STROKE

-Stroke is a term used to describe changes caused by an interruption in the blood supply to a part of the brain. -sometimes called as Brain Attack INCIDENCE/PREVALENCE An estimated 550,000 people experience stroke annually. Leading cause of death in United States for about 150,00 mortalities annually

a. episodes of a temporary reduction in perfusion to a focal region of the brain causing a short-lived disturbance of function b. the patient experiences a temporary focal neurological deficit such as slurred speech, aphasia, amaurosis fugax (monocular blindness), or weakness or paralysis of a limb c. onset is rapid; usually onset is less than 5 minutes d. duration usually 2-15 minutes; can last up to 24 hours e. symptoms (vary depending on the CNS anatomy involved) sensation of swelling or numbness of the hand, arm, or one side of the face or tongue, loss of strength in an arm, hand or leg, difficulties in speaking or reading f. no neurological deficit remains after the attack g. one episode in a lifetime to > 20 in one day h. may be the only warning of an impending stroke 2. Reversible Ischemic Neurological Deficit (RIND) a. focal brain ischemia in which the deficit improves over a maximum of 72 hours b. deficits may not completely resolve in all cases 3. Cerebral Infarction a. permanent neurological disorder; the patient presents with fixed deficits b. can present in 3 forms: 1. Stable-the neurological deficit is permanent and will not improve or deteriorate 2. improving-return of previously lost neurological function over several days to weeks 3. Progressing-the neurological status continues to deteriorate following the initial onset of focal deficits; may see a stabilization period, followed by further progression PATHOPHYSIOLOGY 1. Atherosclerosis and subsequent plaque formation results in arterial narrowing or occlusion and is the most common cause of arterial stenosis. 2. Thrombus formation is most likely to occur in areas where atherosclerosis and plaque

RISK FACTORS 1. Hypertension-most important risk factor for all stroke types; no defined BP indicating increased stroke risk, but risk increases proportionately as BP increases. 2. Heart Disease a. CHF (congestive heart failure) b. CAD (coronary artery disease) c. AFib ( Atrial Fibrilation) d. Rheumatic Heart Disease e. LVH (left ventricular hypertrophy) 3. TIAs, prior stroke, carotid bruits 4. Increased hematocrit, increased fibrinogen 5. Sickle Cell Disease 6. Lifestyle Factors a. Age (older) b. Alcohol abuse c. Cigarette smoking d. Drug abuse e. Genetic factors f. Males 7. Diabetes Mellitus 9. Embolism and Thrombosis ISCHEMIC/EMBOLIC STROKE CLASSIFICATION OF ISCHEMIC EVENTS 1. Transient Ischemic Attacks (TIAs)

deposition have caused the greatest narrowing of vessels. 3. Platelet Aggregation a. exposed subendothelium after injury to vessel b. vessel collagen is exposed to blood triggering "activation" of platelets c. release of ADP from activated platelets causes platelet aggregation d. consolidation of platelet-plug by RBCs, coagulation factors, and formation of fibrin network e. Thromboxane A2 (TX A2) is produced by platelets and endothelium promoting platelet aggregation and vasoconstriction 4. Coagulation Cascade a. a series of enzyme complexes located on the surface of platelets and endothelium which lead to thrombin production b. Thrombin (IIa) then converts Fibrinogen to Fibrin EMBOLIC STROKE the occlusion of a cerebral artery by an embolus causes an embolic stroke. An embolus forms outside the brain, detaches and travels through the cerebral circulation until it lodges and occludes in the cerebral artery.

2. impairment of speech or language 3. transient monocular blindness 2. Middle Cerebral Artery occlusion: a. most occlusions in the first portion of this artery are due to emboli and typically produce a neurological deficit b. opportunity for collateral circulation is restricted to anastomotic blood flow from the anterior and posterior cerebral arteries on the surface of the brain c. Neurological symptoms: 1. hemiplegia (paralysis of one side of the body) 2. hemisensory deficit 3. hemianopsia (blindness in 1/2 of the visual field) 4. aphasia (if infarct is in the dominant hemisphere) 3. Anterior Cerebral Artery occlusion: a. Neurological symptoms: 1. weakness of the opposite leg involvement 2. apraxia (particularly of gait) 3. possible cognitive impairment with or without sensory 4. Vertebrobasilar system: a. Neurological symptoms: 1. severe vertigo, nausea, vomiting, dysphagia, ipsilateral cerebellar ataxia 2. decreased pain and temperature discrimination 3. diplopia, visual field loss, gaze palsies 5. Increased intracranial pressure Increased intracranial pressure can be due to a rise in cerebrospinal fluid pressure. It can also be due to increased pressure within the brain matter caused by lesions (such as a tumor) or swelling within the brain matter itself. ICP is normally 715 mm Hg Signs and symptoms Infants: Drowsiness Separated sutures Soft spot on top of the head (bulging fontanelle) Vomiting Older children and adults: Behavior changes Headache

HEMORRHAGIC STROKE

Caused by rupture of arteriosclerotic and hypertensive vessels, which causes bleeding into the brain tissue.] Aneurysm, one cause of hemorrhage Common after age 50

CLINICAL MANIFESTATIONS 1. Internal Carotid Artery occlusion: a. no characteristic clinical picture b. may range from a TIA to infarction of a major portion of the ipsilateral (on the same side) hemisphere c. if adequate intracranial collateral circulation is present, may see no signs or symptoms d. Neurological symptoms: 1. monoparesis to hemiparesis with or without a defect in vision

 Progressive decreased

consciousness, lethargy Neurologic problems Seizures Vomiting

Blood Glusose Control Prevent Stroke recurrence -cleints receiving anticoagulant theraphy should be assessed properly like bruising and hematuria (aspirin,clopidogrel) Rehabilitation program -physical theraphy -occupational theraphy Speech theraphy NURSING MANAGEMENT Nursing Diagnosis: Ineffective tissue perfusion Risk for aspiration Impaired physical mobility Risk for injury Disturbed sensory perception Ineffective oping Interventions:

DIAGNOSTICS: Ct Scan rule out hemorrhagic stroke MRI DWI (diffusion-weighted imaging) PI (perfusion imaging) ECG- to rule out atrial fibrillation/emboli Carotid duplex scanning identify carotid stenosis Cerebral angiogramvisualizes occluded part Transthoracic or transesophgeal echocardiographyvisualizes thrombosis and valvular diorders

MEDICAL/SURGICAL MANAGEMENT Maintaining Cerebral Oxygenation - possible intubation, mechanical ventilation -BP is evaluated, HPN may be reduce by vasodilators (hydralazine,minoxidil)

Restore Cerebral Blood Flow -Thrombolytic theraphy- recanalization of the occuled vessel and reperfusion of ischemic brain tissue (Streptokinase, urokinase) -Tissue plasminogen activator (rt-PA00 0.9mg/kg a clot specific that digest fibrin Prevent cerebral edema -head elevation -external ventriculostomy drainage ( burr hole) - is usually prescribed Osmotic diuretic (mannitol)

Aspiration precaution- feeding by mouth must proceed cautiously; check gaga reflex to determine if the client can swallow fluids. Hold feedng if there is any sign of aspiration. VS, especially BP Elevate the head of the bed 30 degrees to reduce cerebral edema If the client has drainage-maintain the head in neutral position Straining at stool or with excessive coughing, vomiting, lifting or use of arms to change position should be avoided. Valsalva maneuver increses ICP. For clients receiving thrombolytic therapy, certain interventions can prevent systemic bleeding: do not puncture insertion of ngts, rectal thermometer for 24 hours after infusion. Monitor and notify physician if bleeding occurs after administration of thrombolytic therapy. Encourage clients with hemiplegia to exercise while on bed rest. Help the client out of bed as soon as the clients condition is stabe.

Remember however, that hemiplegia can severely affect balance. Frequently promote ROM as possible. Keep the side rails of the bed raised for clients with recent hemiplegia to protect them from falls. Frequent skin inspections for manifestations of ulcers. If client is ambulatory, remind the client to walk slowly, rest adequately between intervals.

JbbravoPHN1