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TABLE OF CONTENTS

Contents
Acknowledgement
Patients bio data
History of Patient
Introduction
Definition of Medical Diagnosis
Incidence of Condition
Etiology
Pathophysiology
Clinical Manifestations
Treatment
Diagnostic Evaluation
Complications
Nursing Management
Bibliography

Page

ACKNOWLEDGEMENTS
The research would like to extend thanks and appreciation to; subject instructor who provided guidance,
parents who rendered fiscal assistance and emotional support when it was challenging. Without them it
would not have been possible for the completion of this study.

PATIENTS BIO DATA


Name: John Doe
Age: 60
Date of Birth: 11/25/1955
Address: 190 Congress Lane, South
Nationality: Guyanese
Marital Status: Widow
Religion: Hindu
Race: East Indian
Occupation: Unemployed

HISTORY OF PATIENT
Chief Complaint - Patient relative stated he cant move he right hand and foot for like seven days now
and he cant talk.
Past Medical History- Hypertension
Surgical - No previous surgery.
Social- Drinks occasionally
Allergies- Nil known to date
Family - Hypertension (Paternal)

INTRODUCTION TO TOPIC
Strokes are one of the leading causes of long term disability. It is divided into two (2) categories;
hemorrhagic stroke which accounts for approximately 13%, it occurs when there is extravasation of
blood into the brain or subarachnoid space (Hickey, 2009). The other, ischemic stroke, also known as
cerebrovascular accident (CVA) or brain attack, approximately 87%, one in which vascular occlusion
and significant hypoperfusion occur.
Ischemic strokes ever so often follow a warning sign such as; a transient ischemic attack (TIA) which is
referred to as a silent stroke or a reversible ischemic neurologic deficit (RIND). These mainly occur
during the mornings, when blood pressure is at its lowest. TIAs resolve in spontaneous and complete
recovery within one day. TIAs typically last between two and fifteen minutes, although it conceivably
lasts as long as twenty-four hours. The term RIND is usually applied to attacks that continue for more
than twenty four hours without interruption, but less than a week. Multiple TIAs indicates a high risk for
stroke.
Stroke is an urgent health care problem similar to a heart attack. In 1996 arose a revolution surrounding
the approval of thrombolytic therapy for ischemic stroke. With this newly approved therapy, patients
results were fewer stroke symptoms and less loss of function but with early treatment. (National Institute
of Neurologic Disorders and Stroke [NINDS], 1995.)

DEFINITION OF ISCHEMIC STROKE OR CEREBROVASCULAR ACCIDENT


Ischemic Stroke is a sudden loss of functioning resulting from disruption of blood supply to art of the
brain.
INCIDENCE
Internationally
According to the World Health Organization, 15 million people suffer stroke worldwide each year. Of
these, 5 million die and another 5 million are permanently disabled. However, in developed countries the
incidence of stroke is declining, largely due to efforts to lower blood pressure and reduce smoking.
Nevertheless, the overall rate of stroke remains high due to the aging of the population
Male/Female Ratio
Men have a higher age adjusted rate of stroke than women.
Age Range
About 25 % of strokes occur in people younger than 65years (American Heart). The risk of having a
stroke more than doubles each decade after the age of 55.
Ethnicity
Stroke is the fifth leading cause of death for Americans, but the risk of having a stroke varies with race
and ethnicity. The incidence of stroke in African Americans is twice that in Caucasian Americans (Roger
et al., 2012).
ETIOLOGY
An Ischemic stroke is cause by the occlusion of a cerebral artery by either a thrombus (clot) or an
embolus (dislodged clot).
Thrombotic stroke- accounts for more than half of all strokes and are commonly associated with
atherosclerosis, the process by which plaque develop on the inner wall of the blood vessels. Rupture of
one of the plaque exposes foam cells to clot promoting elements in the blood. This results in clot
formation, if it is of sufficient size; blood flow is interrupted causing an occlusive stroke. However, this
may occur over a number of years due to the development of collateral circulation. Thrombolytic strokes
tend to have a slow onset because of gradual occlusion of the arteries.
Embolic Stroke- is caused by an embolus or a group of emboli that break off from one area of the bod
and travel to the cerebral arteries via the carotid artery or vertebrobasilar system the usual source of the
emboli is the heart. The middle cerebral artery (MCA) is the most commonly involved in an embolic
stroke. When the emboli occlude the vessel, it may be temporary if the embolus breaks into smaller
fragments, enters smaller blood vessels and is absorbed. For these reason, embolic strokes are
characterized by the sudden development and rapid occurrence of neurologic deficits. These may lead
to a hemorrhagic stroke because arterial vessels are also venerable to ischemic damage.

Types Of Ischemic Stroke


These stokes are further subdivided into different types based on the cause. They are as follows:
Large artery thrombotic stroke 20%- these strokes are cause by atherosclerosis plaques in the
large blood vessels of the brain. Thrombus formation and occlusion at the site of the
atherosclerosis results in ischemia and infarction. (Hickey, 2009).
Small penetrating artery thrombotic stroke 25%- affect one or more vessels and are the most
common type of ischemic stroke. Small penetrating artery thrombotic stroke are also called
lacunar stroke, because of the cavity that is created after the death of infarcted brain tissue
(American Association of Neuroscience Nurses [AANN], 2011; Hickey, 2009).
Cardiogenic embolic stroke 20%- these are associated with cardiac dysrhythmias, usually atrial
fibrillation. Emboli strokes can be associated with valvar heart disease and thrombi in the left
ventricle. Emboli originate from the heart and circulate to the cerebral vasculature, most
commonly the left middle cerebral artery, resulting in stroke.
Cryptogenic stroke 30%- these strokes have no cause.
Other 5%- These are caused from factors such as illicit drug use, coagulopathies, migraine, and
spontaneous dissection of the carotid or vertebral arteries.
Typical Deficits Artery Involved
1. Anterior Cerebral Artery
Paralysis and cortical hyperesthesia of contralateral lower limb
Mild involvement contralateral arm
Impaired judgement / insight
Apraxia of gait
Sucking / grasp reflex contralateral side
Bowel bladder incontinence
2. Middle Cerebral Artery
Contralateral hemiplegia
Hemianopsia
Vagnosia
Loss sensation
Dysphasia
4. Posterior Cerebral Artery
Alexia
Mental change with memory impairment
Inability to recognize people and things (visual agnosia) often temporary
3rd nerve palsy
Risk Factors for Ischemic Stroke
Non- Modifiable
Age- persons older than 55 years old. While stroke is common among the elderly, a lot of people under
65 also have strokes.

Heredity and race- people whose close blood relations have had a stroke have a higher risk of stroke.
Some strokes may be symptoms of genetic disorders like CADASIL (Cerebral Autosomal Dominant
Arteriopathy with Sub-cortical Infarcts and Leukoencephalopathy), which is caused by a gene mutation
that leads to damage of blood vessel walls in the brain, blocking blood flow. African Americans have a
higher risk of death and disability from stroke than whites. This is because they have high blood
pressure more often. Hispanic Americans are also at higher risk of stroke.
Gender - men have a higher risk of stroke than women. Women are usually older when they have
strokes, and they're more likely to die of strokes than are men.
Atrial Fibrillation- in AF the hearts upper chambers quiver rather than beating in an organized,
rhythmic way. This causes the blood to pool and clot, increasing the risk of stroke. AF increases risk of
stroke five times. People with other types of heart disease have a higher risk of stroke, too.
Obstructive sleep apnea a sleep disorder in which the oxygen level intermittently drops during the
night.
Certain blood disorders- a high red blood cell count makes clots more likely, raising the risk of stroke.
Sickle cell anemia increases stroke risk because the sickled cells stick to blood vessel walls and may
block arteries.
Modifiable
Hypertension- controlling hypertension, the major risk factor, is the key to preventing stroke.
Dyslipidemia- contributes to blood vessel disease, which often leads to stroke.
Diabetes- is an independent risk factor for stroke. Those with diabetes also have high blood pressure,
high blood cholesterol and are overweight andit increases their risk even more. While diabetes is
treatable, the presence of the disease still increases your risk of stroke.
Smoking- Smoking can increase your risk of stroke or further stroke by increasing blood pressure and
reducing oxygen in the blood. Some chemicals found in tobacco smoke damage blood vessel walls,
leading to atherosclerosis. This increases the chance of blood clots forming in the arteries to the brain
and heart.
Sedentary lifestyle- Being inactive, obese, or both, can increase your risk of cardiovascular disease.
Obesity- Being overweight or obese can increase the risk of stroke. Too much body fat can contribute to
high blood pressure, high cholesterol and can lead to heart disease and Type 2 diabetes.
Excessive alcohol consumption - drinking large amounts of alcohol (six or more standard drinks per
day) increases the risk of stroke.

PATHOPHYSIOLOGY
Obstruction of a blood
Disruption of cerebral
flow
Ischemic
Cerebral blood flow
<25ml/100g/min
Neurons unable to maintain aerobic

Neurons

Mitochondria switch to anaerobic

ATP

Acidic pH from

lactic

Depolarizati
on

Intracellular Calcium

Release of
Excitotoxicity
(Cell membrane and protein
are digested, Formation of
free radicals ,Protein
production)
Cell
injury
Cerebral Edema which leads to
Brain Injury

CLINICAL MANIFESTATIONS

More

in Calcium

Apoptosis

An ischemic stroke can cause a variety of neurologic deficits, depending on:


Location of the lesion (which blood vessels are obstructed)
The size of the area of inadequate perfusion
The amount of collateral (secondary or accessory) blood flow
Patient
Textbook
Dysarthria
Communicative Loss
Language and communication are affected by
stroke. It is the most common cause of aphasia or
dysphagia (impaired speech). This may be any of
the following:
Expressive Aphasia- inability to express oneself .
Receptive Aphasia- inability to understand
language.
Global Aphasia- a combination of both expressive
and receptive aphasia, in which a patient can
produce few recognizable words and understand
little or no spoken language.
Other deficits are:
Dsyarthia difficulty in speaking. It is caused by
paralysis of the muscles responsible for producing
speech.
Apraxia- inability to perform a previously learned
action. It may be seen when a patient makes verbal
substitutions for desired syllables or words.

Hemiplegia
Left Hemiparesis
Facial palsy (Drooping of right side of mouth)
Ataxia

Motor Loss
A stroke in an upper neuron lesion and it results in
loss of voluntary control over motor movements.
The most common motor dysfunction is
hemiplegia-paralysis of one side of the body or
part of it- caused by a lesion of the opposite side of
the brain. It occurs because the motor nerve fibers
cross in the medulla before entering the spinal cord
and periphery.
Hemiparesis- weakness of one side of the body or
part of it.

If the brain stem is affected, the patent may


experience hemiparesis or quadriparesis and ataxia
(gait disturbance).
In the early stages of stroke, the initial clinical
features may be flaccid paralysis or hypotoniacannot overcome the forces of gravity, with the
extremities falling to the side- and loss of deep
tendon reflexes.
Hypertonia or spastic paralysis tends to case fixed
positions or contractures of the involved extremity.
When the deep tendon reflexes reappear (usually
by 48 hour), there is increase tone along with
spasticity of the extremities.
Staring straight ahead

Perceptual Disturbances
Perception is the ability to interrupt sensation.
Stroke can result in:
Visual-perception dysfunction- are caused by
disturbances of the primary sensory pathway
between the eye and the visual cortex.
Homonymous hemianopia (blindness in half of the
visual field) may occur from stroke. This may be
permanent or temporary. The affected vision
corresponds to the paralyzed side of the body.
Disturbances in visual-spatial relations- perceiving
the relationship of two or more objects in spatial
areas. This is frequently seen in patients with right
hemispheric damage.

Sensory loss
Sensation may be impaired after stroke. Sensory
loss from stroke may take the form of slight
impairment of touch, or it may by more severe
with loss of proprioception( ability to perceive the
position and motion of body parts) as well as
difficulty in interrupting visual, tactile and
auditory stimuli. Numbness, tingling,

Mental status changes (Disoriented)

hypersensitivity, and varying degrees of sensory


loss can occur.
Agnosias are deficits in the ability to recognize
previously familiar objects by one or more of the
senses.
Neglect Syndrome- the patient is unaware of the
existence of his or her left or paralyzed side.
Example, patient washes or dresses only one side
of the body.
Cognitive Impairment and Psychological Effects
If damage has occurred to the frontal lobe, learning
capacity, memory, or higher cortical intellectual
functions may be impaired. Such dysfunctions may
be reflected in a limited attention span, difficulties
in comprehension, forgetfulness, and a lack of
motivation. The person may often be unaware of
any deficits and may be disoriented to time and
place.

TREATMENT
Medical Management
Patients who have experienced a CVA or TIA should have medical management for secondary
prevention. While only 1 drug, recombinant tissue-type plasminogen activator (rt-PA), has demonstrated
efficacy and effectiveness in treating acute ischemic stroke and is approved by the FDA, other
medications are equally important.
Osmotic Diuretic
Reduction of intracranial and intraocular pressure.
Mannitol 100 ml qid iv
Calcium Channel Blocker
Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in
inhibition of excitation contraction coupling and subsequent contraction.
Amlodipine 10mg po od
H2 Receptor Antagonist
Inhibits the action of histamine at the h2 receptor sites located primarily in gastric parietal cells,
resulting in inhabitation of gastric acid secretion. Use in stroke for short term used of ulcer.
Ranitidine 50mg iv bid
Blood Viscosity Reducing Agent
Decreases blood viscosity by inhibiting platelet aggregation and decreasing fibrinogen. In stroke it
increases blood flow.
Trental 400mg tid
Anticoagulant
Class summary: Anticoagulants such as warfarin are used for secondary stroke prevention. Used to
prevent clot extension and formation. They do not dissolve clots.
Tab ASA 375 mg od
Inj Fragmin 5000 units s/c
Lipid- Lowering Agents
Reduction of lipids/cholesterol reduces the risk of myocardial infarction and stroke sequelae.
Atorvastatin 40mg od

Platelet Inhibiting
Decrease the incidence of cerebral infarction in patients who have experienced TIAs and stroke from
thrombus or embolic cases. Although antiplatelet agents have proved useful for preventing recurrent
stroke or stroke after transient ischemic attacks (TIAs), efficacy in the treatment of acute ischemic stroke
has not been demonstrated.
Plavix 75mg I tab od
Tab ASA 375 mg od

Anti-seizure
While seizures associated with stroke are relatively uncommon, recurrent seizures may be life
threatening. Generally, agents used for treating recurrent convulsive seizures are also used in patients
with seizures after stroke. Benzodiazepines, typically diazepam and lorazepam, are the first-line drugs
for ongoing seizures.
Dilantin 100g tid iv
Antibiotics
Treatment of infection.
Rocephine 1gram iv bd
Inj clindamycin 600mg iv bd
Vitamin
Neurobin 6 amps iv
Vit b 12 2 amps iv
Folic acid 2 tab od
If blood pressure more than or equal to 160/90 :
Hydralazine 10mg 1v, to repeat every 30 minute until blood pressure normal -130/80
Alteplase (thrombolytic therapy) Intravenous thrombolytic therapy uses a medication called tissue
plasminogen activator (tPA, alteplase) that is injected into a vein. Alteplase works to dissolve clots that
are blocking blood flow within arteries of the brain. The benefit of thrombolytic treatment slowly
decreases over several hours. Thus, the earlier the treatment is given after the stroke begins, the more
likely the artery can be opened.
Overall, it is estimated that alteplase treatment is 10 times more likely to help than to harm. However,
approximately 1 in 15 patients who receive thrombolytic therapy develops excessive bleeding
(hemorrhage) in the brain; this type of bleeding can be fatal.

Drug Information
GENERIC NAME: Mannitol
TRADE NAMES: Osmitrol ,Resectisol
PREGNANCY CATEGORY: Category C
THEREUPATIC CLASS: Diuretics
PHARMACOLOGICAL CLASS: Osmotic diuretics
INDICATIONS
IV: Adjunct in the treatment of:
Acute oliguric renal failure, edema, increased intracranial or intraocular pressure, toxic overdose.
GU irrigant: During transurethral procedures (2.55% solution only).
ACTION
Increases the osmotic pressure of the glomerular filtrate, thereby inhibiting reabsorption of water and
electrolytes.
Causes excretion of: Water, sodium, potassium, chloride, calcium, phosphorus, magnesium, urea, uric
acid.
THERAPEUTIC EFFECT:
Mobilization of excess fluid in oliguric renal failure or edema.
Reduction of intraocular or intracranial pressure.
Increased urinary excretion of toxic materials.
Decreased hemolysis when used as an irrigant after transurethral prostatic resection.
METABOLISM AND EXCRETION: Excreted by the kidneys; minimal liver metabolism.

HALF-LIFE: 100 min.


TIME/ACTION PROFILE (diuretic effect)
ROUTE
IV

ONSET
3060 min

PEAK
1 hr

DURATION
68 hr

CONTRAINDICATION/PRECAUTIONS
Contraindicated in:
Hypersensitivity;
Anuria;
Dehydration;
Active intracranial bleeding;
Severe pulmonary edema or congestion.
Use Cautiously in:
OB: Lactation: Safety not established.
ADVERSE REACTIONS/SIDE EFFECTS
CNS: confusion, headache
EENT: blurred vision, rhinitis
CV: transient volume expansion, chest pain, HF, pulmonary edema, tachycardia
GI: nausea, thirst, vomiting
GU: renal failure, urinary retention
F and E: dehydration, hyperkalemia, hypernatremia, hypokalemia, hyponatremia
Local: phlebitis at IV site
INTERACTIONS
Drug-Drug
Hypokalemia the risk of digoxin toxicity.
ROUTE/DOSAGE
Reduction of intracranial/intraocular pressure 0.252 g/kg as 1525% solution over 3060 min (500
mg/kg may be sufficient in small or debilitated patients).
AVAILABILITY (GENERIC AVAILABLE)
IV injection: 5%, 10%, 15%, 20%, 25%
LAB TEST CONSIDERATIONS:
Renal function and serum electrolytes should be monitored routinely throughout course of therapy.
Nursing Consideration
Explain purpose of therapy to patient.
Observe infusion site frequently for infiltration. Extravasation may cause tissue irritation and necrosis.
Do not administer electrolyte-free mannitol solution with blood. If blood must be administered
simultaneously with mannitol, add at least 20 mEq NaCl to each liter of mannitol.

Confer with physician regarding placement of an indwelling Foley catheter (except when used to
decrease intraocular pressure).

GENERIC NAME: Dalteparin


TRADE NAMES: Fragmin
PREGNANCY CATEGORY :Category B
THEREUATIC CLASS: Anticoagulants
PHARMACOLOGICAL CLASS: Antithrombotics, Low molecular weight heparins
INDICATIONS:
Prevention of venous thromboembolism (deep vein thrombosis (DVT) and/or pulmonary embolism
(PE)) in surgical or medical patients.
Extended treatment of symptomatic DVT and/or PE in patients with cancer.
Prevention of ischemic complications (with aspirin) in patients with; unstable angina,nonQ-wave MI.
ACTION
Potentiates the inhibitory effect of antithrombin on Factor Xa and thrombin.
Therapeutic Effects:
Prevention of thrombus formation.
Decreased incidence of death or recurrent MI.
METABOLISM AND EXCRETION: Unknown.
HALF-LIFE: 2.12.3 hr.
TIME/ACTION PROFILE (antithrombotic effect)
ROUTE
Subcut

ONSET
rapid

PEAK
4 hr

DURATION
up to 24 hr

CONTRAINDICATION/PRECAUTIONS
Contraindicated in:
Hypersensitivity to dalteparin, heparin, or pork products
Active major bleeding
Thrombocytopenia related to previous dalteparin therapy.
Use Cautiously in:
Patients with severe renal or hepatic impairment
Retinopathy (hypertensive or diabetic)
Spinal or epidural anesthesia
Geri: Risk of bleeding may be , consider age-related in renal function and body weight
OB: Lactation: Pedi: Safety not established; products containing benzyl alcohol should not be used in
neonates.
Exercise Extreme Caution in:
Spinal/epidural anesthesia or spinal puncture ( risk of spinal/epidural hematoma that may lead to longterm or permanent paralysis)
Severe uncontrolled hypertension
Bacterial endocarditis, bleeding disorders
GI bleeding/ulceration/pathology
Hemorrhagic stroke
Recent CNS or ophthalmologic surgery
Active GI bleeding/ulceration
History of thrombocytopenia related to heparin.
ADVERSE REACTIONS/SIDE EFFECTS
CNS: dizziness
GI: reversible in liver enzymes
Hemat: BLEEDING, thrombocytopenia
INTERACTIONS
Drug-Drug
Risk of bleeding by concurrent use of thrombolytics, anticoagulants, or agents that affect platelet
function including NSAIDS, ticlopidine, clopidogrel, tirofiban, or eptifibatide .
NURSING CONSIDERATION
Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever,
swelling, or difficulty breathing to health care professional immediately.
Instruct patient not to take aspirin or NSAIDs without consulting health care professional while on
dalteparin therapy.
Do not administer IM. Administer into the subcutaneous layer. Rotate injection sites daily.
Syringe Incompatibility. Do not mix with other injections or infusions.
Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry
stool; hematuria; fall in hematocrit or BP; guaiac-positive stools). Notify health care professional if
these occur.
Observe injection sites for hematoma, ecchymosis, or inflammation.

Dalteparin cannot be used interchangeably (unit for unit) with unfractionated heparin or other lowmolecular-weight heparins.

SURGICAL MANAGEMENT
The main surgical procedure for selected patient who have had a TIA or mild stroke is CEA. This is the
most frequently performed non cardiac vascular procedure.
A Carotid endarterectomy (CEA) is the removal of an arteriosclerotic plaque or thrombus from the
carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.

Carotid stenting , with or without angioplasty, is a less invasive procedure that is used for selected
patients with for stenosis. The procedure involves using a balloon-like device to open a clogged artery.
Then, a small metal stent is put in place to help keep the artery open.

DIAGNOSTIC EVALUATION
Clinical history and presentation are usually enough to identify a stroke has occurred.
Patient
Male patient 60 years old. History of high blood
pressure. He lost force in his right side of his body,
leg, and upper arm and difficulty talking one week
ago.
No deviation to his left side.
Biochemistry
Normal Range
Sodium 150.0 mmol/L
136-146
Potassium 3.87mmol/L
3.5-5.5
Chloride 115.6 mmol/L
102-109
Creatinine 1.6 mg/dL
0.88-1.3
Total bilirubin 1.0 mg/dL 0.3-1.3
Direct bilirubin 0.6 mg/dL
0.1-0.4
Indirect bilirubin 0.400 mg/dL 0.0-1.0
Alk Phosphatase 49 U/L
33-96
ALT (SGPT) 9 U/L
10-40
AST(SGOT) 21 U/L
10-40

Text Book
History and Physical Assessment
Any patient with neurologic deficits needs a
careful history and complete physical and
neurological examination.
Laboratory Assessment
No definitive laboratory tests confirm, a stoke has
occurred.
Elevated hematocrit and hemoglobin levels are
often associated with a major stroke as the body
attempts to compensate for lack of oxygen to the
brain.
An elevated white blood cell count may indicate
the presence of an infection.

Hematology
Hemoglobin 16.8 g/dL
PCV/HCT 48.0%
WBC 15,300 mm3
RBC 5.69
Platelets 104 103/uL

14-18
37.0-52.0
5,000-10,000
4.2-6.1
150-400

CT Scan of the Brain


Impressions:
Non hemorrhagic left MCA territory acute
infarctions.
Multiple small infarctions in both corona radiate
and left lentiform nucleus.

Imaging Assessment
The initial diagnostic test for stroke is usually a
noncontrast computed tomography (CT) scan. It
should be done within 25mins or less from the
time the patient arrived at the emergency
department. It is to determine the type of stroke. A
brain computed tomography (to-MOG-rah-fee)
scan, or brain CT scan, is a painless test that uses x
rays to take clear, detailed pictures of your brain.
This test often is done right after a stroke is
suspected
A brain CT scan can show bleeding in the brain or
damage to the brain cells from a stroke. The test
also can show other brain conditions that may be
causing symptoms of the stroke.
Magnetic resonance imaging (MRI) uses magnets
and radio waves to create pictures of the organs
and structures in your body. This test can detect
changes in brain tissue and damage to brain cells
from a stroke. It may be used instead of, or in
addition to, a CT scan to diagnose a stroke.

ECG
Further diagnostic workup for ischemic stroke
involves attempting to identify the source of the
thrombi or emboli. A 12-lead electrocardiogram
(ECG) and a carotid ultrasound are standard tests.
Echocardiography an ultrasound of the heart that
gives information about the size and shape of the
heart and detects how well the heart's chambers

and valves are working. It can detect possible


blood clots inside the heart and problems with the
aorta.
Carotid ultrasound is a test that uses sound waves
to create pictures of the insides of your carotid
arteries- which supply oxygen-rich blood to your
brain. It shows whether plaque has narrowed or
blocked your carotid arteries.
It may include a Carotid Doppler ultrasound.
Doppler ultrasound is one that shows the speed
and direction of blood moving through blood
vessels.

COMPLICATIONS
The most common complications of stroke are:
Brain edema - this is swelling of the brain after a stroke has occurred.
Pneumonia - causes respiratory problems, a complication of many major illnesses. Pneumonia occurs as
a result of not being able to move as a result of the stroke. The damage caused by a stroke can interrupt
your normal swallowing or gag reflex , which can sometimes result in the bolus entering the larynx,
leading to aspiration pneumonia.
Urinary tract infection (UTI) and/or bladder control- UTIs can occur as a result of having the Foleys
catheter placed to collect urine when the patient cannot control bladder function. Inadequate caring for
the catheter can result in a bladder infection.

Seizures - abnormal electrical activity in the brain causing convulsions. These are common in larger
strokes.
Clinical depression - a treatable illness that often occurs with stroke and causes unwanted emotional and
physical reactions to changes and losses. This is very common after stroke or may be worsened in
someone who had depression before the stroke.
Decubitus Ulcer - are pressure ulcers that result from decreased ability to move and pressure on areas of
the body on bony prominent because of immobility. It results from poor nursing care. Regular repositioning of the patient and devices to minimize pressure such as pressure-relieving mattresses may be
implemented.
Limb contractures - joint deformities due to abnormal tightness and shortening of muscle, can occur due
to muscle spasticity and limited mobility following stroke. These can be painful, may lead to skin and
hygiene problems and can often interfere with movement and care of patients. Joint contractures may be
prevented by regular stretching of muscles and movement across joint motion ranges.
Shoulder pain - stems from lack of support of an arm due to weakness or paralysis. This usually is
caused when the affected arm hangs resulting in pulling of the arm on the shoulder. Range of motion
exercises may be done to increase circulation.
Deep venous thrombosis (DVT) - this normally occurs in people who have lost some or all of the
movement in their leg, as immobility will slow the blood flow in their veins, increasing blood pressure
and the chances of a blood clot. Prompt treatment is required because there is a chance the clot may
travel to lungs, and cause a pulmonary embolism.

NURSING MANAGEMENT
Assessment of the Patient (head to toe)
Vital Signs
Temperature: axillary temperature is 36.5
Pulse: radial pulse rate is 108 beats per minute, bounding and strong. Sinus rhythm on ECG
Respiratory: rate 26 breaths per minute, shallow, labored breathing.
Blood pressure: 144/96 mmHg in right hand.
SpO2: 100% on room air.
General Appearance
Patient lying on bed in semi Fowlers position, with rails up for safety. Bedridden since admission day.
Appears well cleaned and wears appropriate clothes. Appears to be in no distress.
Mental status

The client is conscious and responds to yes and no questions by nodding . GCS 11/15 ( E- 4, M-6
[except extremities], V-1)
Skin
Dark brown in color, dry, and wrinkled due to old aging process. Has calluses on heels of the feet.
Darker skin noted around elbows and knees. Skin warm in temperature, afebrile. Turgor of skin
decreased. Hair present on scalp, lower face, nares, chest, legs, and pubic areas and evenly distributed.
Nail
Nails are well-groomed and uniform without deformities. Nails short and concave, with edges smooth.
Hard and firm with uniform thickness. Capillary refill 3 seconds in upper extremities.
Head and Face
The clients skull is proportionate to the body size, normocephalic and midline. His head is round and
symmetrical its consistency is hard. No tenderness, nodules, or infestation on the scalp when palpated.
His hair is evenly distributed and has no signs of alopecia. Hair colour is a mixture of white and black.
Face shape
round and asymmetrical; drooping to right side of mouth. Temporal pulses palpable.
Eyes
Eyebrows are smooth, black in color and distributed evenly and in line with each other. Has mole
located lateral to left eye. Eyelashes are black, evenly distributed, present on both lids and turned
outward. Conjunctivae clear with a few capillary present. Sclera anecteric. Iris black. Pupils equal,
round, and reactive to light and accommodation (PERRLA). No signs of excessive tearing from
lacrimal glands. Mucosa pale pink and moist. Staring straight ahead.
EARS
Auricles in alignment, ear has same color as facial skin. Firm and mobile; non-tender. No presence of
discharges observed.
Nose
Nose in midline, no discharges or polyps, internal mucosa pink and moist, septum midline. Both right
and left nares patent. Nares oval and symmetrically positioned. Sinus non- tender upon palpation.
Mouth
Lips symmetric, acyanotic and dry. Gingiva pink and moist. Tongue is midline, coated with cream filmy
material. Hard palate and soft palate are pinkish in color. Uvula rises evenly, no edema present. Unable
to answer questions. Dysarthria present; tries to speak but words are incomprehensible.
Neck
Neck is straight and symmetrical. Trachea midline. External jugular vein distention noted. Carotid pulse
palpable. Cricoid cartilages smooth and moves during swallowing. No enlarged lymph nodes present.
Thorax and Chest

Thoracic expansion symmetric. No adventitious breath sounds upon auscultation. Apical pulse present,
S1 and S2 heard. No murmurs heard. The areola and nipples are dark brown in color and no discharges
noted.
Abdomen
Soft, flat and symmetrical upon palpation. Uniform in color, no pigmentation and rashes noted. No
abdominal scars and masses. Active bowel sounds audible in four quadrants, same normal. Pubic hair
present. No abnormalities seen in genitals. No skin lesions, discharges or swelling noted. Foleys
catheter insitu draining blood tinged urine. Defecated to a soft brown stool.
Upper Extremities
Arms fair in color and symmetrical. No tenderness upon palpation of muscle and joints. Unable to
passively perform full range of motion at right affected hand; stiffness noted. Muscle strength is 3/5.
Radial and brachial pulses palpable. Has IVF NS infusing at 42cc/hour. No signs of infiltration or
phlebitis noted at infusion site.
Lower Extremities
Legs are symmetrical. Muscles are firm and skin is slightly dry. Unable to passively perform full range
of motion at right affected leg. Muscle strength is 2/5. Popliteal and dorsalis pedis pulses palpable.

PATIENT EDUCATION
Discharge Teaching
The client was advised to have a follow-up check-up, as indicated by the physician.
Diet
Teach patient about implementation of DASH Diet.it is high in fruits and vegetables, moderate in low
fat dairy products, and low in animal protein.
Food Group
Number of Serving/Day
Grains and grain products
7 or 8
Vegetables

4 or 5

Fruits

4 or 5

Low fat or free dairy products

2 or 3

Meat, fish and poultry

Less than or 2

Nuts, seeds and dry beans

4 or 5 weekly

Exercise
The patient was advised to have complete bed rest until strength is regained. Have turn side to side every
2 hours to prevent bed sores. Have ROM exercise on to enhance client's body function.

Assessment
Inability to
feed self.
Right
hemiparesis
Decreased
strength in
right upper
and lower
extremity.

Nursing
Diagnosis
Self-care
deficits related
to
neuromuscular
impairment
secondary to
CV as
evidenced by
inability to
feed self , and
perform
simple tasks.

Goal
After 3 days
of, patient
will
demonstrate
techniques
or lifestyle
changes to
meet selfcare needs.

Patient will
safely
perform to
maximum
ability selfcare
activities
(feeding
self).

Nursing
intervention
Assess ability to
participate in
personal hygiene
activities.

Rationale

Evaluation

This aids in
planning for
meeting
individual
needs

Achieves self
- care as
evidenced by
participation
in hygiene
care and
feeding self.

Encourage
patient in
participating in
care but avoid
doing things for
patient that
patient can do for
self, but provide
assistance as
necessary.

To maintain
self-esteem
and promote
recovery, it is
important for
the patient to
do as much as
possible for
self. These
patients may
become
fearful and
independent,
although
assistance is
helpful in
preventing

Maintain a
supportive, firm
attitude. Allow
patient sufficient
time to
accomplish tasks.

Provide positive
feedback for
efforts and
accomplishments
.

Instruct family to
bring clothing
that is a size
larger than
usually worn by
the patient .

frustration.
Patients need
empathy and
althought they
may feel
awkward at
first, theses
motor skills
can be learned
by repetition
with the
affected side
regaining
strength.
Enhances
sense of selfworth,
promotes
independence,
and
encourages
patient to
continue
endeavors.
This makes is
easier for the
patient to put
on. Clothes
fitted at the
front or with
Velcro
closures are
suitable.

Assessment
Inability to
move right
upper and
lower
extremity as
evidenced by
muscle
strength 3/5 in
upper
extremity and
2/5 in lower
extremity.

Nursing
Diagnosis
Impaired
physical
mobility
related to
limited range
of movement
of right hand
and foot,
ataxia, and
right
hemiparesis.

Goal
Patient will
perform
physical
activity
independently
within 3 to 4
days of
hospitalization
and regain
muscle
strength.

Nursing
Intervention
Assess for the
ability to move
and change
position, to
perform range
of motion to all
joints, for fine
muscle
movement and
for gross
muscle
movement.

Limited range
of motion in
right upper and
lower
extremity.
Monitor the
patients skin
integrity for
areas of
blanching or
redness.

Rationale

Evaluation

There may be
varying
degrees of
involvement
on the affected
side.in the
early phase of
stroke recovery
the patient may
be completely
immobile, then
gradually
progresses
with paresis or
paralysis
limited to one
side of the
body or
extremity.
Impaired
mobility
increases the
risk fr skin
breakdown.
Early

Patient will be
able to
gradually
perform small
movements in
upper right
extremity such
as movement
of fingers to
holding a cup
of tea and
drinking it by
day 3.
Muscle
strength will
improve to 4/5
in both
extremities.

Change
position of
patient at least
every 2 hours,
keeping track
of the position
changes with a
turning
schedule.

Perform active
and passive
range of
movement
exercises at
least 4 times aa
day.

Use pressure
relieving
devices on bed
and chair.

identification
of stage 1
pressure ulcer
allows for the
prompt
initiation of
measures to
relieve
pressure and
promote kin
integrity.
Position
changes
optimizes
circulation to
all tissue and
relieve
pressure.
Patients may
not feel
increase in
pressure or
have the ability
to adjust
positions.
ROM activities
preserve
muscle
strength and
prevent
contractures,
epically in
spastic
extremities.
These devices
decrease the
risk for
pressure ulcer.

Perform
activities in a
quite
environment
with few
distractions.

Impaired
cognitive
function that
occurs with
stroke may
decrease the
patients
attention span
and
concentration
during
mobility
activities.
Apply
Devices are
splinting
used to prevent
devices to right muscle
lower
shortening that
extremity.
occurs with
chronic
flexion. This
will prevent
contractures.

BIBLIOGRAPHY

American Stroke Association2016 American Heart Association, Inc Updated:Jul 1,2015, reviewed on
10/23/2012.
Gary H. Gibbons ; National Heart, Lung, and Blood Institute, November 12, 2013,Updated: October 28,
2015
National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and
Stroke Prevention , Page last reviewed: March 24, 2015, Page last updated: March 24, 2015.
Dorothy Edwards, PhD NINDS National Institute of Neurological Disorders and Stroke