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ADVANCE STROKE NURSING SKILLS

STROKE
Stroke is the condition in which part of the brain abruptly loses its source of nutrients, oxygen and glucose, that are normally delivered to it by way of the va.scular system

The three elements that are common to a stroke are as follows: (1) abrupt onset of focal neurological symptoms (2) symptoms that can be attributed to losing blood flow in a single arterys territory, and (3) symptoms that last for at least twenty-four hours. There is a condition would happened before a stroke rise.

Different kinds of strokes

Ischemic stroke is one in which a solid blood clot blocks the flow of blood in an artery to the brain. This clot obstructs the flow of blood so that any brain tissue that normally is fed by this artery is deprived of the nutrients (oxygen and glucose) that are normally supplied. A hemorrhagic stroke is one in which a blood vessel bursts and the blood creates pressure on the brain.

SPOT A STROKE F.A.S.T

Stroke Evaluation Time Benchmarks

Neuro Protection
AVOID
Hypotension Hypo / Hyper Glycemia Hyperthermia

Neurotropic Therapy (Citicholine, Cerebrolysin, Neuroaid)

Initial Treatment
Hypoglycemia and hyperglycemia need to be identified and treated early in the evaluation. Hyperthermia Supplemental oxygen Optimal blood pressure targets remain to be determined.

Thrombolytic Therapy
Current treatments for acute ischemic stroke include IV thrombolytic therapy with tissuetype plasminogen activator (t-PA) and endovascular therapies, including intraarterial thrombolytic therapy and the use of clot retrieval devices. Surgical management with hemispheric decompression in patients with middle cerebral artery territory infarction and associated life-threatening parenchymal edema has also been supported.

Stabilization of Airway and Breathing

Patients presenting with Glasgow Coma Scale scores of 8 or less, rapidly decreasing Glasgow Coma Scale scores, or inadequate airway protection or ventilation require emergent airway control. In unusual cases of potential imminent brain herniation, where the goal of mechanical ventilation is hyperventilation to decrease ICP by decreasing cerebral blood flow, the recommended endpoint is an arterial pCO2 of 3236 mm Hg. IV mannitol can be considered as well

Stabilization of Airway and Breathing

Supplemental oxygen use should be guided by pulse oximetry. Patients should receive supplemental oxygen if their pulse oximetry reading or arterial blood gas measurement reveals that they are hypoxic (SaO 2 < 94%). The most common causes of hypoxia in the patient with acute stroke are partial airway obstruction, hypoventilation, atelectasis, or aspiration of stomach or oropharyngeal contents.

Intravenous Access and Cardiac Monitoring

Patients with acute stroke require IV access and cardiac monitoring in the emergency department (ED). Patients with acute stroke are at risk for cardiac arrhythmias. In addition, atrial fibrillation may be associated with acute stroke as either the cause (embolic disease) or as a complication.

Blood Glucose Control

Blood sugar control should be tightly maintained with insulin therapy, with the goal of establishing normoglycemia (90-140 mg/dL). Additionally, close monitoring of blood sugar level should continue throughout hospitalization to avoid hypoglycemia. Hyperglycemia can increase severity of stroke injury Hypoglycemia can mimic stroke (decrease sensorium)

Patient Positioning
Studies have shown that cerebral perfusion pressure is maximized when patients are maintained in a supine position. However, lying flat may serve to increase ICP and thus is not recommended in cases of subarachnoid or other intracranial hemorrhage. Because prolonged immobilization may lead to its own complications, including deep venous thrombosis, pressure ulcer aspiration, and pneumonia, patients should not be kept flat for longer than 24 hours.

Blood Pressure Control

In poor flow stateswhich occur with thrombotic and embolic ischemic stroke, as well as with increased ICP due to cerebral edemathe cerebral vasculature loses vasoregulatory capability and thus relies directly on mean arterial pressure (MAP) and cardiac output for maintenance of cerebral blood flow. Therefore, aggressive efforts to lower blood pressure may decrease perfusion pressure and may prolong or worsen ischemia. Rapid reduction of blood pressure, no matter the degree of hypertension, may in fact be harmful. Both elevated and low blood pressures are associated with poor outcomes in patients with acute stroke.

Blood Pressure Control

Most of the time BP is high *do not abruptly decrease BP Maintain MAP of 130

Maintaining SBP 180-220 Use titratable agents like Nicardepine

Candidates for fibrinolysis

Candidates for fibrinolysis

Noncandidates for fibrinolysis

Control of hypotension
Given the need to maintain adequate cerebral blood flow, severe hypotension should be managed in standard fashion with aggressive fluid resuscitation, a search for the etiology of hypotension, and, if necessary, vasopressor support. Evidence suggests that baseline systolic blood pressure below 100 mg Hg and diastolic blood pressure below 70 mm Hg correlate with a worse outcome.

Quick Neurologic Exam

Consciousness Neurologic Deficit NIHSS GCS Scoring Pupillary Size

Additional Care
Speech therapy Rehab therapy Nutritional Support

Nursing Diagnoses Nursing Care Plans For Stroke:

Impaired verbal communcation Impaired physical Mobility Anxiety [specify level] Deficient knowledge regarding diagnosis, prognosis, and treatment options Risk for disturbed Body Image Risk for ineffective Sexual Pattern Self-Care Deficit [specify] Disturbed Sensory Perception (specify) Disturbed Thought Processes Risk for Injury/Trauma

Lets work together to end Stroke! ACT

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