Adult Medical-Surgical Nursing

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Adult Medical-Surgical Nursing

• Neurology Module
• Cerebrovascular Disease II Stroke

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Stroke Definition

• Stroke is a sudden loss of brain function
  resulting from disruption of the blood supply to
  a part of the brain
• Stroke is considered as an emergency condition
  requiring acute management
• A longterm recovery and rehabilitation period is
  often necessary involving the patients family

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Stroke Physiological Effects

• Loss of blood supply in stroke may be temporary
  or permanent
• Stroke leads to loss of
• Movement (motor) including swallowing
• Thought (cognitive function)
• Memory
• Speech
• Sensation (sensory activity)

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Stroke Aetiology

• Hypertension
• Cerebral atherosclerosis
• Family history
• High cholesterol Obesity
• Lack of exercise Smoking
• Malformation of a cerebral vessel, aneurysm
• Drug misuse amphetamines, cocaine
• Trauma (also brain tumour non-acute)

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Stroke Classification

• Ischaemic stroke
• Haemorrhagic stroke
• (A tumour as a space-occupying lesion may give
  gradual symptoms of stroke - non-acute)

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Ischaemic Stroke Pathophysiology

• The blood supply to part of the brain is
  disrupted by
• A thrombus in a large (Carotid) or more commonly
  a smaller cerebral vessel
• An embolus related to cardiac dysrhythmias
  (should be prevented by long-term anticoagulants)
• Prolonged ischaemia from vasospasm, migraine,
  cocaine abuse, severe atherosclerosis, DIC

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Haemorrhagic Stroke Pathophysiology

• Rupture of a cerebral blood vessel leading to
  haemorrhage, loss of blood supply and also
  increased intra-cranial pressure from a
  space-occupying bleed-
• Intra-cerebral (arterial into brain tissue)
• Sub-arachnoid (rapid arterial into CSF
  associated with vasospasm/ ischaemia)
• Subdural (venous, slow haematoma)
• Epidural (arterial, related to trauma)

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Stroke Clinical Manifestations

• Clinical manifestations depend on the site of
  brain damage and on the amount of compensatory
  collateral circulation

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Stroke Clinical Manifestations

• May be loss of consciousness (initial or
  prolonged)
• Initial pyrexia (inflammation and cerebral
  oedema)
• Confusion, restlessness, altered mental status
• Emotional lability, frustration, depression

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Stroke Clinical Manifestations (cont)

• Sensory and motor loss from numbness and weakness
  of the face to the arm, leg, whole side
  (hemiparesis/ hemiplegia). At first flaccid
  later spasticity with ? reflexes
• Aphasia, dysphagia
• Visual disturbance
• Sudden severe headache
• Focal symptoms seizures
• Dizziness, loss of balance

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Stroke Clinical Manifestations (cont)

• Stroke is an upper motor neurone lesion (brain
  and spinal cord)
• Leads to loss of voluntary motor control
• As upper motor neurones decussate (cross) at the
  level of the Pons, the effects are on the
  opposite side of the body

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Stroke Clinical Manifestations (cont)

• Lesion of left cerebral hemisphere ? right- sided
  effects right-sided sensory and motor
  disturbance, dysphagia, aphasia and difficulty in
  understanding, right visual field defect
• Lesion of right hemisphere ? left-sided effects
  left-sided sensory and motor disturbance,?
  distractibility, ? awareness, left visual field
  defect

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Stroke Diagnosis

• History and clinical picture on examination
• CT or MRI scan identifies
• Ischaemic or haemorrhagic
• Site and extent of the problem
• Carotid doppler/ cerebral angiography
• ECG (dysrhythmias)
• Skull/ cervical Xray if trauma suspected
• Lipids, LFT, KFT, CBC, blood coagulation

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Stroke Complications

• The area of injury may extend by
• Further haemorrhage
• Extension of thrombus formation
• ? further cerebral ischaemia or infarct
• Therefore all attempts made to prevent this by
  prompt action

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Stroke Initial Assessment

• Stroke is an acute emergency
• MRI performed
• If haemorrhagic stroke, urgent surgery performed
• If thrombus or embolus diagnosed, optimally
  urgent thrombolytic agent or thrombectomy with
  stent / anticoagulation

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Stroke Initial Medical Management

• Adequate humidified O2
• Adequate hydration to maintain BP and perfusion,
  reduce viscosity
• (Avoid hypotension ? ischaemia avoid
  hypertension ? haemorrhage)
• Adequate haemoglobin
• Prompt assessment to determine treatment

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Stroke Medications in Acute Stage

• Vasodilator to improve blood flow (Norvasc,
  Nitroprusside)
• Controlled anti-hypertensives
• Anticoagulant, antiplatelet, prompt thrombolytics
  via infusion pump
• Vitamin B Complex and B12 ?conductivity
• Maybe anticonvulsant or Dexamethasone
• H2 receptor inhibitor (avoid stress ulcer)

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Stroke Surgery

• If stroke is related to a sub-dural or epidural
  haematoma
• Surgical drainage via burr-holes or craniotomy
  performed to correct intracranial pressure
• If sub-arachnoid haemorrhage
• Ablation therapy may be performed to seal and
  avoid recurrence

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Stroke Nursing Assessment and Monitoring in
Acute Stage

• Glasgow Coma Scale orientation if conscious
• Eyes opening on command
• Equal pupils and reactivity to light
• Ability to speak
• Muscle tone degree of spasticity
• Voluntary/ involuntary movement
• Vital signs
• Fluid balance

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Stroke Nursing Care in Acute Stage

• Air mattress, elevate head 30o / tilt 45o
• Change position 2-hourly if possible, avoid
  dragging (friction), creases in sheets
• Natural position bolster prevents footdrop
• Passive exercise of all limbs, full range of
  movement (to improve circulation and to prevent
  DVT, muscle atrophy, stiff joints)
• Chest physio/ suction/ care of airways

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Stroke Nursing Care in Acute Stage (cont)

• Hygiene clean, dry but moisturised skin
• Mouthcare moist, clean mouth to prevent thrush,
  lubricate lips
• Cleanse and instill drops like artificial tears
  to moisten cornea if unconscious it is good to
  close the eyes sometimes
• Care of Foley catheter bowel care
• Temperature regulation (fan, tepid sponging,
  extra cover as required)

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Caring for the Person and Family

• Mental stimulation and emotional support
• Respect and privacy
• Care and emotional support of the family
• Listen to their expressed fears
• Encourage them to help with care as this is
  therapeutic for them

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Stroke Recovery and Rehabilitation

• Mental stimulation/ emotional support
• Speech therapy
• Physiotherapy to strengthen muscles and mobility
  of limbs, joints, prevent deformity
• Ensure good nutrition and hydration assess
  ability to swallow, process food
• Bowel and bladder care. Hygiene assist self-care
  using unaffected limb oral care
• Importance of rest and sleep (repair)