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