Stroke

• Pathophysiology of Stroke

  Stroke occurs when ischemia (lack of oxygen) or hemorrhage (bleeding) occurs in the brain.
• Risk Factors

  • Nonmodifiable: Age, Gender, Race, Ethnicity, Heredity/family history
  • Modifiable: Hypertension, Metabolic syndrome, Heart disease, Serum cholesterol, Heavy alcohol consumption, Poor diet, Drug abuse, Sleep apnea, Obesity, Physical inactivity, Smoking, Diabetes
• Transient Ischemic Attack (TIA)


  Transient episode of neurologic dysfunction caused by ischemia, without acute infarction of the brain. Symptoms last <1 hour, 1/3 will progress to ischemic stroke. Symptoms include vision difficulty, hemiparesis, diplopia, dysphagia, ataxia, dysarthria, vertigo
• Types of Strokes


  • Ischemic: Result from inadequate blood flow to the brain from partial or complete occlusion of an artery, may progress in the first 72 hours related to growing edema, 80% of all strokes are ischemic strokes (Thrombotic and Embolic)
  • Hemorrhagic: Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles, HTN most common cause
• Hemorrhagic Stroke


  • Often a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding. Manifestations include neurologic deficits, headache ("worst headache of my life"), nausea and/or vomiting, decreased levels of consciousness, hypertension
• NIHSS (National Institutes of Health Stroke Scale)


  A 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss
• Common Deficits Following Stroke

  • Hemiparesis - weakness on one side (usually contralateral)
  • Hemiplegia - the inability to move a group of muscles on one side (paralysis)
  • Dysphagia - impaired muscles of swallowing (risk of choking)
  • Diminished Sensation and Gag reflex
  • Akinesia - loss of skilled voluntary movement
  • Aphasia - communication dysfunction
  • Depression
  • Dysarthria - impaired muscles of speech (does not affect comprehension of language/communication)
  • Global Aphasia - total loss of comprehension and use of language
  • Fluent vs Nonfluent Aphasia
  • Expressive (Broca's) Aphasia - loss of speech production
  • Receptive (Wernicke's) Aphasia - loss of speech comprehension
• Affect Deficits


  Patients who suffer a stroke may have difficulty controlling their emotions. Frustration and depression common in 1st year following stroke. Left brain damage - anxiety, depression. Right brain damage - deny or minimize deficits
• Spatial-Perceptual Deficits


  • Incorrect perception of self and illness - denial of deficits or body parts, Erroneous perception of self in space - neglect of affected side, Inability to recognize an object by sight, touch, or hearing - agnosia, Inability to carry out learned sequential movements on command - apraxia
• Patients with stroke on right side of brain have difficulty in judging position, distance, and movement. They are impulsive, impatient, and denying problems related to stroke. They have impaired judgement and short attention span
• Patients with stroke on left side of brain are slower in organization and performance of tasks, cautious, have memory problems related to language, and have impaired spatial discrimination. They have a fearful, anxious response to stroke but respond well to nonverbal cues
• Sensory-Perceptual Deficits


  • Blindness in same half of each visual field (Homonymous Hemianopsia), Diplopia (double vision), Loss of the corneal reflex, Ptosis (drooping eyelid), Unequal pupils
• Common Deficits following Stroke

  • Dizziness, imbalance, or difficulty walking
  • Headache, Vertigo, Seizures, Nausea, Vomiting
  • Confusion, altered LOC
  • Change in vital signs
  • Elimination (incontinence)
  • Intellectual function
  • Facial droop
• Act FAST (face uneven, arm hanging down, slurred speech, time to call 911) and CALL 9-1-1 IMMEDIATELY at any sign of a stroke
• Diagnostic Studies


  • Noncontrast CT Scan or MRI (indicate size and location of lesion, differentiate ischemic and hemorrhagic stroke)
  • CTA (angiography), MRA
  • Cerebral angiography, Digital subtraction angiography
  • Transcranial Doppler ultrasonography
  • Lumbar puncture
  • Cardiac studies, blood tests
• Initial Interventions


  1. Ensure patent airway and breathing

  2. Call Stroke Alert

  3. Maintain adequate oxygenation

  4. Obtain IV access, give normal saline

  5. Obtain CT scan immediately

  6. Baseline laboratory tests

  7. Vital signs

  8. Determine time of onset (most important point from patient history)

  9. Maintain BP according to guidelines (elevated BP is common, use antihypertensives only if MAP >130 and SBP >220)
• The time a suspected stroke patient arrives in the ED to the start of the thrombolytic infusion (if ischemic stroke) should be 60 minutes or less
• Medications


  • Antiplatelet drugs (Aspirin)
  • Anticipate thrombolytic therapy for ischemic stroke
  • Anticoagulant therapy
  • Statins
  • Monitor for side effects
• Thrombolytics (Recombinant Tissue Plasminogen Activator - rtPA)


  Acts directly on clot to cause lysis. Converts plasminogen to plasmin, which digests fibrin and dissolves clot. Given within 4.5 hours of symptom onset, ideally within 60 minutes of arrival to ED
• Role of the RN in rtPA administration

  1. Assess for exclusions to therapy

  2. Monitor baseline coagulation studies

  3. Insert foley, nasogastric tube and multiple IVs before rtPA administration

  4. Do not give IM injections

  5. Monitor level of consciousness, for symptoms of cerebral hemorrhage

  6. After start of rtPA - no IV starts, IMs, invasive procedures or foley insertions for 24 hours

  7. Teach patient about increased risk of bleeding
• Surgical Care


  • Angioplasty
  • Stenting
  • Carotid endarterectomy
  • Extracranial-intracranial bypass
• tPA


  Tissue plasminogen activator, a thrombolytic medication used to dissolve blood clots
• tPA administration


  1. Within 30 minutes of arrival to ED

  2. Not usually after 4.5 hours after symptoms (Average 4.5 hours)

  3. Can be given up to 4.5 hours but most ideally given within 60 minutes so it can dissolve the clot

  4. Before tPA, do all invasive procedures (draw labs, start 2 or 3 IV lines, foley)

  5. Recommended dose is 0.9 mg/kg (not to exceed 90-mg total dose) infused over 60 minutes with 10% of the total dose administered as an initial intravenous (IV) bolus over 1 minute (by MD)

  6. Know that there is a maximum dose for thrombolytic and usually a doctor gives the first dose

  7. Patient also has to have a cardiac monitor on
• Contraindications to thrombolytic therapy

  • Bleeding
  • High blood pressure etc. (See MI PPT)
  • Hemophilia
  • Willebrands Disease
• If patient has bleeding like hemophilia, Willebrand's disease don't give a thrombolytic
• Role of the RN in rtPA administration


  • Assess for exclusions to therapy
  • Monitor baseline coagulation studies
  • Insert foley, nasogastric tube and multiple IV's before rtPA administration
  • Do not give IM injections
  • Monitor level of consciousness, for symptoms of cerebral hemorrhage
  • After start of rtPA - no IV starts, IMs, Invasive procedures or foley insertions for 24 hours
  • Teach patient about increased risk of bleeding
• Surgical interventions for TIAs from carotid disease

  • Angioplasty - balloon that presses the plaque so blood flow is possible
  • Stenting
  • Carotid endarterectomy - plaque is removed from the artery
  • Extracranial-intracranial bypass - they take a vessel and go right around the blockage
• Angioplasty


  Balloon that presses the plaque so blood flow is possible
• Carotid endarterectomy


  Plaque is removed from the artery
• Extracranial-intracranial bypass


  They take a vessel and go right around the blockage
• Surgical interventions for ischemic stroke

  • Stent retriever
  • MERCI - a good stent retriever that can take the clot and pull it out. A very dangerous surgery cause if they leave the clot, it can lead to another stroke later on.
• Surgical interventions for hemorrhagic stroke

  • Evacuation of cerebellar hematomas >3 cm
  • Evacuation of aneurysm-induced hematomas
  • Resection (clips off vessels feeding area)
  • Clipping of aneurysm
  • Coiling
• Stent retrievers (Solitaire)


  A type of clot retriever device used for ischemic strokes
• MERCI Clot Retrieval Catheter


  A type of clot retriever device used for ischemic strokes
• Treatments for hemorrhagic strokes

  • Coiling
  • Clipping with Bypass
  • Clipping
• Priority nursing problems for stroke patients

  • Risk for ineffective cerebral tissue perfusion
  • Decreased intracranial adaptive capacity
  • Ineffective airway clearance
  • Impaired physical mobility
  • Impaired verbal communication
  • Unilateral neglect
  • Impaired urinary elimination
  • Impaired swallowing
  • Situational low self-esteem
• Nursing management - Collaborative care

  1. Frequent Assessments (Neurologic, Respiratory, Cardiac, Integumentary, GI/GU, Nutrition)

  2. Therapist involvement (OT, PT, ST, Registered Dietician)

  3. Case Management

  4. Education for patient and family
• Nursing management - Musculoskeletal care

  1. Range-of-motion exercises and positioning in acute phase

  2. Paralyzed or weak side needs special attention when positioned

  3. Trochanter roll at hip to prevent external rotation

  4. Hand cones to prevent hand contractures

  5. Arm supports with slings and lap boards to prevent shoulder displacement

  6. Avoidance of pulling the patient by the arm to avoid shoulder displacement

  7. Posterior leg splints, footboards, or high-topped tennis shoes to prevent foot drop

  8. Hand splints to reduce spasticity
• Assistive devices for eating

  • Plate guards
  • Utensil holders
  • Weighted utensils
  • Cup holders
• Nursing management - Communication

  1. Assess patient for both the ability to speak and the ability to understand

  2. Speak slowly and calmly, using simple words or sentences

  3. Gestures may be used to support verbal cues

  4. Allow time for thought completion and speech

  5. For patients with aphasia: look at patient when speaking, use simple words and sentences, ask yes or no questions

  6. Use simple phrases and don't give multiple orders at a time if the patient has aphasia