Ischemic Stroke

TRANSIENT ISCHEMIC ATTACK (TIA)
1. An episode of neurological dysfunction WITHOUT infarction of the brain. TIA can be a warning sign for future stroke (Lewis et al, 2014).
THROMBOTIC STROKE
1. Occurs from injury to a blood vessel wall, clot formation and if clot leads to total occlusion of the blood vessel then infarction and cell death will occur (Lewis et al, 2014).
EMBOLIC STROKE
1. Occurs when an embolus blocks a cerebral artery and results in infarction. Emboli usually originates in inner layer of heart and then travels into cerebral circulation (Lewis et al, 2014).
MRI- MAGNETIC RESONANCE IMAGING
1. Determines extent of brain injury (Lewis et al, 2014).
HYPERTENSION
1. Hypertension is the #1 risk factor for developing stroke as it causes the development of atherosclerotic plaque buildup, narrowing the lumen of the arteries. The more narrow the lumen the higher chance there is of clots obstructing the lumen leading to ischemic stroke (Sacco et al, 1997).
HEART DISEASE: MI, Atrial Fibrillation, Carotid Stenosis, and valve diseases
1. ATRIAL FIBRILLATION
  1. With Atrial Fibrillation the atria contract irregularly and at a rapid rate it causes blood to pool in the atria causing clots to form on the heart walls. These clots can dislodge from the heart wall entering the circulation and travel to the brain to cause a stroke. A Fib patients are at extremely HIGH risk of stroke. Early detection of A FIb and proper drug therapy of anticoagulants is recommended to prevent stroke (Shorten, 2014).
SMOKING
DIABETES
1. Increases development of atherosclerotic plaque buildup and obesity (Sacco et al, 1997)
ABDOMINAL OBESITY AND LIMITED PHYSICAL ACTIVITY
1. Increases risk of HTN, diabetes and atherosclerosis (Sacco et al, 1997)
ILLICIT DRUG USE
1. Cocaine, Methamphetamine, and Heroin
CT: COMPUTED TOMOGRAPHY
1. Indicates the size and location of the lesion and helps to quickly identify the type of stroke (Lewis et al, 2014).
CTA: COMPUTED TOMOGRPHY ANGIGRAPHY
1. Estimates perfusion and detects any DEFECTS in the cerebral arteries (Lewis et al, 2014).
ANGIOGRAPHY
1. Can determine occlusions, atherosclerotic plaque and malformed vessels...RISK OF DISLODGING CLOT (Lewis et al, 2014).
TRANCRANIAL DOPPLER
1. Measures the velocity of blood flow in the cerebral arteries (Lewis et al, 2014).
BLOOD TESTS
1. Helps to identify underlying conditions leading to stroke (Lewis et al, 2014).
Right Hemisphere
1. Hemiplagia to left side (left sided neglect), Spatial/ perceptual deficits, denial of any problems, RAPID performance but SHORT attention span, impulsive, impaired judgment and impaired concept of time. (Lewis, Heitkemper, Dirksen, Bucher, Camera, 2014)
Left Hemisphere
1. Impaired Speech and Language (APHASIAS)
  1. Expressive Aphasia: Difficulty EXPRESSING thoughts
  2. Receptive Aphasia: Difficulty UNDERSTANDING
  3. Anomic/ Amnesic Aphasia: unable to find names for specific objects and people
  4. Global Aphasia: loss of ALL receptive and expressive abilities
2. Hemiplagia to the right side (impaired right to left differentiation), slow performance and cautious, very aware of deficits (can cause anxiety and depression), impaired comprehension of language and math (Lewis, et al., 2014)
Ineffective Airway Clearance
1. Demonstrates effective coughing and maintains a clear airway
  1. Encourage slow, deep breathing, turning and coughing (Lewis et al, 2014).
  2. Patient in sitting position (Lewis et al, 2014).
  3. NPO until SLP swallow assessment (Lewis et al, 2014).
  4. Oxygenation (Lewis et al, 2014).
  5. Suctioning as Needed (Lewis et al, 2014)
Impaired Verbal Communication
1. Effective use of oral and written communication techniques
  1. Simple words and short sentences (Lewis, et al., 2014)
  2. Alternative Communication Aids(Lewis, et al., 2014)
  3. LISTEN ATTENTIVELY AND ALLOW TIME FOR RESPONSE (Lewis, et al., 2014)
Impaired Swallowing
1. No choking, coughing or aspiration
  1. HOB = 90 degrees or as close as possible (Lewis et al, 2014).
  2. Chin Tuck Positioning when eating (Lewis et al, 2014).
  3. Remain Sitting for 30 MINUTES after ALL meals to prevent aspiration (Lewis et al, 2014).
  4. Check for pocketing and perform mouth care AC (Lewis et al, 2014).
  5. NG tube with 30 degree HOB, within 3-4 days of stroke, continued until swallowing assessment deems patient safe (Srigresh, Radhakrishnan, Umamaheswara Rao, 2014)
Preventative Collaborative Care
1. HEALTH MANAGEMENT
  1. Includes: limited alcohol use, cessation of smoking, proper diet and exercise, blood glucose control and BP control (Lewis et al, 2014)
2. PREVENTATIVE DRUG THERAPY
  1. Antiplatelet Therapy
    1. ASA- Aspirin (81-325mg/day)
      1. Loading dose of atleast 160 should be given to all patients not already on antiplatelets. (Candadian Stroke Strategy, 2010)
    2. Clopidogrel- Plavix
    3. Warfarin- Coumadin: given to patients with A Fib and previous Hx of TIA
3. PREVENTION SURGERY
  1. Transluminal Angioplasty: inserting a balloon to open narrowed artery to improve blood flow and prevent future stroke (Lewis et al, 2014).
Acute Collaborative Care
1. Oxygen Administration, artificial airway, intubation and mechanical ventilation if indicated (Lewis, et al., 2014)
  1. O2 Sat <92% O2 set to 2-4l/min. If 92% can't be maintained than ABG's and chest radiograph are recommended. (Summers, et al., 2009)
2. ACUTE DRUG THERAPY
  1. tPA- Tissue Plasminogen Activator (Alteplase)
    1. CT or MRI needed BEFORE administering tPA
      1. Patients eligible for tPA should have CT scan within 25 mins of admittance. (Summers, Leonard, Wentworth, Saver, Simpson, Spilker, Hock, Miller, Mitchell, 2009)
    2. Administered within 4.5 hours of clinical symptoms (Canadian Stroke Strategy, 2010)
      1. Ideally, within 60 mins after admittance to hospital. (Cavalcante, Moreira, Guedes, Araujo, Lopes, Damasceno, Lima, 2009). Total dose: 09.mg/kg with 10 percent (0.09 mg/kg) given as IV BOLUS, and remaining 90% (0.81 mg/kg) given as IV infusion over 60 minutes (Canadian Stroke Strategy, 2010)
    3. NO ANTIPLATELET MEDS GIVEN WITHIN 24 HOURS of tPA. (Lewis, et al., 2014)
    4. Monitor for manifestations of bleeding. (Lewis, et al., 2014)
  2. Warfarin-Coumadin: indicated once patient has stabilized (after 24 hours). (Lewis, et al., 2014)
  3. IV Metoprolol: SBP >220mmHg and DBP > 130mmHg
Psychosocial
1. Family Role Alteration due to Decreased Functionality (Lewis et al, 2014).
2. In 30% of stroke patients: depression, anxiety, fatigue and apathy are neuropsychiatric outcomes of stroke (Hackett, Kohler, O'brien & Mead, 2014).
3. Post - Stroke Depression (PSD): Causes a decrease in patient participation in rehabilitiation during the most crucial time of recovery to prevent negative outcomes. As nurses we should be monitoring and assessing for symptoms of PSD to prevent poor outcomes. Early detection, correct diagnosis and appropriate treatment of PSD increases the chances of good outcomes after a stroke (Matsuzaki et al, 2015).
4. Less common Neuropsychiatric outcomes of stroke include: emotional liability, personality changes and psychosis. These are less common symptoms but are much more challenging to manage (Hackett, Kohler, O'brien & Mead, 2014).
5. Discharge planning: involve family members/caregivers in post stroke treatement planning and needs assessment, enhance their knowledge of illness and encourgae them to participate in rehabilitation sessions and care. Secondary prevention education for patients, and link to social supports and rehab. (Cavalcante, et. al, 2011)
Non- Modifiable: Previous family history of stroke, increased risk if of African American ethnicity, it is more common in men but more fatal in women, and people over the age of 55 are at increased risk of stroke (Lewis et al, 2014)

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Ischemic Stroke

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