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Stroke
• third leading cause of death in US, fourth in MS

• #1 cause of long term disability

• 4.7 million stroke survivors today

What is a stroke?

• Blood flow to the brain is suddenly interrupted

• Brain cells in the immediate area die

• Loss of brain function

• Disability

Types of Stokes

• Ischemic-most common

o Thrombotic –thrombus forming within the brain itself

o Embolic-traveling, possible from DVT, heart (arrythmias)

• Hemorrhagic (15%)- usually have poorer outcomes

o Intracerbral-most common type

 Small vessel within the brain tissue ruptures

 Usually caused by uncontrolled hypertension

o Subarachnoid

 Subarachnoid section in the brain

 Most often caused by a leaking aneurysm

 Arteriovenous malformation-usually develops in utero

• Arteries and veins are not formed like they are suppose to
be in the brain- too much pressure on venous wall

Risk Factors for Stroke

• Age
 • Sex

• Race

• Heredity

• Hypertension

• Prior stroke

• “TIA”

• Smoking- doubles risk for ischemic stroke

o Women shouldn’t be on birth control

• Diabetes

• Carotid artery disease

• Heart disease

o Atrial fibrillation

• High cholesterol

• Obesity and inactivity

• Socioeconomic status

• Geography

• Alcohol abuse

• Illicit drug use

• Phenylpropanolamine (PPA) use [hemorrhagic stroke]

Lifespan Considerations

• Elderly at greatest risk

• Children with sickle cell at risk

o Clotting of red blood cells

• Anyone with multiple risk factors

Pathophysiology
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• Ischemic (low blood flow)

o The arteries

o The heart

o The blood (low cardiac output)

• Hemorrhagic

o High blood pressure, atherosclerosis, vessel defect

 Vessel rupture

 Rapidly increasing ICP

 Vasospasm

Symptoms of a stroke

• Sudden numbness or weakness of the face, arm or leg-especially on one side

• Sudden confusion, trouble speaking, or trouble understanding speck

• Sudden trouble with vision, especially on one side

Primary Prevention

• Teach and know risk factors

• Practice healthy eating habits

• Limit alcohol

• Exercise regularly

• Avoid cigarettes and illicit drugs

• See MD regularly for management of chronic illness (hypertension, diabetes

CVD)

Endarterectomy for Prevention of Ischemic Stroke

• Indications

• Procedure

o Plaque is removed from the vessel wall

• Potential complication
 o Obstruction

o Cranial Nerve Damage

o Hyperperfusion syndrome-due to permanently dilated vessels

o Hemorrhage

o Infection

• Nursing Management

o Monitor BP

o Cardiac monitoring

o Monitoring for neuro changes (altered LOC)

o Monitor for cranial nerve damage

 Hoarseness

 Swallowing problems

o Have trach set at bedside

Secondary Prevention

• Know signs and symptoms of stroke

• Call 911 if symptoms occur

• Initial diagnosis- CT scan

• Prompt treatment improves chances for recovery

Clinical Manifestations

• Motor Loss

o Hemipegia- paralysis on one side

o Hemiparesis- weakness on one side

o Ataxia- incoordination of movement

o Dysphagia- trouble swallowing (difficulty with the muscles that control

swallowing)

• Communication loss
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o Dysarthria- difficulty forming words due to muscle weakness or

paralysis

o Aphasia- has problems speaking, or understanding

o Apraxia-inability to perform a previously learned action or gestures

• Sensory/ Perceptiual loss

o Visually

 Homonymous hemianopsia-loss of half of the visual field

 Diploplia-double vision

 Peripheral vision loss

 Visual-spatial disturbance

o Sensation

 Paresthesia-numbness and tingling

 Proprioception difficulties-position sense- not knowing where

extremety is

o Cognitive deficits

 Memory

 Attention span

 Concentration

 Abstract reasoning

 Judgement

o Emotional deficits

 Emotional lability

 Loss of self-control

 Reduced tolerance to stress

 Depression, withdrawal, isolation

 Fear, hostility, anger

Diagnostic tests

• CT scan

• MRI

• Cerebral angiography/arteriogram

o Go in thru femoral artery

o Inject dye into the brain

o Looking at brain perfusion

• Doppler flow studies (carotid, transcranial)

• EKG

• Echocardiogram

Treatment of an Acute Stroke

• Ischemic

o T-PA (tissue plasminogen activator)

 Must meet criteria for administration

 Must be given within 3 hours of onset of symptoms

 Hemorrhage a risk-critical care observation

o Anticoagulants

 Heparin-watch PTT

 Coumadin-PT and INR 2.5

 Lovenox-look at platelets <100,000 HOLD

 Plavix-antiplatelet

 Aspirin

o Other treatment measures

 Elevate HOB

 Secure airway
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 Monitory hemodynamics

 Monitor for neuro changes

• Hemorrhagic

o Will have increased ICP

o Emergency surgery- if the bleed can be accessed

o Manage vasospasms

 Give calcium channel blockers (Nemotol) check BP every 4 hours

o Systolic around 150 is okay

Stoke Rehabilitation

• Mobilize as early as possible

• Physical therapy

• Occupational therapy

• Speech therapy

• Treat depression

• Educate client and caregivers

• Determine placement options

Nursing Diagnosis R/T Stroke

• Impaired physical mobility

• Acute pain (painful shoulder)

• Self-care deficits

• Disturbed sensory perception

• Impaired swallowing

• Incontinenece

• Disturbed thought processes

• Impaired verbal communication

 • Risk for impaired skin integrity

Nursing Interventions

• Improving mobility and preventing joint deformities

o Mobilize as early as possible

o Proper positioning

o Shoulder positioning

 Put pillow under arm

 Use sling when upright or walking

• Enhancing self-care

o Want patient to be as independent as possible, but not to the point of

frustration

• Managing sensory-perceptual difficulties

o Approach on side where vision is intact

o Arrange things in room where they can see it

o Adequate lighting

• Managing dysphagia

o Speech therapy

o Thick substances

o Chin tuck and swallow

• Attaining bowel and bladder control

• Improving thought processes

o Re-orient, re-assure

• Improving communication

o Give plenty of time to express themselves

• Maintaining skin integrity

• Improving family coping

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• Addressing sexual dysfunction

• Promoting home and community-base care

o Client and family education

Intracranial Aneurysm
• Localized dilation of a cerebral artery resulting from weakness in arterial wall

Causes

• Atherosclerosis

• Congenital vessel defect

• Hypertension

• Head trauma

• Advancing age

Pathophysiology

• Artery enlarges and presses on cranial nerves or brain tissue

o Aneurysm may rupture, spilling blood into the brain (subarachnoid

hemorrhage)
normal brain metabolism disrupted

o Increased ICP

o Ischemia due to reduced perfusion and vasospasm

Clinical Manifestations

• Sudden, SEVERE headache

• Loss of consciousness

• Nuchal rigidity- stiff neck-meningial irritation

• Dizziness, tinnitus

• Symptoms of stroke (motor, cognitive, visual, perceptual deficits)

• Signs of increased ICP

 • Aneurysm may leak, clot off and have no symptoms

• Up to 50% mortality from subarachnoid hemorrhage

Diagnostic Tests

• CT scan

• Cerebral angiography

o Looks at size, location, and vessels of aneurysm

• Lumbar puncture-unless they have increased ICP

o Will find blood in CSF

Medical Management

• Recover from the initial bleed

• Prevent re-bleeding

o Complete bedrest

o Reducing stimuli

• Control vasospasm

o Calcium channel blockers

o BP around 150

• Control hypertension

• Monitor for and treat increased ICP

o Due to blood blocking re-absorption of CSF causing hydrocephalus

Surgical Management

• Aneurysm clipping

o Metal clips around aneurysm

• Trapping of aneurysm

• Wrapping of Aneurysm

• Carotid artery clamp

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• Interventional neuroradiology

o Aneurysm coiling-not possible for everyone, aneurysm must be certain

size

Nursing Diagnosis

• Ineffective cerebral tissue perfusion

• Disturbed sensory perception

• Anxiety

Potential Complications

• Vasospasm

o Worsening headache

o Change in LOC

o Different neuro deficit

• Seizures

o Placed on prophylactic seizure med

• Hydrocephalus

o Can occur weeks after aneurysm rupture

o WET, WOBBLE, WEIRD

• Re-bleeding

o Sudden SEVERE headache

o Renewed nuchal rigidity

o Prevention by controlling blood pressure

Hydrocephalus
Overview: CSF

• Produced and reabsorbed in the arachnoid layer of the brain

• Contained in four ventricles and circulates around the brain

What is Hydrocephalus?

• A condition caused by an imbalance in the rates of production and absorption

of CSF in the ventricular system of the brain, When production is too great or
absorption is inadequate, CSF accumulates in the ventricular system,
USUALLY under increased pressure, producing dilation of the ventricles

• A symptom of an underlying neurological illness

Types

• Congenital

o Abnormal fetal development

o Genetic predisposition

• Acquired

o Occurs during or sometime after birth

o Caused by injury, infection, tumor, hemorrhage

• Other types

o Hydrocephalus ex-vacuo

o Normal pressure hydrocephalus (NPH)

Clinical Manifestations

• Infants and young children

o Rapid head growth, bulging fontanels, separated sutures, vomiting,

setting sun sign

o Closed sutures may re-open in children under 10-12 years

o Later: irritability, change in LOC, seizures

• Older children and Adults

o WET, WOBBLE, WEIRD

 Urinary incontinence, ataxic gait, cognitive changes

o Headache, nausea, vomiting, papilledema, blurred vision-diplopia, sun

setting eyes, poor coordination, developmental delays (children),
change in LOC, irritability, personality changes, cognitive changes
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Diagnostic Tests

• Infants-head circumference

• CT scan

• MRI

• Cisternogram-inject dye into space thru lumbar puncture and watch dye over
a series of days to watch how the CSF circulates to determine if it is an
absorption problem, or what the problem is to see how to fix it. Will a shunt
fix the problem

Medical Management

• Medications to treat increased ICP

o Mannitol

• Lumbar puncture or ventriculostomy to drain excess CSF

Surgical Management

• VentriculoPeritoneal Shunt- VP shunt-fed under the skin into the abdominal

cavity

• Put on non-dominant side of the brain-usually on the right hand side

• Direct removal of the obstruction (tumor)

Nursing Management

• Care Plan: increased ICP

• Routine craniotomy care post-op

o Position dictated by surgeon

 Infants may be kept flat

o Observe for infection

 Redness

o Observe for shunt malfunction

o Observe for CSF leak

Long-Term Management
• Considerations for Children

o Condition is life-long

o Make life as normal as possible

• Prognosis depends on

o Cause

o Rate that it developed

o Number of complications