stroke 2

May/June l LPN2008

STROKE—A SUDDEN interruption of blood supply to anarea of the brain—can be deadly. Stroke is the thirdleading cause of death in the United States, after heartdisease and cancer. About 700,000 people suffer a newor recurrent stroke each year, about one-quarter ofthem fatal. Nearly three-quarters of all strokes occur inpeople over age 65.

Stroke is a leading cause of serious, long-term disabili-ty. For those who survive it, life isn’t the same. Accordingto data from the Framingham Heart Study, 31% ofstroke survivors need help caring for themselves; 20%need help walking; and 71% have a diminished ability towork. Patients who’ve had a stroke may have ongoingweakness or paralysis, decreased sensation, and poormemory. They may have trouble performing activities ofdaily living, such as thinking, speaking, or eating.

Types of strokesThere are four main types of stroke: two caused byblocked blood supply to the brain, and two by bleedingor hemorrhage. Cerebral thrombosis and cerebral em-bolism, caused by clots or particles that plug an artery,

are more common, accounting for about 87% of allstrokes. Hemorrhagic strokes, which can be cerebral orsubarachnoid, account for about 13% of all stroke cases.They occur when a blood vessel on the brain’s surfaceruptures and bleeds into the space between the brain andthe skull. As the blood accumulates, it compresses thesurrounding tissue. Let’s take a closer look at each typeof stroke.

Cerebral thrombosis, the most common type of stroke,occurs when a blood clot (thrombus) forms and blocksblood flow in an artery bringing blood to the brain.Blood clots usually form in arteries damaged by athero-sclerosis (fatty plaque deposits on the vessel walls). Theyoften develop at night or first thing in the morning, whenblood pressure (BP) is low.

A cerebral embolism occurs when a wandering clot(embolus) or some other particle forms in a blood vesselaway from the brain, usually in the heart. The clot travelsthrough the bloodstream until it reaches an artery lead-ing to or in the brain that’s too narrow and creates ablockage. Atrial fibrillation is a common cause ofembolism due to clots forming in the heart. One of these

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The effects of a stroke can be devastating, both physiologically and psychologically.Find out how a stroke affects the body and mind, how it’s treated, and how you canhelp your patient recover.

LENORA M. MAZE, RN, CNRN, MSNClinical Nurse Specialist • Critical Care and Neuroscience Wishard Health Services • Indianapolis, Ind.

The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.

An all-out assault on the brain

2.5CONTACT HOURS

LPN2008 l Volume 4, Number 3

clots may dislodge and travel to thebrain.

Cerebral hemorrhage occurswhen a defective artery in the brain

bursts and leaks blood into the brain.The sudden increase in pressure candamage brain cells in the area ofleakage. If the amount of blood

increases rapidly, the resulting pres-sure can cause unconsciousness ordeath.

Causes of cerebral hemorrhage

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Neurologic deficits of strokeNeurologic deficit Manifestation Nursing implications/patient teaching

Visual field deficitsHomonymous • Unaware of persons or • Place objects within intact visual field.hemianopsia (loss of half objects on side of visual loss • Approach patient from side of intact visual field.of the visual field) • Neglect of one side of the body • Instruct/remind patient to turn head in direction of

• Difficulty judging distances visual loss to compensate for loss of visual field.Loss of peripheral vision • Difficulty seeing at night • Encourage use of eyeglasses if available.

• Unaware of objects or • When teaching the patiient, do so within his intact visual field.the borders of objects • Place objects in center of patient’s intact visual field

Diplopia • Double vision • Explain to patient the location of an object when placing it near him. • Consistently place patient care items in the same location.

Motor deficitsHemipariesis • Weakness of face, arm, and • Place objects within patient’s reach on unaffected side.

leg on one side due to a lesion • Instruct patient to exercise and increase strength on in opposite hemisphere unaffected side.

Hemiplegia • Paralysis of face, arm, and • Encourage patient to provide ROM exercise to affected side.leg on one side due to a lesion • Provide immobilization as needed to affected side. in opposite hemisphere • Maintain body alignment in functional position.

• Exercise unaffected limb to increase mobility, strength, use.

Ataxia • Staggering, unsteady gait • Support patient during initial ambulation phase. • Inability to keep feet together; • Provide supportive device (walker, cane) for ambulation standing requires a broad base • Instruct patient not to walk without assistance or supportive

device.Dysarthria • Difficulty forming words • Provide patient with alternative methods of communicating.

• Allow patient sufficient time to respond to verbal communication. • Support patient and family to alleviate frustration related to dif-ficulty in communicating.

Dysphagia • Difficulty swallowing • Test patient’s pharyngeal reflexes before offering food or fluids. • Assist patient with meals. • Place food on unaffected side of mouth. • Allow ample time to eat.

Sensory deficitsParesthesia (occurs on • Numbness and tingling of extremity • Instruct patient that sensation may be altered. the side opposite • Difficulty with proprioception • Provide ROM to affected areas and apply corrective devices as the lesion) (the perception of the movement needed.

and position of the limbs)

Verbal deficitsExpressive aphasia • May only be able to speak in • Encourage patient to repeat sounds of the alphabet.

single-word responses • Explore patient’s ability to write as an alternative means of communication.

Receptive aphasia • Unable to comprehend the spoken • Speak slowly and clearly to assist patient in forming sounds. word; can speak but may not • Explore patient’s ability to read as an alternative means of make sense. communication.

Global (mixed) aphasia • Combination of expressive and • Speak clearly and in simple sentences; use gestures or receptive aphasia pictures when able.

• Establish alternative means of communication.

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include high BP, trauma, infection,tumor, clotting deficiencies, andblood vessel abnormalities.

Subarachnoid hemorrhage (SAH)occurs when a blood vessel on thebrain’s surface ruptures and quicklybleeds into the space between thebrain and the skull (the subarachnoidspace). An SAH usually triggers anintense headache that many strokepatients have described as “the worstthey’ve ever had.” The patient mayalso have neck pain, nausea, andvomiting. The buildup of pressureoutside the brain can cause rapid lossof consciousness or death.

A number of risk factors may con-tribute to the development of SAH:high BP, alcohol abuse, oral contra-ceptive use, cocaine abuse, nicotineabuse, advancing age, and diagnosticprocedures, such as angiography orlumbar puncture.

Aneurysms and arterio-venous malformationsHemorrhagic strokes can be causedby diseased, abnormal, or weakenedblood vessels. Blood vessel problems

that can cause hemor-rhagic stroke includecerebral aneurysmsand arteriovenous mal-formations (AVMs).

A cerebral aneurysmoccurs when a sectionof a blood vessel wallweakens and balloonsfrom the pressure ofblood flowing throughthe vessel. This pres-sure further weakensthe vessel wall. Ifuntreated, the weak-ened wall ruptures andblood spills into thebrain.

Most cerebralaneurysms are saccular,meaning they have aneck and stem. Theycommonly occur where arteriesdivide into two branches, especiallyin an area called the Circle of Willis(see Figure 1). That’s where BPchanges occur frequently and manyblood vessels branch off, leavingthem prone to weak spots.

Cerebral aneurysms usually aren’tdiscovered until a person developssymptoms, although some are diag-nosed incidentally during magneticresonance imaging (MRI). Symp-toms include a sudden and excruciat-ing headache, a stiff neck, and a

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Neurologic deficits of stroke (continued)

Neurologic deficit Manifestation Nursing implications/patient teaching

Cognitive deficits• Short and long-term memory loss • Frequently reorient patient to time, place, situation. • Decreased attention span • Use verbal and auditory cues to orient patient.• Impaired ability to concentrate • Provide familiar objects (family photographs, favorite objects). • Poor abstract reasoning • Use simple language. • Altered judgment • Match visual tasks with verbal cue; holding a toothbrush, sim-

ulate brushing of teeth while saying, “I’d like you to brush yourteeth now.”• Minimize distracting noises and view when teaching patient. • Frequently repeat and reinforce instructions.

Emotional deficits• Loss of self-control • Support patient during uncontrollable outbursts.• Emotional lability • Discuss with patient and family that outbursts are due to • Decreased tolerance to stressful disease process. situations • Encourage patient to participate in group activity.• Depression • Provide mental stimulation for the patient. • Withdrawal • Control stressful situations, if possible. • Fear, hostility, anger • Provide a safe environment.• Feelings of isolation • Encourage patient to express feelings and frustrations related

to disease process.

Anterior cerebral

Ophthalmic

Middlecerebral

Internalcarotid

Posteriorcommunicating

Posterior cerebral

Superior cerebellar

Basilar

Anterior inferiorcerebellar

Posterior inferiorcerebellar

Vertebral

Anterior spinal

Labyrinthine(internal acoustic)

Anteriorcommunicating

Cerebralarterialcircle

Figure 1. The cerebral arterial circle (Circle of Willis).

LPN2008 l Volume 4, Number 340

What is a stroke? A stroke occurs when a clot or a torn blood vessel inthe brain stops blood from reaching a part of thebrain. Damage to that part of the brain from lack ofblood and oxygen can cause various signs and symp-toms of stroke, such as facial drooping, numbness, andparalysis.

Although anyone can have a stroke, your risk in-creases if you’re male, over age 65, or have one of theseconditions: high blood pressure, high cholesterol, heartdisease, or diabetes. Being overweight, smoking, abus-ing drugs or alcohol, and taking birth control pillsincrease risk, too. African-Americans, people who areHispanic or Asian, and those with a close relative who’shad a stroke are also at higher risk.

How do I know if I’m having a stroke? Signs and symptoms, which depend on the size and lo-cation of the brain injury, usually occur suddenly andmay include: • numbness or weakness of the face, arm, or leg onone side of the body• confusion, trouble speaking or understanding• trouble seeing from one or both eyes• trouble walking, dizziness, or loss of balance or coordination • severe unexplained headache.

If you have any of these problems, call 911 immedi-ately. Don’t try to drive yourself to the hospital—yoursymptoms could worsen while you’re driving.

If you have stroke symptoms that go away after a fewseconds or minutes, you may have had a ministroke(also called a warning stroke). Contact your health careprovider immediately for help because a bigger strokemay be on the way.

How is a stroke treated?Your health care provider will ask you questions aboutyour symptoms and when they started. He’ll do sometests to determine whether the stroke is caused by ablood clot (the more common type of stroke) or bybleeding in the brain. These tests may include com-puted tomography (CT) and magnetic resonanceimaging (MRI) scans of your head. He’ll also test your

blood for other problems and obtain an electroen-cephalogram (EEG), which records the brain’s electri-cal activity and shows where the damage is located.

If the stroke is caused by a blood clot and you arrivedat the hospital within 3 hours of when symptoms start-ed, you may receive a drug to dissolve the clot, andanother drug to thin your blood and prevent new clots.But these drugs won’t be used if your stroke was causedby bleeding in your brain—that kind of stroke mayrequire emergency surgery.

What happens after a stroke?You may work with a physical therapist to regain mus-cle strength, balance, or the ability to walk. A speechtherapist may evaluate how well you can eat, drink,and speak. If an arm or leg is paralyzed, an occupa-tional therapist will help you learn how to dress your-self, bathe, and cook. Depending on how bad yourstroke was, how quickly you recover, and how muchhelp you have at home, you may be released from thehospital within 3 to 5 days. You may go to a rehabili-tation center, a long-term care facility, or your home.The health care team can give you information or re-ferrals for home care, support services, and supportgroups that deal with the issues facing patients andfamilies after a stroke. You can also visit the AmericanStroke Association’s Web site at http://www.strokeassociation.org.

What can I do to prevent a stroke? If your health care provider has prescribed medicinefor high blood pressure, take it as directed. Loseweight if you’re overweight, exercise regularly, and eata well-balanced diet that’s low in fat, cholesterol,sugar, and salt. If you smoke, stop, and don’t drink al-cohol excessively. If you have diabetes, keep yourblood sugar under control.This patient-education guide has been adapted for the 5th-grade level using the Flesch-Kincaid and SMOG formulas. It may be photocopied for clinical use or adapted to meetyour facility’s requirements. Selected references are available upon request.

Special thanks to Tracy Kane, MEd, community health educator, Capital Health System,Trenton, N.J.

PATIENTEDUCATION

StrokeBy LISA HATHAWAY, RN, BSN Clinical Editor, LPN2008

LPN2008

painful reaction to light. The pa-tient’s level of consciousness (LOC)may change. He may also experiencenausea and vomiting, high BP,neurologic deficits, or seizures (seeNeurologic deficits of stroke). Even withimmediate medical care, about 35%of patients who have a cerebralaneurysm die from the initial rup-ture.

An AVM is an abnormal cluster ofblood vessels in the brain. In normalblood flow, the heart pumps bloodvia the arteries to the brain, where itenters a network of capillaries thatnourish brain tissue. Deoxygenatedblood then returns to the heart viaveins.

When an AVM is present, howev-er, blood passes directly from anartery to a vein. This “short-circuit”of the normal pattern of blood flowprevents capillaries in the brain fromreceiving oxygenated blood. If thepressure of the draining veins buildsto an abnormally high level, theweakened blood vessel walls can rup-ture, causing bleeding into the brain.

Warning strokeUnlike a full-blown stroke, transientischemic attack (TIA) is a “warningstroke” that occurs when the bloodsupply to part of the brain is brieflyinterrupted. A TIA can occur days,weeks, or months before a majorstroke. Symptoms occur suddenlyand are similar to those of a hemor-rhagic stroke, but they don’t last aslong. Most are gone within an hour,but they may last up to 24 hours.

A patient with a TIA may describea “veil” partly covering vision in oneeye that clears up spontaneously afterseveral minutes—a sign of temporaryblockage of the retinal artery. He mayalso experience numbness or weak-ness in the face, arm, or leg, especiallyon one side of the body. He may feelconfused or have trouble talking,understanding speech, or walking. He

may also feel dizzy or experience lossof balance and coordination.

A patient with any stroke symp-toms needs urgent evaluation. Aboutone-third of people who have a TIAeventually have acute strokes—manyof which can be prevented by payingattention to TIA warning signs andtreating underlying risk factors.

Evaluating the patient When a potential stroke patient ar-rives at the emergency department,stabilizing his airway, breathing, andcirculation is the primary concern.A brief history should follow, in-cluding the time symptoms began,any other conditions he may have(such as atrial fibrillation and highBP), and any medications he’s tak-ing, such as anticoagulants. If thepatient can’t define an exact timethat his symptoms started, the timehe was last seen to be “normal” canbe used. Other important informa-tion includes any factors surround-ing the onset of symptoms thatmight suggest something other thanstroke.

A brief physical and neurologicexamination includes looking forsigns of trauma, abnormal bruising,evaluating for abnormal or heartsounds or irregular heart rhythms,and assessing the patient’s vital signs,including his temperature and BP.The neurologic examination is briefand focused; a formal stroke score orscale, such as the National Institutesof Health Stroke Scale (NIHSS), canhelp in the diagnosis (see The NIHStroke Scale).

Diagnostic studies recommendedto evaluate someone suspected ofhaving an acute stroke include bloodglucose and electrolyte levels, com-plete blood cell count with plateletcount, prothrombin time, activatedpartial thromboplastin time, interna-tional normalized ratio, and renalfunction studies. To evaluate the

patient’s cardiovascular status, bloodwork should include cardiac enzymesand he should have a 12-lead electro-cardiogram and cardiac monitoring.A chest X-ray isn’t recommendedunless he shows other signs of acutecardiac or pulmonary disease.

A noncontrast computed tomog-raphy (CT) scan of the brain, alongwith MRI, can provide additionalinformation that’s helpful in diagno-sis and treatment. But treatmentshouldn’t be delayed to obtain thesetests if the patient is suffering anacute stroke.

Once a patient is diagnosed withstroke, treatment should beginimmediately. Let’s review theoptions.

Treating strokeStroke can be treated with surgery,medications, supportive care, andrehabilitation. When plaque isblocking the carotid artery, a carotidendarterectomy may be performedto remove it. Another surgical tech-nique is cerebral angioplasty, whereballoons, stents, or coils are used toclear blockage.

The clot-dissolving drug tissueplasminogen activator (tPA) may beprescribed to restore blood flow tothe brain. However, tPA shouldn’tbe used in someone with a hemor-rhagic stroke, and it’s effective only ifgiven within 3 hours of the onset ofstroke symptoms.

Before any surgery is considered,the patient’s health care provider willrequest a consultation with a neuro-surgeon, who’ll consider the patient’sage, timing of the stroke, currentmedical condition, and the cause,location, and mass effect of thestroke.

Your patient may need intracra-nial pressure (ICP) monitoring via acatheter inserted in his brain’s ven-tricles to monitor pressure and draincerebrospinal fluid. Normal ICP is

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LPN2008 l Volume 4, Number 342

less than 10 mm Hg. A pressure over20 mm Hg is considered elevated.

The goals of therapy for a patientwith SAH are to reduce pain,edema, cerebral vasospasm, andvomiting and to prevent or decreaseseizures. Cerebral vasospasm occur-ring 4 to 14 days after the initialbleed accounts for 40% to 50% ofdeaths related to SAH. The calciumchannel blocker nimodipine(Nimotop) is given to decreasecerebral vasospasm. Seizure preven-tion, electrolyte management, andother interventions are needed tocontrol ICP and maximize cerebralperfusion. Keep external stimuli toa minimum by dimming the lightsand avoiding excessive noise. Thepatient usually undergoes surgeryto repair the ruptured vessel.

Mobilizing against complicationsYou can take the following preven-tive measures to help your patientavoid complications after a stroke.

Protect the patient’s airway andkeep him oxygenated. Becausehypoxia can worsen neurologicinjury, maintaining adequate oxy-genation via an effective airway iscritical. Perform pulse oximetry andmonitor your patient’s vital signs todetermine his respiratory status.

The patient may even need to beintubated. He’ll probably alsorequire rigorous pulmonary care toprevent partial airway obstruction,hypoventilation, aspiration pneu-monia, and atelectasis, the mostcommon causes of inadequate oxy-genation (hypoxia) in stroke patients.

Immobility, decreased LOC, res-piratory muscle deconditioning, inef-fective cough, and altered breathingpatterns can pose a risk of partial ortotal lung collapse (atelectasis) andpneumonia for your patient. Aspira-tion pneumonia is the most commonreason for nonneurologic death dur-

ing the first month after a stroke.Pulmonary edema and pulmonaryembolus can be complications ofstroke, compromising oxygenation.

All stroke patients should receivesupplemental oxygen on admission.Oxygen saturation (SpO2) should bekept at least at 94%, so monitor itclosely and take these steps to keep itat the right level:• Elevate the head of the bed to 30degrees to prevent aspiration.• Suction secretions as needed. • Position the patient for maximalchest expansion (frequently turninghim to avoid pooling of secretions).• Coach the patient to take deepbreaths and cough to prevent atelec-tasis.• Auscultate breath sounds fre-quently.• Keep a sharp lookout for signs ofrespiratory distress.

Control his blood pressure. A keyassessment when you’re caring for apatient who’s had a stroke is moni-toring his BP. Right after the stroke,monitor BP frequently, according tofacility policy. Elevated BP can resultfrom stress, a full bladder, pain, pre-existing hypertension, hypoxia, orincreased ICP. In most cases, BPdeclines without treatment.

The current recommendation is notto administer antihypertensive agentsunless the patient’s systolic pressure isgreater than 220 mm Hg or diastolicpressure is greater than 120 mm Hg(unless he’s receiving tPA).

If your patient requires medicationtherapy to lower BP, it should bedone cautiously because lowering ittoo much can lead to inadequate cere-bral perfusion. Expect to administerintravenous labetalol (Normodyne) orsodium nitroprusside (Nitropress) ororal captopril (Capoten) or nicardip-ine (Cardene). Sublingual calciumantagonists such as nifedipine(Procardia) shouldn’t be used becausethey lower systemic BP too much to

maintain cerebral perfusion. The exception to the rule of not

treating mildly elevated BP is apatient given tPA, whose BP must becarefully managed to prevent hemor-rhage. In fact, tPA is contraindicatedwhen systolic pressure is above 185mm Hg or diastolic pressure is above110 mm Hg.

Persistent hypotension followingstroke is rare; if it occurs, it may bethe result of aortic dissection, vol-ume depletion, or decreased cardiacoutput.

Treat hyperthermia. Hyperther-mia during the acute phase of strokeis associated with poor neurologicoutcome and marked increase inmorbidity and mortality. Useantipyretics (acetaminophen is thedrug of choice) and cooling blanketsto control hyperthermia.

Control hyperglycemia. Tightcontrol of your patient’s blood glu-cose level is important throughoutthe acute phase of stroke. Severehypoglycemia can lead to furtherbrain injury, and hyperglycemia isassociated with poor outcomes.Hyperglycemia may be a result ofthe stress response to the stroke. It

The NIH Stroke ScaleThe National Institutes of HealthStroke Scale (NIHSS) is currently themost widely used assessment toolfor stroke patients. It provides ameans for standardized assessmentby all health care professionals.Extensive research has shown that60% to 70% of patients with anacute ischemic stroke and a baselineNIHSS score of less than 10 will havea favorable outcome at 1 year post-stroke, while only 4% to 16% ofpatients with a baseline NIHSS scoregreater than 20 will have a favorableoutcome at 1 year. The NIHSS isavailable online at http://www.strokecenter.org/trials/scales/nihss.html.

May/June l LPN2008 43

may resolve spontaneously, or thepatient may require insulin to main-tain blood glucose levels between 80and 110 mg/dL.

Monitor for arrhythmias. A dam-aged area in the brain’s right hemi-sphere poses a high risk of cardiacarrhythmias, and atrial fibrillation isa common arrhythmia in strokepatients. Cardiac monitoring is indi-cated for any patient with preexistingcardiac disease or one who’s had anembolic stroke. Frequently assessand document the patient’s cardiacrate and rhythm, and auscultate hisheart sounds. Monitor for and reporta new onset of any chest pain orarrhythmia.

Look out for clotting problems.Patients with neurologic injury fre-quently have clotting problems.Although anticoagulant therapy fol-lowing stroke is controversial, it’scommonly given. If your patient isreceiving parenterally administeredanticoagulants, his risk of seriousbleeding complications is increased.

Leg paralysis puts the patient athigh risk for developing deep veinthrombosis (DVT) and subsequentpulmonary embolism. Passive range-of-motion (ROM) exercises for theparalyzed leg, early mobilization, andambulation are essential. Use se-quential pneumatic compressiondevices if the patient is immobile andat high risk for DVT. As ordered,administer subcutaneous unfraction-ated or low-molecular-weight heparinto prevent DVT. (Swelling of one legis the most accurate sign of DVT.)

Monitor the patient for other com-plications, such as cerebral edema,that can lead to increased ICP,seizures, hemorrhage around theinfarction, and myocardial infarctionor arrhythmia. Prompt recognitionand treatment are necessary to limitfurther damage to brain tissue.

Monitor for changes in LOC.Following stroke, changes in the

patient’s LOC usually indicate adeveloping complication. The earliera change is recognized and the causetreated, the less chance of additionalmorbidity and mortality. Even slightchanges such as sleepiness or confu-sion in the early stages of stroke canindicate increasing ICP. Report suchchanges immediately.

Manage your patient’s pain.Many problems can cause pain aftera stroke, including poor positioning,central neurologic impairment, lim-ited mobility, pressure ulcers, andinfection. Your patient may receivean opioid such as codeine or a non-narcotic medication such as aceta-minophen to manage pain. If he’sable to respond, frequently ask himabout pain using a validated pain rat-ing scale. If he can’t respond, lookfor nonverbal cues, like grimacing,resisting movement, or withdrawing.

Reposition the patient frequently.Besides helping prevent DVT, ROMexercises and early ambulation keepjoints moving. Reposition the patientfrequently and use pillows, wedges,and pressure-reducing mattresses orsurfaces to better distribute weight.Pressure ulcers are a complication ofstroke recovery. Assess your patient’sskin with each nursing assessment,paying close attention to his sacrumarea and heels, which are most vul-nerable to pressure ulcers.

Control incontinence. Urinary andfecal incontinence are fairly commonfollowing stroke and can lead to tis-sue breakdown and pressure ulcerdevelopment. Effective managementincludes correcting incontinencewhen possible, using pads or briefsthat wick moisture away from theskin, using moisture-barrier creams,frequent changing and cleansing, andfrequent assessment of the skin formaceration and yeast infections.

Monitor your patient’s urine out-put and assess for a distended blad-der as appropriate. Urine retention

can increase the risk for urinary tractinfection.

Prevent infection. A stroke patientis at high risk for health care-acquiredinfections. Invasive devices, urinarycatheters, pressure ulcers, respira-tory insufficiency, and metabolicchanges all increase infection risk.To lower the risk, change invasivelines according to facility protocol,and discontinue urinary catheters assoon as possible. Prevent skin break-down, encourage deep breathing andcoughing to prevent atelectasis, anduse standard precautions to decreaseinfection risk.

Looking at both sidesSymmetry describes the similarity ofthe sides of the body affected andunaffected by stroke. Make a base-line comparison to gather detailsabout deficits on your patient’s af-fected side. Continued comparisonshelp in assessing and documentingimprovements. A marked decreasein symmetry after baseline measure-ment indicates a developing compli-cation or recurrent stroke.

Neurologic impairment in themuscles on the affected side of thebody can result in rapid decondition-ing. Consult physical therapy onadmission to begin planning an earlyambulation program. Use appropri-ate assistive devices to mobilize thepatient. If he can’t walk, maintainfrequent ROM exercises.

A stroke may cause your patient tolose awareness of the affected side ofhis body. Besides not using this side,he may not even be aware it exists.When severe, this problem can leadto “one-side neglect.” Interventionsto help improve awareness of theneglected side include approachingthe patient from that side, placingthe night stand with the TV remoteand water carafe on that side, andincluding the neglected hand in dailycare activities. Make sure the call

LPN2008 l Volume 4, Number 344

button stays on his unaffected side.For about a month after someone

has a stroke, seizure precautionsshould be implemented and thepatient should be closely monitored.If he develops seizures, fospheny-toin (Cerebyx) and phenytoin(Dilantin) are the preferred anti-seizure medications.

Hard to swallowFor various reasons, a patient canbecome dehydrated and malnour-ished after a stroke. Changes inconsciousness, inability to swallow,excess antidiuretic hormone releasethat causes fluid overload, diabetesinsipidus that causes fluid deficit,and inadequate nutrition can be un-derlying problems. Lab tests toassess nutritional status, serum elec-trolytes, and serum osmolarity willhelp to identify reversible causes.

Half of stroke patients experiencedysphagia, so your patient mayneed dietary modifications to main-tain nutrition. Poor nutritionincreases your patient’s risk forpressure ulcers. Studies also showthat poor baseline nutritional statusis associated with a worse outcomeat 6 months following stroke.

If your patient’s having difficultywith liquids or food, request a con-sult with a speech pathologist toobtain a swallowing study. Ensureproper nutrition through enteral orparenteral routes; feeding tubes maybe needed on a temporary or perma-nent basis.

Carefully monitor your patient’sintake and output. Tachycardia maybe an indication of hypovolemia.Crackles in the lungs or edema canindicate hypervolemia.

On the edgeBecause stroke greatly increases apatient’s risk for falls, implement fallprecautions (including bed alarms),and make sure your patient’s call

button is within easy reach. He mayhave trouble walking, so make surethat sufficient staff are available tohelp him and that he uses appropri-ate assistive devices for ambulation.

Anosognosia, the inability toacknowledge physical impairmentsfrom a stroke, may affect your patient,giving him a false sense of securityand increasing his risk of injury. A bedalarm may be needed to prevent thepatient from getting out of bed unat-tended. Family members or profes-sional sitters may be required around-the-clock to protect him from injury.

About two-thirds of strokepatients develop spasticity in whichcertain muscles are continuouslycontracted, causing stiffness or tight-ness that may interfere with move-ment, speech, and ambulation. Thecause is usually damage to the por-tion of the brain that controlsvoluntary movement. Drugs mostfrequently used to manage general-ized spasticity include tizanidine(Zanaflex), baclofen (Lioresal),diazepam (Valium), and dantrolene(Dantrium). Physical therapy oftenhelps too. For certain patients,surgery to cut or transfer tendonsmay be necessary to relieve spastici-ty. Monitor your patient’s responseto medications, assess his functionalability, and maintain joint mobility.

Debilitating deficitsA stroke can dramatically shortenyour patient’s attention span. Or hemay develop apraxia, the loss ofability to execute or carry out skilledmovements and gestures, despitehaving the desire and the physicalability to do them.

To accommodate these deficits,divide your patient teaching into shortsegments. Short-term memory loss iscommon too, so reinforcement is nec-essary. The patient may ask the samequestion over and over; give him thesame simple answer each time.

About one-quarter of strokepatients are affected by some type ofaphasia, making communication diffi-cult. Aphasia can partially or com-pletely affect his ability to understandspoken words and to speak, read,write, or add and subtract. Only abouthalf of stroke patients affected byaphasia regain language skills within ayear. Consult a speech therapist assoon as aphasia becomes evident.

When caring for a patient withaphasia, speak slowly and clearly, usehand gestures, and encourage thepatient to use hand gestures to con-vey thoughts if you can’t understandwhat he’s saying. Minimize loudnoises when trying to communicate,and focus on his remaining abilities.Patience and understanding areessential.

Emotional lability is commonafter stroke. Because feelings evokedby such a catastrophe include fear,anxiety, frustration, anger, sadness,and grief, a mental health profession-al should be involved in the patient’streatment.

Clinical depression affects up tohalf of stroke patients and can ariseat any time after a stroke. It cancomplicate rehabilitation, limit pro-gress, and negatively impact mentalfunctioning. Monitor your patientfor symptoms of depression, andreport them promptly. Antidepres-sants, typically selective serotoninreuptake inhibitors, are typicallyused to treat poststroke depression.

Ongoing careStroke is a catastrophic, suddenevent that can have a dire effect onyour patient’s circle of family andfriends. If he’s the family’s primarybreadwinner, a financial crisis isadded to the health crisis. A casemanager or social worker should be-gin working with the patient andthe family at admission to helpthem cope with crises, assess their

May/June l LPN2008 45

need for community services, serveas a liaison to the support services,and help put together a realistic andappropriate discharge plan.

Rehabilitation after a strokefocuses on improving the patient’sfunction and quality of life. Post-stroke care can be provided in inpa-tient rehabilitation units, outpatientunits, skilled nursing facilities, or athome. A multidisciplinary teamshould include rehabilitation pro-viders and nurses; physical, occupa-tional, and recreational therapists;speech-language pathologists; voca-tional therapists; mental health pro-fessionals; and social workers.

When a patient is dischargedhome, caregiver burnout is a risk.Frequently, a caregiver spouse orpartner has her own health problemsand is unprepared for the stresses ofcaregiving. Community supportgroups for both stroke patients andcaregivers exist in most large citiesand on the Internet.

Beyond clinical supportEven with prompt and effectivetreatment, many patients who’ve

had a stroke require some level ofrehabilitation, and some requirelong-term care. Your patient andhis family need extensive educationand emotional support. They maynot completely understand what’shappened or how it’ll affect theirdaily lives. Make full use of yourfacility’s counseling resources to besure they have the help they needto cope with life changes that ac-company stroke.

Caring for a patient with a strokecan be extremely challenging—but itcan be equally rewarding. With vigi-lance, frequent assessment, patience,and compassion, you can help yourpatient along the road to recovery. LPN

Selected referencesAmerican Heart Association. Stroke. http://www.americanheart.org/presenter.jhtml?identifier=

1498. Accessed February 11, 2008.

Assessment Made Incredibly Easy!, 4th edition.Philadelphia, Pa., Lippincott Williams &Williams, 2008.

Baldwin KM. Stroke: It’s a knock-out punch.Nursing Made Incredibly Easy! 4(2):10-23,March/April 2006.

Cohn JL, Powers J. Are you ready to manage pa-tients with acute ischemic stroke? LPN2005.1(4):14-26, July/August 2005.

Framingham Heart Study. http://www.nhlbi.nih.gov/about/framingham. Accessed February 15,2008.

Granitto M, Galitz D. Update on stroke: The lat-est guidelines. The Nurse Practitioner. 33(1):39-46,January 2008.

Internet Stroke Center. About stroke. http://www.strokecenter.org/patients/stats.htm.Accessed February 11, 2008.

Porth CM. Essentials of Pathophysiology: Concepts ofAltered Health States, 2nd edition. Philadelphia,Pa., Lippincott Williams & Wilkins, 2006.

Reddy LS. Heads up on cerebral bleeds. NursingMade Incredibly Easy! 2(3):8-16, May/June 2004.

Smeltzer SC, et al. Brunner & Suddarth’s Textbookof Medical-Surgical Nursing, 11th edition. Philadel-phia, Pa., Lippincott Williams & Wilkins, 2007.

On the Web

American Association of Neuroscience Nurses: http://www.aann.orgAmerican Stroke Association: http://www.strokeassociation.orgBrain Attack Coalition: http://www.stroke-site.orgNational Institute of Neurological Disorders and Stroke: http://www.ninds.nih.govNational Stroke Association: http://www.stroke.org

Earn CE credit online: Go to http://www.nursingcenter.com/ce/lpn and receive acertificate within minutes.

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Stroke: An all-out assault on the brain

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46

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Stroke: An all-out assault on the brainGENERAL PURPOSE: To provide the nurse with an overview of the pathology and intervention strategies of stroke. LEARNING OBJECTIVES: Af-ter reading the preceding article and taking this test, you should be able to: 1. Differentiate the types of stroke, their pathology and symptomatol-ogy. 2. Describe treatment and therapeutic nursing interventions for stroke and its complications.

1. Eighty-seven percent of all strokes arecaused bya. subarachnoid hemorrhage (SAH).b. cerebral hemorrhage.c. cerebral thrombosis and cerebral embolism.d. an aneurysm.

2. One common cause of a cerebral em-bolism isa. low blood pressure.b. atrial fibrillation.c. tumor.d. infection.

3. A defective artery in the brain that burstsand leaks blood into the brain results in aa. cerebral thrombosis.b. cerebral embolism.c. cerebral hemorrhage.d. SAH.

4. Which type of stroke triggers an intenseheadache often described as the worst everexperienced?a. cerebral thrombosisb. cerebral embolismc. cerebral hemorrhaged. SAH

5. All of the following may be symptoms ofcerebral aneurysm excepta. tinnitus (ringing in the ear). b. stiff neck.c. a sudden and excruciating headache.d. a change in the patient’s level of conscious-

ness.

6. Which statement about transient ischemicattack (TIA) is true?a. It occurs when the blood supply to part of

the brain is permanently interrupted.b. It can occur days, weeks, or months only af-

ter a major stroke.c. Its symptoms occur suddenly and are similar

to those of a hemorrhagic stroke, but theyare of shorter duration.

d. A few symptoms may last up to 6 months orlonger.

7. Patient history and diagnostic testsneeded in the treatment of stroke includeeach of the following excepta. anticoagulation status.b. determination of when the symptoms

started.c. liver function studies.d. electrocardiogram and cardiac enzymes.

8. Unilateral weakness due to a lesion in theopposite brain hemisphere is known asa. hemiparesis. c. ataxia.b. hemiplegia. d. paresthesia.

9. Using the National Institutes of HealthStroke Scale, most stroke patients with abaseline score of less than 10 will havea. a favorable outcome within 3 to 6 hours

poststroke.b. a favorable outcome at 1 year poststroke.c. motor and sensory deficits lasting 5 to 10

years poststroke.d. permanent motor deficits poststroke.

10. Tissue plasminogen activator (tPA)would most likely be prescribed for the pa-tient with a. hemorrhagic stroke.b. TIA.c. cerebral embolism.d. cerebral thrombosis of 5 hours duration.

11. Which complication occurs 4 to 14 daysafter SAH and accounts for 40% to 50% ofdeaths?a. clots forming in the heartb. cerebral vasospasmc. atrial fibrillationd. anosognosia

12. Which of the following interventions forthe stroke patient is incorrect?a. Administer oxygen.b. Perform pulse oximetry and monitor vital

signs.c. Maintain oxygen saturation (SpO2) at 94% or

higher.d. Maintain a flat supine position.

13. The most common cause of nonneuro-logic death in the first month after stroke is a. aspiration pneumonia.b. cardiac arrhythmias.c. pulmonary embolus.d. renal failure.

14. Which blood pressure reading in astroke patient not on tPA would requiremedical intervention?a. 180/90 c. 200/125b. 190/100 d. 210/115

15. Which statement about poststroke moni-toring and care is correct?a. Sleepiness or confusion may signal reperfu-

sion of a blocked cerebral artery. b. Passive range of motion exercises should

not be attempted without a physician order. c. Stroke patients have no cause for experienc-

ing pain during recovery. d. Blood glucose may become elevated due to

stress.

16. What’s the most accurate sign of deepvein thrombosis after stroke?a. hemiplegia c. ataxiab. swelling of one leg d. leg pain

17. For the patient with one-sided neglect,improving awareness of the affected sidecan best be accomplished bya. placing the call bell on the affected side. b. placing the TV control on the unaffected

side.c. approaching the patient from the affected

side.d. speaking slowly and using hand signals.

18. To support the patient’s emotionaldeficits, all of the following are recom-mended excepta. gently reprimand the patient for emotional

outbursts. b. encourage the patient to express his feelings

and frustrations.c. encourage the patient to participate in men-

tal stimulation activities. d. control stressful situations if possible.

2.5CONTACT HOURS

$ENROLLMENT FORM LPN2008, May/June, Stroke: An all-out assault on the brain

$