Overview
This lecture focuses on the nursing management of stroke, including types, assessment, delegation, interventions, drug therapies, complications, and communication deficits.
Stroke Types & Pathophysiology
- Strokes are classified as ischemic (thrombotic or embolic) or hemorrhagic.
- Thrombotic strokes result from atherosclerosis narrowing arteries, leading to local blood clot formation.
- Embolic strokes often result from cardiac issues (e.g., atrial fibrillation, valve disorders) forming clots that travel to the brain.
- Hemorrhagic strokes are most commonly caused by uncontrolled hypertension, aneurysms, or arteriovenous malformations (AVM).
Signs, Symptoms & Assessment
- Signs and symptoms of ischemic stroke are similar regardless of thrombotic or embolic origin.
- Key stroke complications include risk of aspiration, muscle weakness, and unilateral neglect.
- Use the Glasgow Coma Scale and, for stroke severity, the NIH Stroke Scale.
Delegation in Stroke Care
- Delegate only skills/tasks, never cognitive actions (assessment, intervention, education, evaluation).
- Assign easier, routine tasks (e.g., vital signs) to unlicensed personnel like CNAs.
- Feeding can be delegated only after speech-language pathologist deems it safe.
Ischemic Stroke: Management & Thrombolytics (Alteplase)
- Alteplase (tPA) is indicated for ischemic stroke within 3–4.5 hours of symptom onset, with exceptions.
- Contraindications include age >80, NIHSS ≥25, history of both diabetes and stroke, >1/3 middle cerebral artery involvement, INR >1.7, recent bleeding, or infective endocarditis.
- Intra-arterial tPA can be considered up to 6 hours in specific cases.
Post-Surgical/Endovascular Care
- Monitor for DVT, pressure ulcers, and additional strokes after carotid or cerebral interventions.
- Control risk factors: hypertension, diabetes, atherosclerosis, and smoking cessation.
- Anti-thrombotic therapy includes aspirin and clopidogrel.
- Post-craniotomy meds: Mannitol, dexamethasone, antibiotics, levetiracetam (anti-seizure), PPI or H2 blockers.
Complications & Risk Factors
- Modifiable risk factors: hypertension, diabetes, smoking, atherosclerosis.
- Non-modifiable risk factors: age, ethnicity.
- Monitor for aspiration, especially within 6–9 months after stroke.
Communication & Sensory-Motor Deficits
- Aphasia: loss of ability to understand or express speech (can include both written and spoken).
- Dysarthria: difficulty in speech due to muscle weakness, but written communication is intact.
- Agnosia: inability to recognize objects (can be visual, auditory, or tactile).
- Apraxia: inability to perform purposeful movements.
- Unilateral neglect: ignoring one side of the body, increasing injury risk.
- Homonymous hemianopsia: loss of vision in the same half of each eye.
Positioning After Brain Surgery
- Supra-tentorial surgery: head elevated 30°, patient can be turned side to side.
- Infra-tentorial surgery: patient kept flat to support drainage.
Key Terms & Definitions
- Ischemic Stroke — blockage of blood flow to brain tissue.
- Hemorrhagic Stroke — bleeding within or around the brain.
- Aphasia — brain-related impairment of language skills.
- Dysarthria — motor speech disorder affecting articulation.
- Agnosia — inability to recognize familiar objects.
- Apraxia — inability to carry out purposeful motor tasks.
- Unilateral Neglect — inattention to one side of the body.
- Homonymous Hemianopsia — loss of vision in the same side of both eyes.
Action Items / Next Steps
- Review table 62-2 for contraindications, management, and deficits related to stroke.
- Read textbook sections on core stroke measures and communication strategies with aphasia.
- Study the differences between ischemic and hemorrhagic strokes for exams.