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Objectives of the Program: 1. Differentiate the signs/symptoms of acute ischemic stroke versus acute hemorrhagic stroke. 2. Describe changes and conditions ...
Typology: Study notes
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Presented by: Garden City Hospital Professional Nursing Development
Garden City Hospital is an approved provider of continuing nursing education by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation
Garden City Hospital is an approved provider of continuing nursing education by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation
Acute Ischemic Stroke VS Acute Hemorrhagic Stroke
ISCHEMIC STROKE: Ischemic strokes are commonly caused by atherosclerotic disease of extracranial or intracranial vessels that circulate blood to the brain. (Summers et al, 2009).
Causes of Acute Ischemic Stroke (AIS): Atherosclerotic disease o Extracranial vessels (approximately 20%) o Intracranial vessels (approximately 25%) Cardiogenic embolism (approximately 20%) o Atrial fibrillation Cryptogenic (approximately 30%) o Exact cause unknown
Signs and Symptoms of AIS: Gaze preference Visual field deficits Hemiparesis Hemisensory loss Nausea/vomiting Diplopia, dysconjugate gaze, gaze palsy Dysarthria Dysphagia Vertigo Tinnitus Quadraplegia Decreased level of consciousness (LOC) Hiccups Abnormal respirations Truncal/gait ataxia Limb ataxia, neck stiffness
Types of Cerebral Bleeds: Intracerebral hemorrhage (ICH): Bleeding within the brain tissue Intracranial hemorrhage: o Epidural: Bleeding between the skull and the dura o Subdural: Bleeding between the dura and the brain o Subarachnoid (SAH): Bleeding in the subarachnoid space
The primary cause of SAH is a ruptured cerebral aneurysm (Summers et al, 2009).
Causes of ICH: Arteriovenous malformation Aneurysm rupture Cerebral venous thrombosis Coagulopathies Eclampsia Infection Neonatal germinal matrix or subependymal hemorrhage Sickle Cell disease Illicit or sympathomimetic drug abuse Trauma Vasculitis
Signs and Symptoms of ICH: Headache (Extremely painful) Altered Level of Consciousness (same as AIS) Nausea and vomiting (same as AIS) Seizures Light intolerance Neck pain Gaze preference (same as AIS) Visual field deficits (same as AIS)
Differentiation of Ischemic VS Hemorrhagic Stroke Although presenting symptoms can be similar, with the exception of the severe headache associated with a hemorrhagic stroke, radiologic imaging studies will provide the clinician with the differential.
CT scan is the first diagnostic tool to evaluate for the difference between ischemic or hemorrhagic stroke. It can locate the site of bleeding and indicate any displacement of tissue, hemorrhage or hematoma. If bleeding is present on the CT scan, the patient is disqualified as a candidate for tissue plasminogen activator (tPA). If blood is present, a Neurosurgery consult is completed to determine whether the patient is a candidate for surgical intervention. If no bleeding is present on CT scan, it is termed “CT Negative”; treatment for reversal of stroke will continue as this ONLY refers to the absence of blood NOT the absence of stroke.
An MRI can provide the same valuable information; however the CT scan can be completed more rapidly and does not have the same amount of contraindications as MRI. If a study of vascular formation within the brain tissue is necessary, angiography studies can be completed, though not as a first line study. If a clinician is concerned with ruling out meningitis, a lumbar puncture can be performed as well.
Condition Changes Requiring Rapid Response Intervention
Early mobilization: Avoidance of prolonged bedrest, evaluation and treatment utilizing physical and occupational therapy when patient is stabilized. Hydration/Fluids: An elevated urea, likely indicating dehydration, is associated with higher risk of DVT. Additionally, hydration is generally indicated in part because acute stroke patients are often unable to take in adequate fluids orally. Full-length graduated compression stockings: Patients undergoing surgery have shown a significant reduction in DVTs with the application of stocking prior to surgery. Unlike surgery, stockings cannot be applied before the onset of insult, so there is a chance the patient will develop a DVT prior to stocking application. When utilized stockings should be fitted in accordance with the manufacturers guidelines and removed daily to check for skin problems. Aspirin: When started within 48hours of ischemic stroke it has been shown to reduce relative risk of PE and improves patients’ overall outcome. Heparin: It has been shown to reduce the risk of DVT in ischemic stroke, but can complicate treatment if hemorrhagic complications arise. Low molecular weight heparin (LMWH) has been used in populations with a very low likelihood of hemorrhage after ischemic stroke yet remains at extremely high risk for DVT/PE. Examples of patients that meet this criteria would be patients with severe leg weakness and immobility, cancer, thrombophilia or previous venous thromboembolism. External pneumatic compression: Studies have shown that when coupled with the use of graded compression stockings, they can greatly reduce the incidence of DVT/PE related complications post stroke.
Hypertension (HTN): Blood pressure is generally higher with hemorrhagic stroke patients rather than ischemic stroke patients. Patients that have a history of hypertension tend to have higher blood pressures post infarct; the acute on chronic hypertensive effect. Extremely high blood pressure after stroke has been associated with poorer outcomes independent of age and stroke severity. During the first few days after stroke blood pressure should be monitored and treated only if end organ damage is evident. Conditions that would necessitate lowering of blood pressure immediately post stroke include: Papilloedema or retinal hemorrhage and exudates, marked renal failure with microscopic hematuria and proteinuria, left ventricular failure diagnosed on clinical features and supported by evidence from chest X-ray and/or echocardiogram, features of hypertensive encephalopathy (seizures, reduced conscious level), or aortic dissection. Hypertension must be managed very carefully because an acute reduction in cerebral perfusion can further increase cerebral ischemic damage. When lowering blood pressure the target should be to gradually lower the pressure over hours-days, not minutes.
Cardiac Arrythmias: Routine management of the patient’s cardiac rhythm, either at the bedside or with ambulatory systems that don’t inhibit early mobilization will help identify abnormalities. The most common arrhythmia associated with stroke is atrial fibrillation. Anticoagulation may be considered in this population as to prevent thromboemobolism related to cardiac arrhythmias. At a minimum is recommended that patients exhibiting palpitations, syncope, unexplained breathlessness or recent myocardial infarction are placed on a cardiac monitor.
Myocardial Infarction (MI): Cerebral and coronary atheromas are often present in the same patient, so it is not a surprise that an acute stroke patient may have a history of myocardial infarction. Risk factors that can be modified are one way to reduce the risk of myocardial infarction after stroke (discussed later in this module). If there is a hypercoaguablility factor in the patient who has not at this time had a history of an MI then anticoagulation should be considered if its benefits outweigh the risks (blood pressure under control, not high risk for bleed, ischemic infarct over hemorrhagic infarct).
Urinary Tract Infection (UTI): Urinary tract infections affect about a quarter of the post stroke population. Methods used to avoid UTI’s include: Maintaining adequate hydration and avoiding unnecessary catheterizations. Incomplete bladder emptying can contribute to UTI’s so it is recommended to avoid constipation and drugs with anticholinergic effects.
Aspiration Pneumonia: Bedside swallowing screen should be completed by a suitably trained nurse or healthcare provider to determine whether the patient is able to take oral food and fluids safely versus requiring a more detailed assessment. A structured approach to swallow screening and appropriate feeding has been associated with fewer episodes of aspiration pneumonia. The gag reflex is not a useful indicator of a stroke patient’s swallowing ability. A more detailed assessment of a patient’s swallowing ability would ideally be performed by a Speech and Language Pathologist and potentially supplemented by videofluoroscopy. Evaluation should also take place to determine the strength of the patient’s laryngeal cough reflex. If it is found that the patient is having difficulty safely swallowing or if the clinician is unsure, the patient should be made NPO and hydrated via an alternative route until the results of a detailed assessment have been completed. Aspiration pneumonia should be treated promptly and aggressively so to prevent further complications potentially leading to sepsis.
Dehydration: Multiple factors place post stroke patient’s at risk for dehydration, these include: Swallowing difficulties, immobility-depending on others for help with drinking, communication problems-they cannot ask for drinks, hemianopia or visual neglect-they may not see the water sitting next to them, elderly-have a reduced sensitivity to thirst, fever/chest infection/hyperglycemia/diuretics-all increase their fluid losses, and self restriction of fluid intake-to reduce their
that a HgbA1C be completed to distinguish diabetes from stroke induced hyperglycemia. Hypoglycemia: Hypoglycemic symptoms can mimic that of a transient ischemic attack (TIA) and should be ruled out once suspected in the stroke population. Patients are less likely to suffer from hypoglycemia as a cause of stroke but may be placed at risk by clinicians when trying to correct hyperglycemia. If a patient has a diagnosis of diabetes and has a reduced oral intake due to complications of stroke they too may be placed at higher risk for hypoglycemia. Blood glucose in this population should be regularly monitored and recorded to evaluate and trend fluctuations.
Skin Breakdown: Stroke patients are at risk for skin breakdown because of loss of sensation and impaired circulation, older age, decreased level of consciousness, and inability to move themselves because of paralysis. Related complications such as incontinence can accelerate skin breakdown. Patients should be examined for skin breakdown after being repositioned or sitting. Special care should be taken when moving patients to avoid excessive friction or pressure. Patients should not be left in any single position for longer than 2 hours. The skin must be kept clean and dry, and special mattresses should be used where indicated (Summers et al, 2009)
Airway Obstruction: Patients with a decreased level of consciousness, impaired bulbar function or those who have aspirated may have an obstructed or partially obstructed airway. Central cyanosis, noisy airflow with grunting, snoring or gurgling, an irregular breathing pattern and retracting of the suprasternal area and intercostal muscles may indicate an obstruction. Transient obstruction is common in the acute phase of stroke during sleep and it is important that apneic spells due to an obstructed airway are not mistakenly attributed to periodic respiration and so ignored. If an obstructed airway is suspected, the oropharynx should be cleared of any foreign matter with a gloved finger sweep, the patient’s jaw pulled forward and the neck extended to stop the tongue from falling back and occluding the airway. Placement of an oropharyngeal or nasopharyngeal airway may be necessary and the patient should be evaluated for potential intubation.
Seizures: A small percentage of stroke patients will have a seizure within the first week or two of their stroke; these are referred to as ‘onset seizures’, most occurring within the first 24 hours. Onset seizures are more common in severe strokes, hemorrhagic strokes and strokes involving the cerebral cortex. Diagnosis of seizure should be done utilizing an accurate description from the patient, any witnesses and may require confirmation via electroencephalography (EEG). Anti- epileptic drugs should be used in their usual fashion to treat seizures, though there is no evidence to support the use of anti-epileptic drugs on at risk populations with no evidence of seizure. Precautionary measures at the bedside include: Padding the bedrails and fall prevention guidelines.
Application of the National Institute of Heath Stroke Scale (NIHSS)
The National Institutes of Health Stroke Scale (NIHSS) is a user-friendly, valid and reliable tool for the assessment of brain attack. It is utilized for defining stroke severity and measuring the effects of interventions. It includes an evaluation of eye movement, visual fields, coordination, motor strength, sensation and it also detects the presence of aphasia and neglect. The scale’s 11 categories are listed in the first column. In column 2, the observer selects –from a choice of 3 to 6 numbered descriptors for each item- the one that best depicts the patient’s response. Results are then totaled. A score of zero is considered normal, and 42 is the worst possible examination, reflecting the most severe neurologic deficits. (See example scale below)
Category Description Score Date/Time/Initials 1a. Level of consciousness Alert Drowsy Stuporous Coma
0 1 2 3 1b. LOC, questions (month, age) Answers both correctly Answers one correctly Incorrect
0 1 2 1c. LOC, commands (Open/close eyes, make fist, let go)
Obeys both correctly Obeys one correctly Incorrect
0 1 2
Normal Partial gaze palsy Forced deviation
0 1 2
No visual loss Partial hemianopia Complete hemianopia Bilateral hemianopia
0 1 2 3
Normal Minor Partial Complete
0 1 2 3 5a. Motor arm-Left (Elevate extremity to 90˚ and score drift/movement)
No drift Drift Can’t resist gravity No effort against gravity No movement Amputation, joint fusion etc.
0 1 2 3 4 X
5b. Motor arm-Right (Elevate extremity to 90˚ and score drift/movement)
No drift Drift Can’t resist gravity No effort against gravity No movement Amputation, joint fusion etc.
0 1 2 3 4 X
6a. Motor leg-Left (Elevate extremity to 30˚ and score drift/movement)
No drift Drift Can’t resist gravity No effort against gravity No movement Amputation, joint fusion etc.
0 1 2 3 4 X
6b. Motor leg-Right (Elevate extremity to 30˚ and score drift/movement)
No drift Drift Can’t resist gravity No effort against gravity No movement Amputation, joint fusion etc.
0 1 2 3 4 X
0 1
Case Study: Best Practices in Stroke Rapid Response (for review)
Initial presentation. C.W. was a 78-year-old male diagnosed with colon cancer. He underwent an elective colonoscopy as an outpatient, which revealed a lesion in the proximal area of the hepatic flexure. The patient's physicians decided to treat the patient surgically and scheduled C.W. for an elective colon resection. The patient also presented with a history of chronic atrial fibrillation, hyperlipidemia, diabetes, gout, hypothyroidism, coronary artery disease, and cerebrovascular disease.
On the evening prior to C.W.'s scheduled surgery, the patient first noted a change in his normal speech pattern. C.W. had slurred speech with a mumbling quality, and alerted his nurse of the change. The medical-surgical nurse evaluated the patient's neurologic condition and confirmed the speech difficulties. One hour prior to the development of slurred speech, the patient had received promethazine (Phenergan[R]) 12.5 mg IV for nausea. The patient's blood glucose and vital signs were obtained to rule out symptoms related to hypoglycemia and/or hypotension. The patient's initial blood glucose result was 62 mg/dl. The patient was given 25 cc of 50% dextrose intravenously. The patient's blood glucose was rechecked later, and the level had increased to 143 mg/dl. Because the patient continued to demonstrate slurred speech, his nurse performed a neurological assessment including the NIHSS. The patient's clinical findings met the elements of signs and symptoms of stroke. A rapid response was called and a STAT neurology consult ordered. The transportation department and CT scan tech’s were notified via pager that a stroke patient was to have an exam; the patient was transported via stretcher to CT scan. The scan was negative for bleed and the patient was prepared to undergo thrombolytic therapy and transfer to the ICU.
Initial and repeated nursing assessments of patients experiencing neurologic changes are essential in the early recognition and successful intervention of acute stroke emergencies. Hospitalized patients present unique challenges because other medical/surgical conditions, medications, and procedures may make decision making more complex.
Under the supervision of the physician, nurses administer intravenous weight- based thrombolytic therapy to the ischemic stroke patient who meets the National Institute of Neurological Disorders and Stroke (NINDS) inclusion criteria. During administration of thrombolytic medications, nurses continuously monitor electrocardiogram, blood pressure, and respiratory effort to ensure the patient's hemodynamic stablility. Comprehensive neurologic examination by the ICU nurse or the neurologist is necessary to identify subtle changes, and includes performance of severity indices such as the National Institute of Health Stroke Scale (NIHSS). ICU nurses can assist other bedside clinicians to identify
neurologic findings accurately and integrate these with clinical history to assess rapidly for potential stroke treatments.
A rapid response team assist to respond to in-house stroke emergencies. RN responders provide support in completing a rapid neurologic assessment and screening for potential treatment with thrombolytic therapy. The RN responders are available around the clock every day to bring their clinical expertise to the patient's bedside.
Since the initiation of the Inpatient Stroke Alert Process, staff medical-surgical nursing units have a heightened awareness of the message that "time is brain." All bedside nurses receive education to identify stroke-like symptoms and to recognize a potential neurologic event.
Continued care. Within minutes, the Rapid Response team responded to C.W.'s bedside to offer rapid reassessment and confirmation of his nurse's findings. The rapid response/ICU nurse performed a complete neurologic assessment and scored the patient's stroke severity based on the NIHSS. Documentation on the Neurological Assessment Sheet indicated that the patient was alert and oriented to person, place, and time. The Glascow Coma Score was 15. The patient's pupils were equal, reactive to light, and accomodated, and extraocular movements were intact. C.W. had a slight decrease in the right nasolabial fold; however, facial sensation was intact and the tongue was midline. The patient continued to present with slurred speech; a bedside swallowing evaluation was conducted prior to providing any oral medications. Sensory function and motor strength were intact to all extremities. (Med/Surg Nursing, December 2006)
Management of Acute Stroke: Treatment Modalities
Thrombolytic Therapy: The thrombolytic drug Alteplase or Activase is often referred to as tPA (tissue plasminogen activator). It is the only thrombolytic agent approved by the FDA for the treatment of AIS. Upon administration it: binds fibrin in a clot, converts the trapped plasminogen to plasmin, initiates fibrinolysis and systemic proteolysis (breaking down into smaller clots).
Inclusion Criteria: CT scan negative for hemorrhage 18 years of age or older Have a clinical diagnosis of stroke with a measurable deficit Onset of symptoms o Less than 3 hours o If greater than 3 hours and less than 4.5 hours, eligibility will depend on additional exclusion criteria Review and acceptance of additional laboratory studies
o Intracranial o Retroperitoneal o GI o GU o Respiratory tracts Superficial: o Venous cut downs o Arterial and venous puncture sites o Catheter insertion sites o Needle puncture sites o Sites of recent surgical intervention
Precautions: Avoid IM injections Use extreme caution with venipunctures; only perform as required If arterial puncture is needed during infusion or after, utilize upper extremity. Manual compression will be required. o Pressure to be applied for 30 minutes o Pressure dressing to be applied to site o Frequent checks of the puncture site Pt must be placed on seizure precautions Bedrest x 24 hours HOB at 30 degrees, place tPA sign above bed NPO until evaluated by Speech Therapy or Neurology
Post tPA Assessment and Documentation: Vital signs and NIHSS by nurses o Q 15 minutes X 2 hours from start of tPA o Q 30 minutes X 6 hours o Q hour X 16 hours Temperature Q 4 hours X 24 hours Continuous pulse oximetry Blood glucose (may require tight glycemic control) o Upon admission o Q 6 hours if NPO o AC & HS once patient has resumed meal consumption o Notify physician if blood glucose > 140
Increased Intracranial Pressure (ICP): In the event of ischemia or infarction of the brain tissue, there are structural changes that occur causing a decrease in the collagen and connective tissues of the brain. This loss of vascular structure causes the breakdown of the blood brain barrier and contributes to cerebral edema. With the increase in brain tissue size, CSF and blood should get displaced allowing space for the increasing size of the brain tissue. Only so much space is allotted and the brain will eventually press against the skull causing an increased ICP.
Early Signs of Increased ICP: Change (decrease) in LOC: o Lethargy, confusion, disorientation, restlessness or apathy Headache Change in verbal/motor responses: o Slurred speech o Inability to move extremity o Facial droop Vomiting without nausea Pupils: o Pupillary changes on one side o Sluggish reaction to light bilaterally o Pupillary inequality Motor response: o Sudden weakness o Positive pronator drift Ocular palsies: Paralysis of the muscles used to move the eyes Papilledema: Swelling of the optic disc leading to blurred vision and blind spots
Late Signs of Increased ICP: Unarousable Pupils fixed and dilated Motor response: Profound weakness Abducens Palsies: Nerve problem resulting in double vision Cushings Triad: Increased systolic blood pressure, bradycardia, respiratory irregularity Widened Pulse Pressure: An increased distance between systolic and diastolic BP numbers
Nursing Interventions for Treating Increased ICP: Clustering activities is recommended to reduce the amount of prolonged time with increased ICP. Let your patient rest between activities to allow their ICP to return to baseline. Timely intervention for fevers is important as well to reduce the metabolic (oxygen) demands of the injured brain tissue. To improve venous return, keep the patient’s head and neck aligned and keep the head of the bed above 30 degrees, but below 90 degrees (prolonged hip flexion can increase ICP). If your patient is intubated and/or mechanically ventilated, make sure that tracheostomy ties are not too tight. Limit suctioning to 2 passes with an insertion time of less than 10 seconds each; reduce cough stimulation when possible due to a risk for increasing the patient’s ICP.
Hypertension (HTN): Hypertension aggravates atherosclerosis and increases vascular resistance (vasoconstriction) within the brain.
rehabilitation needs, progress and recovery are unique for each person. Although a majority of functional abilities may be restored soon after a stroke, recovery is an ongoing process (NIH, 2010). Ultimately, rehabilitation after stroke should include optimizing independence with ADLs, prevention of complications and further disability, maximizing function and mobility, improving safety, improving life satisfaction, providing effective coping mechanisms and access to quality social interactions.
Nursing Considerations for Rehabilitation: Range of Motion (ROM): ROM exercises stretch the muscles, ligaments and tendons surrounding a joint. They promote increased joint flexibility and movement reducing pain, stiffness and muscle spasms. Nursing personnel can assist with the procedure by encouraging activity progression according to physician orders and activity protocol. Physical Therapy (PT), Occupational Therapy (OT) and Physical Medicine and Rehabilitation (PM&R) Consults: This multidisciplinary team will work together in order to plan the best rehabilitation for each individual. Subjective and objective assessments are recommended as soon as possible for treatment plan development.
Modifiable Risk Factors: Multiple health-related risk factors can contribute to secondary stroke. These risk factors include: Hypertension Smoking Diabetes Mellitus Atrial Fibrillation Hyperlipidemia Lifestyle modifications can assist the patient in the prevention of secondary complications from stroke. Per physician recommendations patients may be placed on medications to assist with this process.
Early recognition and intervention during stroke can save lives and reduce stroke related complications. Nurses are the front-line agents in the detection of changing conditions with their patients. Accurate and thorough assessments can guide clinicians in the appropriate treatment of patients with Acute Ischemic or Hemorrhagic Strokes.
