In this chapter, we're going to look at the difference between an ischemic stroke and a hemorrhagic stroke and discuss what a transient ischemic attack is. A cerebrovascular disorder is a group of disorders that refer to the functional abnormality of the central nervous system when blood supply to the brain is disrupted. Strokes are the most common disorder in this category.
A stroke is a condition that develops when there's an interruption of normal blood supply in the brain. It can be caused from a blockage or a bleed. A stroke is often referred to as a brain attack. There are three types of strokes.
There's an ischemic, a hemorrhagic, and a transient ischemic attack. The consequence of any of these potentially is brain cell death. An ischemic stroke is a blockage of the cerebral artery.
It's caused by a thrombus or an embolus. There are two types of ischemic strokes. There's an embolic stroke, which is where there's a dislodge clot that leaves part of the body and travels to the brain, or there can be a thrombotic stroke, where clot forms within the artery and cuts off blood supply to that part of the brain.
On this slide, you can see over on the left a picture showing you where there's a clot and how it has cut off blood supply to that dark area of the brain. It's caused ischemic tissue to form. A hemorrhagic stroke is when a vessel ruptures and causes bleeding into the brain tissue surrounding that area. It can be caused by an aneurysm, by high blood pressure, or by aging blood vessels. Again, here's the same picture, but on the right-hand side, you can see how that vessel is ruptured and blood is leaking into those surrounding tissues.
And so your patient is going to have some neurologic impairment with either an ischemic or a hemorrhagic stroke. This slide here just... does a great job of kind of comparing the difference between an ischemic and a hemorrhagic stroke kind of side-by-side for you.
You can also review the table in your book on page 2032. It does a great job of comparing ischemic versus hemorrhagic strokes as well. A transient ischemic attack or a TIA is also referred to as a mini stroke. Symptoms can last anywhere from just a few minutes to hours and then they can go away. This is a warning sign to the patient.
This is screaming that the patient needs to seek out treatment to prevent a more serious stroke from happening. So when a patient comes in and is showing symptoms of a transient ischemic attack, It's very important to do a very thorough neuro assessment. You might see different diagnostic tests ordered such as an ECG, an EKG, or a CT scan. The patient's going to need to follow up with their primary care provider. They're going to need education on risk factors and education about medications.
A lot of these patients that suffer from a transient ischemic attack will be put on an anticoagulant medication if an ischemic stroke is kind of lurking out there. Blood supply to the brain is very important. When arteries become blocked or burst, blood supply is decreased to the brain cells. Brain cells are sensitive. Within five minutes, cells start to show irreversible damage.
This picture just reminds us about the functions of each lobe of the brain. This is important to understand so that you can understand how your patient will look or act if they suffer from damage to a certain area of their brain. Strokes tend to affect one side of the body, so it's important for you to be familiar with the functions of the right side versus the left side.
The right side of the brain is the creative side. The left side of the brain is the logical side. We're going to take a little closer look at the right side versus the left side.
Page 2035 in your book has a table that compares the left versus the right hemisphere when a patient has a stroke. So with the right side of the brain, if a patient suffers a stroke to this side of the brain, you're going to see different symptoms than you would when they have a stroke on the left side of the brain. The right side of the brain is responsible for attention span, emotions, planning, judgment, memory, music and art awareness, and that right side controls the left side of the body. So if the patient suffers a stroke on the right side of the brain, you're going to see left-sided weakness, impaired creativity, trouble with face and name recognition, trouble with conversation. You might see left side neglect.
You might have poor decision-making skills in your patient. And so you can see a list of some other things there that would be affected as well if that right side of the brain is affected with a stroke. So on the left side of the brain, our logical side is impacted. This side of the brain typically is responsible for speaking, writing, reading, math, analyzing information, planning. And so it also is going to control the right side of the body.
So when a patient has a stroke that impacts the left side of the brain, you're going to see right-sided weakness, aphasia, trouble understanding written text, impaired math skills, memory issues. as well as right side neglect potentially. So to help you remember some of the risk factors for strokes, if you think about the acronym strokes happen, that will help you identify some of the risk factors. Now, once you've identified risk factors, then you've got to figure out which ones are modifiable, meaning they can be changed and which ones are non modifiable. Those are the ones the patient has no control over.
So if you look here at this slide, you can see that some of the risk factors are going to include medications, lifestyle, excessive weight, age, family history, other disease processes. So again, sometimes patients have control over. affecting these risks and other times it's completely beyond their control. They were just dealt a bad deck of cards with their genetics. Strokes happen suddenly.
The nurse and family need to be fast to help save brain cells. So if you remember the acronym BE FAST, that will help you recognize the signs and symptoms of a stroke. It's important to note the exact time of onset of symptoms because that is super important for some of your treatments that we're going to talk about. So B is for balance, E is for eyes, F is for face, A is for arms, S is for speech, and T is for time.
Patients get dizzy. They lose their balance. They have trouble seeing out of one or both eyes. They will have facial weakness. They'll have an uneven smile.
They will have weakness in their extremities on one or both sides. Their speech will become impaired and slurred. They'll have difficulty repeating simple phrases.
And then the time piece of it, time is critical, so they need to call 911 immediately if they are seeing these things. Over on the right-hand side of this slide, you see some different terms. You need to be familiar with what these terms are.
Aphasia is the inability to speak. A patient can suffer from receptive aphasia, which is when they are unable to comprehend, or expressive aphasia, when they are unable to respond to words. They can have dysarthria, where they're unable to hear clearly.
Sometimes this will cause slurred speech. They may suffer from apraxia where they can't perform voluntary movements like winking, moving their arm, even though their muscle function is normal. The brain just isn't communicating to be able to do those tasks.
They may have agraphia, which is the loss of ability to write. Alexia is the loss of ability to read. Agnosia, they don't understand sensations.
They're unable to recognize familiar objects or people. Dysphagia. They will have issues swallowing because of weak muscles. And then they may have some visual impairments, which is what hemipnea and hemiparesis is.
Hemipnea is limited vision in half of their visual field. And hemiparesis is weakness or paralysis on one side of their body. Any patient with neurological deficits needs a complete physical and neurological exam.
You want to try to figure out if they are breathing effectively, if they have a cough or a gag reflex, what their blood pressure is like, what their heart rhythm is like, if they have any neurologic deficits. And we use the stroke scale to figure this out and we'll talk more about the stroke scale in just a few minutes. figure out what their symptoms are, when did they start, what was the patient like before the onset of symptoms, get an IV access, check for labs, you want to look for things like their glucose level, a CBC, CMP, their coagulation studies, so their PT, their INR, their platelet count, maybe even a hemoglobin, and then look at their lipid panel.
Lipid panel is going to be important, especially if it's a patient suffering from an ischemic stroke because that's going to tell you a lot about potential atherosclerosis. The NIH stroke scale is scored from 0 to 42. You can see the scale here on the slide. You can also find it in your book on page 2038. The higher the score, the worse the deficit. The stroke scale also will utilize some pictures, get the patient to look at pictures and identify what's going on. So, you know, if you're showing them a picture like number nine, then and you ask them what's happening in the picture, you're able to accurately assess language because they're going to have to talk to you.
If you are giving them a list of words like you see there on the right hand side of the slide and get them to repeat those words or repeat a simple sentence or phrase, that will evaluate for dysarthria, where they're unable to hear clearly or the slurred speech that results because of impaired hearing potentially. When somebody has a stroke, initially a non-contrasted CT scan is typically done. This can determine the difference between a TIA, an ischemic, or a hemorrhagic stroke.
The patient may also get an EKG, an ultrasound of their carotid arteries. They may have an MRI done. They may have a lumbar puncture done, especially if the CT is negative. and intracranial pressure is not elevated, this can help determine a lot of what might be causing the neurosymptoms that they are experiencing.
One medication that we use in patients that have suffered from an ischemic stroke is TPA, tissue plasminogen activator, which is a clot-busting medication. There are very stringent criteria set up in order for a patient to get this particular medication. You need to be aware of that criteria.
You can find it described in your book on page 2037, but I've hit the highlights here on the slide for you. Again, this is used for ischemic stroke patients only. You would not want to give a clot buster to somebody that's had a hemorrhagic stroke.
It's best if it's given within three hours of the onset of symptoms, so time is super, super important. You want to make sure you check labs, check a glucose level, check those coagulation studies. A patient needs to have a PT less than or equal to 15 seconds and an INR of less than or equal to 1.7 and a platelet count greater than 100,000 to get this medication.
They need a blood pressure less than 185 over 110. They can't have any other anticoagulants on board. We need to limit invasive procedures. They shouldn't have a recent history of another stroke, head trauma, or some type of intracranial surgery.
Once the patient gets this medication, they're going to go straight to the ICU. The nurse's role is to monitor bleeding, to do neurologic checks, to administer. other medications if necessary, to check vital signs, to check those lab values, to try to prevent injury in the patient.
So really think about patient safety and then making sure that you are limiting those invasive procedures, even if it's something as simple as a venipuncture or an IM injection. Other things that you may see used to manage a stroke patient include aspirin, heparin. lorazepam, phenytoin, gabapentin, topramate, Lasix, and or mannitol.
With any of these medications, you need to review what type of medication it is, what kind of pertinent nursing implications would be necessary, and then I would encourage you to kind of think about potential adverse effects that could be life-threatening in your patient because that would be important to be able to recognize. From a medical management standpoint, there's a couple of procedures that are frequently done when you have a patient that has suffered from a stroke. There are some endovascular techniques that can be done. This uses catheters to deliver clot disrupting medications or to go in and try to remove a clot that is occluding an artery. This works in minutes and If a medication is instilled through that artery, it can take several hours to see the benefits of that.
Guidelines recommend using this procedure within 6 to 24 hours of a patient having a stroke. A carotid endarterectomy is where they go in and remove the plaque from that carotid artery. Sometimes this is a preventative procedure.
preventative strategy not necessarily done after a patient has suffered from a stroke. So they go in and kind of roto-rooter and clean out that internal space in the artery. On page 2040 in your book, there's a good table that discusses complications and nursing interventions related to this procedure. Common complications include hematomas, hypertension, post-procedure hypotension, and potentially a hemorrhage. So you really want to watch these patients closely after they have undergone a carotid endarterectomy.
Nursing assessment is going to be very, very important, but how you assess your patient is going to vary as their condition progresses. The acute phase of a hemorrhage is going to be very, very important. nursing assessment is typically one to three days after a patient has suffered from a stroke.
And then after that, continued assessment is important, but typically your patient has stabilized, hopefully a little bit after those first couple of days. But again, you really want to think about airway, vital signs, neuro checks, turning your patient every two hours. Communicating effectively.
If you have a patient that has receptive aphasia, you want to use short gestures or short phrases, simple gestures, remove distraction, and be patient with this individual. If they have expressive aphasia, again, patience is super important. Using simple gestures, giving them options, utilizing pictures to help with communication, and giving the patient a dry erase board so that they can potentially write or draw a picture or draw arrows, you know, and insinuate what they are wanting or needing. Diet modifications. Sometimes we have to thicken liquids.
We have to watch for pocketing of food and we have to ensure that the patient is swallowing safely. You want to make sure your patient is on bed rest to try to reduce the risk of injury and if they are going to get up and move around. you want to be there to assist with mobility to limit the possibility of a fall.
You want to promote continence, so sometimes a potty schedule is necessary. Other patients might need a catheter for some time after a stroke. You want to monitor lab values. You want to educate your patient appropriately as well as their family, and you want to evaluate the need for resources.
As far as planning and goal setting for these patients, rehab should begin on day one and continue until the patient has fully recovered or recovered to their highest extent possible. Rehab requires a coordinated effort among the whole healthcare team. Everybody has to communicate and be on the same page.
Goals of rehab should be to improve mobility, Regain self-care abilities. Make sure that we are working on sensory and perceptual abilities. Preventing aspiration. Promoting continence. Improving communication.
Restoring the family function. And then, of course, maintaining skin integrity. A lot of these patients may not be incontinent, but they're not going to be able to move themselves or turn themselves frequently. And so you may need to look at using air mattresses or extra padding and as well as turning your patient at least every two hours.
A big thing to think about when you are trying to set goals for a stroke patient is to be realistic. It's going to take baby steps to get them back where they want to be. And so the patient needs to understand that and not be hard on themselves just because they're not able to jump right out of that bed and take off running across the room. From a nursing management standpoint, with home and community care, again, education is going to be very, very important.
You want to coordinate any sort of resources with. the hospital or other community agencies that the patient may need. You want to offer support groups and then you may need to offer the family respite care, which is where somebody comes in to provide some relief of time to sit with that individual that can't go out and be functional and be part of the family to help do those simple everyday activities.
to give the family a break to go run some errands to go spend some time with you know with a grandchild or whatever the situation is for that family dynamic to go to work potentially evaluation looking for those expected outcomes if the patient has improved their mobility they're able to use the unaffected side to compensate for loss of function sometimes until that affected side regains function. They achieve self-care. They demonstrate safe swallowing.
They have a return of bowel and bladder function back to their pre-stroke level. They improve their ability to communicate. They maintain skin integrity.
They don't have any ulcers that form, any blisters that form. And then the family demonstrates the ability for adequate coping. Again, family dynamics are huge when you have a patient with a severe neurologic injury.
80% of strokes can be prevented. We can manage or treat hypertension. We can educate our patients to stop smoking.
We can educate them to avoid excessive alcohol intake. We can control diabetes. We can encourage a healthy lifestyle with low fat, low cholesterol foods, as well as increased exercise. And then we can give our patients anticoagulants.
as a preventative or maintenance drug if they have certain risk factors. Again, I encourage you to review this information further in your textbook. Make sure that you're paying attention to the charts and tables. There are some great resources within this chapter.