Stroke: NURSING

MANAGEMENT
Zoya Minasyan, RN, MSN-Edu
Structures and Functions of Nervous System

Left hemisphere of cerebrum, lateral surface, showing major lobes and areas of the brain.
Structures and Functions of Nervous System

Structural features of neurons: dendrites, cell body, and axons.

Structures and Functions of Nervous System

Major divisions of the central nervous system (CNS).

Structures and Functions of Nervous System

The cranial nerves are numbered according to the order in which they leave the brain.
 Structures and Functions of Nervous System

Arteries of the head and neck. Brachiocephalic artery, right common carotid artery, right subclavian
artery, and their branches. The major arteries to the head are the common carotid and vertebral arteries.
 Structures and Functions of Nervous System

Arteries at the base of the brain. The arteries that compose the circle of Willis are the two anterior
cerebral arteries joined to each other by the anterior communicating cerebral artery and to the posterior
cerebral arteries by the posterior communicating arteries.
Structures and Functions of Nervous System

The vertebral column (three views).

Stroke
 Stroke occurs when ischemia or hemorrhage into the
brain results in death of brain cells.
 Also known as a brain attack
 Functions are lost or impaired
 Such as movement, sensation, or emotions that were
controlled by the affected area of the brain
 Severity of the loss of function varies according to
the location and extent of the brain involved.
Risk Factors
 Most effective way to decrease the burden of
stroke is prevention.
 Risk factors can be divided into non modifiable and
modifiable risks.
Risk Factors

 Modifiable  Non modifiable

 Hypertension  Age
 Metabolic syndrome  Gender
 Heart disease  Race
 Heavy alcohol consumption  Heredity/family history
 Poor diet
 Drug abuse
 Sleep apnea
 Obesity
 Physical inactivity
 Smoking
Types of Stroke
 Strokes are classified on the basis of underlying
pathophysiologic findings.
 Ischemic
 Thrombotic
 Embolic

 Hemorrhagic
Major Types of Stroke
Ischemic Stroke
 Ischemic strokes result from
 Inadequate blood flow to the brain from partial or
complete occlusion of an artery
 80% of all strokes are ischemic strokes.
 Ischemic strokes can be
 Thrombotic

 Embolic
Ischemic Stroke
 Thrombotic stroke
 Thrombosis occurs in relation to injury to a blood vessel
wall and formation of a blood clot.
 Result of thrombosis or narrowing of the blood vessel

 Most common cause of stroke

• Lacunar strokes
• a stroke from occlusion of a small penetrating artery with
development of a cavity in the place of the infarcted brain
tissue.
• thrombotic strokes are associated with hypertension or
diabetes mellitus, both of which accelerate
atherosclerosis
Pathogenesis of Atherosclerosis

A, Damaged endothelium.
B, Diagram of fatty streak and lipid core formation.
C, Diagram of fibrous plaque. Raised plaques are visible: some are yellow, others are white.
D, Diagram of complicated lesion: thrombus is red, collagen is blue. Plaque is complicated by
red thrombus deposition.
Pathogenesis of Atherosclerosis
 Developmental stages:
 Fatty streaks
 Earliest lesions
 Characterized by lipid-filled smooth muscle cells
 Potentially reversible
 Fibrous plaque
 Beginning of progressive changes in the arterial wall
 Lipoproteins transport cholesterol and other lipids into the arterial
intima.
 Fatty streak is covered by collagen, forming a fibrous plaque that
appears grayish or whitish.
 Result = Narrowing of vessel lumen
 Complicated lesion
 Continued inflammation can result in plaque instability, ulceration, and
rupture.
 Platelets accumulate and thrombus forms.
 Increased narrowing or total occlusion of lumen
Ischemic Stroke
 Embolic stroke
 Occurs when an embolus lodges in and occludes a
cerebral artery
 Results in infarction and edema of the area supplied by
the involved vessel
 Second most common cause of stroke
 Patient with an embolic stroke commonly has a rapid
occurrence of severe clinical symptoms.
 Onset of embolic stroke is usually sudden and may or may
not be related to activity.
 Patient usually remains conscious, although he may have
a headache.
Ischemic Stroke
 Transient ischemic attack
 Transient episode of neurologic dysfunction caused by focal
brain, spinal cord, or retinal ischemia, without acute
infarction of the brain
 Symptoms last <1 hour

• Most TIAs resolve

• encourage patients to go to the emergency room at symptom onset
since once a TIA starts, one does not know if it will persist and
become a true stroke, or if it will resolve.
• In general, one third of individuals who experience a TIA will not
experience another event, one third will have additional TIAs, and
one third will progress to stroke.
Hemorrhagic Stroke
• Result from bleeding into the brain tissue itself or into
the subarachnoid space or ventricles
• Often a sudden onset of symptoms, with progression
over minutes to hours because of ongoing bleeding
 Intracerebral hemorrhage
 Bleeding within the brain caused by rupture of a
vessel
 Hypertension is the most important cause.
 Hemorrhage commonly occurs during periods of
activity.
Hemorrhagic Stroke

Massive hypertensive hemorrhage rupturing into a lateral ventricle of the brain.

Hemorrhagic Stroke
 Intracerebral hemorrhage
 Manifestations
 Neurologic deficits
 Headache
 Nausea and/or vomiting
 Decreased levels of consciousness
 Hypertension
Hemorrhagic Stroke
 Subarachnoid hemorrhage
 Intracranial bleeding into cerebrospinal fluid–filled space between the
arachnoid and pia mater
 Commonly caused by rupture of a cerebral aneurysm
 Majority of aneurysms are in the circle of Willis.
 “Worst headache of one’s life”
 Other causes of subarachnoid hemorrhage include trauma and illicit drug
(cocaine) abuse.
 people who have a hemorrhagic stroke due to a ruptured aneurysm can die
during the first episode or die from subsequent bleeding.
 increases with age,
 higher in women than men.
 Loss of consciousness may or may not occur.
 focal neurologic deficits (including cranial nerve deficits), nausea, vomiting,
seizures, and stiff neck.

Most frequent surgical procedure to prevent re bleeding is clipping of the

aneurysm.
Clinical Manifestations
 Affects many body functions
 Motor activity
 Elimination
 Intellectual function
 Spatial-perceptual
 Personality
 Affect
 Sensation
 Communications
Clinical Manifestations
Motor Function
 Most obvious effect of stroke
 Include impairment of
 Mobility
 Respiratory function
 Swallowing and speech
 Gag reflex
 Self-care abilities
 Loss of skilled voluntary movement
 Alterations in muscle tone
 Alterations in reflexes
Clinical Manifestations
Motor Function
 An initial period of flaccidity
 (also known as hypotonicity is a condition characterized by a decrease
or loss of normal muscle tone due to the deterioration of the lower motor
nerve cells).
 May last from days to several weeks
 Related to nerve damage

 Spasticity of the muscles follows the flaccid stage.

 (an abnormal increase in muscle tension and a reduced ability of a
muscle to stretch)
 Related to interruptions in upper motor neuron influence
Clinical Manifestations
Communication

 Patient may experience aphasia when a stroke

damages the dominant hemisphere of the brain.
 Aphasia is the total loss of comprehension and
use of language.
 Dysphasia refers to difficulty related to the
comprehension or use of language and is due to
partial disruption or loss.
Types of Aphasia
 Broca’s
 Damage to frontal lobe, speak in short phrases that makes sense
but with great effort. “Walk doge””Book –book table”. They are
aware of it and become frustrated.
 Wernicke’s
 Left temporal lobe damage. Long sentences with no meaning,
difficult to understand the meaning of the speech. They are not
aware of it.
 Global
 Severe communication difficulties, limited in ability to speak.
 A massive stroke may result in global aphasia, in which all
communication and receptive function are lost.
Clinical Manifestations
Communication
 Many patients experience dysarthria.
 Disturbance in the muscular control of speech
 Dysarthria does not affect the meaning of communication or
the comprehension of language, but it does affect the
mechanics of speech.
 Some patients experience a combination of aphasia and
dysarthria.

 Impairments may involve

 Pronunciation
 Articulation
 Phonation
Clinical Manifestations
Affect
• Patients who suffer a stroke may have difficulty controlling their
emotions.
• Depression and feelings associated with changes in body image and
loss of function can make this worse.
• Patients may also be frustrated by mobility and communication
problems.

 Emotional responses may be exaggerated or unpredictable.

• An example of unpredictable affect is as follows:
•A well-respected lawyer has returned home from the hospital following a
stroke. During meals with his family, he becomes frustrated and begins to
cry because of difficulty getting food into his mouth and chewing,
something that he was able to do easily before his stroke.
Clinical Manifestations
Intellectual Function

 Both memory and judgment may be impaired as

a result of stroke.
 A left-brain stroke is more likely to result in
memory problems related to language.
Clinical Manifestations
Spatial–Perceptual Alterations

 Stroke on the right side of the brain is more likely to

cause problems in spatial-perceptual orientation.
 However, this may occur with
left-brain stroke.

 An example of behavior with right-brain stroke is the

patient who tries to rise quickly from a wheelchair without
locking the wheels or raising the footrests.
 The patient with a left-brain stroke would move slowly and
cautiously from the wheelchair.
Clinical Manifestations
Spatial-Perceptual Alterations
 Spatial-perceptual problems may be
Incorrect perception of self and illness
perception of self in space
Inability to recognize an object by sight, touch, or
hearing
Inability to carry out learned sequential movements on
command

A stroke on the right side of the brain is more likely to

cause problems in spatial-perceptual orientation,
although this can also occur with left-brain stroke as
well.
Clinical Manifestations
Elimination
 Most problems with urinary and bowel elimination
occur initially and are temporary.
 When a stroke affects one hemisphere of the
brain, the prognosis for normal bladder function
is intact
 partial sensation of bladder and voluntary urination is
present
 Initially, the patient may experience frequency, urgency,
and incontinence.
• Constipation is associated with immobility, weak
abdominal muscles, dehydration, and diminished
response to the defecation reflex.
Diagnostic Studies
 When symptoms of a stroke occur, diagnostic studies
are done to
 Confirm that it is a stroke
 Identify the likely cause of the stroke

 CT is the primary diagnostic test used after a stroke.

 A CT scan can rapidly distinguish between ischemic and
hemorrhagic stroke and help determine the size and
location of the stroke. Serial CT scans may be used to
assess the effectiveness of treatment and to evaluate
recovery.
Diagnostic Studies
 CTA
 CT angiography (CTA) provides visualization of cerebral blood vessels
 MRI, MRA
 MRI is used to determine the extent of brain injury
 Angiography may detect vascular lesions and blocksges
 Cerebral angiography
 Angiography can identify cervical and cerebrovascular occlusion, atherosclerotic
plaques, and malformation of vessels
 Digital subtraction angiography
 Intraarterial digital subtraction angiography (DSA) reduces the dose of contrast
material, uses smaller catheters, and shortens the length of the procedure compared
with conventional angiography
 Transcranial Doppler ultrasonography
 Transcranial Doppler (TCD) ultrasonography is a noninvasive study that measures the
velocity of blood flow in the major cerebral arteries.
 Lumbar puncture
 LICOX system
 The LICOX system may be used as a diagnostic tool for evaluating the progression of
stroke, brain O2 and temperature, page 1432
 LICOX catheter

The LICOX brain tissue oxygen system involves a catheter inserted through an intracranial bolt , placed in
white matter of the brain. (A). The system measures oxygen in the brain (PbtO2), brain tissue temperature,
and intracranial pressure (ICP) (B).
Diagnostic Studies of Nervous System

Normal images of the brain. A, CT scan. B, MRI.

38
Diagnostic Studies of Nervous System

Cerebral angiogram illustrating an arteriovenous malformation (arrow).

Collaborative Care
Prevention
 Goals of stroke prevention include
 Health promotion
 Education and management of modifiable risk factors

 Patients with known risk factors require close

management.
 Diabetes mellitus
 Hypertension

 Obesity

 High serum lipids

 Cardiac dysfunction
Collaborative Care
Prevention
 Antiplatelet drugs are usually the chosen treatment
• Aspirin is the most frequently used as antiplatelet
agent.
• Common dose for aspirin is 81 to 325 mg/day.
• Other drugs include ticlopidine (Ticlid), clopidogrel
(Plavix), dipyridamole (Persantine), and combined
dipyridamole and aspirin (Aggrenox).
• Oral anticoagulation using warfarin is the treatment of

choice for individuals with atrial fibrillation.

Collaborative Care
Prevention
 Surgical interventions
 Carotid end-arterectomy (tube inserted above and below
the blockage, remove the plaque, stitch the artery close,
remove the tube)
 Transluminal angioplasty (insertion of balloon to open
artery in the brain and to improve blood flow)
 Stenting (inflate the balloon cath, imlpant the stent, deflate
the balloon and remove, leave the stent permanently in
place holding the artery open to improve the blood flow)
 Extracranial-intracranial bypass (EC-IC) anastomosing
(surgically connecting) external artery to internal artery-
superficial temporal to middle cerebral artery
 Carotid End-arterectomy

Carotid endarterectomy is performed to prevent impending cerebral infarction. A, A tube is inserted

above and below the blockage to reroute the blood flow. B, Atherosclerotic plaque in the common carotid
artery is removed. C, Once the artery is stitched closed, the tube can be removed. A surgeon may also
perform the technique without rerouting the blood flow.
 Brain Stent

Brain stent used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant the
stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery and then
inflated. The stent expands due to the inflation of the balloon. C, The balloon is deflated and withdrawn,
leaving the stent permanently in place holding the artery open and improving the flow of blood.
Collaborative Care
Acute Care

 Goals for collaborative care during the acute phase

are
 Preserving life
 Preventing further brain damage

 Reducing disability

 Begins with managing the ABCs

 Airway

 Breathing

 Circulation
Collaborative Care
Acute Care

 Causes
 Sudden vascular compromise causing disruption of
blood flow to the brain
 Thrombosis

 Trauma

 Aneurysm

 Embolism

 Hemorrhage
Collaborative Care:Acute Care
 Assessment findings
 Altered level of consciousness
 Weakness, numbness, or paralysis
 Speech or visual disturbances
 Severe headache
 ↑ or ↓ heart rate
 Respiratory distress
 Unequal pupils
 Hypertension
 Facial drooping on affected side
 Difficulty swallowing
 Seizures
 Bladder or bowel incontinence
 Nausea and vomiting
 Vertigo
Collaborative Care
Acute Care
 Interventions
 Ensure patent airway.
 Call stroke code or stroke team.
 Remove dentures.
 Perform pulse oximetry.
 Maintain adequate oxygenation.
 Obtain IV access.
 Maintain BP.
 Obtain CT scan immediately.
 Perform baseline laboratory tests.
 Position head midline.
 Elevate head of bed 30 degrees if no symptoms of shock or
injury occur.
 Institute seizure precautions.
 Anticipate thrombolytic therapy for ischemic stroke.
Collaborative Care
Acute Care

 Watch for hypertension post stroke.

 Drugs to lower BP are used only if BP is markedly
increased. (metoprolol, cardene)
 Fluid and electrolyte balance must be controlled
carefully.
 Adequate hydration promotes perfusion and decreases
further brain injury.
 Adequate fluid intake during acute care via oral,
intravenous (IV), or tube feedings should be 1500 to 2000
mL/day.
 Overhydration may compromise perfusion by increasing
cerebral edema.
Collaborative Care
Acute Care

 Interventions
 Monitor vital signs and neurologic status.
 Level of consciousness
 Monitor sensory function
 Pupil size and reactivity
 O2 saturation
 Cardiac rhythm
Collaborative Care: Acute Care

 Recombinant tissue plasminogen activator

(tPA)
 Used to reestablish blood flow through a blocked artery
to prevent cell death in patients with acute onset of
ischemic stroke symptoms
 Must be administered within 3 to 4.5 hours of onset of
clinical signs of ischemic stroke
 Pt screened before tPA can be given:
 non contrast CT or MRI scan to rule out hemorrhagic stroke
 blood tests for coagulation disorders
 screening for recent history of gastrointestinal bleeding, stroke, or
head trauma within the past 3 months, or
 major surgery within 14 days.
Collaborative Care
Acute Care
 Aspirin is used within 24 to 48 hours of stroke.
 Platelet inhibitors and anticoagulants may be used
in thrombus and embolus stroke patients after
stabilization.
• Contraindicated for patients with hemorrhagic stroke
• The use of anticoagulants (e.g., heparin) in the emergency
phase following an ischemic stroke generally is not
recommended because of the risk for intracranial
hemorrhage.
• Dose of aspirin is 325 mg.
• Common anticoagulants include warfarin (Coumadin).
• Platelet inhibitors include aspirin, ticlopidine (Ticlid),
clopidogrel (Plavix), and dipyridamole (Persantine).
Collaborative Care
Acute Care
 Surgical interventions for stroke
 Ischemic stroke
 MERCI (mechanical embolus removal in cerebral ischemia)
 Hemorrhagic stroke
 Immediate evacuation of aneurysm-induced hematomas
 Cerebellar hematomas >3 cm

 After stroke has stabilized for 12 to 24 hours, collaborative

care shifts from preserving life to lessening disability and
attaining optimal functioning.
 Patient may be transferred to a rehabilitation unit,
outpatient therapy, or home care–based rehabilitation.
Merci Embolus Retriever in Cerebral Ischemic Stroke

The MERCI retriever removes blood clots in patients who are experiencing ischemic strokes. The
retriever is a long, thin wire that is threaded through a catheter into the femoral artery. The wire is
pushed through the end of the catheter up to the carotid artery. The wire reshapes itself into tiny loops that
latch onto the clot and the clot can then be pulled out. To prevent the clot from breaking off, a balloon
at the end of the catheter inflates to stop blood flow through the artery.
Clipping and Wrapping of Aneurysms
 GDC Coil: Gugleilmi detachable coils

A, A coil is used to occlude an aneurysm. Coils are made of soft, spring like platinum. The softness of the
platinum allows the coil to assume the shape of irregularly shaped aneurysms while posing little threat of
rupture of the aneurysm.
B, A catheter is inserted through an introducer (small tube) in an artery in the leg. The catheter is threaded
up to the cerebral blood vessels.
C, Platinum coils attached to a thin wire are inserted into the catheter and then placed in the aneurysm until
the aneurysm is filled with coils. Packing the aneurysm with coils prevents the blood from circulating
through the aneurysm, reducing the risk of rupture.
Nursing Management
Nursing Assessment

 If the patient is stable, obtain

 Description of the current illness with attention to initial
symptoms
 History of similar symptoms previously experienced

 Current medications

 History of risk factors and other illnesses

 Family history of stroke or cardiovascular disease

Nursing Management
Nursing Assessment

 Comprehensive neuro examination

 Levelof consciousness
 Cognition

 Motor abilities

 Cranial nerve function

 Sensation

 Deep tendon reflexes

Nursing Management
Nursing Diagnoses

 Risk for ineffective cerebral tissue perfusion

 Ineffective airway clearance
 Impaired physical mobility
 Impaired verbal communication
 Impaired urinary elimination
 Impaired swallowing
 Situational low self-esteem
Nursing Management
Planning

 Goals are that the patient will

 Maintain stable or improved level of consciousness
 Attain maximum physical functioning

 Maximize self-care abilities and skills

 Maintain stable body functions

 Maximize communication abilities.

 Avoid complications of stroke.

 Maintain effective personal and family coping.

Nursing Management
Nursing Implementation
 Health promotion
 To reduce the incidence of stroke, the nurse should focus
teaching toward stroke prevention.
 Particularly
in persons with known risk factors
 Education about hypertension control and adherence to
medication
 Teaching patients and families about
 Early symptoms
 Stroke
 TIA
 When to seek health care for symptoms
Nursing Management
Nursing Implementation

 Respiratory system
 Management of the respiratory system is a nursing
priority.
 Risk for atelectasis

 Risk for aspiration pneumonia

 Risks for airway obstruction

 May require tracheal intubation and mechanical

ventilation
Nursing Management
Nursing Implementation

 Neurologic system
 Monitor closely to detect changes suggesting
 Extension of the stroke
↑ ICP
 Vasospasm
 Recovery from stroke symptoms
 Table 58-8, page 1472 the NIH Stroke Scale
(NIHSS)national institutes of health stroke scale .
Nursing Management: Nursing Implementation
 Cardiovascular system
 Goals aimed at maintaining homeostasis
 Many patients with stroke have decreased cardiac reserves from
the secondary diagnoses of cardiac disease.
 Monitoring vital signs frequently
 Monitoring cardiac rhythms
 Calculating intake and output, noting imbalances
 Regulating IV infusions
 Adjusting fluid intake to the individual needs of the patient
 Monitoring lung sounds for crackles and rhonchi (pulmonary
congestion)
 Monitoring heart sounds for murmurs
 After stroke, patient is at risk for deep vein thrombosis.
 Related to immobility, loss of venous tone, and ↓ muscle pumping
in leg
 Most effective prevention is keeping the patient moving.
Nursing Management
Nursing Implementation
 Musculoskeletal system
 Goal is to maintain optimal function.
 prevention of joint contractures and muscular atrophy
 range-of-motion exercises and positioning are important.
 Paralyzed or weak side needs special attention when
positioned.
 Avoidance of pulling the patient by the arm to avoid
shoulder displacement
 Hand splints to reduce spasticity
Nursing Management
Nursing Implementation
 Integumentary system
 Susceptible to breakdown related to
 Loss of sensation
 Decreased circulation
 Immobility
 Compounded by patient age, poor nutrition, dehydration,
edema, and incontinence
 Pressure relief by position changes, special mattresses, or
wheelchair cushions
 Good skin hygiene
 Early mobility
 Position patient on the weak or paralyzed side for only 30
minutes.
Nursing Management
Nursing Implementation

 Gastrointestinal system
 Stressof illness.
 Constipation.

 Patients may be placed on stool softeners.

 Physical activity promotes bowel function.

 Urinary system
 promote normal bladder function.
 Avoid the use of indwelling catheters.
Nursing Management
Nursing Implementation

 Nutrition
 Nutritional needs require quick assessment and
treatment.
 May initially receive IV infusions to maintain fluid and
electrolyte balance
 May require nutritional support

 First feeding should be approached carefully.

 Testswallowing, chewing, gag reflex, and pocketing
before beginning oral feeding.
 Feedings must be followed by oral hygiene.
Nursing Management
Nursing Implementation

 Communication
 Nurse’s role in meeting psychologic needs of the patient
is primarily supportive.
 Patient is assessed for both the ability to speak and the
ability to understand.
 Speak slowly and calmly, using simple words or
sentences.
 Gestures may be used to support verbal cues.
Nursing Management
Nursing Implementation

 Sensory-perceptual alterations
 Blindness
in same half of each visual field is a common
problem after stroke.
 Known as homonymous hemi anopsia
 A neglect syndrome (decrease in safety, increase risk for injury)
 Other visual problems may include
 Diplopia (double vision)
 Ptosis (drooping eyelid)
 Homonymous Hemianopsia
(Food on left side is not seen)

Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemi anopsia
Shows that food on the left side is not seen and thus is ignored.
Nursing Management
Nursing Implementation
 Coping
 Affects family
 Emotionally
 Socially
 Financially
 Changing roles and responsibilities
 Explain
 What has happened
 Diagnosis
 Therapeutic procedures
 Should be clear and understood by patient.
 social services referral is often helpful.
Nursing Management: Nursing Implementation

 Ambulatory and home care

 Patient is usually discharged to home, an intermediate or
long-term care facility, or a rehabilitation facility.
 discharge planning with the patient and family starts early
in the hospitalization and promotes a smooth transition from
one care setting to another.
 prepare the patient and family for discharge through
 Education
 Demonstration
 Practice
 Evaluation of self-care skills
 Rehabilitation to promote optimal functioning.
 Physical, mental, and social well-being
 Loss of Postural Stability

Loss of postural stability is common after stroke. The patient is unable to sit upright and tends to fall
sideways. Appropriate support with pillows or cushions should be provided.
Nursing Management
Nursing Implementation
 Ambulatory and home care (cont’d)
 Musculoskeletal interventions
 Balance training
 Transferring from bed to chair
 Bobath method
 Therapists and nurses use the Bobath approach to encourage normal
muscle tone, normal movement, and promotion of bilateral function of
the body.
 An example is to have the patient transfer into the wheelchair
using the weak or paralyzed side and the stronger side to
facilitate more bilateral functioning.
 CIMT is a more recent approach. Constraint-induced movement
therapy (CIMT) encourages the patient to use the weakened
extremity by restricting movement of the normal extremity. This
approach is challenging, and the ability of patients to comply
may limit its use.
Nursing Management
Nursing Implementation
 Ambulatory and home care (cont’d)
 After acute phase, a dietitian can assist in determining
appropriate daily caloric intake based on the patient’s
 Size
 Weight
 Activity level
 Nurse and speech therapist must assess ability of patient to
swallow solids and fluids and must adjust the diet
appropriately.
 Inability to feed oneself can be frustrating and may result
in malnutrition and dehydration.
 Assistive Devices for Eating

A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips are
helpful for some persons.
B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in
one hand and a knife in the other.
C, Plate guards help keep food on the plate.
D, Cup with special handle.
Nursing Management
Nursing Implementation
 Implementa bowel management program for
problems with
 Bowel control
 Constipation
 Incontinence

 High-fiber diet and adequate fluid intake

Nursing Management
Nursing Implementation
 Patients with stroke on right side of brain
 Difficultyin judging position, distance, and movement
 Impulsive, impatient, and denying problems related to stroke
 Respond best to directions given verbally

 Patients with stroke on left side of brain

 Slower in organization and performance of tasks
 Impaired spatial discrimination
 Have fearful, anxious response to stroke
 Respond well to nonverbal cues
Nursing Management
Nursing Implementation
 Interventions for atypical emotional response
 Distract the patient.
 Explain that emotional outbursts may occur.
 Maintain a calm environment.
 Avoid shaming.

 Patients with a stroke may be coping with many losses

 Often go through the process of grief
 Some patients experience long-term depression
 Support communication between the patient and family.
 Discuss lifestyle changes.
 Discuss changing roles within the family.
 Be an active listener.
 Include family in goal planning and patient care.
 Support family conferences.
Nursing Management
Nursing Implementation
 Family members must cope with
 Recognition of behavioral changes resulting from neurologic
deficits that are not changeable
 Responses to multiple losses by both the patient and the family.
 Behaviors that may have been reinforced during the early stages
of stroke as continued dependency

 Stroke support groups within rehab facilities and community

are helpful.
 Mutual sharing
 Education
 Coping
 Understanding
Nursing Management
Nursing Implementation
 Speech, comprehension, and language deficits are the
most difficult problem for the patient and family.
 Speech therapists can assess and formulate a plan to
support communication.
 Nurses can be a role model for patients with aphasia.
 Question #1

A patient with right-sided paresthesias and hemiparesis is

hospitalized and diagnosed with a thrombotic stroke. Over the
next 72 hours, the nurse plans care with the knowledge that the
patient:

1. Is ready for aggressive rehabilitation.

2. Will show gradual improvement of the initial neurologic deficits.
3. May show signs of deteriorating neurologic function as
cerebral edema increases.
4. Should not be turned or exercised to prevent extension of the
thrombus and increased neurologic deficits.
 Question #2

While performing health screening at a health fair, the nurse

identifies which of the following individuals at greatest risk for
experiencing a stroke?

1. A 46-year-old white female with hypertension and oral

contraceptive use for 10 years.
2. A 58-year-old white male salesman who has a total
cholesterol level of 285 mg/dL.
3. A 42-year-old African American female with diabetes mellitus
who has smoked for 30 years.
4. A 62-year-old African American male with hypertension who is
35 pounds overweight.
Answer #2

 Answer: 4
 Rationale:
 Option 4: This individual has five risk factors: age, African
American, male, hypertension, and
overweight.
 Option 1: This individual has two risk factors: hypertension and
oral contraception use.
 Option 2: This individual has two risk factors: male and
increased cholesterol level.
 Option 3: This individual has three risk factors: African
American, diabetes mellitus, and smoking.
Answer #2
 Nonmodifiable risk factors include age, gender, ethnicity/race, and family history/heredity.
Stroke risk increases with age, doubling each decade after 55 years of age. Two thirds of all
strokes occur in individuals >65 years. Strokes are more common in men, but more women die
from stroke than men. Because women tend to live longer than men, they have more
opportunity to suffer a stroke. African Americans have a higher incidence of stroke, as well as
a higher death rate from stroke than whites. A family history of stroke, a prior transient
ischemic attack, or a prior stroke also increases the risk of stroke.
 Modifiable risk factors are those that can potentially be altered through lifestyle changes and
medical treatment, thus reducing the risk of stroke. Modifiable risk factors include
hypertension, increased cholesterol, elevated blood lipid levels, heart disease, smoking,
excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical
exercise, poor diet, and drug abuse.
 Early forms of birth control pills that contained high levels of progestin and estrogen increased
a woman’s chance of experiencing a stroke, especially if she also smoked heavily. Newer, low-
dose oral contraceptives have lower risks for stroke except in those individuals who are
hypertensive and smoke. Other conditions that may increase stroke risk include migraine
headaches, inflammatory conditions. Sickle cell disease is another known risk factor for stroke.
 Question #3

A patient with a stroke has dysphagia. Before allowing the

patient to eat, which of the following actions should the nurse
take first?

1. Check the patient’s gag reflex.

2. Request a soft diet with no liquids.
3. Place the patient in high-Fowler’s position.
4. Test the patient’s ability to swallow with a small amount of
water.
Answer #3

 Answer: 1
 Rationale: Before initiation of feeding, assess the
gag reflex by gently stimulating the back of the
throat with a tongue blade.
 If a gag reflex is present, the patient will gag
spontaneously.
 If it is absent, defer the feeding, and begin exercises to
stimulate swallowing.
 To assess swallowing ability, elevate the head of the
bed to an upright position (unless contraindicated), and
give the patient a small amount of crushed ice or ice
water to swallow.
Case Study
 73-year-old man was admitted to the hospital with
right-sided paresis and expressive aphasia.
 He had been experiencing periods of confusion,
right-sided weakness, and slurred speech for the
past several weeks.
 These episodes were brief and resolved completely
within an hour. No treatments were sought.
Case Study 1
 History of COPD, MI 15 years prior, and atrial
fibrillation

 Over the first 24 hours of admission, his neurologic

deficits gradually progressed.

 By day 2 of admission, he had right-sided flaccid

paralysis and global aphasia.
Discussion Questions
Case Study

1. What is probably the cause of his stroke?

2. Could this stroke have been prevented?

Discussion Questions
Case Study

3. What are the priority nursing interventions for

him?

4. What teaching will you need to do for him and

his family?