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Cerebral function is dependent on oxygen and glucose delivery to the neurons of the brain. When blood flow is
severely compromised or absent, the oxygen and glucose needed to meet the brain’s metabolic needs are not
available. The brain has no capability to store oxygen or glucose, so it relies on a constant supply of these nutrients.
If the supply of glucose stopped, the brain tissue dies.

The disruption in blood flow initiates a complex series of cellular metabolic events. Decreased cerebral blood flow,
the ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood per minute.
Aerobic respiration, neurons are no longer able to maintain aerobic respiration. Anaerobic respiration, the
mitochondria would need to switch to anaerobic respiration, which generates large amounts of lactic acid, causing a
change in the pH and rendering the neurons incapable of producing sufficient quantities of adenosine triphosphate
(ATP) to fuel the depolarization processes. Loss of function, the membrane pumps that maintain electrolyte
balances begin to fail, and the cells cease to function.

3 Prioritized Nursing Diagnoses

1. Risk for ineffective tissue perfusion (cerebral) related to bleeding or vasospasm

2. Acute pain (painful shoulder) related to hemiplegia and disuse
3. Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain

5 Nursing management with Rationale


Optimizing Cerebral Tissue Perfusion(interventions per To prevent additional neurological damage

orders as this can differ depending on kind of
stroke ,location and other factors)

Frequent neurological assessments(per orders) Alerts nurse to neurological changes as early as

possible, enables them to notify MD and intervene
when needed

Monitor vital signs appropriately ,know BP limits Closely monitoring BP is essential in managing ICP

Fall prevention measures (non-skid socks, bed in lowest injury prevention; patient will most likely not be able to
locked position, call bell within reach, and so forth) ambulate as they could prior to stroke and will require

Prevent skin breakdown; turn q2hrs,ensure adequate Stroke patients will be at risk for skin breakdown from
protein intake, offloading pillow support, keep linen an inability to move extremities, incontinence, inability
clean and dry to communicate needs, pain and discomfort
5 medications that are commonly given

Medication Rationale Nursing Considerations

Thrombolytic Thrombolytic agents are 1. Assess patient carefully for bleeding

useful in dissolving clot when every15min during the 1st hr. of therapy, every
Alteplase (Activase)t-PA
started within 3 hours of initial 15–30 during the next 8 hrs. and at least every
symptoms.30% are likely to 4 hrs. for the duration of therapy.
recover with little or no 2. Assess neurologic status throughout therapy.
disability. Treatment is base Altered sensorium or neurologic changes may
on trying to limit the size of be indicative of intracranial bleeding.
the infarct.

Anticoagulants To reduce the risk of blood 1. Assess patient taking anticoagulants for
clots and prevent existing signs of bleeding and hemorrhage (bleeding
Coumadin ®
blood clots from getting gums; nosebleed; unusual bruising, tarry, black
bigger by thinning the blood stool hematuria; fall in hematocrit or blood
pressure; guaiac-positive stools; urine; or NG
2. Monitor prothrombin time (PT) or international
normalized ratio(INR)with warfarin therapy, and
hematocrit,and other clotting factors frequently
during therapy.
Antiplatelet Prevent platelets (blood cells) 1. Monitor patient for signs of thrombotic
from sticking together. thrombocytic purpura(thrombocytopenia,
Plavix ®
Prevent formation of clots microangiopathic hemolytic anemia, neuro-
logic findings, renal dysfunction, fever).May
rarely occur, even after short exposure(<2
wk).Requires prompt treatment
2. Monitor for bruising, change in LOC, prolonged
bleeding time.
Angiotensin II receptor Block angiotensin II, a 1. Assess blood pressure and pulse periodically
antagonists chemical that triggers muscle during therapy.NotifyMD for significant changes.
contraction around blood 2. Assess patient for signs of angioedema
Cozaar ®(Losartan)
vessels, narrowing them. By (dyspnea, facial swelling).May rarely cause
inhibiting the chemical, blood angioedema
vessels can enlarge and
blood pressure is reduced.

Statins Lower cholesterol by 1.Instruct patient to notify healthcare professional if

inhibiting the enzyme in the unexplained muscle pain, tenderness ,or weakness
Lipitor ®(Atorvastatin)
blood that produces occurs, especially If accompanied by fever or
cholesterol in the liver malaise

2. Obtain a dietary history, especially with regard to

fat consumption.

Lab Test Considerations: Evaluate serum

Cholesterol and triglyceride levels before initiating,
after 4–6wk of therapy, and periodically thereafter.