2. Ideally, people who have had a stroke are
admitted to a "stroke unit", a ward or dedicated
area in hospital staffed by nurses and therapists
with experience in stroke treatment. It has been
shown that people admitted to a stroke unit
have a higher chance of surviving than those
admitted elsewhere in hospital, even if they are
being cared for by doctors without experience in
stroke.

3. PHYSICAL EXAMINATION(may include
Glasgow Coma Scale)
BLOOD TEST
CT Scan
ANGIOGRAPHY
ELECTROENCEPHALOGRAPHY
MRI

4. Approaches in stroke vary widely because of the huge
variety of presentations. They will depend on:
The site of occlusion or aneurismal rapture
The degree and extent of the ischemia or haemorrhage
The effectiveness of medical and nursing intervention
The patient’s response
The aims are to prevent further brain damage, reduce
the risk factors, provide supportive care and regain
functional independence.

5. CONSERVATIVE MANAGEMENT – is as follows:
ANTICOAGULANTS therapy has been used in attempt to halt further
deterioration and improve the patient’s recovery. E.g. warfarin, although
doubt has been cast on the usefulness of anticoagulant as it poses a risk of
further heamorrhage into the infracted brain.
ANTIFIBRONOLYTIC agents have been used in patients following
subarachnoid haemorrhage. Their use is thought to prevent re-bleeding
by delaying dissolution of the clot around the aneurysm, but their effort
on the overall outcome is questionable.
ANTIPLATELETAGENT – The use of aspirin as an anti platelet agent has
received attention in recent years.
Other factors – pre-existing contributory disorders may be treated with drugs
therapy, e.g. antihypertensive agents and diuretics may be used in the
patient with raised blood pressure

6. Carotid endarterectomy, which involves the
removal of stenosing or ulcerating atheromatous
lesions at the bifurcation of the common carotid
arteries.
A superficial temporal to middle cerebral artery
anastomosis , which provides an artificial
collateral blood supply to the affected part of the
brain.

7. NURSING PRIORITIES AND MANAGEMENT
Prevention: One of the most important aspect of
stroke management is prevention, by identifying
at-risk individuals and dealing with early
predisposing factors such as hypertension.

8. The following factors put people at greater risk of
having stroke, but action can be taken to
reduce the likelihood of stroke occurring:

9. Hypertension – Using antihypertensive drugs
does reduce the risk of a stroke. Blood pressure
should be checked periodically, e.g. every 4 years
until the age of 40, and every 2 years after that.
Moderation in alcohol consumption is advised as it
raises blood pressure.
Cigarette Smoking – Daily cigarette smoking can
increase the risk of stroke by two and half times.
Smokers should therefore be encouraged to stop
smoking, and young people discouraged from
starting to smoke.

10.  Hypercholesterolaemia – may lead to
coronary heart disease. Patient with
hyperchoresterolaemia can reduce the amount of
cholesterol-rich food they take.
 Obesity – may increase the likelihood of
hypertension. At-risk patients should control their
weight.
 Diabetic patients – are more likely to have a
stroke, so the level of sugar in the blood and urine
should be checked regularly.
 The contraceptive pill – increases the risk of
stroke in young women, particularly if there is a
family history of arterial disease. Other forms of
contraception are therefore more suitable.

11. A successful outcome is more likely
when the optimum techniques and
resources are utilized, encompassing
every member of the multidisciplinary
team. The outcome can also be
influenced by other factors such as
recognizing the need to start the
rehabilitation process as soon as possible.

12. The initial plan for the management of a patient
with acute stroke is to control vital signs, prevent
deterioration of the patient, and prevent medical
complications of the stroke that worsen the patient’s
outcome. Medical complications include respiratory
failure, hypertension, hyperglycemia, cerebral
edema, and fever. The nurse caring for the patient
must coordinate the activities of an interdisciplinary
team to provide high-quality

13. Nurses are generally responsible for ensuring
that risk assessments are carried out soon after
patient admission. These can include assessing
the risks of moving and handling, nutrition,
pressure ulcers, falls and DVT. Each hospital
will have its own policy on which assessments
need to be carried out and which tools should
be used.

14. AIRWAYS – Techniques for maintaining a patent
airway and adequate ventilation are a priority. An
oxygen saturation monitor should be used to
evaluate the patient’s oxygenation. If the patient’s
oxygen saturation is less than 90%, the patient should
be placed on oxygen titrated at 2–4 liters per minute
to maintain an oxygen saturation of 90%. Arterial
blood gases and a chest film should be obtained if a
saturation of >90% cannot be obtained.

15. Neurological assessment and blood pressure should
be checked every 15 minutes for the first 2 hours,
every 30 minutes for the next 6 hours, and then
every hour for the next 16 hours(Adams et al., 2007).
Generally, BP is not treated in ischemic stroke until it
is greater than 220/120 mm Hg. Rapid lowering of
BP can dramatically decrease cerebral perfusion and
worsen the infarction. If the patient has a decreased
LOC, the Glasgow Coma Scale (GCS) can be used to
evaluate him or her.

16. COMMUNICATING – Speech impairment or
loss can be a frightening experience for the
patient and his family. Early referral to a speech
therapist is important in order for an expert
assessment can be performed and a strategy
identified. It is crucial to ascertain the type and
nature of the speech deficit, e.g. whether the
patient’s difficulties are related to expression or
comprehension.

17. Glasgow Coma Scale
Eye Opening Response
• Spontaneous--open with blinking at baseline 4 points
• To verbal stimuli, command, speech 3 points
• To pain only (not applied to face) 2 points
• No response 1 point
Verbal Response
• Oriented 5 points
• Confused conversation, but able to answer questions 4 points
• Inappropriate words 3 points
• Incomprehensible speech 2 points
• No response 1 point
Motor Response
• Obeys commands for movement 6 points
• Purposeful movement to painful stimulus 5 points
• Withdraws in response to pain 4 points
• Flexion in response to pain (decorticate posturing) 3 points
• Extension response in response to pain (decerebrate posturing) 2 points
• No response 1 point

18.  EATING AND DRINKING
Initially the patient’s fluid intake is likely to be via
IV infusion(this maintains arterial BP and, in turn,
prevents cerebral ischemia and infarction)
Maintain accurate fluid balance
Subsequently, oral diet – through NG tube or as
the case may be, will be introduced
Regular oral inspection and oral hygiene should
be carried out.

19. Bedside videofluoroscopic and endoscopic studies:
These tests allow direct visualization of the
laryngopharyngeal structure while the patient is given a
variety of dyed food textures and consistencies.
Both tests are used to evaluate for pooling, spillage,
endotracheal penetration, and aspiration. After these
tests, the radiologist can make recommendations for safe
food and liquid consistency. Patients who are aspirating
or are at risk for aspiration with all types of food and
liquids should receive nutrition through a soft feeding
tube until swallowing is feasible. Weight should be
monitored at least once weekly to assess for adequacy of
nutrition.

20.  ELIMINATION – Interruption of the patient’s
elimination pattern is due to loss of
consciousness and enforced immobility.
Urinary incontinence is best dealt with by
retraining the patient to use bedpans or urinals
at specified intervals, rather than resorting to
catheterization. Condom-type urinary
appliances may be suitable for male patients,
but no successful female equivalent is yet
available.

21.  REHABILITATION - is the process by which those
with disabling strokes undergo treatment to help
return to normal as much as possible regaining and
learning the skills of everyday living. It also aims to
help the survivor understand and adapt to difficulties,
prevents secondary complication and educates family
to play a supporting role. It’s usually multidisciplinary
as it involves staff with different skills working
together to help the person. These include nursing
staff, physiotherapists, occupational therapists, speech
and language therapists, orthotists and usually a
physician trained in rehabilitation medicine. Some
teams may include psychologists, social workers, and
pharmacists. Validated instrument such as the Barthel
Scale may be used to assess the likelihood of a stroke
patient being managed at home with or without
support subsequent to discharge from hospital.

23.  EPIDEMIOLOGY
Stroke was the 2nd most frequent cause of death
worldwide in 2008, accounting for 6.2 million deaths (11% of
total). Approximately, 9 million people had stroke in 2008 and
30 million people have previously had stroke and are still alive.
It is ranked after heart diseases and before cancer. On average, a brain
attack occur every 45 second, and every 3.1 minutes, someone dies of a
stroke.
In the United States, stroke is a leading cause of disability and
the 4th leading cause of death.
The incident of stroke increases exponentially from 30 years of age,
and etiology varies by age. Advanced age is one of the most
significant stroke factor. 95% of stroke occur in people age 45 and
older, and two-thirds of strokes occur in those over the age of 65.
Stroke can occur at any age, including childhood.
Men are 25% more likely to suffer stroke than women, yet 60% of
deaths from stroke occur in women. Since women live longer, they are
older on average when they have their strokes and thus more often killed.

24.  PROGNOSIS Disability affects 75% of stroke
survivors enough to decrease their employability.
Stroke can affect people physically, mentally,
emotionally, or a combination of the three. The
result of stroke vary widely depending on size or
location. Dysfunction corresponds to areas in the
brain that have been affected.
Some of the physical disabilities that can result
from stroke include muscle weakness, numbness,
pressure sores, pneumonia, incontinence, apraxia
(inability to perform learned movement),
difficulties carrying out daily activities, appetite
loss, speech loss, vision loss and pain. If the stroke
is severe enough, or in a certain location such as
parts of the brain-stem, coma or death can result.

25. Emotional problem resulting from stroke can
result from direct damage to emotional centres in
the brain or from frustration and difficulty
adapting to new limitations.
30 – 50% of stroke survivors suffer post stroke
depression, which is characterized by lethargy,
irritability, sleep disturbance, lowered self esteem,
and withdrawal. Cognitive deficits resulting from
stroke include perceptual disorders, aphasia,
dementia, and problems with attention and
memory. A stroke patient may be unaware of his
or her disabilities, a condition called anosognosia.
In a condition called hemispattial neglect, a patient
is unable to attend to anything o the side of space
opposite to the damaged hemisphere. `

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