Zusammenfassung der Ressource
Ischemic Stroke
- Treatment
- Surgical
- MERCI retriever
(Lewis et al., 2011).
- Carotid endarterectomy
(Lewis et al., 2011).
- Repair of aneurysm
(Lewis et al., 2011).
- Removal of tutor
(Lewis et al., 2011).
- Drainage of hematoma
(Lewis et al., 2011).
- Burr hole (Lewis et al., 2011).
- Angioplasty (Lewis et
al., 2011).
- Pharamcological
- Thromolytic; lyse (break
down) existing clots i.e.
Streptokinase, t-PA, rTpa
- tPA
- Must be administered within 3
to 4.5 hours of the onset of
clinical signs of ischemic
stroke (Lewis et al., 2011).
- Administered IV to re-establish
blood flow through a blocked
artery to prevent cell death
(Lewis et al., 2011).
- The door-to-needle time for tPA remains less than
60 mins or 1 hour after onset of clinical signs.
Thrombolytics given in this time frame reduce
disability, but at the expense of an increase in
deaths within 7 to 10 days and an increase in
intracranial hemorrhage (Lewis et al., 2011).
- Anticoagulants;
Inhibit platelet
aggregation,
prevent platelet
plugs e.g. ASA,
Plavix
- No anticoagulant or
antiplatelet drugs are given for
24 hours after tPA treatment
(Lewis et al., 2011).
- Not recommended in the
emergency phase because of
the risk for intracranial
hemorrhage (Lewis et al., 2011).
- Aspirin at a dose of 325 mg may be initiated
within 24 to 48 hours after the onset of an
ischemic stroke
- Complications of aspirin: GI bleeding.
Therefore used cautiously in those
who have a history of peptic ulcer
disease (Lewis et al., 2011).
- Antiplatelets
- Used only after patient’s condition
has been stabilized and to prevent
further clot formation (Lewis et al.,
2011).
- Vasodilators (Lewis et al., 2011).
- Anti-hyperlipidemics (Lewis
et al., 2011).
- Anti-hypertensives
e.g. metoprolol
- Hypertension may be a protective response
to maintain cerebral perfusion
- Use of drugs to lower BP is recommended
only if BP is markedly increased (MAP>130
mm Hg or systolic BP>220 mm Hg) (Lewis et
al., 2011).
- Signs and Symptoms
- Cognitive
(Ignatavicius
& Workman,
2013).
- Denial of illness
- Spatial and proprioveptive dysfunction
- Impairment of memory, judgment,
problem solving, and decision making
- Decreased concentration
- Motor
(Ignatavicius &
Workman, 2013).
- Hemiplegia (paralysis) or hemiparesis
(weakness) contralateral to which part
of the brain is affected
- Quadriparesis if the brainstem is
involved
- Ataxia (gait) if the cerebellum is
affected
- Hypotonia or flaccid
paralysis
- Hypertonia or spastic
paralysis
- Agnosia: unable to use objects
correctly
- Apraxia: unable to carryout purposeful
motor activity or speech
- Bladder and bowel incontinence from
the loss of neurological control in the
cerebral cortex
- Sensory (Ignatavicius &
Workman, 2013).
- Decreased sensation of touch
and pain contralateral to where
the stroke is in the brain
- Unilateral body neglect
syndrome
- Amaurosis fugax: brief episode of
blindness in one eye
- Hemiaopsia: blindness in half the
visual field
- Homonymous hemianopsia
blindness in the same side of both
eyes
- Nystagmus: or other involuntary
eye movements caused from
brainstem and cerebellar
damage
- Cranial Nerve Dysfunction
(Ignatavicius & Workman,
2013).
- CN V: absent gag reflex and
ability to chew
- CN IX and X: decreased ability to
swallow
- CN XII: impaired tongue
movement
- CN VII: facial paralysis
- Cardiovascular
(Ignatavicius &
Workman, 2013).
- Embolic strokes are associated
with heart murmurs,
dysrhythmias (atrial fibrillation is
the most common, and HTN.
- Left vs. Right Hemisphere
(Ignatavicius & Workman,
2013).
- What is an ischemic stroke?
- Ischemic stroke is caused by
occlusion of cerebral artery by
either a thrombus or embolus
(Lewis et al., 2010).
- Brain stores no oxygen or
glucose and thus needs
constant blood flow for normal
function and waste removal
(Lewis et al., 2010).
- Stroke ranks third for mortality
rates in developed countries
(Kearney, 2014).
- Pathophysiology
- Thrombic
Stokes
- Consists of more than
half of all strokes
(Ignatavicius &
Workman, 2013).
- Caused by the development of
atherosclerosis (Ignatavicius &
Workman, 2013).
- A rupture of one of these plaques
exposes cells to clot promoting
elements (Ignatavicius &
Workman, 2013).
- End result is a formation of a blood clot in an
artery supplying blood to the brain. This blood
clot is large enough to interrupt blood flow to
cerebral tissue (Ignatavicius & Workman, 2013).
- Thrombic strokes are
characterized by a slow onset,
taking minutes to hours
(Ignatavicius & Workman, 2013).
- Embolic
Strokes
- Caused by thrombus or thrombi breaking
off an artery anywhere in the body and
traveling to cerebral arteries (Ignatavicius
& Workman, 2013).
- Thrombus formation can be caused from
heart disease, MI, heart valve
prosthetics, non valvular atrial
fibrillation, and plaque (Ignatavicius &
Workman, 2013).
- Embolic strokes are characterized by a
sudden development, rapid
neurological deficits (Ignatavicius &
Workman, 2013).
- Can lead to hemorrghaic stroke because
arterial vessel wall is vulnerable to ischemic
damage (Ignatavicius & Workman, 2013).
- Diagnostic
Tests
- Laboratory Values
- Elevated hematocrit and hemoglobin with severe or major stroke because
body is compensating for decreased oxygen to the brain (Ignatavicius &
Workman, 2013).
- PT, PTT, and INR: used to establish baseline
information for anticoagulation therapy
(Ignatavicius & Workman, 2013).
- Elevated WBC: can indicate presence of
infection (Ignatavicius & Workman, 2013).
- Lumbar puncture: used to rule out meningitis
and subarachnoid hemmorhage (Ignatavicius &
Workman, 2013).
- Imaging Studies
- MRI: to determine the extent
of brain injury and has
greater specificity in
determining the location of
vascular lesions and
blockages than CT (Jauch,
2016).
- CT scan: indicates the size
and location of the lesion
and helps to differentiate
between ischemic and
hemorrhagic stroke (Jauch,
2016).
- Ultrasonography and
echocardiography: help
determine additional
cardiovascular risks (Jauch,
2016).
- Risk Factors
- Modifiable (Choudhury et al.,
2015; Ignatavicius &
Workman, 2013).
- Hypertension and atherosclerosis
- Cardiovascular disease (i.e. atrial
fibrillation)
- Diabetes and glucose metabolism
- High cholesterol levels
- Smoking
- Alcohol consumption
- Illicit drug use (particularly cocaine)
- Lifestyle factors (i.e. obesity, physical activity
diet)
- Sleep apnea
- Blood clotting disorders (high risk for thrombotic
stroke and require preventive anticoagulants)
- TIA patients (should seek anticoagulation
therapy)
- Non modifiable (Choudhury et
al., 2015; Ignatavicius &
Workman, 2013).
- Age; increased risk as age
increases
- Gender; men 30% higher
incidence, post menopausal
women
- Race or ethnicity; American
Indian, Alaskan Natives, Blacks,
Hispanics have a higher chance
- Heredity
- Myocardial
Infarction
- Sickle Cell
Disease
- Collaborative Care
- Nursing
- Managing circulation, airway, breathing → Patients may have
difficulty keeping an open and clear airway because of a
decreased LOC or decreased or absent gag and swallowing
reflexes (Lewis et al., 2011).
- Oxygenation
- Maintaining oxygenation is important - Both hypoxia
and hypercarbia are to be prevented because they can
contribute to secondary neuronal injury (Lewis et al.,
2011).
- Oxygen administration, artificial airway insertion,
intubation, and mechanical ventilation may be required
(Lewis et al., 2011).
- Neurological
Assessment
- Glasgow Coma Scale to address LOC, orientation,
motor, pupils, speech.language, vital signs, and
blood glucose (RNAO, 2005).
- Fluid and
electrolytes
- keep the patient adequately hydrated to
promote perfusion and decrease further
brain injury (Lewis et al., 2011).
- Adequate fluid intake during acute care via oral,
IV, or tube feedings should be 1500 to 2000
mL/day (Lewis et al., 2011).
- IV solutions and water ware avoided because
they are hypotonic and may further increase
cerebral edema and ICP(Lewis et al., 2011).
- Hyperglycemia may be
associated with further brain
damage and should be treated
(Lewis et al., 2011).
- Management of Increased
ICP
- Improve venous drainage (i.e.
elevate HOB)
- Maintain head and neck in alignment
(Lewis et al., 2011).
- Quiet environments will reduce headaches and
reduce aggravation of increased ICP
(Ignatavicius & Workman, 2013).
- Avoid extreme hip and neck flexions that increase
intrathoracic pressure making ICP more difficult to
control. Extreme neck flextion interferes with venous
drainage as well (Lewis et al., 2011).
- Avoid clustering nursing procedures all at
once because the effect of ICP elevation is
more dramatic (Ignatavicius & Workman,
2013).
- CSF drainage (Ignatavicius &
Workman, 2013).
- Diuretic drugs (e.g. mannitol,
furosemide) (Lewis et al., 2011).
- Removal of bone flap to allow for cerebral
edema without increases in ICP (Lewis et al.,
2011).
- Management of Constipation
- Constipation can be caused
from decreased mobility
(Kasaeaneni & Hayes, 2014).
- High fiber food such as fruits or vegetables can be
added to the diet to help increase the volume present
and cause bowel movement by distension (Kasaeaneni
& Hayes, 2014).
- Fiber supplements such as bran, psyllium, or
methylcellulose can be added to help increase the
fiber consumed by the patient (Kasaeaneni & Hayes,
2014).
- Encourage fluid intakes (Kasaeaneni & Hayes,
2014).
- Avoid Hyperthermia
- Contributes to increased cerebral metabolism. A
temperature elevation of even one degree increases
brain metabolism by 10% and contribute to further brain
damage (Lewis et al., 2011).
- Treatment: Aspirin Acetaminophen Cool
blankets (Lewis et al., 2011).
- Education
- Teach patients to recognize the symptoms
of a stroke by using the acronym FAST
- Return demonstrations assist in
evaluating family' ability to perform
patient care tasks; provide verbal and
oral instruction Ignatavicius &
Workman, 2013).
- Teach family about depression that
can occur within 3 months of a
stroke. Post stroke depression is
associated with increased morbidity
(Ignatavicius & Workman, 2013).
- Health teaching for the patient
includes drug therapy, ambulation
skills, nutritional management, and self
management skills (Ignatavicius &
Workman, 2013).
- Health Care Resources
(Ignatavicius & Workman, 2013)
- Available online resources to share with patients
and family include American Heart Association,
National Stroke Association, Agency of Health care
Research and Quality
- SLP (Speech
Language
Pathologist)
- Appointments for
outpatients speech may be
arranged to help the
patient relearn to talk
(Ignatavicius & Workman,
2013).
- Collaborate with the SLP to
conduct a bedside swallowing
screening and evaluation. Patient
may remain NPO until SLP
determines the patient can
tolerate fluids without aspirating
(Ignatavicius & Workman, 2013).
- Home
- Collaborate with case manager
to plan patient's discharge;
coordinate with rehabilitation
therapist to identify need of
assistive devices (Ignatavicius &
Workman, 2013).
- PT
(Physiotherapist)
- To restore movement, balance,
and coordination
- Climb stairs, transfer in and out of bed and chair,
transfer to and from car, mobility aids (Ignatavicius
& Workman, 2013).
- OT (Occupational
Therapist)
- To relearn basic skills such as
bathing and dressing
- Community
Care
- Patients with stroke may be discharged
to a rehabilitation centre or skilled
nursing fac.ility depending on the extent
of their disability and the availability of
caregiver/family support (Ignatavicius &
Workman, 2013).
- Complications
- Increase ICP
- Occurs in response to cerebral
edema (American Heart
Association, 2015).
- Pneumonia
- Due to decreased mobility after a
stroke (American Heart
Association, 2015).
- Aspiration
pneumonia
- Can be caused by impaired tongue
movement, decreased swallowing,
or absent gag reflex (American
Heart Association, 2015).
- Urinary Tract Infection
- Caused by foley catheter being placed
due to bladder incontinence (American
Heart Association, 2015).
- Seizure
- Abnormal electrical activity in the brain
causing convulsions from cerebral damage
(American Heart Association, 2015).
- Clinical
depression
- Causes unwanted emotional and physical
reactions to changes and losses
(American Heart Association, 2015).
- Pressure ulcers
- Results from decreased ability to move and
pressure on areas of the body because of
immobility (American Heart Association, 2015).
- Limb contractures
- Shortened muscles in an arm or leg from
reduced ability to move the affected limb
or lack of exercise (American Heart
Association, 2015).
- Deep Vein
Thrombosis
- Blood clots form in veins of the legs
because of immobility from stroke.
(American Heart Association, 2015).