Stroke

Introduction:

Astroke is also known as a cerebrovascular accident (CVA) or a brain attack. Blood
supply is interrupted to part of the brain, causing brain cells to die; this results in the
patient losing brain function in the affected area. Interruption is usually caused by
an obstruction of arterial blood flow (ischemic stroke), such as formation of a blood
clot, but can also be caused by a leaking or ruptured blood vessel (hemorrhagic
stroke). A blood clot may develop from a piece of unstable plaque lining a vessel
wall that breaks free, or an embolus that travels from elsewhere in the body and
lodges within the vessel. The bleeding may occur as a result of trauma or sponta-
neously, as in the setting of uncontrolled hypertension. Ischemia occurs when insuf-
ficient blood is getting to the brain tissue. This leads to lack of available oxygen
(hypoxia) and glucose (hypoglycemia) for the brain. When these nutrients are not
available for a sustained period, the brain cells die, causing an area of infarction.
Permanent deficits result from infarction. There is increased risk for stroke in
patients with a history of hypertension, diabetes mellitus, high cholesterol, atrial
fibrillation, obesity, smoking, or oral contraceptive use.
Patients may also experience a transient ischemic attack (TIA) in which the
symptoms result from a temporary problem with blood flow to a specific area of
the brain. The symptoms have a duration between a few minutes and 24 hours.

PROGNOSIS

The degree of damage and location of the stroke will determine the outcome for the
patient. Strokes occur suddenly and patients should seek immediate treatment for
the best possible outcome. The majority of strokes are ischemic. Rapid entry into
the healthcare system and treatment with thrombolytic agents (unless there are con-
traindications to this treatment) to break up a clot that has caused the ischemia gives
the patient the best chance for recovery without permanent disability. Patients
with hemorrhagic stroke may need surgery to relieve intracranial pressure or stop
the bleeding. A large area of damage may lead to significant permanent disability
or death.

SIGNS AND SYMPTOMS

• Mental impairment
• Disorientation, confusion
• Emotional changes, personality changes
• Aphasia (difficulty with speech; may be receptive, expressive)
• Slurring of words
• Sensory changes (paresthesia, visual changes, hearing changes)
• Unilateral numbness or weakness in face or limbs
• Seizure
• Severe headache due to increased intracranial pressure from hemorrhage
• TIA symptoms are similar but have a shorter duration and resolve

TREATMENT

It is most important to determine whether the patient has suffered an ischemic or
hemorrhagic stroke as the treatment is different. Giving a thrombolytic agent to the
the brain. Caution is also recommended in patients with head trauma, uncontrolled
hypertension, hemorrhagic retinopathy, gastrointestinal bleeding, recent surgery,
recent MI, or pregnancy.
• Administer TPA (thromoblytic agent) within 3 hours of onset of symptoms,
unless contraindicated.
• Administer anticoagulants for patients with ischemic stroke after use of TPA:
• heparin, warfarin, low-molecular weight heparin, aspirin
• Administer antiplatelet medications to decrease platelet adhesiveness; used
to prevent recurrent stroke:
• clopidogrel, ticlopidine hydrochloride, dipyridamole
• Administer corticosteroid to decrease swelling:
• dexamethasone (Decadron)
• Physical therapy to help maintain muscle tone or return function.
• Speech therapy to help with speech and swallowing.
• Occupational therapy to help regain function.
• Bed rest to reduce chance of injury.
• Adequate nutrition in appropriate food type for patient.
• Carotid artery endarterectomy to remove plaque from within the carotid artery
if stenosis is present.
• Stenting of carotid artery to maintain bloodflow.
• Surgical correction of arteriovenous malformation, aneurysm, intracranial
bleeding.

NURSING DIAGNOSES

• Risk for injury
• Ineffective tissue perfusion

NURSING INTERVENTION

• Monitor vital signs for changes.
patient who has had a hemorrhagic stroke will only cause further bleeding into
• Monitor for signs of increased intracranial pressure—diminished level of con-
sciousness, headaches, restlessness, confusion, nausea and vomiting, speech
changes, or seizures.
• Notify healthcare provider of changes in neurologic status.
• Develop a means of communication with the patient—aphasia may compro-
mise use of call bell system or intercom.
• Assess for neglect syndrome—patient may act as if unaware of the side
affected by paralysis due to the stroke.
• Need for rehabilitation to return to prior functional ability.
• Explain to the patient:
• Home care needs.
• Proper technique to transfer from bed to chair.
• Use of ambulatory assist devices: cane, crutch, walker.
• Special dietary needs; use of Thick-it® for liquids.
• Medication schedule, use, side effects, and interactions. Bookmark and Share

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