MANAGEMENT OF STROKE

STROKE UNIT

Ideally, people who have had a stroke areadmitted to a "stroke unit", a ward or dedicated area in hospital staffed by nurses and therapists with experience in stroke treatment. It has been shown that people admitted to a stroke unithave a higher chance of surviving than those admitted elsewhere in hospital, even if they are being cared for by doctors without experience

in stroke.

INVESTIGATIONS – will be as follows:

PHYSICAL EXAMINATION(may include Glasgow Coma Scale)BLOOD TESTCT Scan ANGIOGRAPHYELECTROENCEPHALOGRAPHYMRI

TREATMENTApproaches in stroke vary widely because of the huge variety of presentations. They will depend on:The site of occlusion or aneurismal raptureThe degree and extent of the ischemia or haemorrhageThe effectiveness of medical and nursing interventionThe patient’s responseThe aims are to prevent further brain damage, reduce the risk factors, provide supportive care and regain functional independence.

TREATMENT CAN BE CONSERVATIVE OR SURGICAL

CONSERVATIVE MANAGEMENT – is as follows:

ANTICOAGULANTS therapy has been used in attempt to halt further deterioration and improve the patient’s recovery. E.g. warfarin, although doubt has been cast on the usefulness of anticoagulant as it poses a risk of further heamorrhage into the infracted brain.

ANTIFIBRONOLYTIC agents have been used in patients following subarachnoid haemorrhage. Their use is thought to prevent re-bleeding by delaying dissolution of the clot around the aneurysm, but their effort on the overall outcome is questionable.

ANTIPLATELETAGENT – The use of aspirin as an anti platelet agent has received attention in recent years.

Other factors – pre-existing contributory disorders may be treated with drugs therapy, e.g. antihypertensive agents and diuretics may be used in the patient with raised blood pressure

SURGICAL MANAGEMENT – uses two techniques:

Carotid endarterectomy, which involves the removal of stenosing or ulcerating atheromatous lesions at the bifurcation of the common carotid arteries.A superficial temporal to middle cerebral artery anastomosis , which provides an artificial collateral blood supply to the affected part of the brain.

NURSING PRIORITIES AND MANAGEMENT

NURSING PRIORITIES AND MANAGEMENTPrevention: One of the most important

aspect of stroke management is prevention, by

identifying at-risk individuals and dealing with early predisposing factors such as hypertension.

REDUCING THE RISK OF STROKE

The following factors put people at greater risk of

having stroke, but action can be taken to reduce the likelihood of stroke occurring:

Hypertension – Using antihypertensive drugs

does reduce the risk of a stroke. Blood pressure should be checked periodically, e.g. every 4 years until the age of 40, and every 2 years after that. Moderation in alcohol consumption is advised as it raises blood pressure.Cigarette Smoking – Daily cigarette

smoking can increase the risk of stroke by two and half times. Smokers should therefore be encouraged to stop smoking, and young people discouraged from starting to smoke.

Hypercholesterolaemia – may lead to coronary heart disease. Patient with hyperchoresterolaemia can reduce the amount of cholesterol-rich food they take.

Obesity – may increase the likelihood of hypertension. At-risk patients should control their weight.

Diabetic patients – are more likely to have a stroke, so the level of sugar in the blood and urine should be checked regularly.

The contraceptive pill – increases the risk of stroke in young women, particularly if there is a family history of arterial disease. Other forms of contraception are therefore more suitable.

NURSING CARE FOLLOWING A STROKE

A successful outcome is more likely when the optimum techniques and resources are utilized, encompassing every member of the multidisciplinary team. The outcome can also be influenced by other factors such as recognizing the need to start the rehabilitation process as soon as possible.

Initial Treatment Concerns

The initial plan for the management of a patient with acute stroke is to control vital signs, prevent deterioration of the patient, and prevent medical complications of the stroke that worsen the patient’s outcome. Medical complications include respiratory failure, hypertension, hyperglycemia, cerebral edema, and fever. The nurse caring for the patient must coordinate the activities of an interdisciplinary team to provide high-quality

Risk AssessmentsNurses are generally responsible for ensuring that risk assessments are carried out soon after patient admission. These can include assessing the risks of moving and handling, nutrition, pressure ulcers, falls and DVT. Each hospital will have its own policy on which assessments need to be carried out and which tools should be used.

IMMEDIATE PRIORITIESAIRWAYS – Techniques for maintaining a patent airway and adequate ventilation are a priority. An oxygen saturation monitor should be used to evaluate the patient’s oxygenation. If the patient’s oxygen saturation is less than 90%, the patient should be placed on oxygen titrated at 2–4 liters per minute to maintain an oxygen saturation of 90%. Arterial blood gases and a chest film should be obtained if a saturation of >90% cannot be obtained.

VITAL SIGNS & NEUROLOGICAL ASSESSMENT Neurological assessment and blood pressure should be checked every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and then every hour for the next 16 hours(Adams et al., 2007). Generally, BP is not treated in ischemic stroke until it is greater than 220/120 mm Hg. Rapid lowering of BP can dramatically decrease cerebral perfusion and worsen the infarction. If the patient has a decreased LOC, the Glasgow Coma Scale (GCS) can be used to evaluate him or her.

COMMUNICATING – Speech impairment or loss can be a frightening experience for the patient and his family. Early referral to a

speech therapist is important in order for an expert assessment can be performed and a strategyidentified. It is crucial to ascertain the type

andnature of the speech deficit, e.g. whether the patient’s difficulties are related to expression

or comprehension.

Glasgow Coma Scale Eye Opening Response • Spontaneous--open with blinking at baseline 4 points • To verbal stimuli, command, speech 3 points • To pain only (not applied to face) 2 points • No response 1 point

Verbal Response• Oriented 5 points • Confused conversation, but able to answer questions 4 points • Inappropriate words 3 points • Incomprehensible speech 2 points • No response 1 point

Motor Response• Obeys commands for movement 6 points • Purposeful movement to painful stimulus 5 points • Withdraws in response to pain 4 points • Flexion in response to pain (decorticate posturing) 3 points • Extension response in response to pain (decerebrate posturing) 2 points • No response 1 point

EATING AND DRINKINGInitially the patient’s fluid intake is likely to be

via IV infusion(this maintains arterial BP and, in

turn, prevents cerebral ischemia and infarction)Maintain accurate fluid balanceSubsequently, oral diet – through NG tube or as the case may be, will be introduced Regular oral inspection and oral hygiene should be carried out.

Bedside videofluoroscopic and endoscopic studies: These tests allow direct visualization of the laryngopharyngeal structure while the patient is given a variety of dyed food textures and consistencies. Both tests are used to evaluate for pooling, spillage, endotracheal penetration, and aspiration. After these tests, the radiologist can make recommendations for safe food and liquid consistency. Patients who are aspirating or are at risk for aspiration with all types of food and liquids should receive nutrition through a soft feeding tube until swallowing is feasible. Weight should be monitored at least once weekly to assess for adequacy of nutrition.

ELIMINATION – Interruption of the patient’s elimination pattern is due to loss of consciousness and enforced immobility. Urinary incontinence is best dealt with by retraining the patient to use bedpans or urinals at specified intervals, rather than resorting to catheterization. Condom-type urinary appliances may be suitable for male patients, but no successful female equivalent is yet available.

REHABILITATION - is the process by which those with disabling strokes undergo treatment to help return to normal as much as possible regaining and learning the skills of everyday living. It also aims to help the survivor understand and adapt to difficulties, prevents secondary complication and educates family to play a supporting role. It’s usually multidisciplinary as it involves staff with different skills working together to help the person. These include nursing staff, physiotherapists, occupational therapists, speech and language therapists, orthotists and usually a physician trained in rehabilitation medicine. Some teams may include psychologists, social workers, and pharmacists. Validated instrument such as the Barthel Scale may be used to assess the likelihood of a stroke patient being managed at home with or without support subsequent to discharge from hospital.

EPIDEMIOLOGYStroke was the 2nd most frequent cause of death worldwide in 2008, accounting for 6.2 million deaths (11% of total). Approximately, 9 million people had stroke in 2008 and 30 million people have previously had stroke and are still alive. It is ranked after heart diseases and before cancer. On average, a brain attack occur every 45 second, and every 3.1 minutes, someone dies of a stroke.

In the United States, stroke is a leading cause of disability and the 4th leading cause of death.

The incident of stroke increases exponentially from 30 years of age, and etiology varies by age. Advanced age is one of the most significant stroke factor. 95% of stroke occur in people age 45 and older, and two-thirds of strokes occur in those over the age of 65. Stroke can occur at any age, including childhood.

Men are 25% more likely to suffer stroke than women, yet 60% of deaths from stroke occur in women. Since women live longer, they are older on average when they have their strokes and thus more often killed.

PROGNOSIS Disability affects 75% of stroke survivors enough to decrease their employability. Stroke can affect people physically, mentally, emotionally, or a combination of the three. The result of stroke vary widely depending on size or location. Dysfunction corresponds to areas in the brain that have been affected.Some of the physical disabilities that can result from stroke include muscle weakness, numbness, pressure sores, pneumonia, incontinence, apraxia (inability to perform learned movement), difficulties carrying out daily activities, appetite loss, speech loss, vision loss and pain. If the stroke is severe enough, or in a certain location such as parts of the brain-stem, coma or death can result.

Emotional problem resulting from stroke can result from direct damage to emotional centres in the brain or from frustration and difficulty adapting to new limitations.30 – 50% of stroke survivors suffer post stroke depression, which is characterized by lethargy, irritability, sleep disturbance, lowered self esteem, and withdrawal. Cognitive deficits resulting from stroke include perceptual disorders, aphasia, dementia, and problems with attention and memory. A stroke patient may be unaware of his or her disabilities, a condition called anosognosia. In a condition called hemispattial neglect, a patient is unable to attend to anything o the side of space opposite to the damaged hemisphere. `

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