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STROKE, References: Lewis, S. L., Bucher, L., Heitkemper, M. M., &…
STROKE
SIGNS AND SYMPTOMS
TIAs signs and symptoms depend on the blood vessel that is involved and the area of the brain that is ischemic
if the carotid system: may have a temporary loss of vision in one eyes (
amaurosis fugax)
, transient hemiparesis, numbness or loss of sensation, or a sudden inability to speak
vertebrobasilar system: tinnitus, vertigo, darkened or blurred vision, diplopia, ptosis, dysarthria, dysphagia, ataxia, and unilateral or bilateral numbness or weakness.
RIGHT-BRAIN DAMAGE
(Stroke on right side of the brain)
paralyzed left side: hemiplegia
left-sided neglect
spatial-perceptual deficits
tends to deny or minimize problems
rapid performance, short attention span
impulsive, safety problems
impaired judgement
impaired time concepts
LEFT-BRAIN DAMAGE
(stroke on left side of the brain)
paralyzed right side: hemiplegia
impaired speech/language aphasias
impaired right/left discrimination
slow performance, cautions
aware of deficts: depression, anxiety
impaired comprehension related to language, math
MOTOR FUNCTION
akinesia
alterations in muscle tone
alteration in reflexes
initial hyporeflexia (depressed reflexes) progresses to hyperreflexia (hyperactive reflexes) for most pt
COMMUNICATION
aphasia
expressive aphasia (inability to produce language)
global aphasia (total inability to communicate)
receptive aphasia (loss of comprehension)
dysphasia (impaired ability to communicate)
dysarthria (a disturbance in the muscular control of speech)
EMOTION
exaggerated or unpredictable
INTELLECTUAL
LEFT BRAIN STROKE: Memory problems related to language - cautious in making judgements
ex: move slowly and cautiously from the wheelchair
RIGHT BRAIN STROKE: impulsive and move quickly
ex: rise quicly from a wheelchair without locking the wheels or raising the footrests
ELIMINATION
Initially, pt may experience frequency, urgency, and incontinence. Also experience frequent constipation (associate with immobility, weak abdominal muscles, dehydration, and diminished response to the defecation reflex.
SPARTIAL-PERCEPTUAL ALTERATIONS
incorrect perception of self and illness (deny illnesses or not recognize their own body parts
neglects all input from affected side (erroneous perception of self in space)
agnosia - inability to recognize an object by sight, touch, or hearing
apraxia - inability to carry out learned sequential movements on command
MEDICATIONS
Antiplatelet
Aspirin
Clopidogrel
Ticlopidine
Anticoagulation
Heparin
Warfarin
Antihypertension
HMG CoA reductase inhibitor
Simvastatin
Lovastatin
Factor Xa inhibitors
Rivaroxaban
Dabigatran
Apixaban
PATHOPHYSIOLOGY
Stroke occurs when
ischemic
(inadequate blood flow) to a part of the brain or
hemorrhage
(bleeding) into the brain that results in the death of brain cells.
Functions such as movement, sensation, thinking, talking, or emotions that were controlled by the affected area of the brain are lost or impaired.
If blood flow to the brain is totally interrupted, neurologic metabolism is altered in 30 secs, metabolism stops in 2 minutes, and cellular death occurs in 5 minutes
transient ischemic attack
another risk factor associated with stroke
is a transient episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischemia, but without acute infarction of the brain
may be due to microemboli that temporarily block the blood flow.
RELATED DISORDERS
Hypertension
High cholesterol
Diabetes Mellitus
INDIPENDENT NURSING INTERVENTION
During acute phase of stroke
Maintain patent airway and administer O2
monitor vital signs
maintain BP 150/100
suction secretions to prevent aspiration
monitor for increased ICP
position client on side with HOB elevated 15-30 degrees
monitor level of consciousness, pupillary response, motor and sensory response, cranial nerve function, and reflexes
maintain quiet environment
insert urinary catheter
give IV fluids
administer anticoagulants, antiplatelets, diuretics, antihypertensives, and antiseizure meds
establish form of communication
Postacute phase of stroke
place antiembolism stockings
perform passive range of motion exercises to prevent contractures
provide skin, mouth, and eye care
monitor gag reflex and ability to swallow
provide sips of fluid and slowly advance diet
provide soft and semi soft foods and flavored, cool or warm, thickened fluids
place food in the back of mouth
when client is eating, position sitting up with head and neck positioned slightly forward and flexed
Chronic phase of stroke
place client's personal objects within the visual field
approach client from unaffected side
encourage client to turn the head to scan the complete range of vision
teach client to touch and use both sides of the body
provide eye care for visual deficits
place patch over affected eye if they have diplopia
increase mobility as tolerated
encourage fluid intake and a high fiber diet
administer stool softeners
encourage independence in activities
provide gait training
PRIORITY NURSING ASSESSMENT
SUBJECTIVE DATA
Past health history:
hypertension, previous stroke, TIAs, aneurysm, cardiac disease, dysrhythmias, HF, infective endocarditis. Hyperlipidemia, diabetes, gouts. Previous head injury, fam hx of HTN, diabetes, stroke, CAD, TIA
Medication:
oral contraceptives, use of and compliance with antihypertensive and anticoagulant therapy, illegal substances and drug use
OBJECTIVE DATA
emotional lability, lethargy, apathy or combativeness, fever
loss of cough reflex, labored or irregular respirations, tachypnea, wheezes (aspiration), airway occlusions, apnea, coughing when eating or delayed coughing
hypertension, tachycardia, carotid bruit
loss of gag reflex, bowel incontinence, decreased or absent bowel sounds, constipation
frequency, urgency, incontinence
Act FAST
Facial drooping
Arm weakness
Slurred speech
Time (call 911)
COLLABORATIVE NURSING INTERVENTIONS
speech therapist
assess swallowing reflex
evaluate patient for communication defects (aphasia)
physical therapist
position patient in a functional posisiton
assess function and together with patient, plan a rehabilitation program
DELEGATED TASKS
LPN/LVN
administer scheduled anticoagulant and antiplatelet medcations
UAP
obtain VS frequently and report these to RN
measure and record urine output
assist with positioning patient and turning patient at least every 2hr (as directed by RN)
perform passive and active ROM exercises
place equipment needed for seizure precautions in pt room
Ischemic stroke
results from inadequate blood flow to the brain from partial or complete occlusion of an artery
Thrombotic stroke
occurs from injury to a blood vessel wall and formation of a blood clot
the lumen of the blood vessel become narrowed and, if it becomes occluded, infarction occurs
result of thrombosis or narrowing of the blood vessel
Embolic stroke
when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel.
Hemorrhagic stroke
result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles
intracerebral hemorrhage
bleeding within the brain caused by a rupture of a vessel
Common cause: hypertension
Manifestation: neurologic deficits, headache, nausea, vomiting, decreased LOC, and hypertension
subarachnoid hemorrhage
when there is intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain
LOC range from alert to comatoes
other manifestations: focal neurologic deficits, nausea, vomiting, seizures, and stiff neck
References:
Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing:
Assessment and Management of Clinical Problems (10th ed.). St. Louis, MO: Elsevier, Inc.
Silvestri, L. A., & Silvestri, A. E. (2020). Saunders Comprehensive Review for Nclex-Rn (8th ed.). Philadelphia, PA: W.B. Saunders.