Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 58: Nursing Management: Stroke

Key Points – Printable

PATHOPHYSIOLOGY OF STROKE
•	The brain requires a continuous supply of blood to provide the oxygen and glucose that neurons need to function. A stroke occurs when 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. 
•	Blood is supplied to the brain by two major pairs of arteries: the internal carotid arteries (anterior circulation) and the vertebral arteries (posterior circulation). Factors that affect blood flow to the brain include systemic blood pressure (BP), cardiac output, and blood viscosity.
•	Atherosclerosis, a hardening and thickening of arteries, is the major cause of ischemic stroke. It can lead to thrombus formation and contribute to emboli.

RISK FACTORS FOR STROKE
•	The most effective way to decrease the burden of stroke is prevention. Nonmodifiable risk factors include age, gender, race, and heredity. 
•	Hypertension is the single most important modifiable risk factor; others include increased serum cholesterol, smoking, excessive alcohol consumption, obesity, physical inactivity, poor diet, and drug abuse.
•	Several conditions are associated with stroke risk, including atrial fibrillation, cardiac valve abnormalities, and diabetes mellitus. 

TYPES OF STROKE
Ischemic Stroke
•	A transient ischemic attack (TIA) is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of the brain. Clinical symptoms typically last less than 1 hour. Although most TIAs resolve, one third will progress to an ischemic stroke.
•	An ischemic stroke results from inadequate blood flow to the brain from partial or complete occlusion of an artery and accounts for approximately 80% of all strokes. Ischemic strokes are further divided into thrombotic and embolic.
•	A thrombotic stroke occurs from injury to a blood vessel wall and formation of a blood clot. The lumen of the blood vessel becomes narrowed, and if it becomes occluded, infarction occurs. 
o	The extent of the stroke depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation. 
o	A lacunar stroke refers to a stroke from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue. Although a large percentage of these are asymptomatic, when present, symptoms can cause considerable deficits.
•	Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel. The patient commonly has a rapid occurrence of severe clinical symptoms. Prognosis is related to the amount of brain tissue deprived of its blood supply.

Hemorrhagic Stroke
•	Hemorrhagic strokes result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles.
•	Intracerebral hemorrhage is bleeding within the brain caused by a rupture of a vessel. Most often there is a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding. The prognosis of intracerebral hemorrhage is poor.
•	Subarachnoid hemorrhage occurs when there is intracranial bleeding into the cerebrospinal fluid–filled space between the arachnoid and pia mater membranes on the surface of the brain. 
o	It is commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse. 
o	Most are viewed as a “silent killer” as patients do not have warning signs of an aneurysm until rupture has occurred.
o	Approximately 55% of patients do not survive; complications are common.

CLINICAL MANIFESTATIONS OF STROKE
•	The clinical manifestations are related to the location of the stroke.
•	A stroke can have an effect on many body functions, including motor activity, bladder and bowel elimination, intellectual function, spatial-perceptual alterations, personality, affect, sensation, swallowing, and communication.
•	Motor deficits include impairment of mobility, respiratory function, swallowing and speech, gag reflex, and self-care abilities.
•	The patient may experience aphasia, dysphasia, and dysarthria, a disturbance in the muscular control of speech. 
•	Patients may have difficulty controlling their emotions. Both memory and judgment may be impaired as a result of stroke.
•	A stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation, including agnosia, apraxia, and unilateral neglect.

DIAGNOSTIC STUDIES
•	Diagnostic studies are done to confirm that it is a stroke and not another brain lesion, such as a subdural hematoma, and to identify the likely cause of the stroke. 
•	The single most important diagnostic tool for patients who have experienced a stroke is the noncontrast CT scan. It indicates the size and location of the lesion and differentiates between ischemic and hemorrhagic stroke.

COLLABORATIVE CARE
Preventive Therapy
•	The goals of stroke prevention include management of modifiable risk factors to prevent a stroke. Health promotion focuses on healthy diet, weight control, regular exercise, no smoking, limiting alcohol consumption, and routine health assessments.
•	Measures to prevent the development of a thrombus or embolus are used in patients at risk for stroke. Antiplatelet drugs are usually the chosen treatment to prevent further stroke in patients who have had a TIA related to atherosclerosis.
•	Surgical interventions for the patient with TIAs from carotid disease include carotid endarterectomy, transluminal angioplasty, stenting, and extracranial-intracranial bypass.

Acute Care: Ischemic Stroke
•	The goals for collaborative care during the acute phase are preserving life, preventing further brain damage, and reducing disability. 
•	Acute care begins with managing the airway, breathing, and circulation; elevated BP is common immediately after a stroke and may be a protective response to maintain cerebral perfusion. 
•	Baseline neurologic assessment is carried out, and patients are monitored closely for signs of increasing neurologic deficit and increased ICP.
•	Fluid and electrolyte balance must be controlled carefully. The goal generally is to keep the patient adequately hydrated to promote perfusion and decrease further brain injury.
•	During initial evaluation the single most important point in the patient’s history is the time of onset: Recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs of ischemic stroke. It is used to reestablish blood flow through a blocked artery to prevent cell death. 
•	After the patient has stabilized and to prevent further clot formation, patients with strokes caused by thrombi and emboli may be treated with platelet inhibitors and anticoagulants.

Acute Care: Hemorrhagic Stroke
•	Goals for managing airway, breathing, circulation, and intracranial pressure are the same as the patient with ischemic stroke.
•	A number of surgical interventions are used to treat hemorrhagic strokes, including resection, clipping of an aneurysm, and evacuation of hematomas; the procedure chosen depends on the cause of the stroke. 
•	Seizure prophylaxis is recommended; additional drug therapy is used to manage hypertension and reduce the incidence of cerebral vasospasms.

Rehabilitative Care
•	Treatment changes as the patient progresses from the acute to the rehabilitation phase.
•	After the stroke has stabilized for 12 to 24 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal function.

NURSING MANAGEMENT: STROKE
•	The nursing care of the patient who has experienced a stroke is comprehensive. Nursing goals are that the patient will maintain a stable or improved level of consciousness, attain maximum physical functioning, attain maximum self-care abilities and skills, maintain stable body functions, maximize communication abilities, maintain adequate nutrition, avoid complications of stroke, and maintain effective personal and family coping.
•	To reduce the incidence of stroke, the nurse plays a major role in health promotion and education regarding reducing modifiable risk factors.

Acute Intervention
•	During the acute phase following a stroke, management of the respiratory system is a nursing priority. Stroke patients are particularly vulnerable to respiratory problems, including atelectasis, airway obstruction, and aspiration pneumonia.
•	The patient’s neurologic status must be monitored closely to detect changes suggesting extension of the stroke, increased ICP, vasospasm, or recovery from stroke symptoms.
•	Nursing goals for the cardiovascular system are aimed at maintaining homeostasis; the nurse must perform a thorough cardiac assessment, manage infusions, and monitor fluid balance. Measures to prevent deep venous thrombosis (DVT) are often implemented.
•	To maintain optimal function of the musculoskeletal system, measures are used to prevent joint contractures and muscular atrophy.
•	The skin of the patient with stroke is particularly susceptible to breakdown related to loss of sensation, decreased circulation, and immobility.
•	The most common bowel problem for the patient who has experienced a stroke is constipation. Patients may be prophylactically placed on stool softeners and/or fiber.
•	The primary urinary problem is poor bladder control, resulting in incontinence. Efforts should be made to promote normal bladder function and to avoid the use of indwelling catheters.
•	The patient may initially receive IV infusions to maintain fluid and electrolyte balance, as well as for administration of drugs. Patients with severe impairment may require enteral or parenteral nutrition support. Swallowing ability will need to be assessed.
•	Assess the patient both for the ability to speak and the ability to understand and support the patient accordingly.
•	Homonymous hemianopsia (blindness in the same half of each visual field) is a common problem after a stroke. Persistent disregard of objects in part of the visual field should alert the nurse to this possibility.
•	A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. Use nursing interventions designed to facilitate coping by providing information and emotional support.

Rehabilitation Care
•	The patient is usually discharged from the acute care setting to home, an intermediate or long-term care facility, or a rehabilitation facility. 
•	Regardless of the care setting, ongoing rehabilitation is essential to maximize the patient’s abilities. Rehabilitation requires a team approach so the patient and family can benefit from the combined, expert care of an interdisciplinary team. 
•	The goals for rehabilitation of the patient with stroke are mutually set by the patient, family, nurse, and other members of the rehabilitation team.
•	The nurse initially emphasizes the musculoskeletal functions of eating, toileting, and walking for the rehabilitation of the patient. Interventions advance in a manner of progressive activity.
•	After the acute phase, a dietitian can assist in determining the appropriate daily caloric intake based on the patient’s size, weight, and activity level. The diet must also be adjusted for the ability of the patient to swallow solids and fluids. 
•	A bowel management program is implemented for problems with bowel control, constipation, or incontinence. Nursing measures are also focused on promoting urinary continence.
•	Patients who have had a stroke frequently have perceptual deficits. For example, patients with a stroke on the right side of the brain usually have difficulty in judging position, distance, and rate of movement.
•	The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. Nurses should help patients and families cope with these losses.
•	Speech, comprehension, and language deficits are the most difficult problems for the patient and family. Speech therapists can assess and formulate a plan of care to support communication.