Nursing Care of Clients with Stroke

Stroke

AKA

Cerebrovascular accident

Cerebral Infarction

Brain attack

2/13/2014 Maria Carmela Domocmat, MSN, RN

Definition:

decreased blood supply to the brain

Sudden loss of function resulting from a

disruption of the blood supply to a part of

the brain

Functional abnormality of the CNS that

occurs when the blood supply is disrupted


Incidence

700K stroke/year 500K: first attacks

200K: recurrent attacks

87% are ischemic

Others: intracerebral and subarachnoid hemorrhagic strokes


Incidence

On average, every _____ seconds someone in the United States has a stroke

Who has more stroke incidence? Men or women?

Each year, about 46K more women than men have a stroke.

Male:Female ratio 1.25:1

Ratio reverses after age 80

One in ____ strokes is a recurrent stroke, and the risk for a second stroke is highest during the first ____days after the first ischemic symptoms

2/13/2014

45

4 30

Maria Carmela Domocmat, MSN, RN

Phil Stat

April 2011 Stroke Deaths in Philippines

reached 40,245 or 9.55% of total deaths.

#3 in the top 20 causes of death in the

country

The age adjusted Death Rate is 82.77

per 100,000 of population ranks

Philippines is #106 in the world


http://www.worldlifeexpectancy.com/philippines-stroke

Mortality

Stroke accounted for about 1 of every ____ deaths in the United States in 2004.

About _____of stroke deaths in 2003 occurred out of hospital.

When considered separately from other CVDs, stroke ranks _______among all causes of death, behind diseases of the heart and cancer.

2/13/2014

16

No. 3

50%


Mortality

Among persons 45 to 64 years of age, 8-12% of ischemic strokes and 37-38% of hemorrhagic strokes result in death within 30 days.

2/13/2014

•On average, every 3 - 4 minutes someone dies of a stroke


Mortality

From 1994 to 2004, the stroke death rate fell 20.4%, and the actual number of stroke deaths declined 6.7%


Mortality

From 1995 to 1998, mortality rates for subarachnoid hemorrhage, and intracerebral hemorrhage were higher among blacks than whites.


Death rates from intracerebral hemorrhage were also higher among Asians/Pacific Islanders than among whites.

All minority populations had higher death rates from subarachnoid hemorrhage than did whites.


Five classes of stroke by "severity―

least to most severe

Transient Ischemic Attack (TIA), "angina" of the brain TIA is warning sign of stroke

localized ischemic event

produces neurological deficits lasting only minutes or hours

full functional recovery within 24 to 48 hours

Reversible Ischemic Neurological Deficit (RIND) similar to TIA

findings last between 24 hours and three weeks

usual full functional recovery within three to four weeks

Partial, Nonprogressing Stroke some neurological deficit, but stabilized

Progressing Stroke (stroke in evolution) deterioration of neurological status often with grand mal seizure activity

has residual neurological deficits that last indefinitely

Completed Stroke results from a stroke in evolution


Two types of stroke by "cause"

1. Ischemic

2. Hemorrhagic Stroke (bleeding)



Brain Attack/ Stroke

Ischemic Stroke Hemorrhagic

Stroke

Thrombotic Embolic Aneurysm AV

amlformation

HTN

Ischemic

Incidence: 80% to 85%

also known as occlusive stroke (clot)

slower onset

results from inadequate blood flow leading

to a cerebral infarction

caused by cerebral thrombosis or embolism

within the cerebral blood vessels

most common cause: atherosclerosis


Ischemic

caused by thrombus and embolus

Thrombotic – most common

Embolic – assoc with hypercoagulability conditions

Types

Large artery thrombosis

Small penetrating artery thrombosis

Cardiogenic embolism

Cryptogenic


Manifestations of Ischemic Stroke

Symptoms depend upon 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


Hemorrhagic stroke (bleeding)

Incidence: 15% to 20%

abrupt onset

intracerebral hemorrhagic stroke: blood

vessels rupture with a bleed into the brain

Caused by bleeding into brain tissue, the

ventricles, or subarachnoid space

occurs most often in hypertensive older

adults



May be due to spontaneous rupture of small vessels primarily related to Hypertension

subarachnoid hemorrhage due to a ruptured aneurysm

or intracerebral hemorrhage related to amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms,

or medications such as anticoagulants or thrombolytic therapy



Brain metabolism is disrupted by

exposure to blood

ICP increases due to blood in the

subarachnoid space

Compression or secondary ischemia

from reduced perfusion and

vasoconstriction injures brain tissue


Manifestations of Hemorrhagic

stroke

Similar to ischemic stroke

Severe headache

Early and sudden changes in LOC

Vomiting


Subarachnoid Hemorrhage (SAH) most often caused by rupture of saccular

intracranial aneurysms

more than 90% are congenital aneurysms

Epidural Bleeds cerebral arterial vessels are involved

often a loss of consciousness for a short period of time called transient unconsciousness

Subdural Bleeds veins are involved

may not be evident until months after an initial trauma


Transient Ischemic Attack (TIA)

Temporary neurologic deficit resulting

from a temporary impairment of blood

flow

―Warning of an impending stroke‖

Diagnostic work-up is required to treat

and prevent irreversible deficits


Assessment

History and physical exam

Computerized tomogram (CT) scan

Magnetic resenance imaging (MRI)

Doppler echocardiography flow analysis

Carotid artery duplex doppler ultrasonography

EEG - shows abnormal electrical activity

Lumbar puncture - shows if blood is found in the cerebral spinal fluid as a result of a cerebral bleed

Cerebral angiography - shows blood flow in cerebral arteries may be done with or without contrast


Intracerebral hemorrhage


CEREBROVASCULAR ACCIDENTS

The Stroke Continuum

5 Classes of stroke by severity

1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration

2. Reversible Ischemic Neurologic deficit (RIND)

3. Partial, Nonprogressing Stroke

4. Progressing Stroke (or Stroke in evolution)

4. Completed stroke


Are you at risk?

RISKS FACTORS

Non-modifiable

• Age (over 55)

• male gender,

• African American race


Risk factors

Modifiable risk factors uncontrolled Hypertension: the primary risk

factor

Cardiovascular disease

Elevated cholesterol and triglycerides or elevated hematocrit

Obesity

Diabetes

Oral contraceptive use

Smoking and drug and alcohol abuse

chronic atrial fibrillation


RISKS FACTORS

Modifiable

Hypertension

Cardio disease

Obesity

Smoking

Diabetes mellitus

Hypercholesterolemia

hypercoagulable state

illicit drug use (esp cocaine)

nonvalvular atrial fibrillation


Risk Factors

Heart disease

AFib, Valvular Dz, MI, endocarditis

Hypertension

Smoking

Diabetes/Metabolic Syndrome

Dyslipidemia

Pregnancy

Drug Abuse/Meds

Bleeding Disorders/Anticoagulant Use


Risk Stratification for Stroke

Highest Risk: Prior Stroke or TIA

High Risk: Any of the following

Prior thromboembolism

Female >75 yo

SBP >160

Heart failure/LV dysfunction

Moderate Risk: None of above, but HTN

Low Risk: None of the above, no HTN


Healthy lifestyle and stroke

A study of more than 37 000 women age 45 or older participating in the Women’s Health Study suggests that a healthy lifestyle consisting of ____________________ ______ _____________ _________ ______________ and _________ were associated with a significantly reduced risk of total and ischemic stroke but not of hemorrhagic stroke.

2/13/2014

abstinence from smoking, low BMI, moderate alcohol

consumption, regular exercise, healthy diet


Prevention

avoid

smoking

sedentary lifestyle

high-fat diet

increase fruits and veg

low saturated and trans fat

light to mod alcohol consumption


Stroke Prevention: Lifestyle

People who have had a stroke or TIA

can take steps to prevent a recurrence:

Quit smoking.

Exercise and maintain a healthy weight.

Limit alcohol and salt intake.

Eat a healthier diet with more veggies, fish,

and whole grains.


Preventive Treatment and

Secondary Prevention

Modifiable risk factors:

Hypertension: the primary risk factor

Cardiovascular disease

Elevated cholesterol or elevated hematocrit

Obesity

Diabetes

Oral contraceptive use

Smoking and drug and alcohol abuse


Preventive Treatment and

Secondary Prevention

Health maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease

Carotid endarterectomy

Anticoagulant therapy

Antiplatelet therapy: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid)

Statins

Antihypertensive medications


Stroke Prevention: Medications

For people with a high risk of stroke,

doctors often recommend medications to

lower this risk.

Anti-platelet medicines (aspirin,

clopidogrel [Plavix], Dipyridamole)

Anti-clotting drugs (warfarin)

Anti Hpn


Stroke Test: Talk, Wave, Smile

The F.A.S.T. test helps spot symptoms. It

stands for:

Face. Ask for a smile. Does one side droop?

Arms. When raised, does one side drift down?

Speech. Can the person repeat a simple

sentence? Does he or she have trouble or slur

words?

Time. Time is critical. Bring to hospital STAT if

any symptoms are present.


Clinical Manifestations

depend on the location of the lesion


Assessment

Transient hemiparesis

Loss of speech

Hemisensory loss

Wernicke‟s aphasia

Broca‟s aphasia

Dysarthria

Dysphagia

Apraxia

2/13/2014

Hemianopia

Horner‟s syndrome

Agnosia

Unilateral neglect

Paresthesia

Depression

Incontinence

Proprioception disturbance


Signs and Symptoms of

Childhood Stroke:

Severe headache- this is often the first complaint

Nausea and/or vomiting

Warm, flushed, clammy skin

Slow, full pulse – may have distended neck veins

Speech difficulties- absent, slurred or inappropriate speech

Eye movement problems – partial or complete blindness, blurred vision, unequal pupils

Numbness – paralysis, weakness, or loss of coordination of limbs, usually on one side of the body; loss of balance

Facial droop or salivary drool

Urinary incontinence

Seizures

Brief loss of consciousness; unconscious „snoring‟ respirations

May show signs of rapid recovery (TIA)

Glasgow Coma Scale (GCS)

most widely used scoring system to quantify level of consciousness following traumatic brain injury; scores range from 3 to 15, based on the sum of the best eye opening response, the best verbal response, and the best motor response

Eye Opening (E) Verbal Response (V) Motor Response (M)

• 4=Spontaneous 5=Normal 6=Normal

• 3=To voice 4=Disoriented 5=Localizes to pain

• 2=To pain 3=Inappropriate 4=Withdraws to pain

• 1=None 2=Incomprehensible 3=Flexes to pain

• 1=None 2=Extends to pain 1=None

Total = E+V+M


Assessment

Neurologic assessment

Cognitive changes

Motor

Sensory

CN

Cardiovas


Cognitive changes

denial of illness

spatial and proprioceptive (awareness of body

position if space) dysfunction

impair memory, judgment, problem-solving,

decision-making

decreased ability concentrate

aphasia – inability to use or comprehend

language

alexia – reading problems

agraphia – difficulty with writing


Motor changes

Hemiphlegia – paralysis on one side of body

Hemiparesis – weakness on one side of body

Hypotonia or flaccid paralysis – unable to

overcome forces of gravity, and et tend to fall on

one side

Hypertonia or spastic paralysis – fixed positions

or contractures of involves ext; ROM restricted,

shoulder subluxation easily occur

a temporary, partial dislocation of the shoulder

Incontinence


Ataxia –staggering, unsteady gait unable

to keep feet together; needs a broad

base to stand

Dysarthria - difficulty in speaking

Aphasia - loss of speech

Dysphagia –difficulty in swallowing


Sensory

Agnosia – is a loss of ability to recognize

objects, persons, sounds, shapes, or smells

while the specific sense is not defective nor is

there any significant memory loss.

Apraxia – inability to perform a previously

learned action


Sensory

Neglect syndrome – unaware of existence of

his/her paralyzed side

Amaurosis fugax – is loss of vision in one eye

due to a temporary lack of blood flow to the

retina.

Hemianopsia – blindness in one half of visual

field

Homonymous hemianopsia – blindness in

same side of both eyes; must turn head to

have complete range of vision


Hemianopsia

loss of vision in

one-half the

normal visual

field (usually the

right or left half)

of one or both

eyes.


http://www.wrongdiagnosis.com/bookimages/8/2608.png

Hemianopsia

absence of vision in half of a visual field

The visual field of each eye can be

divided in two vertically, with the outer

half being described as temporal, and

the inner half being described as nasal.


Hemianopsia

"Binasal hemianopsia" can be broken

down as follows:

bi-: involves both left and right visual fields

nasal: involves the nasal visual field

temporal: involves the temporal visual field

lateral: involves the lateral visual field

hemi-: involves half of each visual field

anopsia: blindness



http://www.wrongdiagnosis.com/bookimages/14/4774.1.png


Paris as seen with full visual fields

Right homonymous hemianopsia


http://upload.wikimedia.org/wikipedia/commons/thumb/0/08/Rhvf.png/300px-Rhvf.png

Left homonymous hemianopsia


Bitemporal hemianopsia


Binasal hemianopsia


Binasal hemianopsia

or Binasal hemianopia

is the medical description of a type of

partial blindness where vision is missing

in the inner half of both the right and left

visual field. It is associated with certain

lesions of the eye and of the central

nervous system, such as congenital

hydrocephalus.


CN function

chew, swallow, facial paralysis, gag reflex, tongue

movement

CV

heart murmur, dysrhythmias, HTN

psychosocial

emotional lability - a condition of excessive

emotional reactions and frequent mood changes; is

the regular occurrence of unstable, disproportionate

emotional displays


Labs

no definitive lab test confirm stroke

HCt, Hb, INR, PT, PTT, LP

Radiographic

CT, CTA

other Dx

MRI, MRA, ECG


General manifestations


Localization

Middle cerebral artery:

Aphasia

Dysphagia

HEMIPARESIS on the OPPOSITE side-

more severe on the face and arm than

on the legs


Localization

Anterior cerebral artery:

Weakness

Numbness on the opposite side

Personality changes

Impaired motor and sensory function


Localization

Posterior cerebral artery:

Visual field defects

Sensory impairment

Coma

Less likely paralysis


DIAGNOSTIC tests

1. CT scan

2. MRI

3. Angiography


Hypodense area:

• Ischemic area with

edema, swelling

• Indicates >3 hours old

• No fibrinolytics!


(White areas indicate hyperdensity = blood)

Large left frontal intracerebral

hemorrhage.

Intraventricular

bleeding is also present

No fibrinolytics!


Acute subarachnoid

hemorrhage

Diffuse areas of white

(hyperdense) images

Blood visible in

ventricles

and multiple areas on

surface of brain

Glucose and electrolyte tests: Hypoglycemia is the most common electrolyte abnormality

that produces stroke-like symptoms

Electrolyte disorders, hyperglycemia, hypoglycemia, and uremia

Complete blood count:

Prothrombin time (PT) and activated partial

thromboplastin time (aPTT) tests

Cardiac enzymes

Arterial blood gas (ABG) analysis


Carotid duplex

Carotid duplex scanning is one of the most useful tests in evaluating patients with stroke.

Increasingly, it is being performed earlier in the evaluation, not only to define the cause of the stroke but also to stratify patients for either medical management or carotid intervention if they have carotid stenoses. Patients with symptomatic critical stenoses on carotid duplex scanning may require anticoagulation before intervention is performed.


Angiogram

2/13/2014

This is an angiogram of

the right carotid artery

showing a severe

narrowing (stenosis) of

the internal carotid artery

just past the carotid fork.

There is enlargement of

the artery or ulceration in

the area after the

stenosis in this close-up

film. Note the narrowed segment toward the

bottom of the picture.


.

http://www.strokecenter.org/patients/viewer/ais/ais_coronal_clot_500.jpg

Time lost is Brain lost

The consequences of delaying treatment for stroke can be catastrophic.

"Time is brain" is an adage used by stroke professionals to reinforce the critical need for early and rapid intervention.


2/13/2014

Every minute that the brain is

deprived of oxygen, 1.9 million neurons, 14 billion synapses,

and 7.5 miles of myelinated fibers

are lost.

After 12 minutes without treatment,

a pea-sized piece of brain tissue dies.


2/13/2014

Every minute that the brain is

deprived of oxygen, 1.9 million neurons, 14 billion synapses,

and 7.5 miles of myelinated fibers

are lost.

After 12 minutes without treatment, a pea-sized piece of

brain tissue dies.


Management

to prevent or minimize the damaging

effects of stroke; dependent on the type

of CVA

Expected outcomes

prevent or minimize the damaging effects of

stoke

depends on the type of CVA

Prompt diagnosis and treatment

Assessment of stroke: NIHSS assessment

tool


Stroke: Emergency Treatment

ischemic stroke emergency treatment focuses on medicine to

restore blood flow.

A clot-busting medication is highly effective at dissolving clots and minimizing long-term damage, but it must be given within three hours of the onset of symptoms.

Hemorrhagic strokes are more difficult to manage.

Treatment usually involves attempting to control high blood pressure, bleeding, and brain swelling.


Treatment Occlusive stroke

Pharmacologic thrombolytics

Criteria for tissue plasminogen activator (tPA): see Chart 62-2

IV dosage and administration

Patient monitoring

Side effects: potential bleeding

anticoagulant therapy: heparin, coumadin

antiplatelet therapy: aspirin, dipyridamole (Persantine) platelet aggregation inhibitor: clopidogrel (Plavix),

ticlopidine HCL (Ticlid)

steroids: dexamethasone (Decadron)


Treatment Occlusive stroke

Elevate HOB unless contraindicated

Maintain airway and ventilation

Provide continuous hemodynamic

monitoring and neurologic assessment

surgery

bypass

carotid endarterectomy


Hemorrhagic stroke (ICH)

Care is primarily supportive

surgical excision of aneurysm

Prevention: control of hypertension

Bed rest with sedation

Oxygen

Treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding


Treatment ICH

Pharmacologic

antihypertensive agents : alpha-blockers and beta-blockers

systemic steroids: dexamethasone (Decadron)

osmotic diuretics: mannitol

antifibrinolytic agents: aminocaproic acid (Amicar)

vasodilators

anticonvulsants

Recombinant factor VIIa (rFVIIa) therapy

Reverse coagulopathies Vitamin K, FFP, Platelets


Treatment ICH

Neurosurgical ICU

Constant monitoring

Bedrest

Pain control

Reverse coagulopathies

Vitamin K, FFP, Platelets

ICP control

Mannitol, Induced Coma, Hyperventilation


Treatment of SAH

Neurosurgical ICU

Constant monitoring

Bedrest

Pain control

Reverse coagulopathies

DVT Prophylaxis

Blood Pressure Management

Management of Aneurysms/AVMs


Treatment

Common to both types of stroke

care based on findings

therapies

nutritional support

physical

speech

behavioral

occupational


NINDS Recommended Stroke Evaluation Time

Benchmarks for Potential Thrombolysis

Candidate

Time Interval

Door to doctor

Access to neurologic expertise

Door to CT scan completion

Door to CT scan interpretation

Door to treatment

Admission to monitored bed

Time Target

10 min

15 min

25 min

45 min

60 min

3 h


General Management of Patients With

Acute Stroke

Blood glucose

Blood pressure

Cardiac monitor

Intravenous fluids

Oral intake

Oxygen

Temperature

Treat hypoglycemia with D50 Treat hyperglycemia with insulin if serum glucose >200 mg/dL

See recommendations for thrombolysis candidates and noncandidates

Continuous monitoring for ischemic changes or atrial fibrillation

Avoid D5W and excessive fluid administration IV isotonic sodium chloride solution at 50 mL/h unless otherwise indicated

NPO initially; aspiration risk is great, avoid oral intake until swallowing assessed

Supplement if indicated (Sa02 <90%, hypotensive, etc)

Avoid hyperthermia, oral or rectal acetaminophen as needed


Nursing Process—Planning Patient

Recovery After an Ischemic Stroke

Major goals include: Improved mobility

Avoidance of shoulder pain

Achievement of self-care

Relief of sensory and perceptual deprivation

Prevention of aspiration

Continence of bowel and bladder

Improved thought processes

Achievement of a form of communication

Maintenance of skin integrity

Restoration of family functioning

Improved sexual function

Absence of complications


NURSING INTERVENTIONS:

ACUTE

1. Ensure patent airway

2. Keep patient on LATERAL position

3. Monitor VS and GCS, pupil size

4. IVF is ordered but given with caution as not to increase ICP

5. Insert NGT

6. Medications: Steroids, Mannitol (to decrease edema), Diazepam


In acute stage of stroke

If grand mal seizure activity note time,

length, behaviors

Monitor neuro status, vital signs, LOC, GCS

Maintain adequate fluids

Position with HOB elevated 15 to 30

degrees with client turned or tilted to

unaffected side

Provide activity as ordered



Perform passive and/or active range of

motion exercises

Maintain proper body alignment

Care for post op client as indicated

Provide care for client with increased

intracranial pressure


A. Nonsurgical Management Monitor (and intervene) in neurologic, ICP status

Drug therapy

Monitor other complications

Carotid Artery Angioplasty

Hypothermia Treatment

B. Surgical Management Endarterectomy

Extracranial-Intracranial Bypass

Management of AVM

Management of aneurysms

Management of intracranial bleeding



Monitor for potential complications :

musculoskeletal problems, swallowing

difficulties, respiratory problems, and

signs and symptoms of increased ICP

and meningeal irritation


Long-term care of client with stroke

Monitor to facilitate normal elimination

patterns

Teach/evaluate the use of supportive

devices

Maintain client in a safe environment

Prevent the effects of immobility


Long-term care of client with stroke

Support the maintenance of adequate nutrition in light of feeding and swallowing problems

Assist with eating and ADL as indicated

Provide emotional support

Provide methods of communication for client with aphasia

Focus on patient function; self-care ability, coping, and teaching needs to facilitate rehabilitation


Nursing Diagnoses

Nursing Diagnoses

Impaired physical

mobility

Acute pain

Self-care deficits

Disturbed sensory

perception

Impaired swallowing

Urinary incontinence

Disturbed thought

processes

Impaired verbal

communication

Risk for impaired

skin integrity

Interrupted family

processes

Sexual dysfunction


Nursing Diagnoses

Ineffective Tissue Perfusion (cerebral) and

Potential for increased ICP r/t interruption to

arterial bloodflow.

Impaired Physical Mobility, self-care deficit and

potential for deep vein thrombosis or pulmonary

embolism r/t neuromuscular impairment or

cognitive impairment.

Disturbed Sensory Perception and risk for injury

r/t altered sensory reception, transmission, and

integration.


Nursing Diagnoses

Unilateral Neglect r/t effects of disturbed

perceptual abilities or hemianopsia

Impaired Verbal Communication r/t decreased

circulation in the brain

Impaired Swallowing, Risk for imbalanced

nutrition: less than body requirements,

constipation and risk for aspiration r/t

neuromuscular impairment


Nursing Diagnoses

Total Urinary Incontinence and Bowel

Incontinence r/t neurologic dysfunction

Ineffective Coping, caregiver role strain, r/t

recent change in health status, Inadequate

coping method or unsatisfactory support

system


Collaborative Problems/Potential

Complications

Decreased cerebral blood flow

Inadequate oxygen delivery to brain

Pneumonia


Interventions

Focus on the whole person

Provide interventions to prevent

complications and to promote

rehabilitation

Provide support and encouragement

Listen to the patient


Improving Mobility and Preventing

Joint Deformities

Turn and position the patient in correct alignment every 2 hours

Use splints

Practice passive or active ROM 4 to 5 times day

Position hands and fingers

Prevent flexion contractures

Prevent shoulder abduction

Do not lift by flaccid shoulder


Correctly position patient to prevent contractures

Place pillow under axilla

Hand is placed in slight supination- ―C‖

Change position every 2 hours


Positioning to Prevent Shoulder

Abduction


Prone Positioning to Help Prevent

Hip Flexion



Joint Deformities

Implement measures to prevent and treat shoulder problems

Perform passive or active ROM 4 to 5 times day

Encourage patient to exercise unaffected side

Establish regular exercise routine

Use quadriceps setting and gluteal exercises



Joint Deformities

Assist patient out of bed as soon as

possible: assess and help patient

achieve balance and move slowly

Implement ambulation training


Enhance self-care

Set realistic goals with the patient

Encourage personal hygiene

Ensure that patient does not neglect the

affected side

Use assistive devices and modification

of clothing


Carry out activities on the unaffected side

Prevent unilateral neglect- place some items on the affected side!!!

Keep environment organized

Use large mirror


Improve communication

Implement strategies to enhance communication

Anticipate the needs of the patient

Provide time to complete the sentence

Provide a written copy of scheduled activities

Use of communication board

Give one instruction at a time


Care of the client with Aphasia

Say one word at a time

Identify one object at a time

Give simple commands

Anticipate needs

Allow to verbalize no matter how long it

takes him

Speech therapy


Maintain skin integrity

Use of specialty bed

Regular turning and positioning

Keep skin dry and massage NON-

reddened areas

Provide adequate nutrition


Manage sensory-perceptual

difficulties

Care of the client with Hemianopsia

Approach from the unaffected side

Place articles on the unaffected side

Encourage the patient with visual field loss

to turn his head and look to side

Teach scanning techniques. Turn head from

side to side to see entire visual field

Encourage to turn the head to the affected

side to compensate for visual loss


Manage dysphagia

Nutrition

Consult with speech therapist or

nutritionist

Have patient sit upright to eat, preferably

OOB

Use chin tuck or swallowing method

Feed thickened liquids or pureed diet


Manage dysphagia

Provide smaller bolus of food

Place food on the UNAFFECTED side

Manage tube feedings if prescribed

Promote nutrition

TPN, NGT feeding, gastrostomy feeding


Bowel and bladder control

Help patient attain bowel and bladder control

Assess and schedule voiding

Implement measures to prevent constipation: fiber, fluid, and toileting schedule

Provide bowel and bladder retraining Promote elimination

I and O; Start urinary and bowel program


Bowel and bladder control

Intermittent catheterization in acute stage

Offer bedpan on a regular schedule

High fiber diet and prescribed fluid intake

The best time for a bowel movement is 20 - 40

minutes after a meal, since feeding stimulates

bowel activity.

Some people drink warm prune juice or fruit

nectar as a stimulus to bowel movements.


Improve thought processes

Support patient and capitalize on the

remaining strengths

Improve family coping

Help patient cope with sexual

dysfunction

Provide support and encouragement


Aneurysm Precautions

Absolute bed rest

Elevate HOB 30° to promote venous drainage or keep the bed flat to increase cerebral perfusion

Avoid all activity that may increase ICP or BP; implement Valsalva maneuver, acute flexion, and rotation of the neck or head

Exhale through mouth when voiding or defecating to decrease strain


Aneurysm Precautions

Nurse provides all personal care and

hygiene

Provide nonstimulating, nonstressful

environment: dim lighting, no reading, no

TV, and no radio

Prevent constipation

Restrict visitors


Interventions

Relieve sensory deprivation and anxiety

Keep sensory stimulation to a minimum for aneurysm precautions

Implement reality orientation

Provide patient and family teaching

Provide support and reassurance

Implement seizure precautions

Implement strategies to regain and promote self-care and rehabilitation


Surgical Management

• Endarterectomy

• Extracranial-Intracranial Bypass

• Carotid artery angioplasty

• Management of AVM

• Management of Aneurysms

• Management of intracranial bleeding


Surgical treatments of aneurysms

Clipping

Embolization

Intra-Cranial Angioplasty and Stent (ICAS)

Clipping

Surgical

treatment of

aneurysms

involves placing

clip on neck of

aneurysm.


Embolization

• Endovascular repair of cerebral aneurysm.

• Anterior communicating artery aneurysm before and after GDC coil embolization


http://upload.wikimedia.org/wikipedia/en/3/3a/GDCcoilAneurysm.jpg

http://en.wikipedia.org/wiki/Cerebral_aneurysm

http://en.wikipedia.org/wiki/Cerebral_aneurysm

Intra-Cranial Angioplasty and Stent

• ICAS (Intra-Cranial Angioplasty and Stent)

of Basilar

Artery Stenosis


http://upload.wikimedia.org/wikipedia/en/2/2e/IntraCranialAngioplastyStentBasilarArtery.jpg

Stent


Extracranial-intracranial bypass surgery

(EC-IC bypass)

is a treatment for blocked

blood vessels in the brain.

The purpose of the

operation is to use a

healthy blood vessel to

bypass the block and

provide an additional blood

supply to areas of the brain

that have been deprived of

blood.


Rehabilitation

Learning to live to one’s maximum

potential with a chronic impairment and

it’s resultant disability

Promotes reintegration into the client’s

family and community

Influenced by the client and client’s

motivation


Goals of Rehab

Prevent complications

Correction of deformities

Restoration of function to achieve maximum

independence

Limitation of disability


Goal of Stroke Rehabilitation

Most mildly impaired individuals achieve

their best functional recovery in 3 weeks

While it can take up to 12 weeks for the

most severe


Elite support

walker

Bar Grab

Pivoting for

Bathrooms

http://elderstore.net/evaelitesupportwalker.aspx

http://elderstore.net/dependabar.aspx

http://elderstore.net/stairlift.aspx

Home Care and Teaching for the

Patient Recovering From a Stroke

Prevention of subsequent strokes, health

promotion, and implementation of follow-

up care

Prevention of and signs and symptoms

of complications

Medication teaching

Safety measures


Home Care and Teaching for the

Patient Recovering From a Stroke

Adaptive strategies and use of assistive devices for ADLs

Nutrition: diet, swallowing techniques, and tube feeding administration

Elimination: bowel and bladder programs and catheter use

Exercise and activities: recreation and diversion

Socialization, support groups, and community resources


Aphasia

Ten Guidelines for Interacting with a Stroke

Survivor © American Stroke Foundation

I. Treat me the same way as you did before my stroke – I am the same person.

II. Every stroke is different; therefore every stroke survivor is different. Common impairments for stroke survivors are: Vision, balance, speech, hearing, and paralyzed on one side.


http://www.americanstroke.org/content/view/91/125/



III. Some stroke survivors have difficulty communicating verbally as well as reading, writing, spelling, and understanding what is being said, this is called aphasia. Our brains have been rewired which affects our communication. So, we need you to: Give us enough time to respond. Talk slowly; offer at times to repeat yourself. Be patient when trying to communicate with us. It is okay to help us find a word when we are having trouble.





IV. There are other ways of communication besides words. Gestures, Facial expressions, Body languages, Pictures, Pen & paper.

V. Treat us like adults and not children. Speak directly to us, not our spouse or friend. Don’t talk like the stroke survivor isn’t there. Laugh with us not at us.





VI. Give the stroke survivor a chance to be independent. Ask before you help them. Follow his/her instructions for initiating the help.

VII. Many stroke survivors have problems with balance. A rough pat on my back, shoulder, or arm can easily set us off balance and can hurt me. Be gentle and understand that it can take a lot of concentration to walk, especially on uneven surfaces.





VIII. Wheelchair and walker are extensions of us. Please respect our space. If you bump the chair, please say excuse me. Please don’t lean on a wheelchair.

IX. Talk to us at eye level when possible when we are in a wheel chair. You can also back up a few feet to make it easier for a person in a wheelchair to look at you.





X. When we are tired and/or frustrated, ALL of our basic

skills (i.e. talking, walking, handwriting, and

concentration) diminish. If we are more agitated than

usual, we are probably tired or frustrated!

Have patience and encourage us to rest or “take a

break” when appropriate.



What‟s in store

in the future?

Roles in Stroke Nursing

Nurses have responded to the challenge of

making stroke systems of care a reality in

recent years.

Stepping into new roles, such as stroke

response nurse, stroke nurse practitioner,

stroke coordinator, and stroke research

nurse, stroke nurses are using evidence-

based practice to organize and deliver stroke

services and facilitate optimal outcomes for

stroke patients.


Clot Dissolving

Substance in

Vampire Bat Saliva

Cell and Tissue

Transplants

Venom from Pit

Viper

Free Radical

Scavengers


Nursing Care of Clients with Stroke

Health & Medicine

Transcript of Nursing Care of Clients with Stroke