Chapter 58: Stroke

What is the most common bowel problem in stroke patients?

Constipation - prophylactic stool softeners and/or fiber - physical activity

What is dysarthria?

Dysarthria is disturbance in the muscular control of speech Impairments may involve: Pronunciation Articulation Phonation

Which is more common, hemorrhagic or ischemic strokes?

Ischemic, which accounts for 80% of all strokes (TIA is usually a precursor; higher risk of stroke if you've had a TIA)

What criteria must be met before beginning oral feedings?

Swallow screen by RN evaluation from speech pathologist (SLP)

What are some physical therapy techniques to regain musculoskeletal function?

*Bobath approach* is to help the patient gain control over patterns of spasticity by inhibiting abnormal reflex patterns (e.g. have pt transfer with weaker side and use stronger side to facilitate more bilateral functioning) *Constraint-induced movement therapy* (CIMT) encourages the patient to use the weakened extremity by restricting movement of the normal extremity

Where are the majority of cerebral aneurysms?

*Circle of Willis* cerebral aneurysms are "silent killers" symptoms of aneurysms include: focal neurologic deficits (including cranial nerve deficits) nausea/vomiting seizures stiff neck

Bridge to NCLEX question: The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

*c. patency of the cerebral blood vessels.* Rationale: Angiography provides visualization of cerebral blood vessels and can help estimate perfusion and detect filling defects in the cerebral arteries.

Bridge to NCLEX question: Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

*d. sudden onset of severe headache.* Rationale: A hemorrhagic stroke usually causes a sudden onset of symptoms, which include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.

What are four surgical interventions for patients with TIA secondary to carotid disease?

- Carotid endarterectomy ("CEA"): The "Roto-Rooter" - Transluminal angioplasty: insertion of a balloon to open a stenosed artery in the brain and improve blood flow - Stenting: involves intravascular placement of a stent in an attempt to maintain patency of the artery. The stent can be inserted during an angioplasty - Extracranial-intracranial bypass: anastomosing (surgically connecting) a branch of an extracranial artery to an intracranial artery (most commonly, superficial temporal to middle cerebral artery) beyond an area of obstruction with the goal of increasing cerebral perfusion

What are some examples of nursing diagnoses for stroke patients?

- Risk for ineffective cerebral tissue perfusion - Ineffective airway clearance - Impaired physical mobility - Impaired verbal communication - *Unilateral neglect* (esp. L Side Neglect for R sided CVA) - Impaired urinary elimination - Impaired swallowing - Situational low self-esteem

Name some of the exclusion criteria for tPA

- hemorrhagic stroke - coagulation disorders - recent history of gastrointestinal bleeding, stroke, or head trauma within the past 3 months - major surgery within 14 days - hypertension - seizures

What are three factors that determine extent of thrombotic stroke?

1) rapidity of onset 2) size of lesion(s) 3) presence of collateral circulation

What is a vasospasm?

A vasospasm is a narrowing of a blood vessel and is a complication of aneurysmal subarachnoid hemorrhage Vasospasms can be treated with the calcium channel blocker nimodipine (Nimotop)

What are some visual problems that may occur with a stroke?

Diplopia (double vision) Loss of the corneal reflex Ptosis (drooping eyelid) Homonymous hemianopsia (R or L sided visual field loss)

What are signs of increased ICP?

EARLY: Decreased LOC Vomiting Severe headache Dilated pupil LATE: Fixed and dilated bilateral pupils Cushing's Response: Hypertension w/ bradycardia (very late sign = herniation), Chayne-Stokes respirations *Increased ICP more likely to occur in hemorrhagic but can occur ischemic strokes (from cerebral edema)*

What are the goals of stroke prevention?

Health promotion for a healthy lifestyle and management of modifiable risk factors to prevent a stroke Modifiable factors: Healthy diet Weight control Regular exercise *No smoking* Limited alcohol consumption Routine health assessments

What accelerates atherosclerosis?

Hypertension and diabetes Thrombosis develops readily where atherosclerotic plaques have already narrowed blood vessels

Why is hyperventilation used to manage ICP?

Hyperventilation causes cerebral vasoconstriction, thereby transiently decreasing intracranial pressure (ICP) However, should only be used as a bridge to more effective therapy to reduce ICP

Why are IV solutions with glucose and water avoided in ischemic stroke patients?

IV solutions with glucose and water are avoided because they are hypotonic and may further increase cerebral edema and ICP. In addition, hyperglycemia may be associated with further brain damage and should be treated

Where is an intracerebral hemorrhage most serious?

In the pons because it affects basic life functions (e.g. respiratory control)

What is the LICOX system?

LICOX measures brain oxygenation and temperature and may be used as a diagnostic tool to evaluate the progression of stroke

What is the main goal for the musculoskeletal system in stroke patients?

Maintain optimal function Prevent of joint contractures and muscular atrophy using passive and/or active ROM exercises Position joints to reduce dependent edema

Preventative drug therapy for ischemic stroke patients/ Acute drug therapy once patient has stabilized

Measures to prevent development of a thrombus or embolus - *Antiplatelet drugs* are used for patients with hx of TIA related to atherosclerosis, *ASA is #1* other antiplatelet drugs: ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine), and combined dipyridamole and aspirin (Aggrenox). Use cautiously in patients with hx PUD - patients with a fib use oral anticoagulant e.g. warfarin (Coumadin), rivaroxaban (Xarelto), and dabigatran etexilate (Pradaxa). The latter two do not require close monitoring - Statins (simvastatin [Zocor], lovastatin [Mevacor]) have also been shown to be effective in the prevention of stroke for individuals who have experienced a TIA in the past - Use of anticoagulants (e.g., heparin) in the emergency phase following an ischemic stroke is generally not recommended because of the risk for intracranial hemorrhage

What is the window for tPA?

Must be administered within 3 to 4.5 hours of onset of clinical signs of ischemic stroke *door to drug time is 1 hour* tPA helpful in 40% of cases (intra-arterial tPA can be given within 6 hours: catheter guided to clot via angiogram so less is needed)

What is a stroke?

There is an interruption, either from ischemia to a part of the brain or hemorrhage into the brain, in the blood supply that results in the death of brain cells

Why are a non-contrast CT or MRI performed?

These diagnostic tools: - Indicate the size and location of the lesion - Differentiate between ischemic and hemorrhagic stroke

How do you manage ICP?

Use interventions that improve venous drainage: - Head in alignment - *HOB elevated* - Avoid stimulation (like suctioning, turning, painful procedures) - Diuretics (esp. Mannitol) - Hyperventilation (if pt herniating)

Why are patients at an increased risk for VTE following a stroke?

Weak or paralyzed lower extremities are particularly vulnerable. Related to immobility, loss of venous tone, and ↓ muscle pumping in leg. Prevention: passive/active range of motion exercises, compression stockings, positioning extremity to reduce dependent edema

Is elevated BP common immediately after a stroke?

YES. May reflect body's attempt to maintain cerebral perfusion (a good thing!) Use of drugs to lower BP is recommended *only if BP is markedly increased (MAP > 130 mm Hg or SBP > 220 mm Hg)*. In the case of an acute stroke, IV antihypertensives such as metoprolol (Lopressor) and nicardipine (Cardene) are preferred

What causes cerebral edema in stroke patient?

materials of blood clots or tissue injury create an osmotic environment allowing the movement of water into interstitial spaces

Wernicke's Aphasia

• A type of fluent aphasia (speech is present but contains little meaningful communication) • Damage occurs in left temporal lobe, although it can result from damage to right lobe. • May speak in long sentences that have no meaning, add unnecessary words, and even create made-up words. • May say,"You know that smoodle pinkered and that I want to get him round and take care of him like you want before." *word salad* • Often difficult to follow what person is trying to say. • Usually have great difficulty understanding speech. • Often unaware of their mistakes.

Global Aphasia

• A type of nonfluent aphasia. • Results from damage to extensive portions of language areas of brain. • Have severe communication difficulties. • May be extremely limited in ability to speak or comprehend language.

What are clinical manifestations of left-sided brain damage (stroke on left side of brain)?

• Paralyzed right side: hemiplegia • *Impaired speech/language aphasias* • Impaired right/left discrimination • Slow performance, cautious • Aware of deficits: *depression, anxiety* (frustration and depression are common in 1st year following stroke) • Impaired comprehension related to language, math

Drug therapy for hemorrhagic stroke

*Management of hypertension is the main focus*: Oral and IV agents are used to maintain BP within a normal to high-normal range (Systolic BP less than 160 mm Hg) Seizure prophylaxis is situation-specific

What are some possible causes of an intracerebral hemorrhage?

*hypertension*, vascular malformations, coagulation disorders, anticoagulant and thrombolytic drugs, trauma, brain tumors, and ruptured aneurysms

NCLEX Review Questions: The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? Clopidogrel (Plavix) Enoxaparin (Lovenox) Dipyridamole (Persantine) Enteric-coated aspirin (Ecotrin) Tissue plasminogen activator (tPA)

* Clopidogrel (Plavix), Dipyridamole (Persantine), Enteric-coated aspirin (Ecotrin)* Rationale: Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke not prevent TIAs or strokes.

NCLEX Review Questions: Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A) Hypertension B) Hyperlipidemia C) Alcohol consumption D) Oral contraceptive use

*A) Hypertension* Rationale: Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.

NCLEX Review Questions: Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A) Maintenance of the patient's airway B) Positioning to promote cerebral perfusion C) Control of fluid and electrolyte imbalances D) Administration of tissue plasminogen activator (tPA)

*A) Maintenance of the patient's airway* Rationale: Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

NCLEX Review Questions: The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A) Safety measures B) Patience with communication C) Mobility assistance on the right side D) Place food in the left side of patient's mouth.

*A) Safety measures* Rationale: A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

Pre-test questions: The nurse observes a student nurse assigned to initiate oral feedings for a 68-year-old woman with an ischemic stroke. The nurse should intervene if she observes the student nurse... A) giving the patient 8 ounces of ice water to swallow. B) telling the patient to perform a chin tuck before swallowing. C) assisting the patient to sit in a chair before feeding the patient. D) assessing cranial nerves IX and X before the patient attempts to eat.

*A) giving the patient 8 ounces of ice water to swallow.* Rationale: The majority of patients after a stroke have dysphagia. The gag reflex and swallowing ability (cranial nerves IX and X) should be assessed before the first oral feeding. To assess swallowing ability, the nurse should elevate the head of the bed to an upright position (unless contraindicated) and give the patient a very small amount (not 8 ounces) of crushed ice or ice water to swallow. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.

What are four non-modifiable risk factors for stroke?

*Age*: Stroke risk doubles each decade after 55 *Gender*: More common in men; more women die (because they live longer, higher chance of suffering a stroke) *Ethnicity/race*: Higher incidence in African Americans *Heredity/family history*: Genetic risk factors are important in the development of all vascular diseases, including stroke

NCLEX Review Questions: A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient's integumentary system? A) Position the patient on her weak side the majority of the time. B) Alternate the patient's positioning between supine and side-lying. C) Avoid the use of pillows in order to promote independence in positioning. D) Establish a schedule for the massage of areas where skin breakdown emerges.

*B) Alternate the patient's positioning between supine and side-lying.* Rationale: A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

NCLEX Review Questions: The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A) Impulsivity B) Impaired speech C) Left-side neglect D) Short attention span

*B) Impaired speech* Rationale: Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.

NCLEX Review Questions: Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? A) Present several thoughts at once so that the patient can connect the ideas. B) Ask open-ended questions to provide the patient the opportunity to speak. C) Finish the patient's sentences to minimize frustration associated with slow speech. D) Use simple, short sentences accompanied by visual cues to enhance comprehension.

*D) Use simple, short sentences accompanied by visual cues to enhance comprehension.* Rationale: When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation.

Pre-test questions: The physician orders alteplase (Activase) for a 58-year-old man diagnosed with an acute ischemic stroke. Which nursing action is most appropriate? A) Administer the medication by an IV route at 15 mL/hr for 24 hours. B) Insert two or three large-bore IV catheters before administering the medication. C) If gingival bleeding occurs, discontinue the medication and notify the physician. D) Reduce the medication infusion rate for a systolic blood pressure above 180 mm Hg.

*B) Insert two or three large-bore IV catheters before administering the medication.* Rationale: Before giving alteplase, the nurse should start two or three large bore IVs. Bleeding is a major complication with fibrinolytic therapy, and venipunctures should not be attempted after alteplase is administered. Altepase is administered IV with an initial bolus dose followed by an infusion of the remaining medication within the next 60 minutes. Gingival bleeding is a minor complication and may be controlled with pressure or ice packs. Control of blood pressure is critical prior to altepase administration and for the following 24 hours. Before administering altepase, a systolic pressure above 180 mm Hg or diastolic pressure above 110 mm Hg requires aggressive blood pressure treatment to reduce the risk of cerebral hemorrhage.

NCLEX Review Questions: The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation? A) Specific patient neurologic deficits B) The patient's ability to communicate C) Rehabilitation potential of the patient D) Presence of complications of a stroke

*C) Rehabilitation potential of the patient* Rationale: Although a patient's neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family's coping with the situation. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities.

NCLEX Review Questions: Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A) Overestimation of physical abilities B) Difficulty judging position and distance C) Slow and possibly fearful performance of tasks D) Impulsivity and impatience at performing tasks

*C) Slow and possibly fearful performance of tasks* Rationale: Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.

Pre-test questions: The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A) "Take the person to the hospital if a headache lasts for more than 24 hours." B) "Stroke symptoms usually start when the person is awake and physically active." C) "A person with a transient ischemic attack has mild symptoms that will go away." D) "Call 911 immediately if a person develops slurred speech or difficulty speaking."

*D) "Call 911 immediately if a person develops slurred speech or difficulty speaking."* Rationale: Medical assistance should be obtained immediately for someone with signs and symptoms of a stroke such as sudden numbness; weakness; paralysis of the face, arm, or leg (especially on one side of the body); sudden confusion; trouble speaking or understanding; slurred speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; loss of balance or coordination; or a sudden, severe headache with no known cause. A person with signs and symptoms of a transient ischemic attack should seek medical attention immediately because it is unknown if the symptoms will resolve or persist and progress to a stroke. Onset of signs and symptoms of a stroke vary depending on the type. Onset of an ischemic thrombotic stroke usually occurs at rest. Onset of an ischemic embolic stroke is not related to rest or activity, and onset of a hemorrhagic stroke usually occurs with activity.

Pre-test questions: The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A) A 92-year-old female who takes warfarin (Coumadin) for atrial fibrillation. B) A 28-year-old male who uses marijuana after chemotherapy to control nausea. C) A 42-year-old female who takes oral contraceptives and has migraine headaches. D) A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.

*D) A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.* Rationale: Stroke risk increases after 65 years of age. Strokes are more common in men. Hypertension is the single most important modifiable risk factor for stroke. Diabetes mellitus is a significant stroke risk factor; and smoking nearly doubles the risk of a stroke. Other risk factors include drug abuse (especially cocaine), high-dose oral contraception use, migraine headaches, and untreated heart disease such as atrial fibrillation.

Pre-test questions: A 74-year-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A) Assist the patient to the bathroom every 2 hours. B) Provide incontinence briefs to wear during the day. C) Administer a bisacodyl (Dulcolax) rectal suppository every day. D) Arrange for several servings per day of cooked fruits and vegetables.

*D) Arrange for several servings per day of cooked fruits and vegetables.* Rationale: Patients after a stroke frequently have constipation. Dietary management includes the following: fluid intake of 2500 to 3000 mL daily, prune juice (120 mL) or stewed prunes daily, cooked fruit three times daily, cooked vegetables three times daily, and whole-grain cereal or bread three to five times daily. Patients with urinary incontinence should be assisted to the bathroom every 2 hours when appropriate. Suppositories may be ordered for short-term management if the patient does not respond to increased fluid and fiber. Incontinence briefs are indicated as a short-term intervention for urinary incontinence.

NCLEX Review Questions: The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A) TIA B) Embolic stroke C) Thrombotic stroke D) Subarachnoid hemorrhage

*D) Subarachnoid hemorrhage* Rationale: Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.

List the diagnostic studies that would be ordered for a stroke

*Diagnosis of Stroke (Including Extent of Involvement)* • Computed tomography (CT) scan: lesions/rule out hemorrhagic • CT angiography (CTA): can provide an estimate of perfusion and detect filling defects in cerebral arteries • Magnetic resonance imaging (MRI): lesions/rule out hemorrhagic • Magnetic resonance angiography (MRA): can detect vascular lesions and blockages, similar to CTA • CT/MRI perfusion and diffusion imaging *Cerebral Blood Flow* • Cerebral angiography and/or carotid angiography (can identify cervical and cerebrovascular occlusion, atherosclerotic plaques, and malformation of vessels) • Digital subtraction angiography (shorter, less dye than conventional angiography) • Transcranial Doppler US (measures the velocity of blood flow in the major cerebral arteries) • Carotid duplex scanning *Cardiac Assessment* • Electrocardiogram • Chest x-ray • Cardiac markers (troponin, creatine kinase-MB) • Echocardiography (transthoracic, transesophageal) *Additional Studies* • Complete blood count, including platelets • Coagulation studies: prothrombin time, activated partial thromboplastin time • Electrolytes, blood glucose • Renal and hepatic studies • Lipid profile • Cerebrospinal fluid analysis (though LP is avoided if increased ICP is suspected)

What are the three types of aphasia?

*Expressive*: inability to produce language *Receptive*: loss of comprehension *Global*: total inability to communicate - occurs in massive stroke nonfluent: minimal speech activity with slow speech fluent: speech is present but contains little meaningful communication

What are the two types of stroke?

*Hemorrhagic*: a burst blood vessel may allow blood to seep into and damage brain tissues until clotting shuts off the leak *Ischemic* a) Embolic: a blood clot or other debris circulates in the blood and reaches an artery in the brain that is too narrow to pass through, where it becomes lodged and blocks blood flow *symptoms develop rapidly* b) Thrombotic: clot forms in artery, narrowing the lumen and eventually blocking blood flow *most common cause of stroke, 60%* -2/3 are associated w/HTN and DM *symptoms develop slowly*

List some modifiable risk factors for stroke

*Hypertension* (most important risk factor) Heart disease *Serum cholesterol* *Smoking* Excess alcohol consumption Obesity Sleep apnea Metabolic syndrome Lack of physical exercise *Poor diet* (high in fat, low in fruits&veggies) Drug abuse

Bridge to NCLEX question: Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

*a. depression, d. sleep disturbances, e. denial of severity of stroke* Rationale: The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. Some patients experience long-term depression, manifesting symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy required to perform previously simple tasks can result in anger and frustration. Frustration and depression are common in the first year after a stroke. A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. The family is often affected emotionally, socially, and financially as their roles and responsibilities change. Reactions vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow.

Bridge to NCLEX question: For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

*b. time at which stroke symptoms first appeared.* Rationale: During initial evaluation, the most important point in the patient's history is the time since onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs of ischemic stroke; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with acute onset of ischemic stroke.

Where are the two places a hemorrhagic stroke can occur?

*brain tissue itself* - intracerebral/intraparenchymal *subarachnoid space or ventricles* - blood clogs up the CSF system - LP performed

Bridge to NCLEX question: Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

*c. assisting the patient to stand to void.* Rationale: In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. Nurses should promote normal bladder function and avoid the use of indwelling catheters. A bladder retraining program consists of (1) adequate fluid intake, with most fluids administered between 7:00 am and 7:00 pm; (2) scheduled toileting every 2 hours with the use of a bedpan, commode, or bathroom; and (3) noting signs of restlessness, which may indicate the need for urination. Intermittent catheterization may be used for urinary retention (not urinary incontinence). During the rehabilitation phase after a stroke, nursing interventions focused on urinary continence include (1) assessment for bladder distention by palpation; (2) offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; (3) using a direct command to help the patient focus on the need to urinate; (4) assistance with clothing and mobility; (5) scheduling most fluid intake between 7:00 am and 7:00 pm; and (6) encouraging the usual position for urinating (i.e., standing for men and sitting for women).

Bridge to NCLEX question: The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output. b. oxygen content of the blood. c. degree of collateral circulation. d. level of carbon dioxide in the blood.

*c. degree of collateral circulation.* Rationale: The extent of the stroke depends on the rapidity of onset, size of the lesion, and presence of collateral circulation.

Bridge to NCLEX question: 4. A patient with right-sided hemiplegia and aphasia resulting from a stroke most likely has involvement of the a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

*c. left middle cerebral artery.* Rationale: If the middle cerebral artery is involved in a stroke, the expected clinical manifestations include aphasia, motor and sensory deficit, and hemianopsia on the dominant side and include neglect, motor and sensory deficit, and hemianopsia on the nondominant side.

Bridge to NCLEX question: 6. A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

*c.prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow.* Rationale: In a carotid endarterectomy, the atheromatous lesion is removed from the carotid artery to improve blood flow.

Bridge to NCLEX question: Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-year-old Native American. b. 35-year-old Asian American woman who smokes. c. 32-year-old white woman taking oral contraceptives. d. 65-year-old African American man with hypertension.

*d. 65-year-old African American man with hypertension.* Rationale: Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, ethnicity or race (incidence is highest in African Americans; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum levels of cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocystinemia, and sickle cell disease.

Hemorrhagic stroke: Intracerebral hemorrhage

Bleeding within brain caused by rupture of a vessel, *hypertension is most common cause* symptoms (often severe HA w/N&V) begin abruptly and hemorrhage often occurs during activity poor prognosis, with mortality rate of 40-80% w/in 30 days clinical manifestations: Neurologic deficits Headache Nausea and/or vomiting Decreased levels of consciousness Hypertension progresses over 24 hours

What are the different patterns of aphasia based on affected areas of the brain?

Broca's Wernicke's Global Other (damage to different language areas of brain)

What is included in a nurses secondary assessment?

Comprehensive neurologic exam: Level of consciousness - NIHSS Cognition Motor abilities Cranial nerve function Sensation Proprioception Cerebellar function Deep tendon reflexes

Which type of ischemic stroke occurs faster?

Embolic strokes have rapid occurrence of severe clinical manifestations (there is little time for collateral circulation to be accommodated) Usually less warning signs than with thrombotic Recurrence is common unless underlying cause is treated

Managing ICP in patients with SAH

Following aneurysmal occlusion via clipping or coiling hyperdynamic therapy (hemodilution-induced hypertension using vasoconstricting agents such as phenylephrine or dopamine [Intropin] and hypervolemia) may be instituted Vasospasms can be treated with the calcium channel blocker nimodipine (Nimotop) Hemorrhagic strokes can result in bleeding into ventricles --> hydrocephalus, may require ventriculostomy for cerebrospinal fluid drainage Otherwise, same as management with ischemic stroke... Use interventions that improve venous drainage: - Head in alignment - *HOB elevated* - Avoid stimulation (like suctioning, turning, painful procedures) - Diuretics (esp. Mannitol) - Hyperventilation (if pt herniating)

Hemorrhagic stroke: Subarachnoid hemorrhage (SAH)

Intracranial bleeding into cerebrospinal fluid-filled space between the arachnoid and pia mater Common causes: rupture of a cerebral aneurysm AVM *trauma* drug abuse (cocaine, meth) sudden emotional distress can trigger event (e.g., a really scary movie)

What is the primary clinical assessment tool to evaluate and document neurological status in acute stroke patients?

NIH Stroke Scale (NIHSS). It can serve as a measure of stroke severity and is a predictor of both short- and long-term outcomes of stroke patients. It also serves as a data collection tool for planning patient care and provides a common language for exchanging information among health care providers Assesses: LOC, LOC questions, LOC commands, best gaze, visual, facial palsy, motor and drift, limb ataxia, sensory, best language, dysarthria, extinction or inattention (e.g. cannot recognize hand), distal motor function

What are three surgical interventions for patients with hemorrhagic stroke?

Resection: in patients with arteriovenous malformation (AVM) Clipping of an aneurysm: blocks blood flow to aneurysm and prevents future rupture (SAH usually caused by ruptured aneurysm and is usually in Circle of Willis) Evacuation of hematomas (> 3 cm)

What are signs of improvement in the ambulatory and home care phase of recovery?

Spasticity at this phase of stroke denotes progress toward recovery As improvement continues, small voluntary movements of the hip or shoulder may be accompanied by involuntary movements in the rest of the extremity (synergy) Final stage of recovery occurs when the patient has voluntary control of isolated muscle groups

Clinical Manifestations of Stroke: Motor function

Symptoms are caused by the destruction of motor neurons in the pyramidal pathway (nerve fibers from the brain that pass through the spinal cord to the motor cells) impairment of: Mobility Respiratory function Swallowing and speech Gag reflex Self-care abilities *most obvious effect of stroke* - Loss of skilled voluntary movement (Akinesia) - Impairment of integration of movements - Alterations in muscle tone - Alterations in reflexes (hyporeflexia -> hyperreflexia) period of flaccidity (nerve damage) followed by spasticity (interrupted upper motor neuron influence)

What is a TIA?

TIA is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain *symptoms usually last < 1 hr* may be due to microemboli that temporarily block blood flow

Broca's Aphasia

• A type of nonfluent aphasia (minimal speech activity with slow speech) • Damage to frontal lobe of brain. • Frequently speak in short phrases that make sense but are produced with great effort. • Often omit small words such as"is,""and,"and "the." • May say,"Walk dog,"meaning,"I will take the dog for a walk,"or"book book two table,"for "There are two books on the table." • Typically understand speech of others fairly well. • Often aware of their difficulties and can become easily frustrated.

Collaborative Care: Stroke Acute Care Three goals: Preserving life Preventing further brain damage Reducing disability

• Maintenance of airway: may have difficulty maintaining own airway due to a decreased level of consciousness or decreased or absent gag and swallowing reflexes (always follow ABCs) • Fluid therapy (control fluid/electrolyte balance, overhydration may increase cerebral edema) • Treatment of cerebral edema • Prevention of secondary injury *Ischemic Stroke* • Tissue plasminogen activator (tPA) IV or intraarterial • Stent retrievers • MERCI retriever *Hemorrhagic Stroke* • Surgical decompression if indicated • Clipping or coiling of aneurysm

What are clinical manifestations of right-sided brain damage (stroke on right side of brain)?

• Paralyzed left side: hemiplegia • *Left-sided neglect* • Tends to deny or minimize problems • Rapid performance, short attention span • *Impulsive, safety problems* • Impaired judgment • Impaired time concepts • *Spatial-perceptual deficits*, which patient may not be aware of - incorrect perception of self and illness - unilateral neglect - agnosia: inability to recognize object by sight, touch or hearing - apraxia: inability to carry out learned sequential movements on command

Other Aphasia

• Results from damage to different language areas in brain. • Some people may have difficulty repeating words and sentences even though they can speak and they understand the meaning of the word or sentence. • Others may have difficulty naming objects even though they know what the object is and what its use is.