Stroke for nursingد.رشاد عبدالغني

8/3/2019 Stroke for nursing.

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Stroke


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Introduction

Cerebrovascular disease is the most common acute

neurologic illness. It is also the most important cause

of disability for adults and the third leading cause of

death for both men and women.

Stroke is defined as rapidly developing clinical signs

of disturbances of cerebral function lasting more

than 24 hours with no apparent cause other than that

of vascular origin.


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The use of the term "brain attack" has been

championed by the educational campaigns of

national health organizations to help inform thepublic about the urgency of stroke.

Transient ischaemic attack( TIA) is an acute loss offocal brain function with symptoms lasting less than

24 hours.


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Epidemiology

Stroke is the third commonest cause of death forboth men and women. Stroke occurs in allage groups across the world, although therisk increases markedly with age - 90% of

all stroke cases are in people who are 55 orolder. Stroke incidence is higher among menthan women, and mortality increases with

age reaching major proportions after age 55.Incidence: 1-2 per 1000 population per year.

Prevalence: 5 per 1000 population.


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Pathological types:

It has been estimated that 80 % of stoke are due

to brain infarction, 10 % to intracerebralhaemorrhage and 10 % to subarachnoid

haemorrhage.


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Causes:

Ischaemic stroke

Atherothrombosis

Embolismfrom heart or from a plaque complicated by thrombosis inan extracranial artery

Inflammatory vascular disease: Giant-cell arteritis,Takayasu's

disease , Systemic lupus erythematosus, meningitis, syphilis)Hematologic abnormalities lead to thrombosis include deficiencies of

proteins C and S and antithrombin III; sickle cell anemia;hyperhomocystinemia; and antiphospholipid antibody (aPL)syndrome.

Haemorrhagic stroke:

HTN, aneurysm, AVM , Trauma, amyloidosis

Haematological disorders: Haemophilia, leukemia

Subarachnoid haemorrhage:aneurysm, AVM


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Risk Factors

HTN

DM

Cardiac Disease

SmokingPrevious TIA

hyperlipidaemia

Alcohol

Raised haematocrit


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All patients evaluated for stroke should have an

emergent computed tomography (CT) scan of the

brain to rule out other potential mimics of an

ischemic event such as an intracranial tumor,

abscess, or hemorrhage.


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The following investigations should be done for all

patients to evaluate and determine the most likely cause

of a stroke :

Chest x rays, and laboratory studies ( CBC, platelets,

ESR, RFT, blood glucose , electrolytes and urine

analysis).

Additional diagnostic testing in selected cases, such as

electrocardiography (ECG), carotid ultrasound and

transcranial Doppler ultrasonography, magnetic

resonance imaging (MRI), echocardiography, abdominalUS, fasting lipids, clotting screen, autoantibodies, blood

culture, treponemal serology may be used in the

subsequent evaluation to determine the cause of a stroke.


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Angiography:

indications for cerebral angiography in stroke patients :

To identify a suspected intracerebral arteriovenous

malformation or aneurysm in patients with intracerebral

haemorrhage (in atypical location of hypertensive angiopathy)

for whom active surgical management is contemplated.

Investigation of primary subarachnoid haemorrhage.


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Features of Stroke

MCA:

Hemiparesis ( arm > leg)

hemianaesthesia

Dysphasia

ACA Hemiparesis ( leg > arm), urine incontinence.


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PCA: Hemianopia, cortical blindness, amnesia,

thalamic pain.

Basilar: ataxia, diplopia, nystagmus, dysphagia,

facial weakness, loss of consciousness.


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The differential diagnosis

Trauma (eg, subdural hematomas);

Tumour

Seizures

Acute metabolic disorders


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Medical complications

Many medical complications of stroke arepreventable or controllable. These include fever,

dysphagia/aspiration pneumonia, deep vein

thrombosis (DVT), decubitus ulcers,

fluid/electrolyte problems, hyperglycemia,

pulmonary embolism, and urinary tract infection.


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Neurologic complications

Several neurologic sequelae occur in the acute period

of stroke.

Cerebral edema/herniation.

Seizures. About 5% to 10% of patients with strokehave seizures, one-third of which occur within the first

2 weeks.

M t f t t k


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Management of acute stoke

General measures

Careful nursing: Regular turning of patient to avoid pressure

sores, skin kept dry and clean.

Care of airway: Oropharyngeal tube with regular suction of

secretions if patient unconscious.

Fluids balance: Nasogastric feeding if patient cannotswallow, bladder catheterisation if patient incontinent.

Physiotherapy: Start immediately to prevent joint

contractures, to clear chest secretions, to promote recovery

of strength and coordination.

Speech and occupational therapy to assess functional

problems and to encourage recovery of skills.

M di l


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Medical treatment

eneral precautions:

Rapid lowering of blood pressure should be avoided

unless it is critically high ( persistent diastolic

pressure higher than 120 mm Hg ) and of course

hypotension should be reversed.

Intravenous solutions that contain excessive

amounts of free water such as 5% dextrose may

increase cerebral edema and are contraindicated. A

solution of 5% dextrose and 0.45% normal saline is

preferable.


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Acute Stroke TherapyTissue plasminogen activator (tPA):

Intravenous (IV) tissue plasminogen activator (tPA)has been proven to be beneficial for carefully

selected patients who can be treatedwithin 3 hours

of onset of ischaemic stroke.


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Anticoagulants

The possible indications for heparin in acute cerebral

ischemia include:

-Deep vein thrombosis prophylaxis.

-Progressing stroke

-Vertebrobasilar ischemia.

-Permanent source of embolism e.g Cardioembolic

stroke ( Prosthetic valves, Atrial fibrillation ).

O d d i t


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Oedema-reducing agentsOsmotic agents such as mannitol or glycerol areprobably more effective in reducing ICP. It is important to

keep in the mind that these agents may have only atransient benefit, and there is some evidence that a rebound

increase in cerebral edema may occur when they are

discontinued. The dosage of mannitol is usually 0.5 to 1.5

g/kg IV. The dosage of glycerol is 1 g/kg PO q 6h.

Corticosteroids have not been shown to be effective incerebral infarct or cerebral haemorrhage .

S k i


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Stroke prevention

Is directed to the underlying pathologic processes and

risk factors such as atherosclerosis, arteritis, cardiacdisease, HTN, and so on. The options for treatment

or long-term prevention of ischemic or recurrent

ischemic stroke include:

Oral anticoagulants

Antiplatelet agents: Aspirin, Ticlopidine,

Dipyridamole, Clopidogrel Carotid endarterectomy (CEA)

Angioplasty with placement of stents.

T f i b l h h


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Treatment of intracerebral haemorrhage

Medical treatment of intracerebral

haemorrhage is supportive. For largecerebellar haemorrhage surgical

decompression is required if vital structures

of the medulla are at risk. Surgicalevacuation of a hematoma is considered for

lobar haemorrhage if there is signs of

herniation.


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Subarachnoid haemorrhage

Clinical picture

SAH presents with severe headache of sudden onsetthat can be accompanied by loss of consciousness at

onset.

Neck stiffness, photophobia, Nausea and vomiting

are due to increased intracranial pressure (ICP) andmeningeal irritation.

Focal neurological deficits may also occur.


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An LP is indicated only if the CT scan is -ve or

not available, but the risk of herniation by LP

must be considered in patient with impairedconscious level or signs of increased intracranial

pressure. The CSF of SAH is uniformly bloody in

the early stages and xanthochromic (yellow) afterfew hours.


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Diagnosis

History taking and neurological examination are

the essential core of the diagnosis of the SAH.

Whenever a SAH is suspected, a CT scan is the

diagnostic procedure of choice.


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Angiography

Cerebral angiography is the definitive diagnostic

procedure for detecting intracerebral aneurysm(s)or AVM. TCD is recommended every 2-3 days to

detect presence of vasospasm.


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Management

Management of patients with SAH is directed to

prevent and manage relatively commoncomplications of SAH, such as rebleeding,

vasospasm, hydrocephalus, hyponatremia, and

seizures. Bed rest, analgesics to relieve headacheand stable maintenance of BP in hypertensive

patients are generally recommended. Oral

nomodipine in a dose of 60 mg every 4 h P.O is

recommended to reduce the poor out come related

to vasospasm.

S


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SurgeryEarly surgical clipping of the aneurysm is the method of

the choice, but interventional endovascular occlusive

procedures are occasionally used for surgically unclippable

aneurysms such as balloon embolisation or coil

embolisation.

Complete excision of AVM is the most effective methodof treatment of AVM. Embolisation and or stereotactic

radiotherapy may provide an alternative method.

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Stroke for nursingد.رشاد عبدالغني