Most hypertensive: headache, vomiting, seizures, changes in mental status, fever, changes EKG

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1 Wk 2. Management of Clients with Stroke 1. Stroke neurologic changes by interruption in blood supply to brain 1) Etiology Ischemia: thrombosis or embolism thrombotic strokes > embolic strokes (1) Thrombosis starts with damage to endothelial lining of vessel (2) Embolism embolus forms outside the brain travels thru cerebral circulation (3) Hemorrhage arteriosclerotic and hypertensive vessels bleeding into brain tissue 2) Risk Factors Modifiable risk factors elimination through lifestyle changes Hypertension: adequate BP 38% reduction in stroke incidence Cardiovascular disease, atrial fibrillation DM: macrovascular changes in DM Prior stroke, carotid stenosis, history TIAs Hyperlipidemia, cigarette smoking, heavy alcohol consumption, cocaine use, obesity 3) Pathophysiology Hypoxia, cerebral ischemia: brain cannot use anaerobic metabolism Short-term ischemia temporary neurologic deficits (TIA) No restore of blood flow irreversible damage or infarction 4) Clinical Manifestations (1) Early Warnings Transient ischemic attacks transient hemiparesis, loss of speech, hemisensory loss lasting less than 24 hrs (2) Generalized Findings Most hypertensive: headache, vomiting, seizures, changes in mental status, fever, changes EKG (3) Specific Deficits After Stroke Stroke manifestations related with causes and area of brain Hemiparesis and Hemiplegia

2 Aphasia Dysarthria Dysphagia Apraxia Visual Changes Homonymous Hemianopia Horner Syndrome Agnosia Unilateral Neglect Sensory Deficits Behavioral Changes Incontinence 5) Diagnostic Findings noncontrast CT scan to rule out hemorrhagic stroke no cellular changes on CT Standard MRI: limited value in acute ischemic stroke usually not apparent until 8 ~ 12 hrs after onset 6) Medical Management (1) Identify Stroke Early standardized assessment tools Acute Stroke Quick Screen National Institutes of Health Stroke Scale (NIHSS) (2) Maintain Cerebral Oxygenation Maintaining patent airway turned on affected side to promote drainage of saliva from the airway cloths should be loosened, head should be elevated, neck not be flexed intubation/mechanical ventilation (3) Restore Cerebral Blood Flow R/O intracerebral hemorrhage recanalization of occluded vessel, reperfusion of ischemic brain tissue Thrombolytic agents: exogenous plasminogen activators (4) Prevent Complications Bleeding

3 Cerebral Edema IICP: change in LOC, reflex hypertension, worsening neurologic status Blood Glucose Control Severe hyperglycemia reduced perfusion during thrombolysis Stroke Recurrence Recurrence in first 4 wks: 0.6% ~ 2.2% Aspiration high risk for aspiration pneumonia Other Potential Complications Depend on location of lesion (5) Rehabilitation After Stroke 7) Interdisciplinary management recommended plan of care using interdisciplinary services (1) Physical Therapy build strength, preserve ROM and tone (2) Occupational Therapy Relearn ADL, use assistive devices for independence (3) Speech Therapy (4) Case Management 8) Nursing Management (1) Ineffective Tissue Perfusion Serial assessments: as every 15 mins for unstable pts to every 2 to 4 hrs for stable pts (2) Hemorrhage No arterial punctures or insertions of nasogastric tubes (3) Risk for Aspiration Assess manifestations of aspiration fever, dyspnea, crackles, rhonchi, confusion, and decreased PaO2 (4) Impaired Physical Mobility Assess degree of muscle strength to use as a baseline value

4 Encourage Bed Exercises learn to move weak leg by sliding unaffected leg Help to Sit Up out of bed as soon as medically stable safest to pivot on unaffected leg Teach the Client How to Use a Wheelchair Hemiplegia pts can propel wheelchair with unaffected arm and leg Promote Walking tilt table: standing position when balance is problem Teach Bracing Teach how to apply and remove the brace, to observe skin for breakdown, to give proper skin care, (5) Risk for Hyperthermia Bleeding or edema of hypothalamus ischemia of thermoregulatory center (6) Risk for Impaired Skin Integrity Assess skin every 2 hrs (7) Risk for Contracture Early: flaccidity present b/c loss of cerebral connections for sensory and motor nerves Reduce joint contracture - Allow to sit upright for short periods only - When the client is on one side, do not flex the hip acutely - Do not place a pillow under the affected knee; this encourages flexion deformity and impedes circulation - place a folded towel under knee for short periods; maintain this position for 15 to 30 minutes several times a day (8) Self-Care Deficit Encourage to perform as many self-care activities as possible to use the affected arm (9) Risk for Injury Keep side rails up : protect from rolling out of bed (9) Imbalanced Nutrition: Less Than Body Requirements Assess total intake Fear choking and frustrated by eating difficulties may avoid eating, obtain adequate nutrition

5 Feeding techniques - Promote Head Control placing a hand on the forehead, caregiver approaches from midline Not to throw head back to propel food: head in midline and flexed slightly forward (10) Impaired Verbal Communication expressive deficit > receptive deficit after initial recovery may understand more than they can respond to clearly (11) Disturbed Thought Processes Continually reorient a confused pt (12) Disturbed Sensory Perception Approach from the side that is not visually impaired (13) Unilateral Neglect Initially focusing on the client s unaffected side Greet pt as you enter room, especially if the entrance is toward neglected side 9) Surgical Management rapid evacuation of the hematoma in hemorrhagic stroke No Surgery with bleeding in deep cerebral structures (basal ganglia or thalamus) aimed at reducing IICP 2. Traumatic brain injury US, head injury approximately every 15 seconds 1) Etiology and Risk Factors Motor-vehicle accident <Mechanisms> Coup-Contrecoup Injuries Penetrating Trauma Scalp Injuries: lacerations, hematomas, contusions or abrasions to the skin Skull Fractures caused by a force sufficient to fracture cause brain injury r <Brain Injuries>

6 open, closed, contusion, concussion Concussions Contusions more extensive damage than concussions Diffuse Axonal Injury Most severe form of head injury no focal lesion to remove, injury at microscopic level classified as mild, moderate, or severe <Focal Injuries> Epidural Hematoma called extradural hematoma between skull and dura mater Subdural Hematoma Collection of blood in subdural space (between dura mater and arachnoid mater) less often, caused by bleeding directly into brain tissue IICP similar symptoms to epidural or subdural hematomas, 2) Pathophysiology blow to the surface of brain rapid brain tissue displacement, disruption of blood vessels bleeding, tissue injury, edema 3) Clinical Manifestations (1) Skull Fractures CSF or other fluid draining from ear or nose Assess subtle changes in V/S Headache (2) Concussions loss of consciousness for 5 minutes or less (3) Contusions Various symptoms Cerebral Contusions agitated, confused, may remains alert: temporal lobe contusion.

7 Brain Stem Contusions immediately unresponsive or partially comatose 4) Medica management Major goals: treatment of hypoxia and acid-base disorders Control IICP Stabilization of other conditions - ventilatory support - management of fluid balance and elimination - management of nutrition and gastrointestinal function 5) Nursing Management risk for Ineffective Airway Clearance, Ineffective Tissue Perfusion, seizures, paralysis, infection, diabetes insipidus, and Post-trauma Syndrome Risk for contractures Impaired skin integrity Impaired oral mucous membranes Imbalanced nutrition Risk for imbalanced fluid volume Risk for falls Risk for increased ICP Disturbed thought processes Interrupted family processes 6) Surgical Management epidural clot may be surgically evacuated through burr holes or craniotomy Debridement of a penetrating wound or depressed skull fracture cranial defect surgically corrected by cranioplasty Before surgery ICP is reduced as much as possible Baseline neurologic data documented 7) Rehabilitation inpatient or outpatient setting physical, occupational, speech, cognitive therapy returning maximal function Nurses play a major role in the rehabilitation of the head-injured Rehab with feeding tubes or tracheostomy tubes May be transferred to extended-care facility