Downloaded 16 times
![REFERENCES
• Black M Joyce, Hawks Jane Hokanson. Medical-surgical nursing: clinical
management for positive outcomes. 7th ed. Elsevier publishers:2005;
2107-36.
• Kasper DL, Braunwald E, Fauci AS, et al, editors. Harrison’s principles of
internal medicine, 16th ed. [monograph on the Internet]. New York (NY):
The McGraw-Hill Companies, Inc.; 2004-2005
• Smeltzer Suzanne C, Bare Brenda G. Brunner & Suddarth’s Textbook of
medical-surgical nursing. 11th ed. lippincott williams & wilkins:2009;
2206-25.
• Monahan, Sands. et al. Phipp’s medical surgical nursing: health and illness
perspective. 8th ed. Elsevier publishers:2007; 1861-72.
• Chintamani; textbook of medical-surgical nursing; published by: Elsevier;
7th edition; page no- 1466-90
• http://www.google.co.in/?gws_rd=cr&ei=HBbHUqnQO4qJrAf8hoDIDA#
q=stroke+rehabilitation+pdf](https://image.slidesharecdn.com/stroke-230225064802-5e30df43/85/Stroke-ppt-77-320.jpg)
More Related Content
Stroke.ppt
- 1. CEREBROVASCULAR ACCIDENT CHANDRA PRAKASHMEENA M.SC.NURSING 2ND YEAR COLLEGE OF NURSING AIIMS JODHPUR
- 2. INTRODUCTION • CVD orCVA refers to a functional abnormality of the central nervous system that occurs when the normal blood supply to the brain is disrupted. • Brain & cerebral nerve cells extremely sensitive to a lack of oxygen • severity of the loss of function varies according to the location and extent of the brain involved.
- 3. INCIDENCE • The strokeis the leading cause of death and disability in India. The estimated prevalence rate of stroke in India is (84-262 per 1,00,000) in rural areas as compared to (334-424 per 1,00,000 population) in urban areas. There is also a wide variation in case fatality rates with the highest being 42% in Kolkata(2018). • World: 1 in 6 persons gets a stroke in their lifetime. • India has reported 1.6 million stroke cases per year(2015.)
- 4. ANATOMY OF BRAINAND ITS BLOOD SUPPLY •Four vessels supply nutrient and oxygen rich blood to the brain : •Two internal carotid arteries (anterior circulation: most of the frontal, parietal &temporal lobes, basal ganglia, part of diencephalon.) •Two vertebral arteries (posterior circulation: middle & lower part of temporal lobes, occipital lobes, cerebellum, brain stem and part of diencephalon.)
- 5.
- 6. Control Centers ofthe Brain
- 7. DEFINITION OF STROKE Stroke,Cerebrovascular Accident (CVA) or “Brain Attack” defined as sudden loss of brain function resulting from disruption of blood supply to a part of brain, which results in infarction or death of brain tissue. -WHO A stroke is a medical emergency in which the blood supply to any portion of the brain is interrupted or reduced
- 9.
- 10. Types of stroke •Ischemic,80% - thrombosis, 50% (small & large-vessel) - embolism, 30% •Hemorrhagic, 20% - intracerebral (Hypertension as risk) - subarachnoid (aneurysm)
- 11. TRANSIENT ISCHEMIC ATTACK •These are brief, transient and focal disturbances of neurological function that clear with little or no residual deficit within 24 hrs. • Most of them last for only 7 to 10 minutes. • Also called as “little strokes” or “mini stroke”. • 40% of the client develop stroke in 5 yrs. • Accounts for 80-85% of all strokes. • Results from partial or complete occlusion of an artery.
- 12. Ischemic stroke canbe:- Due to systemic hypo perfusion OR Watershed stroke( 15% ) Embolic stroke (24%) Thrombotic stroke (61%)
- 13. RISK FACTORS Non modifiablerisk factors: Age- 60% - 65% of all strokes occur in persons over 65 yrs. of age. Gender- men>women Race- African, Americans are twice likely to develop thrombotic stroke & 3 times more likely for haemorrhagic one. Genetics- Those with family history of CVA have greater risk.
- 14. Modifiable Risk Factors Lifestylerisk factors •Being overweight or obese •Physical inactivity •Heavy or binge drinking •Use of illicit drugs such as cocaine and methamphetamines Medical risk factors •High blood pressure •Cigarette smoking or exposure to secondhand smoke. •High cholesterol. •Diabetes. •Obstructive sleep apnea •Cardiovascular disease 14 http://chicagostrokemd.com/stroke-risk-factors/
- 15. Etiology •A stroke occurswhen the blood supply to your brain is interrupted or reduced. This deprives your brain of oxygen and nutrients, which can cause brain cells to die. • A stroke may be caused by a blocked artery (ischemic stroke) or a leaking or burst blood vessel (hemorrhagic stroke). •Some people may experience a temporary disruption of blood flow through their brain (Transient ischemic attack).
- 16.
- 17.
- 18. SIGN AND SYMPTOMS SYMPTOMS Facialdrooping Arm weakness Slurred speech Blurred vision or blindness in one or both the eyes. Severe headache Sudden loss of balance, dizziness or falling without any apparent reason.
- 20. Left and RightHemisphere Stroke: Left (Dominant) Hemisphere Stroke: Common Pattern • Aphasia • Right hemiparesis • Right-sided sensory loss • Right visual field defect • Poor right conjugate gaze • Difficulty reading, writing, or calculating Right (Non-dominant) Hemisphere Stroke: Common Pattern • Neglect of left visual field • Extinction of left-sided stimuli • Left hemiparesis • Left-sided sensory loss • Left visual field defect • Poor left conjugate gaze • Dysarthria • Spatial disorientation
- 22. SPECIFIC DEFICITS AFTERCVA •Visual field deficits •Motor deficits •Sensory deficits •Perceptual deficits •Cognitive deficits •Emotional deficits
- 23. Clinical features: MotorSymptoms • Contralateral hemiparesis • Dysphasia/ Aphasia • Dysphagia • Apraxia • Dysarthria • Bowel and bladder incontinence
- 24. Clinical features: SensorySymptoms • Paresthesia • Anesthesia • Blurred vision • Diplopia • Agnosia • Shoulder pain • Unilateral neglect
- 25. Clinical features: AlteredMental Status • Change in intelligence and personality • Altered thought process • Poor reasoning and judgment • Emotional liability • Memory loss
- 26. Diagnostic tests forstroke
- 27. Diagnostic Evaluation •History andPhysical examination •Computed Tomography (CT) scan of the head •12-lead ECG, chest X-ray •Complete blood count, PT, PTT •Bio chemistry (sodium, phosphate, glucose abnormalities may mimic stroke) •Urine and serum toxicology (drugs and alcohol) •Arterial blood gas •Lumbar puncture •Electroencephalogram (EEG)
- 28. Other Neuroimaging Techniques& Ancillary Tests • Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) • Ultrasound (Carotid Duplex, Transcranial Doppler, 2-D echo) • Conventional Angiography • Positron Emission Tomography (PET scan)
- 29. Carotid Duplex ComputedTomography
- 31.
- 32.
- 33.
- 34. 1. Time ofPatient arrives in Emergency 34 Our TIME starts now !!
- 35. 2. Evaluation byDOCTOR/RN 35
- 36. Evaluation by DOCTOR/RN •Historyof event •Vitals •Time of onset : Accurate eg. 3:19 PM. •Initiate Lab work •Neurological assessment using NIHSS. 36
- 37. National Institutes ofHealth Stroke Scale(NIHSS) •Useful in determining suitability for thrombolysis. •Useful for post thrombolysis monitoring. 37
- 38. Lab Investigation • Completehemogram • Coagulogram: INR/PT/PTI • Complete Biochemistry • Stat blood sugar 38
- 39. 3. Inform tostroke team 39 • Neurologist • Stroke Nurse Coordinator • Neuro-radiologist
- 40. NCCT CT ANGIO 40 InitiateCT Head and CT Angio of Cerebral and Neck Vessels
- 41. Thrombolysis: Golden Hour Intravenous Thrombolytic Therapy Inj. tPA (clot busting drug) Dosages: 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with 10% of the dose given as a bolus over 1 minute
- 42. Eligibility criteria • Age>18 yrs. • Diagnosis of ischemic stroke • Comes within 4½ hrs of onset • No seizure at onset of stroke • Not taking warfarin • Prothrombin time ≤15 sec • Not receiving heparin during the past 48 hours with elevated thromboplastin time • No prior intracranial haemorrhage • No major surgical procedure within 14 days
- 43. Exclusion criteria •Symptoms suggestiveof SAH. •Stroke or serious head trauma within 3 months •Major surgery or serious bodily trauma within 2 weeks •History of a prior ICH, thrombocytopenia •Use of oral anticoagulants •Patient with an NIHSS score of greater than 22.
- 44. Pre thrombolysis management •Vitals • NIHSS(national Institute of health stroke scale) • 2 IV Cannula 18 G. Preferably in Brachial Veins. • Blood tests • Stat Blood Sugar • Stat PT and INR • Urinary Catheterization. • RT Insertion. • NCCT Head and CT Angio of neck and cerebral vessels • Pt./Relatives Counseling For event, prognosis, available Best Treatment Modalities. • Informed written consent from pt./close relative. 44
- 45. BLOOD PRESSURE •If SystolicBP is >180 mm of Hg or Diastolic BP is >110 mmHg •Confirm with 2 readings 5-10 minutes apart •If persistent, Inj Labetalol 10-20 mg IV over 1-2 mins. •Repeat every 10-20 mins to a total dose of 300mg or bradycardia. 45
- 46. Complications of Thrombolysis •Anaphylaxis •Intracranialhemorrhage (ICH) •Systemic bleeding 46
- 47. Therapy for patientswith ischemic stroke not receiving t-PA • Intra arterial thrombolytics: e.g. Heparin • Antihypertensive : Are given rarely to reduce the BP in acute phase, as it acts as a compensatory mech. to perfuse the brain. • Anticoagulation : Anti platelets and Anti Thrombotic e.g. Heparin, low dose aspirin × 4 to 10 days. • Analgesic:-if headache e.g. codeine, stronger narcotics are avoided
- 48. Cont.. • Anticonvulsants :Phenytoin (dilating), phenobarbital • Elevate the head end of the bed to promote venous drainage and to lower increased ICP. • Intubation with an endotracheal tube to establish patent airway if necessary • Continuous hemodynamic monitoring. Systolic pressure should be maintained at < 180 mm hg, diastolic pressure at <100 mm hg to reduce the potential for additional bleeding.
- 49.
- 50. EMERGENCY MANAGEMENT • Oxygenation@ 2-4 l/min • Assess the level of consciousness • Maintain the patent airway • Call a stroke code or stroke team • Cardiac and pulse oximetry monitoring • IV lines • Vital sign monitoring and GCS • Anticipate thrombolytic therapy for ischemic stroke • obtain CT scan immediately • NPO • Management of blood glucose abnormalities (hyperglycemia associated with poorer prognosis) • Management of fever and infections (ischemia worsened by hyperthermia, improved by hypothermia
- 51. Medical Management • Thrombolytictherapy (within 3 hours): tissue plasminogen activator • Anticoagulants: Heparin • Antiplatelets: Aspirin, Clopidogrel • Antiepileptic • Steroids • Antihypertensives • H2 receptor blockers • Osmotic diuretics • ABC • NG insertion • Foley catheter insertion
- 52. Surgical management forischemic stroke Carotid endarterectomy Carotid stenting mechanical Thrombectomy
- 53. Surgical management forhaemorrhagic stroke Decompressive craniotomy Clipping
- 54. Post stroke careand quality measures Post stroke care consist of following continuum: •Phase 1: 3hrs-24hrs (Emergency/ Hyperacute phase) pre- hospital and emergency care protocols •Phase 2: 24-72 hrs (Acute Care) Clarifying the cause of stroke, preventing medical complications, preparation for discharge •Phase 3: Rehabilitation and secondary prevention
- 55. Intensive management PREVENTION OFCOMPLICATIONS:- •Symptoms related to presence of intracranial bleed in the patient after tPA. •Cardiac monitoring. •If spo2 <92%, supplement oxygenation 2-4L/min •If saturation persistently below 92%, ABG, CXR recommended •Treat cerebral edema, if present •Evaluate for hypoxia, hypothermia •Avoid hypotonic fluids •IV mannitol (0.25-0.50g/kg) q6h
- 56. Cont... •Anticonvulsants for patientswho have had >1 seizure •Some patients may develop infections in the rehabilitation phase of the stroke •Causes 15-25% of deaths associated with strokeMost common cause: •Aspiration secondary to dysphagia •Early mobility, good pulmonary care •Prophylactic intubation •Patients may develop incontinent bladder after the stroke •Restrict fluids in the evening
- 57. MOBILIZATION OF PATIENT:- •Keep the patient mobile after 24 hrs from the occurrences of the stroke. • Mobilize early when hemodynamically stable • Reduces atelectasis, pneumonia, DVT, PE • Nurse should monitor the first transfer from bed to upright position PREVENTION FROM DVT:- • Patient may develop DVT(2.5% and pulmonary embolism (1.2%) • Pneumatic compression devices and compression stockings • LMWH/ UFH
- 58. SKIN CARE ANDPOSITIONING:- •Skin care should be done to prevent the bed sores. •Loss of sensation, impaired circulation, old age, inability to move, depressed consciousness •Major pressure areas: heels, sacrum, Scapula. •Change position q2h •Skin- clean and dry •Special mattresses
- 59. FEEDING:- •Swallow assessment. GaggingSwallow Screen •During swallowing- choking, coughing, wet voice, delay in initiation, uncoordinated chewing or swallowing, loss of food from mouth •50% of stroke patients malnourished at 2-3 weeks after stroke •Assess- diet history, BMI, Mid arm circumference, triceps skin fold thickness •Monitor weight changes and dietary intake •Prolonged dysphagia anticipated >6 weeks: early gastrostomy feed.
- 60. PREVENTION OF RE-OCCURANCE •Itis seen that the patients have the 50% more chances of developing the second stroke after the first attack so secondary precautions is important to decrease the chances of the stroke. •Explaining stroke •Risk factors- modifiable •Compliance to medication •Lifestyle modification-DASH diet, Exercise, Moderate alcohol, smoking cessation •Warfarin use: INR 2.0-3.5, weekly-monthly INR, bleeding risk
- 61. REHABILITATION •Stroke rehabilitation isa progressive, dynamic, goal orientated process •enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative and/or social functional level. •“Getting back on own feet is likely one of top concerns after a stroke”
- 62. REHABILITATION Stroke rehabilitation mayinclude some or all of the following activities: • Therapy for communication disorders • Strengthening motor skills • Mobility training • Range of motion therapy • Constraint-induced therapy • Electrical stimulation • Virtual reality.
- 63. Prognosis •Depends upon conditionon admission • Recurrence
- 64. NURSING MANAGEMENT Nursing Assessment:- •Airway Breathing and Circulation assessment. • Neurological assessment. • Thorough history collection • Vital signs monitoring. • On-going Monitoring.
- 65. NURSING MANAGEMENT ABC Cerebral perfusion Aphasia Management Swallowing technique Care of unilateral neglect Bedsore prevention Measures to prevent bleeding (Antiplatelets/ Anticogulants) Speech therapy Coma stimulation program Physiotherapy Occupational therapy Preventive measures
- 66. Nursing Diagnosis:- • Ineffectiveairway clearanc nrelated to (R/T) unconsciousness or ineffective cough reflex • Ineffective cerebral tissue perfusion related to interruption of cerebral blood flow as evidenced by altered level of consciousness, changes in motor/sensory responses, restlessness, sensory, language, and changes in vital signs • Impaired Physical Mobility related to Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis, Perceptual/cognitive impairment as evidenced by Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength/control. • Impaired verbal Communication related to Impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle tone/control; generalized weakness/fatigue as evidenced by dysarthria, Inability to modulate speech, and Inability to produce written communication.
- 67. Nursing Diagnosis • Alteredbody temperature: hyperthermia related to disease process as evidenced by increase in temperature • Risk for impaired skin integrity, immobility and mechanical factors( shearing , friction) • Fluid and Electrolyte Imbalances related to fluid loss secondary to diarrhea • Ineffective Coping related to Situational crises, vulnerability, unknown disease pathology as evidenced by Inappropriate use of defense mechanisms, Inability to cope/difficulty asking for help, Change in usual communication patterns, Inability to meet basic needs/role expectations. • Self care deficit related to paralysis of right side of body secondary to cerebrovascular accident as evidenced by inability of patient to perform the activities of daily life.
- 68. Ineffective airway clearancerelated to (R/T) unconsciousness or ineffective cough reflex • Position to facilitate drainage oropharyngeal secretions. •Turn side to side every 2 hours. •Elevate the head of the bed to 30 degrees. •Clear secretions from the airway using suction, as necessary; provide for pulmonary hygiene. •Provide for chest physical therapy.
- 69. Ineffective cerebral tissueperfusion related to interruption of cerebral blood flow as evidenced by altered level of consciousness, changes in motor/sensory responses, restlessness, sensory, language, and changes in vital signs • Monitor vital and neurological signs. • Maintain cerebral venous outflow by elevating the head of the bed 30 degrees. • Maintain head in neutral position. • Avoid positions that increase intra-abdominal/intrathoracic pressure (hip flexion, prone position, etc. • Maintain normothermia. • Maintain blood pressure within targeted range set for sufficient cerebral perfusion pressure. • Monitor peripheral oxygenation with pulse oximeter.
- 70. Impaired physical mobilityR/T neurological deficits • Assess type and degree of impairment. •Provide slings, braces, support shoes, etc., as necessary. •Support alternative methods of mobility. •Collaborate with physical therapist to support exercise and mobility.
- 71. Impaired verbal Communicationrelated to Impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle tone/control; generalized weakness/fatigue as evidenced by dysarthria, Inability to modulate speech, and Inability to produce written communication. • Assess type of communication deficit present. •Develop and establish appropriate alternative methods for communication.
- 72. Sensory/perceptual R/T alteredconsciousness, impaired sensation, or impaired vision •Assess impact of deficits on function and safety. •Develop compensatory strategies to meet particular patient needs. •Provide for patient safety to prevent burns, injury, or falls. •For double vision, patch one eye. •Approach patient from unaffected side if homonymous hemianopsia is present. •Provide appropriate stimulation to involved areas of sense.
- 73. Risk of aspirationR/T inability to protect airway or unconsciousness • Maintain on nothing by mouth (NPO) status. • Clear with a swallow assessment before beginning oral intake. • When oral intake is resumed, take precautions to prevent aspiration (elevate head of bed, hold head up, etc.).
- 74. Risk of InfectionR/T use of invasive devices and hospitalization • Follow aseptic technique. •If urinary catheter is in place, remove as soon as possible. •Monitor intravascular device sites for infection. •Monitor chest x-ray and blood chemistries for evidence of infection.
- 75. RESEARCH STUDY • Dyslipidaemiain stroke • Aims and objects of study: To study the association of dyslipidaemia with stroke. • Study design- Retrospective cross-sectional descriptive study • Method of collection of data- A hundred patients between 30 to 90 years of age ,with first ever stroke, during a 12- month period were included in the study. History and physical examination details were collected from patient records. Laboratory investigations were also obtained . • Data Analysis- Data collected was analysed by frequency, mean, standard deviation and chi-square test.
- 76. Results: The lipidprofile of the study sample was analysed according to the ATP III classification for identification of dyslipidemia. The findings revealed that 56% of the patients had dyslipidemia . 40% had high total cholesterol, 7% had high triglycerides and only 3% had high LDL. However, 28% of the patients showed low HDL levels.10% had both high total cholesterol and low HDL. Conclusion: This study showed a significant association of 56% between dyslipidemia and stroke. Although high LDL is usually held responsible for cerebrovascular accidents, our study showed a significant proportion of patients with low HDL. Thus, besides generating Indian evidence to correlate dyslipidemia with stroke, this study upholds that primary prevention is the key to overcoming the burden of stroke in our country.
- 77. REFERENCES • Black MJoyce, Hawks Jane Hokanson. Medical-surgical nursing: clinical management for positive outcomes. 7th ed. Elsevier publishers:2005; 2107-36. • Kasper DL, Braunwald E, Fauci AS, et al, editors. Harrison’s principles of internal medicine, 16th ed. [monograph on the Internet]. New York (NY): The McGraw-Hill Companies, Inc.; 2004-2005 • Smeltzer Suzanne C, Bare Brenda G. Brunner & Suddarth’s Textbook of medical-surgical nursing. 11th ed. lippincott williams & wilkins:2009; 2206-25. • Monahan, Sands. et al. Phipp’s medical surgical nursing: health and illness perspective. 8th ed. Elsevier publishers:2007; 1861-72. • Chintamani; textbook of medical-surgical nursing; published by: Elsevier; 7th edition; page no- 1466-90 • http://www.google.co.in/?gws_rd=cr&ei=HBbHUqnQO4qJrAf8hoDIDA# q=stroke+rehabilitation+pdf