Transcript Hemorrhagic Stroke

Neuro Concept:
Cerebral Vascular Accident (CVA)
Or
Stroke
Transient Ischemic Attack “TIA”
 Transient ischemic attack
 Transient episode of neurologic
dysfunction caused by focal brain, spinal
cord, or retinal ischemia, without acute
infarction of the brain
 Symptoms last <1 hour
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Collaborative Care
Prevention
 Antiplatelet drugs are usually the
chosen treatment to prevent further
stroke in patients who have had a TIA.
 Aspirin is the most frequently used
antiplatelet agent.
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Collaborative Care
Prevention
 Surgical interventions for the patient
with TIAs from carotid disease include
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Carotid endarterectomy
Transluminal angioplasty
Stenting
Extracranial-intracranial bypass
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Carotid Endarterectomy
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Nursing Management
Education
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Health promotion
 To reduce the incidence of stroke, the nurse should focus teaching
toward stroke prevention.
 Particularly in persons with known risk factors
 Education about hypertension control and adherence to
medication
 Teaching patients and families about
 Early symptoms
 Stroke
 TIA
 When to seek health care for symptoms
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Stroke
 Stroke occurs when ischemia or
hemorrhage into the brain results in
death of brain cells
 Also known as a brain attack
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Stroke
 Functions are lost or impaired.
 Such as movement, sensation, or
emotions that were controlled by the
affected area of the brain
 Severity of the loss of function varies
according to the location and extent of
the brain involved.
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Stroke
 Third most common cause of death in
the United States and Canada
 Leading cause of serious, long-term
disability
 Approximately 35% of individuals who
have an initial stroke die within 1 year.
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Collaborative Care
Prevention
 Priority for decreasing morbidity and
mortality from stroke
 Goals of stroke prevention include
 Health promotion for the well individual
 Education and management of
modifiable risk factors to prevent a stroke
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Collaborative Care
Prevention
 Patients with known risk factors
require close management.
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Diabetes mellitus
Hypertension
Obesity
High serum lipids
Cardiac dysfunction
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Modify Risk Factors
 Most effective way to decrease the
burden of stroke is prevention.
 Risk factors can be divided into nonmodifiable and modifiable risks.
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Risk Factors
Modifiable
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Hypertension
Metabolic syndrome
Heart disease
Heavy alcohol consumption
Poor diet
Drug abuse
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Risk Factors
Nonmodifiable
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Age
Gender
Race
Heredity/family history
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Risk Factors
Modifiable
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Sleep apnea
Obesity
Physical inactivity
Smoking
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Atherosclerosis
of
Extracranial & Intracranial Arteries
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Clinical Manifestations of CVA
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Symptoms
Personality
Affect
Sensation
Communication
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Diagnostic Studies
 When symptoms of a stroke occur,
diagnostic studies are used to:
 Confirm that it is a stroke
 Identify the likely cause of the stroke
 CT is the primary diagnostic test used
after a stroke
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Diagnostic Studies
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CT
MRI
Angiography
Transcranial Doppler
LICOX
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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Diagnostic Studies
 For cardiac assessment
 Electrocardiogram
 Chest x-ray
 Cardiac enzymes
 Echocardiography
 Holter monitor
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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Types of Stroke
 Strokes are classified on the basis of
underlying pathophysiologic findings.
 Ischemic (thrombotic & embolic)
 Hemorrhagic
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Major Types of Stroke
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Ischemic Stroke
 Ischemic strokes result from
 Inadequate blood flow to the brain from
partial or complete occlusion of an artery
 Ischemic strokes can be
 Thrombotic
 Embolic
 80% of all strokes are ischemic strokes.
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Thrombotic Stroke
 Thrombotic stroke
 Thrombosis occurs in relation to injury to
a blood vessel wall and formation of a
blood clot.
 Result of thrombosis or narrowing of the
blood vessel
 Most common cause of stroke
 Lacunar strokes are typically
asymptomatic.
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Embolic Stroke
 Embolic stroke
 Occurs when an embolus lodges in and
occludes a cerebral artery
 Results in infarction and edema of the
area supplied by the involved vessel
 Second most common cause of stroke
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Embolic Stroke Manifestations
 Embolic stroke
 Patient with an embolic stroke commonly
has a rapid occurrence of severe clinical
symptoms.
 Onset of embolic stroke is usually sudden
and may or may not be related to activity.
 Patient usually remains conscious,
although he may have a headache.
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Hemorrhagic Stroke
 Account for approximately 15% of all
strokes
 Result from bleeding into the brain
tissue itself or into the subarachnoid
space or ventricles
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Hemorrhagic Stroke
 Intracerebral hemorrhage
 Often a sudden onset of symptoms, with
progression over minutes to hours because of
ongoing bleeding
 Bleeding within the brain caused by rupture of a
vessel
 Hypertension is the most important cause.
 Hemorrhage commonly occurs during periods
of activity
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Hemorrhagic Stroke
 Intracerebral hemorrhage
 Manifestations
 Neurologic deficits
 Headache
 Nausea and/or vomiting
 Decreased levels of consciousness
 Hypertension
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Hemorrhagic Stroke
 Subarachnoid hemorrhage
 Intracranial bleeding into cerebrospinal
fluid–filled space between the arachnoid
and pia mater
 Commonly caused by rupture of a
cerebral aneurysm
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Hemorrhagic Stroke
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Hemorrhagic Stroke
 Subarachnoid hemorrhage
 An aneurysm may be saccular or berry.
 Majority of aneurysms are in the circle
of Willis.
 “Worst headache of one’s life”
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Hemorrhagic Stroke
 Subarachnoid hemorrhage
 Most frequent surgical procedure to
prevent rebleeding is clipping of the
aneurysm.
 Coiling is another procedure.
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Clinical Manifestations
Hemorrhagic CVA
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Affects many body functions
Motor activity
Elimination
Intellectual function
Spatial-perceptual alterations
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Manifestations of CVA Left & Right
Clinical Manifestations
Motor Function
 Most obvious effect of stroke
 Include impairment of
 Mobility
 Communication
 Respiratory function
 Swallowing and speech
 Gag reflex
 Self-care abilities
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Clinical Manifestations
Motor Function
 Characteristic motor deficits
 Loss of skilled voluntary movement
 Impairment of integration of movements
 Alterations in muscle tone
 Alterations in reflexes
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Clinical Manifestations
Motor Function
 An initial period of flaccidity
 May last from days to several weeks
 Related to nerve damage
 Spasticity of the muscles follows the
flaccid stage.
 Related to interruptions in upper motor
neuron influence
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Clinical Manifestations
Communication
Aphasia is the loss of comprehension and use of language
 Expressive aphasia (non-fluent): With expressive aphasia,
the person knows what he or she wants to say, yet has
difficulty communicating it to others. It doesn't matter
whether the person is trying to say or write what he or she is
trying to communicate.
 Receptive aphasia (fluent): With receptive aphasia, the
person can hear a voice or read the print, but may not
understand the meaning of the message. Oftentimes,
someone with receptive aphasia takes language literally.
Their own speech may be disturbed because they do not
understand their own language
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Aphasia Types Continued
 Anomic aphasia. With anomic aphasia, the person has word-
finding difficulties. This is called anomia. Because of the
difficulties, the person struggles to find the right words for
speaking and writing.
 Global aphasia. This is the most severe type of aphasia. It is
often seen right after someone has a stroke. With global
aphasia, the person has difficulty speaking and
understanding words. In addition, the person is unable to
read or write.
Clinical Manifestations
Communication
 Many patients experience dysarthria.
 Disturbance in the muscular control of
speech
 Impairments may involve
 Pronunciation
 Articulation
 Phonation
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Clinical Manifestations
Affect
 Patients who suffer a stroke may have
difficulty controlling their emotions.
 Emotional responses may be
exaggerated or unpredictable.
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Clinical Manifestations
Intellectual Function
 Both memory and judgment may be
impaired as a result of stroke.
 A left-brain stroke is more likely to
result in memory problems related to
language (refer to aphasia slides)
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Clinical Manifestations
Spatial–Perceptual Alterations
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Stroke on the right side of the brain is more likely to cause problems
in spatial-perceptual orientation
 Left hemiplegia may result in problems with spatial-perceptual tasks:
ability to judge distance, size, position, rate of movement, form and how
parts relate to wholes
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People with severe spatial-perceptual deficits may have more trouble
with self-care than those with equally severe language deficits. They may
not be able to read a paper - because they lose their place on the page.
 Quick and impulsive behavior results in overestimating their abilities
 They are often unaware of their deficits, and may think themselves
capable of tasks they really are not capable of
 These alterations may also occur with left-brain stroke
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Clinical Manifestations
Spatial-Perceptual Alterations
 Spatial-perceptual problems may be
divided into four categories.
1 Incorrect perception of self and illness
2 Erroneous perception of self in space
3 Inability to recognize an object by sight,
touch, or hearing
4 Inability to carry out learned sequential
movements on command
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Clinical Manifestations
Elimination
 Most problems with urinary and bowel
elimination occur initially and are
temporary.
 When a stroke affects one hemisphere
of the brain, the prognosis for normal
bladder function is excellent.
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Brain Stent
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Nursing Management
Nursing Assessment
 If the patient is stable, obtain
 Description of the current illness with
attention to initial symptoms
 History of similar symptoms previously
experienced
 Current medications
 History of risk factors and other illnesses
 Family history of stroke or cardiovascular
disease
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Collaborative Care
Acute Care
 Goals for collaborative care during the
acute phase are
 Preserving life
 Preventing further brain damage
 Reducing disability
 Treatment differs according to type of
stroke and as patient changes.
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Collaborative Care
Acute Care
 Begins with managing the ABCs
 Airway
 Breathing
 Circulation
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Collaborative Care
Acute Care
 Recognize Causes
 Sudden vascular compromise causing
disruption of blood flow to the brain
 Thrombosis
 Trauma
 Aneurysm
 Embolism
 Hemorrhage
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Collaborative Care
Acute Care
 Assessment findings
 Altered level of consciousness
 Weakness, numbness, or paralysis
 Speech or visual disturbances
 Severe headache
 ↑ or ↓ heart rate
 Respiratory distress
 Unequal pupils
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Collaborative Care
Acute Care
 Assessment findings
 Hypertension
 Facial drooping on affected side
 Difficulty swallowing
 Seizures
 Bladder or bowel incontinence
 Nausea and vomiting
 Vertigo
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Collaborative Care
Acute Care
 Interventions: initial
 Ensure patent airway.
 Call stroke code or stroke team.
 Perform pulse oximetry.
 Maintain adequate oxygenation.
 Obtain IV access with normal saline.
 Maintain BP according to guidelines.
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Collaborative Care
Acute Care
 Interventions: initial
 Remove clothing.
 Obtain CT scan immediately.
 Perform baseline laboratory tests.
 Position head midline.
 Elevate head of bed 30 degrees if no
symptoms of shock or injury occur
 Institute seizure precautions.
 Anticipate thrombolytic therapy for
ischemic stroke.
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Collaborative Care
Acute Care
 Hypertension is common immediately
after stroke.
 Drugs to lower BP are used only if BP is
markedly increased.
 Fluid and electrolyte balance must be
controlled carefully.
 Adequate hydration promotes perfusion
and decreases further brain injury.
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Collaborative Care
Acute Care
 Interventions: ongoing
 Monitor vital signs and neurologic status.
 Level of consciousness
 Monitor and sensory function
 Pupil size and reactivity
 O2 saturation
 Cardiac rhythm
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Nursing Management
Nursing Implementation
 Respiratory system
 Management of the respiratory system is
a nursing priority.
 Risk for atelectasis
 Risk for aspiration pneumonia
 Risks for airway obstruction
 May require endotracheal intubation and
mechanical ventilation
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Collaborative Care
Acute Care
 Recombinant tissue plasminogen
activator (tPA)
 Used to reestablish blood flow through a
blocked artery to prevent cell death in
patients with acute onset of ischemic
stroke symptoms
 Must be administered within 3 to 4.5
hours per qualifying criteria- of onset of
clinical signs of ischemic stroke
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Collaborative Care
Acute Care
 Aspirin is used within 24 to 48 hours of
stroke.
 Platelet inhibitors and anticoagulants
may be used in thrombus and embolus
stroke patients after stabilization.
 Contraindicated for patients with
hemorrhagic stroke
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Merci Embolus Retriever in Cerebral Ischemic
Stroke
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Nursing Management
Nursing Assessment
 Comprehensive neuro examination
 Level of consciousness
 Cognition
 Motor abilities
 Cranial nerve function
 Sensation
 Proprioception
 Cerebellar function
 Deep tendon reflexes
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Nursing Management
Nursing Diagnoses
 Risk for ineffective cerebral tissue
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perfusion
Ineffective airway clearance
Impaired physical mobility
Impaired verbal communication
Unilateral neglect
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Nursing Management
Nursing Diagnoses
 Impaired urinary elimination
 Impaired swallowing
 Situational low self-esteem
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Nursing Management
Nursing Implementation
 Neurologic system
 Monitor closely to detect changes
suggesting
 Extension of the stroke
 ↑ ICP
 Vasospasm
 Recovery from stroke symptoms
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Nursing Management
Nursing Implementation
 Cardiovascular system
 Goals aimed at maintaining homeostasis
 Many patients with stroke have
decreased cardiac reserves from the
secondary diagnoses of cardiac disease.
 Cardiac efficiency may be compromised.
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Nursing Management
Nursing Implementation
 Cardiovascular system
 Nursing interventions
 Monitoring vital signs frequently
 Monitoring cardiac rhythms
 Calculating intake and output, noting
imbalances
 Regulating IV infusions
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Nursing Management
Nursing Implementation
 Cardiovascular system
 After stroke, patient is at risk for deep
vein thrombosis.
 Related to immobility, loss of venous tone,
and ↓ muscle pumping in leg
 Most effective prevention is keeping the
patient moving.
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Nursing Management
Nursing Implementation
 Musculoskeletal system
 Goal is to maintain optimal function.
 Accomplished by the prevention of joint
contractures and muscular atrophy
 In the acute phase, range-of-motion
exercises and positioning are important.
 Paralyzed or weak side needs special
attention when positioned.
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Nursing Management
Nursing Implementation
 Musculoskeletal system
 Trochanter roll at hip to prevent external
rotation
 Hand cones to prevent hand contractures
 Arm supports with slings and lap boards
to prevent shoulder displacement
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Nursing Management
Nursing Implementation
 Musculoskeletal system
 Avoidance of pulling the patient by the
arm to prevent shoulder displacement
 Posterior leg splints, footboards, or
high-topped tennis shoes to prevent foot
drop
 Hand splints to reduce spasticity
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Nursing Management
Nursing Implementation
 Integumentary system
 Susceptible to breakdown related to
 Loss of sensation
 Decreased circulation
 Immobility
 Compounded by patient age, poor
nutrition, dehydration, edema, and
incontinence
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Nursing Management
Nursing Implementation
 Integumentary system
 Pressure relief by position changes,
special mattresses, or wheelchair
cushions
 Good skin hygiene
 Emollients applied to dry skin
 Early mobility
 Position patient on the weak or paralyzed
side for only 30 minutes.
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Nursing Management
Nursing Implementation
 Gastrointestinal system
 Stress of illness contributes to a catabolic
state that can interfere with recovery.
 Constipation is the most common bowel
problem.
 Patients may be placed on stool softeners
or fiber prophylactically.
 Physical activity promotes bowel
function.
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Nursing Management
Nursing Implementation
 Urinary system
 In the acute stage, poor bladder control
results in incontinence.
 Efforts should be made to promote
normal bladder function.
 Avoid the use of indwelling catheters.
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Nursing Management
Nursing Implementation
 Nutrition
 Nutritional needs require quick
assessment and treatment.
 May initially receive IV infusions to
maintain fluid and electrolyte balance
 May require nutritional support
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Nursing Management
Nursing Implementation
 Nutrition
 First feeding should be approached
carefully.
 Test swallowing, chewing, gag reflex, and
pocketing before beginning oral feeding.
 Feedings must be followed by oral
hygiene.
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Nursing Management
Nursing Implementation
 Communication
 Nurse’s role in meeting psychologic needs
of the patient is primarily supportive.
 Patient is assessed for both the ability to
speak and the ability to understand.
 Speak slowly and calmly, using simple
words or sentences.
 Gestures may be used to support verbal
cues.
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Nursing Management
Nursing Implementation
 Sensory-perceptual alterations
 Blindness in same half of each visual field
is a common problem after stroke.
 Known as homonymous hemianopsia
 Other visual problems may include
 Diplopia (double vision)
 Loss of the corneal reflex
 Ptosis (drooping eyelid)
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Homonymous Hemianopsia
(Food on left side is not seen)
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Nursing Management
Nursing Implementation
 Coping
 CVA is often a “family disease”
 Affects family
 Emotionally
 Socially
 Financially
 Changing roles and responsibilities
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Nursing Management
Nursing Implementation
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Coping
 Explain
 What has happened
 Diagnosis
 Therapeutic procedures
 Should be clear and understood by patient
 Patient’s family should be given a careful, detailed explanation of
what has happened to the patient.
 Family members usually have not had time to prepare for the
illness—social services referral is often helpful
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Collaborative Care
Rehabilitation
 After stroke has stabilized for 12 to 24
hours, collaborative care shifts from
preserving life to lessening disability
and attaining optimal functioning
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Ideally, discharge planning with the
patient and family starts early in the
hospitalization and promotes a smooth
transition from one care setting to
another.
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Patient is usually discharged from the
acute care setting to home, an
intermediate or long-term care facility, or
a rehabilitation facility.
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Nurse initially emphasizes
musculoskeletal functions of
 Eating
 Toileting
 Walking
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Nurses have an excellent opportunity to
prepare the patient and family for
discharge through
 Education
 Demonstration
 Practice
 Evaluation of self-care skills
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Nursing Management
Nursing Implementation/Collaborative Care
 Ambulatory and Home Care
 Rehabilitation is the process of
maximizing the patient’s capabilities and
resources to promote optimal
functioning.
 Physical, mental, and social well-being
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 The rehabilitation nurse assesses the
patient and family for
 Rehabilitation potential of the patient
 Physical status of all body systems
 Presence of complications caused by the
stroke or other chronic conditions
 Cognitive status of the patient
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 The rehabilitation nurse assesses the
patient and family for:
 Family resources and support
 Expectations of the patient and family related
to the rehabilitation program
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Rehabilitation goals are mutually set by
 Patient
 Family
 Nurse
 Other members of rehabilitation team
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Rehabilitation goals
 Learn techniques to self-monitor and
maintain physical wellness.
 Demonstrate self-care skills.
 Exhibit problem-solving skills with self-care.
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Rehabilitation goals
 Avoid complications associated with stroke.
 Establish and maintain a useful
communication system.
 Maintain nutritional and hydration status.
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Rehabilitation goals
 List community resources for equipment,
supplies, and support.
 Establish flexible role behaviors to promote
family cohesiveness.
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 If muscles are still flaccid several weeks
after the stroke, prognosis for regaining
function is poor.
 Focus of care is on preventing additional
loss.
 Most patients begin to show signs of
spasticity with exaggerated reflexes
within 48 hours following the stroke.
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Loss of Postural Stability
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Musculoskeletal interventions
 Balance training
 Transferring from bed to chair
 Bobath method or constraint-induced
movement therapy may be used in
musculoskeletal rehabilitation.
 CIMT is a more recent approach.
97
Nursing Management
Nursing Implementation
 Ambulatory and home care
 After acute phase, a dietitian can assist in
determining appropriate daily caloric
intake based on the patient’s
 Size
 Weight
 Activity level
98
Nursing Management
Nursing Implementation
 Ambulatory and home care
 Nurse and speech therapist must assess
ability of patient to swallow solids and
fluids and must adjust the diet
appropriately.
 Inability to feed oneself can be frustrating
and may result in malnutrition and
dehydration.
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Assistive Devices for Eating
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Interventions to promote self-feeding
 Removing unnecessary items from tray or
table, reducing spills
 Providing a nondistracting environment to
reduce sensory overload with distraction
101
Nursing Management
Nursing Implementation
 Ambulatory and home care
 Patients with stroke on right side of brain
 Difficulty in judging position, distance, and
movement
 Impulsive, impatient, and denying problems
related to stroke
 Respond best to directions given verbally
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Patients with stroke on left side of brain
 Slower in organization and performance of
tasks
 Impaired spatial discrimination
 Have fearful, anxious response to stroke
 Respond well to nonverbal cues
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Interventions for atypical emotional
response
 Distract the patient.
 Explain that emotional outbursts may occur.
 Maintain a calm environment.
 Avoid shaming or scolding patient.
104
Nursing Management
Nursing Implementation
 Ambulatory and home care
 Patients with a stroke may be coping with
many losses (i.e., sensory, intellectual).
 Often go through the process of grief
 Some patients experience long-term
depression.
105
Nursing Management
Nursing Implementation
 Ambulatory and home care
 Nurse may assist the coping process.
 Support communication between the patient
and family.
 Discuss lifestyle changes.
 Discuss changing roles within the family
 Be an active listener.
 Include family in goal planning and patient
care.
 Support family conferences
106
Nursing Management
Nursing Implementation
 Ambulatory and home care
 Implement a bowel management
program for problems with
 Bowel control
 Constipation
 Incontinence
 High-fiber diet and adequate fluid intake
107
Collaborative Care
 Ambulatory and home care
 Speech, comprehension, and language
deficits are the most difficult problem for
the patient and family.
 Speech therapists can assess and
formulate a plan to support
communication.
108
Nursing Management
Planning
 Goals are that the patient will:
 Maintain stable or improved level of
consciousness
 Attain maximum physical functioning
 Maximize self-care abilities and skills
 Maintain stable body functions
 Maximize communication abilities.
 Avoid complications of stroke.
 Maintain effective personal and family
coping.
109
Nursing Management
Nursing Implementation/Education
 Ambulatory and home care
 Family members must cope with these
aspects of patient’s behavior:
1. Recognition of behavioral changes resulting
from neurologic deficits that are not
changeable
2. Responses to multiple losses by both the
patient and the family
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Nursing Management
Nursing Implementation
 Ambulatory and home care
 Stroke support groups within rehab
facilities and community are helpful.
 Mutual sharing
 Education
 Coping
 Understanding
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