Transcript Adult Medical-Surgical Nursing 2

Adult Medical-Surgical
Nursing
Neurology Module:
Cerebrovascular Disease II:
Stroke
Stroke: Definition
Stroke is a sudden loss of brain function
resulting from disruption of the blood
supply to a part of the brain
Stroke is considered as an emergency
condition requiring acute management
A longterm recovery and rehabilitation
period is often necessary involving the
patient’s family
Stroke: Physiological Effects
Loss of blood supply in stroke may be
temporary or permanent
Stroke leads to loss of:
Movement (motor) including swallowing
Thought (cognitive function)
Memory
Speech
Sensation (sensory activity)
Stroke: Aetiology
Hypertension
Cerebral atherosclerosis
Family history
High cholesterol; Obesity
Lack of exercise; Smoking
Malformation of a cerebral vessel,
aneurysm
Drug misuse: amphetamines, cocaine
Trauma ; (also brain tumour: non-acute)
Stroke: Classification
Ischaemic stroke
Haemorrhagic stroke
(A tumour as a space-occupying lesion
may give gradual symptoms of stroke non-acute)
Ischaemic Stroke: Pathophysiology
The blood supply to part of the brain is
disrupted by:
A thrombus in a large (Carotid) or more
commonly a smaller cerebral vessel
An embolus related to cardiac
dysrhythmias (should be prevented by
long-term anticoagulants)
Prolonged ischaemia from vasospasm,
migraine, cocaine abuse, severe
atherosclerosis, DIC
Haemorrhagic Stroke:
Pathophysiology
Rupture of a cerebral blood vessel leading
to haemorrhage, loss of blood supply and
also increased intra-cranial pressure from
a space-occupying bleed:Intra-cerebral (arterial into brain tissue)
Sub-arachnoid (rapid arterial into CSF;
associated with vasospasm/ ischaemia)
Subdural (venous, slow haematoma)
Epidural (arterial, related to trauma)
Stroke: Clinical Manifestations
Clinical manifestations depend on the site
of brain damage and on the amount of
compensatory collateral circulation
Stroke: Clinical Manifestations
May be loss of consciousness (initial or
prolonged)
Initial pyrexia (inflammation and cerebral
oedema)
Confusion, restlessness, altered mental
status
Emotional lability, frustration, depression
Stroke: Clinical Manifestations
(cont)
Sensory and motor loss from numbness
and weakness of the face to the arm, leg,
whole side (hemiparesis/ hemiplegia). At
first flaccid; later spasticity with ↑ reflexes
Aphasia, dysphagia
Visual disturbance
Sudden severe headache
Focal symptoms: seizures
Dizziness, loss of balance
Stroke: Clinical Manifestations
(cont)
Stroke is an upper motor neurone lesion
(brain and spinal cord)
Leads to loss of voluntary motor control
As upper motor neurones decussate
(cross) at the level of the Pons, the effects
are on the opposite side of the body
Stroke: Clinical Manifestations
(cont)
Lesion of left cerebral hemisphere → rightsided effects: right-sided sensory and
motor disturbance, dysphagia, aphasia
and difficulty in understanding, right visual
field defect
Lesion of right hemisphere → left-sided
effects: left-sided sensory and motor
disturbance,↑ distractibility, ↓ awareness,
left visual field defect
Stroke: Diagnosis
History and clinical picture on examination
CT or MRI scan identifies:
Ischaemic or haemorrhagic
Site and extent of the problem
Carotid doppler/ cerebral angiography
ECG (dysrhythmias)
Skull/ cervical Xray if trauma suspected
Lipids, LFT, KFT, CBC, blood coagulation
Stroke: Complications
The area of injury may extend by:
Further haemorrhage
Extension of thrombus formation
→ further cerebral ischaemia or infarct
Therefore all attempts made to prevent
this by prompt action
Stroke: Initial Assessment
Stroke is an acute emergency
MRI performed:
If haemorrhagic stroke, urgent surgery
performed
If thrombus or embolus diagnosed,
optimally urgent thrombolytic agent or
thrombectomy with stent / anticoagulation
Stroke: Initial Medical Management
Adequate humidified O2
Adequate hydration to maintain BP and
perfusion, reduce viscosity
(Avoid hypotension → ischaemia;
avoid hypertension → haemorrhage)
Adequate haemoglobin
Prompt assessment to determine
treatment
Stroke: Medications in Acute Stage
Vasodilator to improve blood flow
(Norvasc, Nitroprusside)
Controlled anti-hypertensives
Anticoagulant, antiplatelet, prompt
thrombolytics via infusion pump
Vitamin B Complex and B12 ↑conductivity
Maybe anticonvulsant or Dexamethasone
H2 receptor inhibitor (avoid stress ulcer)
Stroke: Surgery
If stroke is related to a sub-dural or
epidural haematoma:
Surgical drainage via burr-holes or
craniotomy performed to correct
intracranial pressure
If sub-arachnoid haemorrhage:
Ablation therapy may be performed to seal
and avoid recurrence
Stroke: Nursing Assessment and
Monitoring in Acute Stage
Glasgow Coma Scale: orientation if
conscious
Eyes opening on command
Equal pupils and reactivity to light
Ability to speak
Muscle tone: degree of spasticity
Voluntary/ involuntary movement
Vital signs
Fluid balance
Stroke:
Nursing Care in Acute Stage
Air mattress, elevate head 30o / tilt 45o
Change position 2-hourly if possible, avoid
dragging (friction), creases in sheets
Natural position; bolster prevents footdrop
Passive exercise of all limbs, full range of
movement (to improve circulation and to
prevent DVT, muscle atrophy, stiff joints)
Chest physio/ suction/ care of airways
Stroke:
Nursing Care in Acute Stage (cont)
Hygiene: clean, dry but moisturised skin
Mouthcare: moist, clean mouth to prevent
thrush, lubricate lips
Cleanse and instill drops like artificial tears
to moisten cornea if unconscious; it is
good to close the eyes sometimes
Care of Foley catheter; bowel care
Temperature regulation (fan, tepid
sponging, extra cover as required)
Caring for the Person and Family
Mental stimulation and emotional support
Respect and privacy
Care and emotional support of the family
Listen to their expressed fears
Encourage them to help with care as this
is therapeutic for them
Stroke:
Recovery and Rehabilitation
Mental stimulation/ emotional support
Speech therapy
Physiotherapy to strengthen muscles and
mobility of limbs, joints, prevent deformity
Ensure good nutrition and hydration:
assess ability to swallow, process food
Bowel and bladder care. Hygiene: assist
self-care using unaffected limb; oral care
Importance of rest and sleep (repair)