objects.
o Be consistent in using the same words and gestures each
time you give instructions or ask a question.
o Keep extraneous noises and sounds to a minimum..

Maintaining Skin Integrity
o A regular turning and positioning schedule must be followed.
o Pressure-relieving devices may be employed but do not replace
regular turning and positioning.
o The turning schedule (at least every 2 hours)
o When the patient is positioned or turned, care must be used to
minimize shear and friction forces, which cause damage to
tissues and predispose the skin to breakdown.
o The patient’s skin must be kept clean and dry;
o gentle massage of healthy (nonreddened) skin and adequate
nutrition are other factors that help to maintain normal skin and
tissue integrity.

Assessment of the Patient with a
Hemorrhagic Stroke
Complete and ongoing neurologic assessment; use
neurologic flow chart
Altered LOC
Sluggish pupillary reaction
Motor and sensory dysfunction
Cranial nerve deficits
Speech difficulties and visual disturbance
Headache and nuchal rigidity
Other neurologic deficits

Collaborative Problems and Potential
Complications of the Patient with a
Hemorrhagic Stroke
Vasospasm
Seizures
Hydrocephalus
Rebleeding
Hyponatremia

Planning and Goals for the Patient with a
Hemorrhagic Stroke
Goals may include:
o Improved cerebral tissue perfusion
o Relief of anxiety
o The absence of complications

Nursing Interventions for the Patient with
a Hemorrhagic Stroke
 Optimizing cerebral tissue perfusion; implementing aneurysm
precautions
o Provide a nonstimulating environment, prevent increases
in ICP, prevent further bleeding
o Absolute bed rest with HOB 30 degrees
o Avoid all activity that may increase ICP or BP; Valsalva
maneuver, acute flexion or rotation of neck or head
o Stool softener and mild laxatives
o Nonstimulating, nonstressful environment; dim lighting,
no reading, no TV, no radio
o Visitors are restricted

Nursing Interventions of the Patient with
a Hemorrhagic Stroke
Relieving anxiety
o Keep sensory stimulation to a minimum for
aneurysm precautions
o Realty orientation
Monitoring and managing potential complications
o Seizure precautions
Patient and family education
o strategies to regain and promote self-care and
rehabilitation

Home Care and Education for the Patient
Recovering from a Stroke
 Prevention of subsequent strokes, health promotion, and
follow-up care; refer to Chart 62-6
 Prevention of and signs and symptoms of complications
 Medication education
 Safety measures
 Adaptive strategies and use of assistive devices for ADLs
 Nutrition: diet, swallowing techniques, tube feeding
administration
 Elimination: bowel and bladder programs, catheter use
 Exercise and activities, recreation and diversion
 Socialization, support groups, and community resources

9- stroke hemorrhagic and ischemic 9.pptx

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9- stroke hemorrhagic and ischemic 9.pptx