complex week 10

criteria

-within 4.5 hours ->80 yrs old -severe stroke >25 -taking oral anticoagulant -history of diabetes and prior ischemic stroke -closed head/facial trauma or stroke within past 3 months -systolic >185 diastolic >110 -acute bleeding (platelets <100,000, heparing within 48 hours, INR >1.7 or PT >15) -glucose <50 -recent GI hemorrhage, recent MI, major surgery within 14 days

Increased ICP leads to...

- Reduced cerebral perfusion - Which then leads to ischemia / infarct - Cerebral cortex damage - Herniation, if not addressed Cushing's Triad: 1. A change in respirations, often irregular and deep, such as Cheyne stokes 2. A widening pulse pressure (the difference between the systolic and the diastolic BP) 3. Bradycardia

SAH vs ICH

- Subarachnoid Hemorrhage: bleeding outside of the brain tissue Below arachnoid, but above pia Damages brain tissue if comes in contact w/ blood outside of vessel-> why you need surgery to remove SAH- not in brain yet, well contained, but more blood accumulates in limited space it causes comprsesion - Intracerebral Hemorrhage: bleeding within the brain tissue - Below the pia

AVMs rupture due to...

- Trauma - Chronic or acute hypertension - Nothing

Vague presentation of ICP

- "Worst headache of my life" - Meningeal irritation (stiff neck, photophobia, projectile vomiting and headache) - Nausea / Vomiting - Altered mental status - Collapse

Other secondary injury to ICP

- Aneurysmal rebleeding - Cerebral vasospasm - Hydrocephalus Blood causes vasospasm as they leave blood vessels - Seizure - Cerebral Hyponatremia—possibly due to pituitary gland. Antidiuretic hormones getting confused and retaining water - Fever Higher fever higher risk for brain hypoxia Typhoid fever- pt who recovers may not regain full consciouness or mental status after b/c brain hypoxia from fever

Immediately after the rupture of an AVM...

- Blood exits the vasculature at arterial pressure - Less perfusion to areas of the brain served by this artery - Flooding of the subarachnoid space

After the rupture of an AVM

- Blood spreads to other areas within the skull - Intracranial pressure (ICP) increases - Pressure stops the bleeding, clot forms

SAH is usually caused by ruptured...

- Cerebral aneurysms - Saccular "bubble," usually at arterial bifurcations - Arteriovenous malformation - Developmental vascular anomalies Biforcation! weakness in vessel wall and now you have bubble/aneurysm. One day can eruopt. Can be in SAH or in brain itself

Securement of the aneurysm

- Craniotomy and clipping - by Neurosurgery - Endovascular coiling - by Neuro Interventional Radiology If it burst: Coiling- view pic after. Insert metal coil in aneurysm to prevent it from rupturing. Stabilizes it Clip- closes it

Most significant risk factors for ICP

- Family History (OR 4.0) - Smoking (RR 2-7) - Hypertension (RR 2.5) - Moderate or Heavy Alcohol Use (RR 2.1) - Sympathomimetic Drugs (RR Unknown)

Specific presentation of ICP

- Focal neurological deficits - Aphasia - Hemiparesis - Oculomotor deficits - Recent head injury- EX: fall, assault

Diagnosis may require... Discovery of etiology requires...

- Head CT - Brain MRI - Lumbar Puncture -CT Angiography -MR Angiography

Different strokes

- Ischemic strokes are most common at 80-90% - Treated by Neurology - Hemorrhagic strokes are 10-20% of all strokes - Evenly divided between SAH and ICH - Treated by Neurosurgery

Control ICP via...

- Neuro-specific diuretic (Mannitol) - External Ventricular Drain Mannitol- osmotic diuretic Only given with ICP or rhabdomyalysis

stroke- 3-4.5 hours exclusion criteria

1. age >80 2. severe stroke (NIHSS >25) 3. taking oral anticoagulant regardless of INR 4. history of both diabetes and prior ischemic stroke

stroke- 3-4.5 hours inclusion criteria

1. diagnosis of ischemic stroke causing measurable neurologic deficit 2. onset of symptoms 3-4.5 hours before beginning treatment

stroke- within 3 hours inclusion criteria

1. diagnosis of ischemic stroke causing measurable neurologic deficit 2. onset of symptoms <3 hours before beginning treatment 3. age > 18 years

stroke- within 3 hours exclusion criteria

1. head trauma or prior stroke in previous 3 months 2. symptoms suggest subarachnoid hemorrhage 3. arterial puncture at noncompressible site in previous 7 days (EX: GI bleed) 4. history of previous intracranial hemorrhage 5. elevated BP (systolic >185 or diastolic >110) 6. evidence of active bleeding on examination 7. acute bleeding diathesis, including but not limited to -platelet count <100,000 -heparin within past 48 hours, resulting in aPTT greater than the upper limit or normal (35) -current use of anticoagulant with INR >1.7 or PT >15 seconds 8. blood glucose <50 9. CT demonstrates multilobal infarction (hypodensity >1/3 cerebral hemisphere)

Stroke algorithm 2015

1. identify s/s of possible stroke and active emergency response 2. critical EMS assessments and actions- support ABCs, oxygen if needed, stroke assessment, establish time of onset, triage to stroke center, alert hospital, check glucose 3. immediate general assessment and stabilization- -assess ABCs, vital signs, oxygen if needed -obtain IV access and lab assessments -glucose check -neuro assessment -activate stroke team -order CT scan or MRI of brain -12 lead ECG MUST BE DONE WITHIN 10 MINS OF ARRIVAL 4. immediate neuro assessment by stroke team or designee -review pt history -establish time of s/s onset or last known normal -perform neuro exam (NIH stroke scale) MUST BE DONE WITHIN 25 MINS OF ARRIVAL 5. does CT scan show hemorrhage? MUST BE DONE WITHIN 45 MINS OF ARRIVAL Yes hemorrhage: 7. -consult neurologist or neurosurgeon; consider transfer if not available -> -begin stroke or hemorrhage pathway. admit to stroke unit or ICU No hemorrhage: 6. probably ischemic stroke; consider fibrinolytic therapy -check for fibrinolytic exclusions. repeat neuro exam if pt remains candidate for t-pa-> give t-pa if family and pt want. no anticoagulant or antiplatelet treatment for 24 hours MUST BE DONE WITHIN 1 HOUR OF ARRIVAL -begin post t-pa stroke pathway. aggressively monitor: BP and neuro assessments -emergency admission to stroke unit or ICU MUST BE DONE WITHIN 3 HOURS OF ARRIVAL if pt is not a candidate for t-pa-> administer aspirin -begin stroke or hemorrhage pathway. admit to stroke unit or ICU -check glucose because hypoglycemia could seem like stroke -Could be during sleep- ask onset? EX: if patient went to bed at 9 and woke up with symtoms you use 9 as your onset time ---Goal is that 50% of all patients are given within 60 minutes

IV TPA (tissue plasminogen activator) should be administered within how many hours from the onset of ischemic stroke symptoms? A CT scan of the head is done before TPA administration to determine:

3 hours (or 4.5) Presence of hemorrhage

Intensive Monitoring

30% of patients will deteriorate in the first 24 hours. Intensive monitoring by nurses trained in stroke is very important -Trained in neurological assessment (NIHSS) -Trained in monitoring of bleeding complications (major and minor) -Ongoing management of blood pressure, temperature, oxygenation, and blood glucose "Should I call an RRT/Stroke team?"

1. Acetaminophen should be given to patients with ischemic stroke if the temperature is above: A. 99 degrees Fahrenheit B. 100 degrees Fahrenheit C. 101 degrees Fahrenheit D. 102 degrees Fahrenheit

A

1. Which of the following medications is recommended to reduce the BP before giving TPA? A. Labetalol 20 mg IV B. Metoprolol 5 mg IV C. Nitroglycerin ointment 3 inches D. Nicardipine 20 mg/hour drip

A

A ____ or _____ is ideally done ASAP in the ED for stroke patients or from the time stroke symptoms are noted. The reason for not giving tPA for patients with critically high BP (see guidelines) is to _________ ______ is the drug of choice to manage HTN during stroke. _____ increases infarct size and risk for conversion of ischemic stroke to a hemorrhagic one. goal? National benchmarks for stroke management include (but not only): Establishing onset of symptoms is essential and challenging particularly if stroke happened during sleep. Stroke algorithm benchmark is to give tPA within _____of arrival to the ED of suspected ischemic stroke patient.

A CT scan or an MRI of the brain is ideally done ASAP in the ED for stroke patients or from the time stroke symptoms are noted. Read the algorithm over and over. The reason for not giving tPA for patients with critically high BP (see guidelines) is to prevent intracerebral hemorrhage. Labetalol is the drug of choice to manage HTN during stroke. Hyperglycemia increases infarct size and risk for conversion of ischemic stroke to a hemorrhagic one. The goal is to keep blood sugar between 140-180 in most institutions. National benchmarks for stroke management include (but not only): TPA in less than 3 hours; anti-thrombotics (e.g., aspirin [after 24 hours post tPA] if applicable); DVT prophylaxis; starting patient on statins, swallow/dysphagia evaluation and smoking cessation interventions if applicable. Establishing onset of symptoms is essential and challenging particularly if stroke happened during sleep. Stroke algorithm benchmark is to give tPA within 60 minutes of arrival to the ED of suspected ischemic stroke patient. But, tPA can be given up to 4.5 hours from the onset of symptoms.

External Ventricular Drain (EVD) Assessment:

HOB 30°unless otherwise ordered • Neuro. Assessment Q1hr • Verify order for drain height (mmHG or cmH2O) and drainage parameters (mL/hour) Q-Shift/PRN • Maintain cylinder in an upright position • Document CSF outputs Q1hr • Color and clarity of CSF drainage • Tubing for kinking • Dressing Q1hr Note the presence of tidaling of the CSF in the tubing (fluctuations of the meniscus)

Pre-securement care for ICP

Airway monitoring & control -Reduced alertness, may not be able to protect airway Hemodynamic monitoring & control -Maintain SBP 90-140 ICP monitoring & control -Goal ICP 5-15 mmHg Hourly neuro assessments -Detect early deterioration in rebleed Temperature monitoring & control -Acetaminophen Q4-6 Hours PRN. -Fever is associated with poor recovery Oro or nasogastric tube -Maintain NPO aside from meds; procedures pending Hydration via IV fluids Control intubation is better than emergency- don't want decompensation or respiratory arrest BP maintain 90-140 or MAP Temp- don't want a fever!!!!! Don't want ICP Don't stimulate rectum b/c that will increase pressure, NPO Prophylaxis medications -Seizure -DVT -Constipation PRN medications -Nausea -Pain / agitation ---Don't over-sedate! Phenytoin/dilantin- anticonvulsant. To prevent seizures. Recovering from a stroke can cause a seizure! Serum level of 10-20!! Don't give too fast IV Don't oversedate because you can't correctly assess neuro status then

Nursing Care and Secondary Prevention: Knowing and Practicing the Guidelines smoking

All ischemic stroke or TIA patients who have smoked in the past year should be strongly encouraged not to smoke. Avoid environmental smoke. Counseling, nicotine products, and oral smoking cessation medications have been found to be effective for smokers.

1. A neurologic assessment must be performed during TPA administration: A. Every 5 minutes B. Every 15 minutes C. Every 30 minutes D. Every 60 minutes

B

1. Before receiving TPA for ischemic stroke, the patient's blood pressure should be: A. Less than 200/100 B. Less than 185/110 C. Less than 170/100 D. Less than 155/90

B

Nursing Care and Secondary Prevention: Knowing and Practicing the Guidelines alcohol use obesity

Patients with prior ischemic stroke or TIA who are heavy drinkers should eliminate or reduce their consumption of alcohol. Light to moderate levels of less than or equal 2 drinks per day for men and 1 drink per day for non-pregnant women may be considered. Weight reduction may be considered for all overweight ischemic stroke or TIA patients to maintain the goal of a BMI of 18.5 to 24.9 kg/m2 and a waist circumference of less than 35 in for women and less than 40 in for men.

Cushings triad-

BP widening, bradycardia, altered respiration (low)

1. The recommended dose of IV TPA for ischemic stroke is; A. 0.3 mg/kg B. 0.6 mg/kg C. 0.9 mg/kg D. 1.2 mg/kg

C

1. Which of the following IV fluids should a patient with ischemic stroke receive? A. D5 (0.9%) Normal Saline B. Dextrose 5% in water C. 0.9% Normal Saline D. Lactated Ringers

C

Post-securement care

Continue pre-securement care Liberalize BP parameters Nimodipine (60mg Q4Hrs or 30mg Q2Hrs) High BP is risk of post-op Nimodipine- CA+ channel blocker. Lowers BP reduces ICP Level to tragus!! If the bag is too high the pressure will not be draining as much

1. Which of the following is a contraindication for TPA in ischemic stroke? A. Serum glucose of 300 mg/dl B. INR of 1.2 C. Hemoglobin of 11 mg/dl D. Platelet count of 95,000 mm3

D

1. Insulin is given to ischemic stroke patients with a serum glucose: A. Greater than 110 mg/dl B. Greater than 120 mg/dl C. Greater than 130 mg/dl D. Greater than 140 mg/dl

D ???

General measures to prevent elevation of ICP

HOB up 30° or as physician specifies, reverse Trendelenburg position may be used if blood pressure is stable. Head position may be one of the single most important nursing modalities for controlling increased ICP. Good head and body alignment: prevents increased intrathoracic pressure and allows venous drainage. Pain management: provide good pain control on a consistent basis Keep patient normothermic. Put the head up!! 30 at least Unnecessary interventions-> EX: no coughing, no bending knee, no unnecessary suctioning, pain management Fever increases oxygen demand

Recommendations for Treatment of Elevated Blood Pressure in Acute Ischemic Stroke: Nursing Knowledge Blood Pressure Level Eligible for thrombolytic therapy Diastolic 121-140 mm Hg

Diastolic 121-140 mm Hg May repeat or double labetalol every 10 min to a maximum dose of 300 mg or give initial labetalol bolus and then start labetalol drip at 2 to 8 mg/min Or Nicardipine 5 mg/h IV drip as initial dose, titrate up to desired effect by increasing 2.5 mg/h every 5 min to maximum dose of 15 mg/hr Titrate to desired effect by increasing 2.5 mg/hr every 5 min to maximum dose of 15 mg/hr. If blood pressure is not controlled by labetalol, consider sodium nitroprusside but avoid if possible.

External Ventricular Drain (EVD) Key Points:

Drain by pressure, height @ 30 degrees, drain by amount (EX: 10/hr) Normal CSF- looks like water. Has a lot of sugar Tidaling- CSF can move in container- you must calibrate it and 0 it once a shift. Level it at the tragus • Clamp (hold drainage) whenever the HOB changes in relation to the height of the cylinder • Label EVD tubing to prevent inadvertent access • NO pressure bag required • RN may NOT flush or obtain CSF sample • Prime system with normal saline • Integra EVD is MRI SAFE Zero: level EVD transducer to the TRAGUS (ear)

Recommendations for Treatment of Elevated Blood Pressure in Acute Ischemic Stroke: Nursing Knowledge Blood Pressure Level Eligible for thrombolytic therapy During and after treatment Monitor blood pressure - Diastolic >140 mm Hg or Systolic >230 mm Hg

During and after treatment Monitor blood pressure - Diastolic >140 mm Hg or Systolic >230 mm Hg Treatment: Labetalol 10 mg IV over 1-2 min, may repeat every 10-20 min, maximum dose: 30 mg or Labetalol 10 mg IV followed by infusion at 2-8 mg/min or Nicardipine drip, 5 mg/h, titrate up to desired effect by increasing 2.5 mg/h every 5 min to maximum dose of 15 mg/hr

General Supportive Care of Stroke - Focus on Prevention of Complications

Dysphagia Screening to prevent risk of aspiration pneumonia and determine feeding mobility Early mobility to prevent DVT, pulmonary emboli Bowel and bladder care - best to avoid urinary catheter insertion but if necessary remove as soon as possible Other interventions include: -Falls prevention -Skin Care**** -Mouth Care -Passive/Active Range of Motion Exercises -Hydration -Flu/Pneumonia Vaccination

early and late signs of ICP

Early signs: decreased level of consciousness, deterioration in motor function, headache, visual disturbances, changes in blood pressure or heart rate, changes in respiratory pattern Late signs: pupillary abnormalities, more persistent changes in vital signs, changes in respiratory pattern with changes in arterial blood gases Intervention: thorough neurological assessment, notify physician immediately, emergency brain imaging, maintain ABCs

Hemorrhage Symptoms

Focal neurological deficits as in AIS (Arterial Ischemic Stroke) Headache (especially in subarachnoid hemorrhage) Neck pain Light intolerance Nausea, vomiting Decreased level of consciousness

Nursing Care and Secondary Prevention: Knowing and Practicing the Guidelines Prosthetic Heart Valves

For patients with ischemic stroke or TIA who have modern mechanical prosthetic heart valves, oral anticoagulants are recommended, with an INR target of 3.0 (range, 2.5-3.5). For patients with mechanical prosthetic heart valves who have an ischemic stroke or systemic embolism despite adequate therapy with oral anticoagulants, aspirin 75 to 100 mg/d, in addition to oral anticoagulants, and maintenance of the INR at a target of 3.0 (range, 2.5-3.5) is reasonable. For patients with ischemic stroke or TIA who have bioprosthetic heart valves with no other source of thromboembolism, anticoagulation with warfarin (INR, 2.0-3.0) may be considered.

Nursing Care and Secondary Prevention: Knowing and Practicing the Guidelines Valvular heart disease, Rheumatic mitral valve disease

For patients with ischemic stroke or TIA who have rheumatic mitral valve disease, whether or not AF is present, long-term warfarin therapy is reasonable, with a target INR of 2.5 (range, 2.0-3.0). Anti-platelet agents should not be routinely added to warfarin in the interest of avoiding additional bleeding risk. For ischemic stroke or TIA patients with rheumatic mitral valve disease, whether or not AF is present, who have a recurrent embolism while receiving warfarin, adding aspirin (81 mg/d) may be indicated.

Nursing Care and Secondary Prevention: Knowing and Practicing the Guidelines afib

For patients with ischemic stroke or TIA with persistent or paroxysmal (intermittent) AF, anticoagulation with adjusted-dose warfarin (target INR, 2.5; range, 2.0-3.0) is recommended. In patients unable to take oral anticoagulants, aspirin 325 mg/d is recommended. Aspirin should be used concurrently for the ischemic CAD patient during oral anticoagulant therapy in doses up to 162 mg/d, preferably enteric-coated. If no contraindication (EX: GI bleed history) keep range 2-3 and take aspirin

Nursing Care and Secondary Prevention: Knowing and Practicing the Guidelines Physical activity

For those with ischemic stroke or TIA who are capable of engaging in physical activity, at least 30 minutes of moderate-intensity physical exercise most days of the week may reduce risk factors and comorbid conditions that increase the likelihood of recurrence of stroke. For those with disability after ischemic stroke, a supervised therapeutic exercise regimen is recommended.

Intensive Monitoring for stroke 5 complications?

Glucose Monitoring - hyperglycemia can lead to infarct expansion, hemorrhagic expansion and reduced benefit or recanalization -hemorrhagic conversion. Need 140-180 level Pneumonia accounts for 15 to 25% of deaths in stroke patients Pulmonary embolism found in 2.5% of stroke patients during the first week in stroke units UTI in 15 to 60% of stroke patients Malnutrition in 50%, 2-3 weeks post CVA Reversal agent for t-pa? no

Nursing Care and Secondary Prevention: Knowing and Practicing the Guidelines cholesterol control

Ischemic stroke or TIA patients with elevated cholesterol, comorbid CAD, or evidence of an atherosclerotic origin should be managed according to NCEP III guidelines, which include lifestyle modification, dietary guidelines, and medication recommendations. Statin agents are recommended, and the target goal for cholesterol lowering for those with CHD or symptomatic atherosclerotic disease is an LDL-C of less than 100 mg/dL and LDL-C less than 70 mg/dL for very-high-risk persons with multiple risk factors. Patients with ischemic stroke or TIA presumed to be due to an atherosclerotic origin but with no preexisting indications for statins (normal cholesterol levels, no comorbid CAD, or no evidence of atherosclerosis) are reasonable to consider for treatment with a statin agent to reduce the risk of vascular events. Ischemic stroke or TIA patients with low HDL-C may be considered for treatment with niacin or gemfibrozil.

The 5 Key Stroke Syndromes: Classic Signs Referable to Different Cerebral Areas L v R

Left (Dominant Hemisphere) -Left gaze preference- because they cant see on R -Right visual field deficit -Right hemiparesis -Right hemisensory loss Right (Nondominant Hemisphere) -Right gaze preference -Left visual field deficit -Left hemiparesis -Left hemisensory loss neglect (left hemi-inattention)

Nursing Care and Secondary Prevention: Knowing and Practicing the Guidelines diabetes

More rigorous control of blood pressure and lipids should be considered in patients with diabetes. Although all major classes of antihypertensives are suitable for the control of BP, most patients will require greater than 1 agent. ACEIs and ARBs are more effective in reducing the progression of renal disease and are recommended as first-choice medications for patients with DM. Glucose control is recommended to near-normoglycemic levels among diabetics with ischemic stroke or TIA to reduce microvascular complications. The goal for Hb A1c should be less than or equal to 7%.

Differential Diagnosis Between Stroke and Bell's Palsy

NOTES: -bells palsy- paralysis of face -bels palsy can't close eye tightly on affected side, stroke they can. -stroke symptoms occur BELOW the eyes EX: stroking on the R side, will be blind on the R side but facial droop on L side -When the cortex is injured (such as in stroke), there's weakness in the *contralateral lower face only. * -When the facial nerve is injured (such as in Bell's Palsy), there's weakness in the *ipsilateral upper and lower face.* STROKE: The strictly contralateral innervation of the lower half of the face and dual innervation of the upper half of the face is critical when assessing facial weakness. Lesions that damage the motor cortex, such as acute ischemic strokes, will result in *contralateral facial weakness of the lower face only, with preservation of the muscles of the upper face on both sides,* due to the dual innervation of the upper face. -*Patients will have a weak smile, but will be able to close their eye tightly and wrinkle their forehead symmetrically*. This pattern is often referred to as "central facial weakness," because it's caused by injury to the cerebral cortex, which is a part of the central nervous system. BELLS PALSY: As Bell's palsy affects the facial nerve, it causes *facial weakness in a peripheral pattern*—that is, weakness involving the mouth, eye and forehead. Specific clinical features include: *weakness raising the eyebrow and furrowing the brow; difficulty or inability to close the eye; weakness in grimacing and smiling; and flattening of the nasolabial fold*. Although the exact cause of Bell's palsy is often unknown, infectious causes are thought to contribute in the majority of cases. It's widely believed that the most common cause is reactivation of herpes simplex virus-1. Bell's palsy is treated with a 10-day course of steroids. In some cases antiviral therapy may also be prescribed. While some patients are left with permanent facial paralysis, the majority of patients with Bell's Palsy experience a complete, or near complete, recovery.

The 5 Key Stroke Syndromes: Classic Signs Referable to Different Cerebral Areas brainstem

Nausea and/or vomiting Diplopia, dysconjugate gaze, gaze palsy Dysarthria, dysphagia Vertigo, tinnitus Hemiparesis or quadriplegia Sensory loss in hemibody or all 4 limbs Decreased consciousness Hiccups, abnormal respirations

Intracranial Pressure (ICP)- normal iCP, intracranial hypertension, CPP normal

Normal ICP - 5 -15 mm Hg Intracranial Hypertension - >20 mm Hg Cerebral Perfusion Pressure (CPP) -is MAP - ICP (MAP= SBP + 2 (DBP) /3 -Normal range: 70 to 85 mm Hg -As ICP increases, CPP decreases or approaches zero

Nursing Assessment stroke: Neurological Assessment, Vital Signs and Other Acute Care Assessments in non Thrombolysis-Treated Patients Patients NOT treated with thrombolytics: when to call physician? meds/fluids?

Patients not treated with thrombolytics: In ICU, every hour with neurological checks or more frequently if necessary In non-ICU setting, depending on patient's condition and neurological assessments, at a minimum check neurological and vital signs q 4 hrs Call physician for further treatment based on clinician/institution guidelines: -Systolic BP >220 or <110 mm Hg -Diastolic BP >120 or <60 mm Hg -Pulse <50/ or >110/min -Respirations >24/min -Temp >99.6°F -Worsening of stroke symptoms or other decline in neurological status -IV fluids NS at 75-100 mL/hr -Antithrombotics should be ordered within first 24 hrs of hospital admission -Repeat brain CT scan or MRI may be ordered 24-48 hrs after stroke or prn For O2 sat <92%, give O2 by cannula at 2-3 L/min No bleeding complications, no need to monitor Continuous cardiac monitoring for 24-48 hrs Measure intake and output

Nursing Assessment stroke: Neurological Assessment, Vital Signs and Other Acute Care Assessments in Thrombolysis-Treated Patients Patients treated with Thrombolytics: frequency of neruo checks? temp checks? when to call physician? meds/fluids?

Patients treated with Thrombolytics: Neurological checks and vital signs (except temp) q 15 min during rtPA infusion, then every 30 min for 6 h, then q 60 min for 16 hrs (total of 24 hrs) Note: Frequency of blood pressure assessments may need to be increased if systolic BP stays 180 mm Hg or diastolic BP stays 105 mm Hg. Temp q 4 hrs or prn Treat temps >99.6°F with acetaminophen as ordered Call physician if: -Systolic BP >185 or <110 mm Hg -Diastolic BP >105 or <60 mm Hg -Pulse <50/ or >110/min -Respirations >24/min -Temp >99.6°F Worsening of stroke symptoms or other decline in neurological status -IV fluids NS at 75-100 mL/hr -No heparin, warfarin, aspirin, clopidogrel or dipyridamole for 24 hrs, then start the antithrombotic as ordered -Brain CT or MRI after rtPA therapy (at 24 hrs) For O2 sat <92%, give O2 by cannula at 2-3 L/min Monitor for major and minor bleeding complications Continuous cardiac monitoring up to 72 hrs or more Measure intake and output

Recommendations for Treatment of Elevated Blood Pressure in Acute Ischemic Stroke: Blood Pressure Level Eligible for thrombolytic therapy Pre-treatment Systolic >185 mm Hg or Diastolic >110 mm Hg

Pre-treatment Systolic >185 mm Hg or Diastolic >110 mm Hg Treatment: Check blood pressure every 15 min for 2 h, then every 30 min for 6 hrs, and then every hour for 16 hrs Sodium nitroprusside 0.5 µg/kg per min IV infusion as initial dose and titrate to desired blood pressure level Labetalol 10-20 mg IV over 1-2 min. May repeat 1 or nitropaste 1-2 in or Nicardipine drip, 5 mg/h, titrate up by 0.25 mg/h at 5- to 15-minute intervals; maximum dose: 15 mg/hr, if blood pressure is not reduced and maintained at desired levels (systolic 185 mm Hg and diastolic 110 mm Hg), do not administer rtPA

Nursing Care and Secondary Prevention of stroke: Knowing and Practicing the Guidelines hypertension

Prevention of recurrent stroke and other vascular events in persons who have had an ischemic stroke and beyond the hyperacute period. This benefit extends to persons with and w/o a history of hypertension and should be considered for all ischemic stroke and TIA patients. An absolute target BP level and reduction are uncertain and should be individualized; benefit has been associated with an average reduction of less than 10/5 mm Hg, and normal BP levels have been defined as < 120/80 mm Hg Several lifestyle modifications have been associated with BP reductions and should be included as part of a comprehensive approach. Optimal drug regimen remains uncertain; however, available data support the use of diuretics and the combination of diuretics and an ACEI. Choice of specific drugs and targets should be individualized on the basis of reviewed data and consideration, as well as specific patient characteristics (e.g., extracranial cerebrovascular occlusive disease, renal impairment, cardiac disease, and DM).

______ is the most predominant symptom in SAH In measuring intracranial pressure, the device must be calibrated periodically with the transducer at the level of _______ Standard interventions for any patient with SAH or intracerebral bleed is _________ Nursing care must consider interventions that do not further increase ICP. such as? Monitor patient for deterioration by ________ _______ are given to reduce intracranial pressure. Part of the assessment is to monitor for sign of ________

Severe headache is the most predominant symptom in SAH In measuring intracranial pressure, the device must be calibrated periodically with the transducer at the level of the pinna or tragus of the ear. Standard interventions for any patient with SAH or intracerebral bleed is seizure precaution. Pad bed, set up suction. Patient can be place on phenytoin (Dilantin) or Levetiracetam (Keppra) as seizure prophylaxis. Nursing care must consider interventions that do not further increase ICP. Clustering interventions is typically not a good idea as it can increase the ICP. Monitor patient for deterioration by doing frequent neuro checks using a tool or a checklist. Osmotic diuretics are given to reduce intracranial pressure--mannitol, dexamethasone, prednisone Part of the assessment is to monitor for sign of meningitis- photophobia, neck stiffness, n/v

Nursing Care of the Stroke Patient

Stroke is a complex disease requiring the efforts and skills of the multidisciplinary team. Nurses are often responsible for the coordination of that care. Coordinated care can result in: improved outcomes, decreased LOS, translating to decrease costs.

Recommendations for Treatment of Elevated Blood Pressure in Acute Ischemic Stroke: Nursing Knowledge Blood Pressure Level Eligible for thrombolytic therapy Systolic 180-230 mm Hg or Diastolic 105-120 mm Hg

Systolic 180-230 mm Hg or Diastolic 105-120 mm Hg Treatment: Labetalol 10 mg IV over 1-2 min, may repeat every 10-20 minutes, maximum dose of 30 mg May repeat or double labetalol every 10-20 min to a maximum dose of 30 mg or Give initial labetalol 10 mg IV followed by infusion at 2-8 mg/min bolus and then start a labetalol drip at 2-8 mg/min

Recommendations for Treatment of Elevated Blood Pressure in Acute Ischemic Stroke Blood Pressure Level Not eligible for thrombolytic therapy Systolic >220 mm Hg or Diastolic >121-140 mm Hg Diastolic >140 mm Hg

Systolic >220 mm Hg or Diastolic >121-140 mm Hg Treatment: Labetalol 10-20 mg IV over 1-2 min May repeat or double every 10 min (maximum dose: 300 mg) Nicardipine 5 mg/h IV infusion as initial dose; titrate to desired effect by increasing 2.5 mg/h every 5 min to maximum of 15 mg/hr Aim for a 10% to 15% reduction of blood pressure Diastolic >140 mm Hg Treatment: Nitroprusside 0.5 µg/kg per min IV infusion as initial dose with continuous blood pressure monitoring. Aim for a 10% to 15% reduction of blood pressure

Recommendations for Treatment of Elevated Blood Pressure in Acute Ischemic Stroke: Nursing Knowledge Blood Pressure Level Not eligible for thrombolytic therapy Treatment Systolic >220 mm Hg or Diastolic >120 mm Hg

Systolic >220 mm Hg or Diastolic >120 mm Hg Observe unless other end-organ involvement, e.g., aortic dissection, acute myocardial infarction, pulmonary edema, or hypertensive encephalopathy Treat other symptoms of stroke such as headache, pain, agitation, nausea, and vomiting Treat other acute complications of stroke, including hypoxia, increased ICP, seizures, or hypoglycemia

In Summary: Stroke Benchmarks

Thrombolytic Therapy NIH Stroke scale VTE prophylaxis Early antithrombotic Assessed for rehab Discharged on Antithrombotic Therapy Anticoagulation Therapy for Atrial Fib/Flutter Antithrombotic Therapy By End of Hospital Day Two Discharged on Statin Medication Stroke Education Dysphagia screening Modified Rankin Score at discharge Thrombolytic Therapy - Acute ischemic stroke patients who arrive at the hospital within 2 hours of time last known well and for whom IV t-PA was initiated at the hospital within 3 hours of time last known well. T-pa can convert to hemorhhagic stroke

The 5 Key Stroke Syndromes: Classic Signs Referable to Different Cerebral Areas Cerebellum

Truncal/gait ataxia Limb ataxia Neck stiffness

Arteriovenous malformation

Usually congenital and asymptomatic No capillary to dampen flow from high-pressure artery to low-pressure vein Capillaries enlarge and become like an AV fistula

stroke- within 3 hours relative exclusion criteria

pts may receive fibrinolytic therapy despite 1 or more relative contraindications. consider risk/benefit of t-pa if any of these relative contraindications is present: -only minor or rapidly improving stroke symptoms (clearing spontaneously) -seizure at onset with postictal residual neurologic impairments -major surgery or serious trauma within previous 14 days -recent GI or urinary tract hemorrhage within past 21 days -recent acute MI within past 3 months

Monro - Kellie Doctrine

the sum of volumes of brain, CSF, and intracranial blood is constant (this is the ICP) any change in the intracranial components is compensated by a reciprocal change in the volume of another component if not, ICP rises

2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke READ recommendations for AIS patients who: 1. were treated with IV altephase 2. were treated with IV altephase and have concomitant conditions 3. have mild stroke symptoms and were not treated with IV altephase

updated guideline increases the recommended time frame for mechanical thrombectomy in select patients from 6 hours to 24 hours after stroke begins recommendations: 1. Aspirin is generally withheld for 24 hours. 2. Earlier aspirin treatment might be considered if • It is known to provide substantial benefit in the absence of IV alteplase, or • Withholding such treatment is known to cause substantial risk ---if you have history of heart attack (or heart attack at same time) you need aspirin bc it really reduces mortality in heart attacks!! 3. Dual antiplatelet therapy with aspirin and clopidogrel (Plavix) started within 24 hours and continued for 21 days may prevent secondary stroke. ---pepto bismol, salicylate cannot give b/c its the same as aspirin.

External Ventricular Drain (EVD) Complications:

• CSF leakage • Aneurysmal re-bleeding • Drain blockage • Infection

External Ventricular Drain (EVD) Notify the MD/PA IF:

• Dressing has CSF fluid • ICP>20 for more than 5 min. • Outpouring of bright red blood and/or CSF • No drainage for 2hrs • Absence of CSF tidaling Dressing is damp, loose, or solid