chapter 8 - acute stroke care

cardiac monitooring: pts with SAH are at risk for

"stunned myoocardium" with cardiac dysrhythmias

for every 10 elevatino in BP after tPA is given, the odds of hemorrage increases

59%

What is the hemorrhagic conversion rate for ischemic stroke patients who received IV thrombolysis?

6.4%

What blood pressure range should be maintained for the first 24 hours after post IV thrombolysis and endovascular thrombectomy?

< 180/105

What assessments should be conducted on the patient, puncture site, and extremity after reperfusion therapy?

Checking for hematoma, swelling, bleeding, pseudoaneurysm, artery dissection, or clot formation

What neurovascular checks should be performed after the procedures?

Checking pulses distal to arterial puncture site, capillary refill, skin color, temperature, sensation, motor function

What should be monitored for in relation to potential blood loss complications?

Hypotension and tachycardia

what is the moost costly and debilitating type of stroke

ICH

cardiac monitooring: pts with large deficits and right hemispheric strookes are at inc risk ofo

MI, HF and afib

pt with pulmonary emblus from VTE in lower extremity and a contraindication for anticoagulant tx may benefit from

placement of an inferior vena cava filter

early frequent and shrt sessions of mobility are rec and reduces risk oof

postural hypotension which could result in dec cerebral perfusioon

clinical significance in hemorrhagic transfoormation is determined by presence oof any foollowiing conditions

pt is symptomatic, requiries a change in tx, resuslts in disability or death h

post IV thromblysis and endoovascular thrombectomy mgt: VS and neuroo asssessment

- assess every 15 min for 2 hrs - assess every 30 min foor 6 hrs - assess every hr for 16 hrs, then accoording to level oof care

post stroke complications specific to hemorrhagic stroke pts: nursing considerations

- close BP, temp and glucose mgt - ongoing neuro assessments being alert for new deficits that my inidicate DCI - anticipate sensory depresssion or drowsiness - seizure precautions - ECG changes, which frequently occur after SAH haltough most abnormalities are benign, cardiac ischemia should be ruled out befoore adduming the change is of neurological origin - cardiac markers and serial 12 lead ECGs may be warranted

post stroke complications specific to hemorrhagic stroke pts: vasospasm

- common cause of neurological deterioration after an SAH pt is initially stabilized, results in delayed cerebral ischemia DCI - occurs usually between days 4 and 10 following the original bleed (can be seen up to 21 days post SAH) - transcranial dooppler TCD is useful in monitoring for vasosspasm ass well as CT perfusiioin study to detect areas of hypoperfusion tx

post stroke complications specific to hemorrhagic stroke pts: hyponatremia

- occurs in up to 50% of SAH pts - results from cerebral salt wasting CSW or SIADH - tx is for NA lesss than 135 or clinical deterioration attributable to this

post stroke complications specific to hemorrhagic stroke pts: rebleeding

- sym of this are related to an inc in ICP - IV vasoactive meds are used too dec BP or maintain hemodynamic parameters to limit risk of rebleeding or poor cerebral perfusioino

post stroke complications specific to hemorrhagic stroke pts: hydrocephalus

- usually presents in first 24 hrss after injury - watch for dec in LOC due to risiing ICP - ventricular cath may be placed to drain CSF

post stroke complications specific to hemorrhagic stroke pts: seizures

-20-50% of SAH pts will have this, most often after MCA rupture - blood irritating the parenchymal tissue or an increased ICP can causes these - antiseizure meds are no loonger a class A rec as SE ooutweight the benefit - continuous EEG may be used

What is the hemorrhagic conversion rate in absence of reperfusion therapy for ischemic stroke patients?

1.5%

for each degree increase, the normal metabolic demand increases by

10%

What should be monitored for to detect potential complications after thrombolysis and thrombectomy?

Bleeding from any site or angioedema

pts wtiih SAH often have hyponatremia due to

CSW or SIADH

Nursing considerations for decompressive craniectomy: protective helmet

Ensure protective helmet when out of bed because the skull is no longer intact

Nursing considerations for decompressive craniectomy: bone flap storage

If the bone flap is stored in subcutaneous tissue (abdomen or thigh), provide wound care and monitor for signs of infection

What symptoms should be monitored for related to potential complications after the procedures?

Increased back pain or thigh pain, pallor, pain, paresthesia in the sheath extremity

what is first indicatoor of neurogical change

LOC

What should be monitored for signs of deterioration after reperfusion therapy?

Neuro assessments

Nursing considerations for decompressive craniectomy: wound care

Optimal wound care is essential to limit skin flora exposure to the surgical site

Nursing considerations for decompressive craniectomy: bone flap replacement

The bone flap (either the patient's own bone or prosthetic material) may be replaced in 6-8 weeks after the risk for swelling and increased intracranial pressure has passed

How can limb blood flow be monitored post-procedure?

Using plethysmography or pulse ox probe on the toe of the extremity

HI 1

along the margins of infarct

hemorrhagic transformation has been considered a marker of successful reperfusion therapy and is considered a good sign as long as it is nto

clinically siignificant

PH 1

clot not exceeding 30% of infarcted area, with mild space occupying effect

fever - body temp > 100.9F increases metabolic demand on the already injured brain; it also accelerates the ischemic cascade thus contributing too the

conversioon of penumbra to infarct

PH H2

dense clot exceediinig 30% of infarct volume with significant space occupying effect

SIADH

euvolemic or hypervolemia, tx is fluid restriction or mild hypertonic saline solution

post IV thromblysis and endoovascular thrombectomy mgt: groin puncture site

every 15 min for 1 hr, every 30 min for the next hr, every hour for four hours

the low sodium state in CSW is caused by

excessive removal of salt by the kidneys and is not a delusinoal low sodium level as seen in SIADH

when systemic BP is too low or reduced dramatically perfusion pressure may be inadequate for the pneumbra, resulting in

extension of infarct or loss of penumbra

most common complication of SAH

fever

parenchymal hemorrhage PH

hemoorrhage with mass effect, pts usually symptomatic

what is a poost stroke coomplicationo specific to ischemic stroke pts

hemorrhagic conversion/transfoormation

petechial hemorrhage AKA

hemorrhagic infarct HI

anticoagulation is contranidicated for

hemorrhagic stroke and large territory ischemic stroke pts

clinical sym of CSW include

hyponatremia and poolyuria

CSW

hypovolemia, tx is mild hypertonic saline solution or mineralocorticoids

when systemic BP is too high, the BBB may be disrupted resulting in

increasing cerebral edema, hemorrhagic transformation, or expansioon of hemoorrhagic strooke

hyperglycemia leads to

infarct expansion, hemorrhagic transformation, and reduced recanalization with thromblytics associated with inc length of stay and inc mortality

what is preferred fluid for cerebral edema

isotonic fluids - 0.9% NS or LR

cerebral edema is seen with

large territory ischemic stroke and hemorrhagic strokes and primary reason for decompressive craniotomy

decompressive craniectomy

partial bone flap removal allows the size of the cranial vault to be altered, providing the brain room to swell, dec the threat of herniatiion

petechial hemorrhage

patchy hemorrhage often foound on routine 24 hr imaging but without space occupying effect, so pts are sually asymptommatic

DVT assessment

redness, swelling, tenderness of extremities risk due to immobility and limb paralysis

DCI

refers to acute neurological deterioooration, including but not limited to new hemiparesis, aphasia, and altered LOC

when noxious stimulation is warranted to determine responose level - vary the methods to produce least amt of bruisin

sternal pressure, trapezius pinch, supraorbital pressure

thromobemblic deterrent TED stocking should NOOT be used for what pop

stroke population

in addition to BP mgt, 3 clinical protocols have become standard of care for acute stroke

temp, blood sugar, dysphagia

post stroke complications specific to hemorrhagic stroke pts: DCI

term interchangeable with vasospasm, but they are not the same, vasospasm can be a cause of DCI

HI 2

within infarcted areas