Stroke: Diagnosis, Management, Treatment, Interventions and Rehabilitation

TIA s/ go away w/in?

24 hrs IF blood flow is not restored w/ in that time frame- indicates a stroke

Think FAST

How do you know someone is having a stroke? F- face (drooping, asymmetry- ask to smile) A-arm (cause weakness in limbs- raise both arms) S-speech (slurred) T-time (critical) take to hospital right away

What does the first responder do for a stroke pt?

performs an initial neurologic exam using well-established stroke assessment tools. (paramedics, EM tech).

Stroke pt: immobility complications

pneumonia, atelectasis, and pressure injuries, venous thromboembolism (VTE), especially deep vein thrombosis (DVT), which can lead to a pulmonary embolism (PE).

Glascow coma scale- sudden drop in how many is an emergency?

2

Stoke pt: Urinary and/or bowel incontinence

Give stool softeners and bladder stimulating agents to prevent straining

Stroke complication: Hydrocephalus

(increased cerebrospinal fluid [CSF] within the ventricular and subarachnoid spaces) may occur as a result of blood in the CSF. This prevents CSF from being reabsorbed properly by the arachnoid villi because of obstruction by small clots. Cerebral edema, which interferes with the flow of CSF out from the ventricular system, may also develop. Eventually the ventricles become enlarged. If hydrocephalus is left untreated, increased intracranial pressure (ICP) results. Observe for signs and symptoms of hydrocephalus, which are similar to those of ICP elevation, including a change in the LOC.

Stroke priority problems

1-Inadequate perfusion 2-Impaired swallowing 3-Impaired physical mobility & self-care deficit 4-Aphasia or dysarthria (slurred speech) 5-Urinary &/or bowel incontinence 6- Disturbed sensory perception 7-Unilateral body neglect

Time Plan Time Zero Arrival to the emergency department (ED)

10 Minutes Patient seen by ED physician for initial assessment. 15 Minutes Patient seen by stroke team. 25 Minutes Non-contrast computed tomography (CT) scan performed. 45 Minutes CT scan results available to stroke team and decision made for treatment. 60 Minutes Door-To-Needle (DTN): Fibrinolytic therapy initiated within 3 hours unless contraindicated.

Nursing role w/ Fibrinolytic therapy:

Assess for bleeding, bruising, hematoma For pts receiving plt. Inhibitors monitor plt. Counts for the first 3, 6, & 12 hrs after the start of the infusion or per agency protocol. If plt. Count decreases to below 100,000/mm^3, the infusion needs to be readjusted or discontinued. NEVER GIVE- Altepase for a hemorrhagic stroke

Stroke pt: psychosocial

Assess for emotional lability (uncontrollable emotional state) especially if the frontal lobe or right side of the brain has been affected. In such cases, the patient often laughs and then cries unexpectedly for no apparent reason. Explain the cause of uncontrollable emotions to the family or significant others so they do not feel responsible for these reactions.

Also assess hourly w/ stroke pt?

Assess for: Denial of illness Spatial & proprioceptive (awareness of body position in space) dysfunction Impairment of memory, judgement, or problem-solving & decision-making abilities Decreased ability to concentrate & attend to tasks Difficulty in remembering events (past or present)

Nursing Safety Priority Critical Rescue stroke pt

Be alert for symptoms of increased ICP in the stroke patient and report any deterioration in the patient's neurologic status to the primary health care provider or Rapid Response Team immediately! The first sign of increased ICP is a declining level of consciousness (LOC).

Stroke Management; Non-Pharmacologic Therapies:

Embolectomyà Make sure client gives informed consent first Carotid artery angioplasty with stentingà Informed consent (whether by pt or caregiver required) Monitor for increased ICP Avoid clustering nursing procedures to prevent stress and increased ICP

Endovascular Interventions.

Endovascular procedures to improve PERFUSION include intra-arterial thrombolysis using drug therapy, mechanical embolectomy (clot removal), and carotid stent placement. Intra-arterial thrombolysis has the advantage of delivering the fibrinolytic agent directly into the thrombus within 6 hours of the stroke onset. It is particularly beneficial for some patients who have an occlusion of the middle cerebral artery or those who arrive in the ED after the window for IV alteplase. Patients having either fibrinolytic therapy or endovascular interventions are admitted to the critical care setting for intensive collaborative monitoring. Carotid artery angioplasty with stenting is common to prevent or, in some cases, help manage an acute ischemic stroke. This interventional radiology procedure is usually done under moderate sedation. It may be performed by a cardiovascular surgeon or interventional radiologist. A technique using a distal/embolic protection device has made this procedure very safe. The device is placed beyond the stenosis through a catheter inserted into the femoral artery (groin). The device catches any clot debris that breaks off during the procedure. Placement of a carotid stent is performed to open a blockage in the carotid artery typically at the division of the common carotid artery into the internal and external carotid arteries. Throughout the procedure, the patient's neurologic and cardiovascular statuses must be carefully assessed. Nursing Safety Priority Action Alert Before discharge after carotid stent placement, teach the patient to report these symptoms to the health care provider as soon as possible: • Severe headache • Change in LOC or COGNITION (e.g., drowsiness, new-onset confusion) • Muscle weakness or motor dysfunction • Severe neck pain • Swelling at neck incisional site • Hoarseness or difficulty swallowing (due to nerve damage) When the stroke is hemorrhagic and the cause is related to an AVM or cerebral aneurysm, the patient is evaluated for the optimal procedure to stop bleeding. Some procedures can be used to prevent bleeding in an AVM or aneurysm that is discovered before symptom onset or SAH. Procedures occur in the interventional radiology suite or operating room. Following carotid stent placement, hyperperfusion syndrome can occur, which has a high morbidity and mortality rate. This syndrome is thought to be the result of an impaired autoregulation of cerebral blood flow that results from long-standing decreased cerebral PERFUSION pressure resulting from carotid artery disease. The signs and symptoms include severe temporal headache, hypertension, seizures, and focal neurologic deficits. This syndrome may be associated with intracranial hemorrhage and may occur within 1 hour after the procedure up to 24 hours or even 1 week later (Orion etal., 2015).

Aphasia or dysarthria d/t decreased circulation in the brain or facial muscle weakness: locations - lobe Expressive aphasia Receptive aphasia

Expressive Aphasia (Frontal lobe) Receptive Aphasia (Temporal lobe) Both are a result of cerebral hemisphere damage (left cerebral hemispere is the speech center for most pt)

Stroke pt. in terms of triage?

FIrst!!!!! As soon as possible

Medication used for stroke and when it can be given>

Fibrinolytic drug- Tissue Plasminogen activator/ t-PA, Alteplase (Activase) used for treatment Used to break up the clot (monitored in ICU because of high risk for bleeding) Given w/in 3 hr or less (AHA) SOMETIMES benefits of giving the medication at 4.5 hrs after a coronary event

The two major treatment modalities for patients with acute ischemic stroke are

IV fibrinolytic therapy and endovascular interventions. Regardless of the immediate management approach used, once the patient is stable, provide ongoing supportive care. Provide interventions to prevent and/or monitor for early signs of complications, such as hyperglycemia, urinary tract infection, and pneumonia. Implement interventions to prevent patient falls.

In ED- assess stroke pt. w/ 10 min of arrival. Stroke Management; Common Assessment Findings Priority-

In ED- assess stroke pt. w/ 10 min of arrival. Stroke Management; Common Assessment Findings Priority- ABCs LOC- neurological assessment (Glasgow Coma Scale or NIH) Confusion Vision (black- hemianopia) Loss of coordination Muscle weakness Loss of movement Decorticate posturing (towards core) Decerebrate posturing Facial droop, slurred speech Cranial nerve assessment Cardiovascular- cushing's triad Emotional liability Carotid- doppler (90% occlusion to have s/) PRIORITY ASSESSMENT- ABCs (airway, breathing, circulation) Supplemental oxygen to maintain oxygen saturation Ventilator support for respiratory depression, fatigue, decreased LOC or compromised airway. Inadequate perfusion to the brainàPosition pt lying down. During immediate stroke position on side. For us to know-position HOB 30 Monitor vital q15min For ischemic strokes, SBP more than 180 mm Hg- notify HCP & anticipate IV antihypertensive meds. Monitor BP & MAP q5min. until SBP is between 140-150 mm Hg to maintain brain perfusion. Avoid a sudden SBP drop to less than 120mmHg with drug administration, which may cause brain ischemia. Monitoring for Other Complications.

Stroke pt: Mobility & ADL

In collaboration with the rehabilitation therapists, assess the patient's functional ability for bed MOBILITY skills, ambulation with or without assistance, and ADL ability, including feeding, bathing, and dressing. Screen for dysphagia- identify risk for aspiration: NPO; thickened liquids/dysphagia diet/tube feeding per MD orders Risk for aspiration d/t impaired swallowing as a result of muscle weakness- maintain NPO until swallowing ability is assessed. Speech pathologist for swallow eval Consider supplements for malnourishment Collab w/ nutrition (mon. pts. Wgt daily & serum pre-albumin levels to notice any decrease Oral hygiene protocol to reduce risk of pneumonia It is not unusual for the patient to eventually have a flaccid arm and spastic leg on the affected side because the affected leg often regains function more quickly than the arm. Be sure to support the affected flaccid arm of the stroke patient, and teach unlicensed assistive personnel (UAP) to avoid pulling on it. Position the arm on a pillow while the patient is sitting to prevent it from hanging freely, which could cause shoulder subluxation. The physical therapist (PT) or occupational therapist (OT) may provide a slinglike device to support the arm during ambulation. Patients begin rehabilitation as soon as possible to regain function and prevent complications of immobility, such as pneumonia, atelectasis, and pressure injuries, venous thromboembolism (VTE), especially deep vein thrombosis (DVT), which can lead to a pulmonary embolism (PE). This risk is highest in older patients and those with a severe stroke. provide care to prevent this complication by applying intermittent sequential pneumatic devices, changing the patient's position frequently, and ambulating the patient if possible. Report any indications of DVT to the primary health care provider and document assessments in the patient's record. Use a gait belt for ambulating

In some cases, the patient's blood pressure may be too high to give the medication.: fibrinolytic

In this instance, the patient receives a rapid-acting antihypertensive drug such as labetalol (Normodyne) or nicardipine (Cardene) until the blood pressure is below 185/110

Monitoring for Other Complications.- stroke

Monitor the patient with an aneurysm or arteriovenous malformation (AVM) and patients following repair of these vessel malformations for signs and symptoms of hydrocephalus and vasospasm. If blood is in the subarachnoid space, the patient is at risk for cerebral vasospasm. Rebleeding or rupture is a common complication for the patient with an aneurysm or AVM.

Stroke Discharge Home Care Measures:

Need for caregivers to plan for routine respite care and protection of own health Evaluation for potential safety risks such as throw rugs or slippery floors Awareness of potential patient frustration associated with communication Access to health resources such as publications from the AHA Referral to hospice and encouragement of family discussion of advance directives As part of the discharge process, teach the family about the signs and symptoms of depression that may occur within 3 months after a stroke. The strongest predictors of post-stroke depression (PSD) are: a history of depression, severe stroke, and post-stroke physical or cognitive impairment. Patients may not exhibit typical signs of depression because of their cognitive, physical, and emotional impairments. PSD is associated with increased morbidity and mortality, especially in older men. The three areas that should be included in patient and family education are: disease prevention, disease-specific information, and self-management. The teaching plan may include lifestyle changes, drug therapy, ambulation/transfer skills, communication skills, safety precautions, nutritional management, activity levels, and self-management skills. Health teaching should focus on tasks that must be performed by the patient and the family after hospital discharge. Return demonstrations help to evaluate the family members' competency in tasks required for the patient's care (Fig. 45-3). Provide both written and verbal instruction in all these areas.

NURSE PRIORITIES: for a stroke pt

Nonsurgical Management. Nursing interventions are initially aimed at monitoring for neurologic changes or complications associated with stroke and its treatment. Priority collaborative stroke prob: Inadequate perfusion to brain d/t interruption of arterial blood flow and possible increase ICP Decreased mobility and ability to perform ADLs d/t neuromuscular or cognitive impairment. Aphasia or dysarthria d/t decreased circulation in the brain or facial muscle weakness Sensory perception deficits d/t altered neurologic reception & transmission

Ongoing drug therapy

Ongoing drug therapy depends on the type of stroke and the resulting neurologic dysfunction. In general, the purposes of drug therapy are to prevent further thrombotic or embolic episodes (with antithrombotics and anticoagulation) and to protect the neurons from hypoxia. Antithrombotics include the use of aspirin or other antiplatelet drugs (e.g., clopidogrel [Plavix]) and are the standard of care for treatment following acute ischemic strokes and for preventing future strokes. Sodium heparin and other anticoagulants, such as warfarin (Coumadin, Warfilone), are used in the presence of atrial fibrillation. Anticoagulants are high-alert drugs that can cause bleeding, including intracerebral hemorrhage. An initial dose of 325mg of aspirin (Ecotrin, Ancasal) is recommended within 24 to 48 hours after stroke onset (CDC, 2017). Aspirin should not be given within 24 hours of fibrinolytic administration. Aspirin is an antiplatelet drug that prevents further clot formation by reducing platelet adhesiveness (clumping or "stickiness"). It can cause bruising, hemorrhage, and liver disease over a long-term period. Teach the patient to report any unusual bruising or bleeding to the primary health care provider. A calcium channel blocking drug that crosses the blood-brain barrier such as nimodipine (Nimotop) may be given to treat or prevent cerebral vasospasm after a subarachnoid hemorrhage. Vasospasm, which usually occurs between 4 and 14 days after the stroke, slows blood flow to the area and causes ischemia. Nimodipine works by relaxing the smooth muscles of the vessel wall and reducing the incidence and severity of the spasm. In addition, this drug dilates collateral vessels to ischemic areas of the brain. Stool softeners, analgesics for pain, and antianxiety drugs may also be prescribed as needed for symptom management. Stool softeners also prevent the Valsalva maneuver during defecation to prevent increased ICP.

To help communicate with the patient with aphasia, use these guiding principles:

Present one idea or thought in a sentence (e.g., "I am going to help you get into the chair."). Use simple one-step commands rather than ask patients to do multiple tasks. Speak slowly but not loudly; use cues or gestures as needed. Avoid "yes" and "no" questions for patients with expressive aphasia. Use alternative forms of communication if needed, such as a computer, handheld mobile device, communication board, or flash cards (often with pictures). Do not rush the patient when speaking. For more specific communication strategies for the patient with aphasia or dysarthria, collaborate with the speech-language pathologist.

STK- 4; Thrombotic Therapy

Pt arrived at hospital w/in 2hr of LKW time t-PA (initiated)

STK-5; Antithrombotic Therapy By End Of Hospital Day Two

Pt experienced ischemic stroke- receive med for further thrombosis

STK- 8; Stroke Education

Pt. experienced a stroke- pt. and family receive Causes Stroke prevention s/s FAST How to react Verbally, hand-outs

STK-2; Discharged on Antithrombotic Therapy

Pt. experienced a thrombotic stroke are discharged on therapy Warfarin (ex)

STK- 1; Venous Thromboembolism (VTE Prophylaxis)

Pt. experienced stroke at risk for this will receive mechanical prophylaxis (SCDs) & prophylaxis meds (heparin, low molecular wgt heparin) Q pt. w/in 24 hrs of receiving a stroke

STK-3; Anticoagulation Therapy for Atrial Fibrillation/Flutter

Pts discharged on anticoags (warfarin)

Contraindications for Altepase (fibrinolytic)

Recent head injury or trauma (last 4 wks) don't qualify for activase or surgery d/t risk of bleeding DM, & hrt dx, over 80 NEVER GIVE- Altepase for a hemorrhagic stroke

Rebleeding or rupture is a common complication for the patient with an aneurysm or AVM.- STROKE PT

Recurrent hemorrhage may occur within 24 hours of the initial bleed or rupture and up to 7 to 10 days later.

Specific s/s of stroke need to be monitored, depend on extent & location of ischemia & the arteries involved: FIVE most common:

Sudden confusion or trouble speaking or understanding others Sudden numbness or weakness of the face, arm, or leg Sudden trouble seeing in one or both eyes Sudden dizziness, trouble walking, or loss of balance or coordination Sudden severe headache with no known cause

Stroke pt: If surgery is performed, assess the patient for the following and if present, notify the health care team immediately.

Surgical site for a puncture site hematoma or signs of infection, such as localized edema and erythema. Change in vital signs such as tachycardia, hypo- or hypertension, and elevated temperature. Neurologic changes (decreased LOC, visual changes, new-onset weakness), which may indicate extension of the stroke area, cerebral vasospasm, or cerebral brainstem herniation.

expressive phasia

The inability to produce language ( despite being able to understand language) (broca's or motor) aphasia is the result of damage in Broca's area of the frontal lobe. Motor speech prob. Pt understands what is said but cannot speak & has difficulty writing but may be able to read. Pt. aware, may become frustrated

Stroke pt: ICP risk

The patient is most at risk for increased ICP resulting from edema during the first 72 hours after onset of the stroke. Some patients may have worsening of their neurologic status starting within 24 to 48 hours after their endovascular procedure from increased ICP (Chart 45-6). Reassess patients with acute stroke and after endovascular treatment of stroke symptoms every 1 to 4 hours, depending on severity of the condition. Use the approved agency assessment strategy and documentation tools.

STK-10; Assessed for Rehabilitation

They are assessed before discharge and ability to take care of self

STK-6; Discharged on a Statin Medication

Thrombotic stroke- sent home on statin

Stroke pt: Deep Vein Thrombosis (DVT) Prophylaxis

Use intermittent pneumatic compression (IPC) in addition to routine care (aspirin and hydration) to reduce the risk of DVT in immobile stroke patients, unless contraindicated. Do NOT use elastic compression stockings in ischemic stroke patients.

Nursing Safety Priority Drug Alert: fibrinolytic In addition to frequent monitoring of vital signs,:

carefully observe for signs of intracerebral hemorrhage and other signs of bleeding during administration of fibrinolytic drug therapy. • Perform a double check of the dose. Use a programmable pump to deliver the initial dose of 0.9mg/kg (maximum dose 90mg) over 60 minutes, with 10% of the dose given as a bolus over 1 minute. Do not manually push this drug. • Admit the patient to a critical care or specialized stroke unit. • Perform neurologic assessments, including vital signs, every 10 to 15 minutes during infusion and every 30 minutes after that for at least 6 hours; monitor hourly for 24 hours after treatment. Be consistent regarding the device used to obtain blood pressures because blood pressures can vary when switching from a manual to a noninvasive automatic to an intra-arterial device. • If systolic blood pressure is 180mmHg or greater or diastolic is 105mmHg or greater during or after tissue plasminogen activator (tPA), give antihypertensive drugs as prescribed (IV is recommended for faster response). • To prevent bleeding, do not place invasive tubes, such as nasogastric (NG) tubes or indwelling urinary catheters, until the patient is stable (usually for 24 hours). • Discontinue the infusion if the patient reports severe headache or has severe hypertension, bleeding, nausea, and/or vomiting; notify the health care provider immediately. • Obtain a follow-up CT scan after treatment before starting antiplatelet or anticoagulant drugs.

Clinical findings of hydrocephalus

changes in LOC Clinical findings may also include headache, pupil changes, seizures, poor coordination, gait disturbances (if ambulatory), and behavior changes.

MIXED or GLOBAL aphasia. Mixed aphasia:

combination of difficulty understanding words and speech difficulty reading and writing Global aphasia: profound speech and language problems often no speech or sounds that can be understood

If blood is in the subarachnoid space, the patient is at risk for cerebral vasospasm. Signs and symptoms of vasospasm may include:

decreased LOC, motor and reflex changes, and increased neurologic deficits (e.g., cranial nerve dysfunction, motor weakness, and aphasia). The symptoms may fluctuate with the occurrence and degree of vasospasm present. Hemorrhage-related cerebral vasospasm can result in permanent vascular changes and irreversible neurologic impairment.

Priority for stroke pt.

ensure pt. is transported to a stroke center (rapidly recognize & treat, provide diagnostic (CT) & stroke therapy w/ IV fibrinolytic therapy. A focused hx to determine pt. has a recent bleeding event or is taking an anticoagulant is an important part of the rapid stroke-assessment protocol, After fibrinolytic therapy or determining that the pt. is not a candidate, more extensive diagnostic tests and evals are done to identify the cause and area of brain involved.

Stroke pt: glascow coma scale should be performed?

hourly

What does last known well mean? (LKW)

iDENTIFICATION OF BRAIN ATTACK OR STROKE- last time pt. did not have s/ In other words, when did they start?

Unilateral body neglect: Hemianopsia

in which the vision of one or both eyes is affected. This problem places the patient at additional risk for injury, especially falls, because of an inability to recognize his or her physical impairment or because of a lack of proprioception (position sense). Teach the patient to touch and use both sides of the body. When dressing, remind the patient to dress the affected side first.

Receptive aphasia

inability to understand spoken or written words (Wernicke's or sensory) is caused by injury involved Wernicke's area in the temporoparietal area. Difficulty understanding spoken words Difficulty understanding written words Speech often meaningless (even though they may be able to talk) Made-up words Usually pt. has some degree of dysfxn in the areas of both expression and reception.

The patient with a left hemisphere lesion generally has

memory deficits and may show significant changes in the ability to carry out simple tasks, such as eating and grooming. Help with ADLs but encourage the patient to do as much as possible independently. To assist with memory problems, re-orient the patient to the month, year, day of the week, and circumstances surrounding hospital admission. Establish a routine or schedule that is as structured, repetitious, and consistent as possible. Provide information in a simple, concise manner.

TEST used to determine eligibility for IV fibrinolytics

neurologic assessment The National Institutes of Health Stroke Scale (NIHSS)- when the pt arrives in the ED. 11 areas: LOC (O alert- 3 unresponsive) LOC questions, LOC commands (tasks), Best gaze, visual (hemianopia -less vision or blindness (anopia)), facial palsy- paralysis, motor (arm), motor (leg), limb ataxia (impaired balance or coordination), sensory (pinprick, sharp or dull), best language (aphasia), dysarthria (slurred speech), extinction & inattention (neglect- visual, tactile, auditory, spatial, personal inattention or extinction to bilateral stimulation). Score- 0-40 (0 indicating no neurologic deficits) monitor for signs of brain stem herniation (increased ICP, decreased strength in extremities, focal or global activity, or asymmetrical pupils) monitor for seizure activity, implement seizure precautions do not administer anti-seizure meds prophylactically

Stroke pt: cardiovascular assessment:

pts. w/ embolic strokes may have a heart murmur, dysrhythmias (A fib) or HTN It is not unusual for the patient to be admitted to the hospital with a blood pressure greater than 180 to 200/110 to 120mmHg, especially if he or she has a hypertensive bleed. Although a somewhat higher blood pressure of 150/100mmHg is needed to maintain cerebral PERFUSION after an acute ischemic stroke, pressures above this reading may lead to extension of the stroke.

Cushing's triad

r/t ICP Severe HTN Widened pulse pressure Bradycardia

Stroke pt: skin

regular skin checks, turning (q2h )

Stroke problems: Sensory changes (Disturbed Sensory Perception)

related to altered neurologic reception, transmission and perception.

Stroke problems: Aphasia or dysarthria (slurred speech)

related to decreased circulation in the brain or facial muscle weakness.- Aphasia: Inability to speak or comprehend language

Stroke problems: Impaired Swallowing

related to neuromuscular impairment.

Stroke problems: Impaired Physical Mobility and Self-Care Deficit

related to neuromuscular or cognitive impairment. Ensure adequate rest, emotional support, allow independence (allow them to do everything they can for themselves), devices

Stroke problems: Urinary and/or Bowel Incontinence

related to reflex bladder and bowel. .

Rebleeding or rupture is a common complication for the patient with an aneurysm or AVM.- STROKE PT- Assess for

severe headache, nausea and vomiting, a decreased LOC, and additional neurologic deficits. Potential consequences of a second cerebral hemorrhagic event may be catastrophic.

Apraxia may be present. Typically the patient with apraxia exhibits a

slow, cautious, and hesitant behavior style. The physical therapist (PT) helps the patient compensate for loss of position sense.

Stroke meds to cont?

statins

embolectomy

surgical removal of an embolus

Stroke problems: Unilateral body neglect

syndrome related to disturbed perceptual abilities or hemianopsia.-Unilateral inattention (body neglect) syndrome: Being unaware of the existence of his or her paralyzed side (particularly common with strokes in the right cerebral hemisphere)

Stroke problems: Inadequate perfusion

to the brain related to interruption of arterial blood flow and a possible increase in ICP.

IF homonymous hemianopsia is present, teach the patient to

turn his or her head from side to side to expand the visual field because the same half of each eye is affected. This scanning technique is also useful when the patient is eating or ambulating. Place objects within the patient's field of vision. A mirror may help visualize more of the environment. If the patient has diplopia (double vision), a patch may be placed over the affected eye and changed every 2 to 4 hours.

Disturbed sensory perception: adapting to neurologic deficits Therefore the patient with a stroke is expected to adapt to sensory perception changes in

vision, proprioception (position sense), and sensation and to be free from injury. Patients with right hemisphere brain damage typically have difficulty with visual-perceptual or spatial-perceptual tasks. They often have problems with depth and distance perception and with discrimination of right from left or up from down. Because of these problems, patients can have difficulty performing routine ADLs. Caregivers can help the patient adapt to these disabilities by using frequent verbal and tactile cues and by breaking down tasks into discrete steps. Always approach the patient from the unaffected side, which should face the door of the room!

Currently, the U.S. Food and Drug Administration (FDA) approves administration of alteplase within 3 hours of stroke onset. The American Stroke Association endorses extension of that time frame to 4.5 hours to administer this fibrinolytic for patients unless they fall into one or more of these categories:

• Age older than 80 years • Anticoagulation regardless of international normalized ratio (INR) • Imaging evidence of ischemic injury involving more than one third of the brain tissue supplied by the middle cerebral artery • Baseline National Institutes of Health Stroke Scale score greater than 25 • History of both stroke and diabetes

Increased cranial pressure (ICP) s/

• Decreased level of consciousness (LOC) (lethargy to coma) • Behavior changes: restlessness, irritability, and confusion • Headache • Nausea and vomiting (may be projectile) • Change in speech pattern/slurred speech: • Aphasia • Change in sensorimotor status: • Pupillary changes: dilated and nonreactive pupils ("blown pupils") or constricted and nonreactive pupils • Cranial nerve dysfunction • Ataxia • Seizures (usually within first 24 hours after stroke) • Cushing's triad: • Severe hypertension • Widened pulse pressure • Bradycardia • Abnormal posturing: --Decerebrate --Decorticate

Best practices for managing increasing ICP for patients experiencing a stroke include:

• Elevate the head of the bed per agency or primary health care provider (PHCP) protocol to improve PERFUSION pressure. • Provide oxygen therapy to prevent hypoxia for patients with oxygen saturation less than 94% or per agency or PHCP protocol or prescription. • Maintain the head in a midline, neutral position to promote venous drainage from the brain. • Avoid sudden and acute hip or neck flexion during positioning. Extreme hip flexion may increase intrathoracic pressure, leading to decreased cerebral venous outflow and elevated ICP. Extreme neck flexion also interferes with venous drainage from the brain and intracranial dynamics. • Avoid the clustering of nursing procedures (e.g., giving a bath followed immediately by changing the bed linen). When multiple activities are clustered in a narrow time period, the effect on ICP can be dramatic elevation. • Hyperoxygenate the patient before and after suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries. • Provide airway management to prevent unnecessary suctioning and coughing that can increase ICP. • Maintain a quiet environment for the patient experiencing a headache, which is common with a cerebral hemorrhage or increased ICP. • Keep the room lights low to accommodate any photophobia (sensitivity to light) the patient may have. • Closely monitor blood pressure, heart rhythm, oxygen saturation, blood glucose, and body temperature to prevent secondary brain injury and promote positive outcomes after stroke. Although the optimal blood pressure range after stroke is controversial, the primary health care provider often desires that the patient with acute ischemic stroke be slightly hypertensive, with a systolic blood pressure (SBP) between 140 and 150mmHg to promote cerebral tissue PERFUSION. treat hyperthermia w/ antipyretic, cooling blankets treat hyperglycemia keeping glucose levels in a target range, typically 100 to 180 mg/dL

Specific teaching for stroke patients (and their families) includes:

• Provide information about prescribed drugs to prevent another stroke and control hypertension. Instruct the patient and the family in the name of each drug, the dosage, the timing of administration, how to take it, and possible side effects. • Teach the patient how to climb stairs safely, if he or she is able; transfer from the bed to a chair; get into and out of a car; and use any aids for MOBILITY. • Provide important information regarding what to do in an emergency and who to call for nonemergency questions. Patients who have had a TIA or stroke are at risk for another stroke. Teach family members to observe for and act on signs of a new stroke using the F.A.S.T. pneumonic: • Face drooping • Arm weakness • Speech or language difficulty • Time to call 9-1-1 Depending on the location of the lesion, the patient may be anxious, slow, cautious, and hesitant and lack initiative (left hemisphere lesions). As a result of right hemisphere lesions, he or she may be impulsive and seemingly unaware of any deficit.

The eight core measures for Ischemic Stroke Care for all patients include: joint commission core measures

• Venous thromboembolism (VTE) prophylaxis • Discharge with antithrombotic therapy • Discharge with anticoagulation therapy for atrial fibrillation/flutter • Thrombolytic therapy as indicated • Antithrombotic therapy re-evaluated by end of hospital day 2 • Discharge on statin medication • Stroke education provided and documented • Assessment for rehabilitation

Several important parts of the history should be collected: for a stroke pt

• What was the patient doing when the stroke began? Hemorrhagic strokes tend to occur during activity. • How did the symptoms progress? Symptoms of a hemorrhagic stroke tend to occur abruptly, whereas thrombotic strokes generally have a more gradual progression. • Did the symptoms worsen after the initial onset, or did they begin to improve? • What is the patient's medical history (with specific attention directed toward a history of head trauma, diabetes, hypertension, heart disease, anemia, and obesity)? • What are the patient's current medications, including prescribed drugs, over-the-counter (OTC) drugs, herbal and nutritional supplements, and recreational (illicit) drugs? • What is the patient's social history, including education, employment, travel, leisure activities, and personal habits (e.g., smoking, diet, exercise pattern, drug and alcohol use)? During the interview, observe the patient's level of consciousness (LOC) and assess for indications of impaired COGNITION and SENSORY PERCEPTION. Question the patient or family member about the presence of SENSORY PERCEPTION deficits or motor changes, visual problems, problems with balance or gait, and changes in reading or writing abilities. When LOC is suddenly decreased or altered, immediately determine if hypoglycemia or hypoxia is present because these conditions may mimic emergent neurologic disorders. Hypoglycemia and hypoxia are easily treated and reversed, unlike brain injury from inadequate PERFUSION or trauma. The patient with an SAH Subarachnoid hemorrhage (SAH) , particularly when the hemorrhage is from a ruptured (leaking) aneurysm, often reports the onset of a sudden, severe headache described as "the worst headache of my life." Additional symptoms of SAH or cerebral aneurysmal and AVM bleeding are: nausea and vomiting, photophobia, cranial nerve deficits, stiff neck, and change in mental status. There may also be a family history of aneurysms.