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TEXTBOOK DISCUSSION : Stroke

Definition: A stroke is a "brain attack" or cerebrovascular attack (CVA). It can happen to


anyone at any time. It occurs when blood flow to an area of brain is cut off. When this
happens, brain cells are deprived of oxygen and begin to die. When brain cells die during
a stroke, abilities controlled by that area of the brain such as memory and muscle
control are lost.

Types:
Ischemic Stroke (accounts for 85% of strokes )
o sudden loss of function that occurs when a blood vessel carrying blood to the
brain is blocked by a blood clot which disrupts blood circulation in the brain;
usually a result of long-standing cerebrovascular disease; can occur in two ways:
Embolic
In an embolic stroke, a blood clot or plaque fragment forms somewhere in
the body (usually the heart) and travels to the brain (embolus). Once in
the brain, the clot travels to a blood vessel small enough to block its
passage. The clot lodges there, blocking the blood vessel and causing a
stroke. About 15% of embolic strokes occur in people with atrial fibrillation
(Afib).
Thrombolic
A thrombotic stroke is caused by a blood clot that forms inside one of the
arteries supplying blood to the brain. This type of stroke is usually seen in
people with high cholesterol levels and atherosclerosis. The medical word
for a clot that forms on a blood-vessel deposit is thrombus. Two types of
blood clots can cause thrombotic stroke: large vessel thrombosis and
small vessel disease.
o Large Vessel Thrombosis
The most common form of thrombotic stroke that occurs in the
brains larger arteries. In most cases it is caused by long-term
atherosclerosis in combination with rapid blood clot formation.
High cholesterol is a common risk factor for this type of stroke.
o Small Vessel Disease
Occurs when blood flow is blocked to a very small arterial vessel
(small vessel disease or lacunar infarction). Little is known about
the causes of this type of stroke, but it is closely linked to high
blood pressure.
Hemorrhagic Stroke (accounts for 15% of strokes, but responsible for 40% of deaths)
o Caused by a brain aneurysm burst or a weakened blood vessel leak. Blood spills
into or around the brain and creates swelling and pressure, damaging cells and
tissue in the brain. There are two types of hemorrhagic stroke called intracerebal
and subarachnoid.
Hemorrhagic
The most common; happens when a blood vessel inside the brain bursts
and leaks blood into surrounding brain tissue (intracerebal hemorrhage).
High blood pressure and aging blood vessels are the most common
causes of this type of stroke. Sometimes, it can be caused by an
arteriovenous malformation (AVM). AVM is a genetic condition of abnormal
connection between arteries and veins and most often occurs in the brain
or spine. If AVM occurs in the brain, vessels can break and bleed into the
brain. The cause of AVM is unclear but once diagnosed it can be treated
successfully.
Subarachnoid
This type of stroke involves bleeding in the area between the
brain and the tissue covering the brain, known as the
subarachnoid space. This type of stroke is most often caused by a
burst aneurysm. Other causes include: AVM, bleeding disorders,
head injury, and blood thinners.
Risk Factors for Stroke
People over the age of 55
Male
African Americans,Hispanic, Native American Indian, Alaska
native, and Asian/Pacific Islander ethnic groups
Hypertension (controlling hypertension, the major risk factor, is the key to
preventing stroke)
Cardiovascular disease (cerebral emboli may originate in the heart)
Atrial fibrillation
Coronary artery disease
Heart failure
Left ventricular hypertrophy
Myocardial infarction (especially anterior)
Rheumatic heart disease
High cholesterol levels
Obesity
Elevated hematocrit (increases the risk of cerebral infarction)
Diabetes mellitus (associated with accelerated atherogenesis)
Oral contraceptive use (increases risk, especially with coexisting hypertension,
smoking, and high estrogen levels)
Smoking
Drug abuse (especially cocaine)
Excessive alcohol consumption

SIGNS & SYMPTOMS ACCORDING TO SIGNS & SYMPTOMS AS MANIFESTED


TEXTBOOK BY PATIENT
Numbness or weakness of the face,
arm, or leg, especially on one side
of the body
Confusion or change in mental
status
Trouble speaking or understanding
speech
Visual disturbances
Difficulty walking, dizziness, or loss
of balance or coordination
Sudden severe headache
Dysarthria (difficulty in speaking)
Dysphasia or aphasia
Apraxia (inability to perform a
previously learned action)
MEDICAL MANAGEMENT
Patients who have experienced a TIA or mild stroke from atrial fibrillation or from
suspected embolic or thrombotic causes are candidates for nonsurgical medical
management. Those with atrial fibrillation are treated with dose-adjusted warfarin sodium
(Coumadin) unless contraindicated. Platelet-inhibiting medications (aspirin, dipyridamole
[Persantine], clopidogrel [Plavix], and ticlopidine [Ticlid]) decrease the incidence of cerebral
infarction in patients who have experienced TIAs from suspected embolic or thrombotic
causes. Currently the most cost-effective antiplatelet regimen is aspirin 50 mg/d and
dipyridamole 400 mg/d.

THROMBOLYTIC THERAPY
Thrombolytic agents are used to treat ischemic stroke by dissolving the blood clot that
is blocking blood flow to the brain. The only FDA approved treatment for ischemic strokes is
tissue plasminogen activator (Recombinant tPA, also known as IV rtPA, given through an IV in
the arm). Recombinant tPA works by dissolving the clot and improving blood flow to the part
of the brain being deprived of blood flow. If administered within 3 hours(and up to 4.5 hours
in certain eligible patients), tPA may improve the chances of recovering from a stroke. A
significant number of stroke victims dont get to the hospital in time for tPA treatment so its
important to identify the signs of stroke immediately.

THERAPY FOR PATIENTS WITH ISCHEMIC STROKE NOT RECEIVING t-PA


Not all patients are candidates for t-PA therapy. Other treatments include
anticoagulant administration (IV heparin or low-molecular weight heparin) for ischemic
strokes and careful maintenance of cerebral hemodynamics to maintain cerebral perfusion.
Increased intracranial pressure (ICP) and its associated complications may occur following a
large ischemic stroke. Interventions during this period include methods to reduce ICP, such
as administering an osmotic diuretic (eg, mannitol), maintaining PaCO2 within the range of
30 to 35 mm Hg, and positioning to avoid hypoxia.

SURGICAL MANAGEMENT
Prevention of Ischemic Stroke. The main surgical procedure for managing TIAs and
small stroke is carotid endarterectomy. This involves the removal of an atherosclerotic
plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive
disease of the extracranial cerebral arteries.This surgery is indicated for patients with
symptoms of TIA or mild stroke found to be due to severe (70% to 99%) carotid artery
stenosis or moderate (50% to 69%) stenosis with other significant risk factors.

Endovascular Procedures such as mechanical thrombectomy is strongly


recommended. A large blood clot is removed by sending a wired-caged device called
a stent retriever, to the site of the blocked blood vessel in the brain. To remove the
brain clot, a catheter is thread through an artery in the groin up to the blocked artery
in the brain. The stent opens and grabs the clot, allowing doctors to remove the stent
with the trapped clot. Special suction tubes may also be used. The procedure should
be done within six hours of acute stroke symptoms, and only after a patient receives
tPA.

Surgical Treatment. For strokes caused by a bleed within the brain (hemorrhagic
stroke), or by an abnormal tangle of blood vessels (AVM), surgical treatment may be
done to stop the bleeding. If the bleed is caused by a ruptured aneurysm (swelling of
the vessel that breaks), a metal clip may be placed surgically at the base of the
aneurysm to secure it.

NURSING MANAGEMENT
Elevation of the head of the bed to promote venous drainage and to lower increased
ICP
Intubation with an endotracheal tube to establish a patent airway, if necessary
Continuous hemodynamic monitoring. Systolic pressure should be maintained at less
than 180 mm Hg, diastolic pressure at less than 100 mm Hg. Maintaining the blood
pressure within this range reduces the potential for additional bleeding or further
ischemic damage.
Maintain adequate blood pressure levels in the immediate postoperative period.
Hypotension is avoided to prevent cerebral ischemia and thrombosis. Sodium
nitroprusside is commonly used to reduce the blood pressure to previous levels.
Close cardiac monitoring is necessary because these patients have a high incidence of
coronary artery disease.
Focus on assessing cranial nerves VI, X, XI, and XII
Improve mobility and prevent joint deformities through correct positioning. This
prevents contractures; relieves pressure, assists in maintaining good body alignment,
and prevents compressive neuropathies, especially of the ulnar and peroneal nerves.
Preventing Shoulder Adduction by placing a pillow in the axilla when there is limited
external rotation; this keeps the arm away from the chest. This helps to prevent
edema and the resultant joint fibrosis that will limit range of motion if the patient
regains control of the arm.
Positioning the Hand and Fingers by placing a resting splint to support the wrist and
hand in a functional position to prevent hand edema.
Changing Positions every 2 hours to promote venous return and prevent edema and
pressure ulcers.
Establishing an Exercise Program. The affected extremities are exercised passively
and put through a full range of motion four or five times a day to maintain joint
mobility, regain motor control, prevent contractures in the paralyzed extremity,
prevent further deterioration of the neuromuscular system, and enhance circulation.
Preparing for Ambulation. As soon as possible, the patient is assisted out of bed. The
patient is usually ready to walk as soon as standing balance is achieved. Parallel bars
are useful in these first efforts. A chair or wheelchair should be readily available in
case the patient suddenly becomes fatigued or feels dizzy. The training periods for
ambulation should be short and frequent. As the patient gains strength and
confidence, an adjustable cane can be used for support. Generally, a three- or four-
pronged cane provides a stable support in the early phases of rehabilitation.
Preventing Shoulder Pain by never lifting the patient by the flaccid shoulder or pull on
the affected arm or shoulder. If the arm is paralyzed, subluxation (incomplete
dislocation) at the shoulder can occur from overstretching the joint capsule and
musculature by the force of gravity when the patient sits or stands in the early stages
after a stroke. Many shoulder problems can be prevented by proper patient
movement and positioning. Range-of-motion exercises are important in preventing
painful shoulder. Overstrenuous arm movements are avoided.
Enhancing Self-Care. As soon as the patient can sit up, personal hygiene activities are
encouraged. The patient is helped to set realistic goals; if feasible, a new task is
added daily. The first step is to carry out all self-care activities on the unaffected side.
during the acute phase of care. Support and encouragement are provided to prevent
the patient from becoming overly fatigued and discouraged.
Managing sensory-perceptual difficulties. Make eye contact with the patient and draw
his or her attention to the affected side by encouraging the patient to move the head.
Stand at a position that encourages the patient to move or turn to visualize who is in
the room. Increasing the natural or artificial lighting in the room and providing
eyeglasses are important in increasing vision.
Managing Dysphagia by having the patient sit upright, preferably out of bed in a chair,
and instructing him or her to tuck the chin toward the chest as he or she swallows, will
help prevent aspiration. If the patient cannot resume oral intake, a gastrointestinal
feeding tube will be placed for ongoing tube feedings.
Managing Tube Feedings by elevating the head of the bed at least 30 degrees to
prevent aspiration, checking the position of the tube before feeding, ensuring that the
cuff of the tracheostomy tube (if in place) is inflated, and giving the tube feeding
slowly. The feeding tube is aspirated periodically to ensure that the feedings are
passing through the gastrointestinal tract. Retained or residual feedings increase the
risk for aspiration.
Attaining Bladder and Bowel Control. Intermittent catheterization with sterile
technique is carried out. The upright posture and standing position are helpful for
male patients during this aspect of rehabilitation. Patients may also have problems
with bowel control or constipation, with constipation being more common. Unless
contraindicated, a high-fiber diet and adequate fluid intake (2 to 3 L per day) should
be provided and a regular time established (usually after breakfast) for toileting.
Improving thought processes. Supportive care is given by reviewing the results of
neuropsychological testing, observes the patients performance and progress, gives
positive feedback, and, most importantly, conveys an attitude of confidence and
hope.
Improving communication by being sensitive to the patients reactions and needs and
responding to them in an appropriate manner, always treating the patient as an adult.
Provide strong moral support and understanding to allay anxiety. Have the patients
attention, speak slowly, and keep the language of instruction consistent. One
instruction is given at a time, and time is allowed for the patient to process what has
been said. The use of gestures may enhance comprehension. Speaking is thinking out
loud, and the emphasis is on thinking.
Maintaining Skin Integrity by having a regular turning and positioning schedule to
minimize pressure and prevent pressure ulcers. Keep patients skin must be kept
clean and dry.
Improving family coping by having some type of counseling and support system
available to the family to prevent the care of the patient from taking a significant toll
on their health and interfering too radically with their lives.
Help with sexual functioning. By allowing the patient and partner focus on providing
relevant information, education, reassurance, adjustment of medications, counseling
regarding coping skills, suggestions
for alternative positions, and a means of sexual expression.

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