University of Dammam

College of Nursing
Critical Care Nursing Course (1610 – 412)

Dr. Sahar Elmetwally

A. Prof. Medical Surgical Nursing
1434-2013

By
Dr. Sahar Elmetwally
2012 - 1433

1 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

Outlines:

1. Overview about the stroke

2. Definition of stroke – related terminologies.
3. Causes & predisposing factors of stroke
4. Classifications of stroke:
a. Ischemic stroke
b. Hemorrhagic stroke
5. Pathophysiology of different types of stroke
6. Manifestations of stroke
7. Diagnosis of stroke
8. Management of stroke:
 Medical & surgical management
 Nursing management
 Rehabilitation
Objectives:

 At the end of this lecture, the student will be able to :

1. Define stroke - related terminologies.

2. Identify the causes & predisposing factors of stroke.
3. Discuss the pathophysiology of stroke.
4. Compare between the different types of stroke.
5. Describe manifestations of strokes.
6. List three diagnostic studies used in acute phase of stroke.
7. Mention three drug groups used in treatment of stroke.
8. List two surgical procedures used in treatment of stroke.

2 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

9. Identify the key components of the assessment of patient experiencing strokes

10.Formulate an individualized nursing care plan of stroke patient.

Overview of stroke:
 Stroke is one of the leading causes of permanent disability in adults.
 It is the third leading cause of morbidity and mortality.
 High proportion experiencing recurrence within weeks to years.
 Chances for complete recovery depending on circulation returning to normal soon
after the initial stroke.
 The area of the brain involved and the extent of the insult influence the prognosis.

 Right CVA results in Left side involvement often associated with safety/
judgment.
 Left CVA results in Right side involvement often associated with speech
problems.

Definitions of stroke – related terminologies:

Cerebrovascular accident (CVA) commonly referred to as a stroke and now being

termed “brain attack”.

Stroke is defined as the clinical syndrome of rapid onset of cerebral deficit

(usually focal) , lasting more than 24 hours or leading to death, and results from
a disruption of blood flow to a region of the brain . Blood flow is disrupted because
of the rupture, stenosis or occlusion of the blood vessels.

Transient Ischemic Attack (TIA) is an alteration of cerebral tissue perfusion related

to a temporary neurological disturbance. It is manifested by sudden loss of motor or
sensory function. It lasts for a few minutes to a few hours, but no longer than 24
hours. It is caused by temporarily diminished blood supply to an area of the brain &
leaving no residual deficits with complete functional recovery.

3 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

Classification of stroke

Pathophysiology of stroke:

Pathophysiology of ischemic stroke:

1. Partial or complete occlusion of a cerebral blood vessel is resulting from

cerebral thrombosis (due to arteriosclerosis) or embolism.

2. Ischemia related to decreased blood flow to an area of the brain secondary to

systemic disease, such as cardiac or metabolic disease.

4 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

 When blood flow to any part of the brain is impeded, nutrients & oxygen
deprivation of the cerebral tissue begins.
 Deprivation for 1 minute can lead to reversible symptoms, such as loss of
consciousness.
 Oxygen deprivation for longer periods( more than 10 minute) can produce
necrosis of the neurons.

The necrotic area (infracted) is irreversible and the surrounding area of potentially
salvageable is called “ischemic penumbra.”

Pathophysiology of hemorrhagic stroke:

1. Hemorrhage occurring when a blood vessels leaks or breaks in the brain tissue
(intracerebral) or in the subarachnoid space (subarachnoid)
 Blood outside of the vessels act as an irritant to the tissue

5 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

Predisposing factors of stroke:

1. Incidence increased with aging.

2. Health behaviors : cigarette smoking, alcohol abuse.
3. Cardiovascular diseases :MI, atrial fibrillation, hypertension, atherosclerosis.
4. Vascular abnormalities: cerebral aneurysms & arteriovenous malformations
5. History of Transient Ischemic Attacks.
6. Drugs : oral contraceptive , anticoagulant and antiplatelet.
7. Metabolic diseases: diabetes mellitus, Hyperlipidemia
8. Blood disorders (such as sickle cell disease)
9. Sedentary lifestyle, lack of exercise & obesity.
10.Family history.
Manifestations of Stroke:
 Altered level of conscious .
 Change in mental status.
 Haemiparesis: weakness on one side of the body.
 Hemiplegia: paralysis on one side of the body .
 Ataxia: inability to coordinate muscular movement .
 Dysphagia.
 Dysarthria: the inability to pronounce speech clearly (slurring of speech).
 Paresthesia: numbness and tingling of body parts occurs .
 Agnosia: disturbance in ability to recognize a familial objects through the
senses .
6 Management of stroke patient
 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

 Loss of sensation / perception..

 Diplopia : double vision.
 Aphasia: inability to communicate, it may involve all aspect of
communication including speaking, reading, writing & understanding.
 Short term and long term memory loss.
 Decreased attention span.
 Impaired ability to concentrate & poor reasoning.
 Unusual emotional response; depression, Loss of self control, Withdraw,
anger, fear & emotional lability.
 Bowel and bladder dysfunction, retention, impaction or incontinence.
 Seizures, fever.

Table 1: Clinical manifestations according to types of stroke are:

Item Thrombotic Embolic Hemorrhagic

Time / Tend to develop No time Typically occur during

activity during sleep or pattern, active working
pattern within 1 hour of Unrelated to
arising. activity
Onset Ischemia Occur Rapid onset of complete
produced rapidly within 10 hemiplegia occurs over
gradually so seconds & often minutes to 1 hour
clinical S &S without warning. Severe headache neck
develop more stiffness (nuchal rigidity)
slowly

Progress Relative Relative Usually loss of function

Prognosis preservation of preservation of with slower recovery , less
consciousness. consciousness complete recovery.

Rapid progression to
coma.

7 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

Diagnosis of stroke:
A. Laboratory studies:
 Complete blood cell count (CBC)
 Coagulation parameters
 ABGs indicate hypoxia
 Electrolytes
 Glucose
 Lipid profile

B. Diagnostic studies:
 CT scan
 MRI
 Lumbar puncture
 Cerebral angiogram
 Carotid Doppler
 Angiography
 ECG
 EEG
 ICP > 15 mm Hg

Management of stroke:

1. Medical management:
Treat according to the cause.
 Thrombolytic agents -------- tissue plasminogen activator (t-PA)
 Anticoagulation and antithrombotic ( heparin and Warfarin)
 Antiplatelet agents (aspirin and dipyridamole ).
Anti-hypertensive (Control of blood pressure ) .

Further Treatment of stroke patient:

 Treatment of all risk factors.
 Controlling increased Intracranial Pressure.
 Osmotic diuretics such as furosemide or mannitol can be used to treat cerebral
edema.
 Specific neurological issues, e.g. epilepsy, pain, incontinence & fever.
8 Management of stroke patient
 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

 Dexamethasone to reduce cerebral oedema.

 Possible administration of blood products.
 Stool softeners.
 Control of seizure .

2. Surgical Management:
a. Carotid endarterectomy.
b. Repair of aneurysm .
c. Angioplasty and stents.
d. Shunting may be required if hydrocephalus present.

3. Nursing Management:
Assessment:
 A thorough Neurological Assessment is essential to identify deficits the patient
is experiencing.
 A complete bedside NIHSS (Notational Institute of Health Stroke Scale)
assessment may be performed on admission to the intensive care unit.

The NIHSS is a valuable tool that can be used in the emergency

department to rate severity of the stroke and determine if the
individual is a candidate for t-PA (see Table 2).
The NIHSS is also helpful for making subsequent assessments
and should be performed in conjunction with the
neurological examination.

Patients with an NIHSS score of <10 have a much more

favorable outcome at 1 year than patients with an NIHSS
score of >20.

Assess & record the following: assess history:

9 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

Activity at onset of CVA.

Progression and severity of symptoms.
Level of consciousness, orientation, cognition, memory.
Ability to concentrate and attend to tasks.
Motor status include e.g. gait, balance, weakness to total paralysis of extremities.
 Sensory status ( speech, hearing, vision).
Cranial nerve function.
Bowel and bladder incontinence, retention.
Body image & self concept disturbance.

Table 2 ■ National Institutes of Health Stroke Scale

Items tested Response Score
1.a. Level of consciousness (LOC) -Alert 0
-Drowsy 1
-Stuporous 2
-Coma 3
1.b. LOC questions ( orientation) Answers both correctly 0
Answers one correctly 1
Answers neither correctly 2
1.c. LOC commands ( response) Performs both correctly 0
Performs one correctly 1
Performs neither correctly 2
2. Best gaze Normal 0
Partial gaze palsy 1
Forced deviation 2
3. Visual No visual loss 0
Partial hemianopia 1
Complete hemianopia 2
Bilateral hemianopia 3
4. Facial palsy Normal 0
Minor paralysis 1
Partial paralysis 2
Complete paralysis 3
5. Motor arm No drift 0
Drift 1
Some effort against gravity 2
No effort against gravity 3
No movement 4

10 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

Amputation, joint fusion explain 9

6. Motor leg No drift 0
Drift 1
Some effort against gravity 2
No effort against gravity 3
No movement 4
Amputation, joint fusion explain: 9
7. Limb ataxia Absent 0
Present in one limb 1
Present in two limbs 2
8. Sensory Normal 0
Mild to moderate loss 1
Severe to total loss 2
9. Best language No aphasia 0
Mild to moderate 1
Severe 2
Mute 3

Personality changes, emotional lability.

Past medical history.
Social history.
Current medication & non prescribed drugs . the nurse should be alert for
anticoagulants, aspirin, vasodilator & illegal drug use.
Frequent monitors of blood pressure, heart rate, and respirations.

-Blood pressure should be monitored and assessed continually for

causative factors of rises. Elevated blood pressure may be due to a
physiological response to hypoxia, increasing ICP, hemorrhagic
transformation, full bladder, pain, nausea, a loud environment, or
preexisting hypertension.
Continuous Cardiac Monitoring
 Assessment of oxygenation The oxygen level can be monitored through arterial
blood gases (ABGs), oxygen saturation not less than 92%.
 Blood Glucose Monitoring for Hyperglycemia & Hypoglycemia.
Assess nutrition daily with I &O, WT, %diet, calorie count
 Carefully monitored for infection, changes in temperature ( Treat if greater than 99
F with Tylenol).
Monitors the patient for major and minor bleeding complications in the first 24 to 36
hours after administration of rtPA.

11 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

Plan:
The nurse plays a significant role in preventing complications or any
neurological deficit produced by a stroke. Effective interventions for the treatment of
acute stroke help lower the death rate and reduce the morbidity of patients who have
had a stroke.

 Patient outcome and nursing intervention

a. Respiratory
o Patient will maintain adequate airway.
o Patient will maintain oxygen saturation (SpO2) within normal limits.
o Atelectasis will be prevented.
Monitor breath sounds every shift.
Check oxygen saturation every shift.
Oxygen with humidity if needed.
Place in semi-fowler`s .
Instruct to cough and deep breath and incentive spirometry every 2 hours while
awake.
Assist with removal of airway secretions as needed. Be certain to preoxygenate
before suctioning.

b. Neurological:
o Patient will maintain adequate cerebral perfusion pressure:
Obtain vital signs and perform a neurological assessment to establish a baseline
and to monitor for the development of additional deficits.
Use NIHSS for detection of early changes suggesting edema or extension of stroke.
Position head of bed at 30 degrees to promote venous return.
Avoid wide fluctuations in BP to minimize the risk of additional cerebral ischemia,
infarction, and or hemorrhage .
Avoid valsalva, including hip flexion, straining at defecation, rectal temperature,
sustained cough because valsalva increase ICP.
Provide rest periods between nursing intervention to minimize ICP.
Provide quite environment.
Implement DVT precautions to include sequential compression devices.

o Patient will not develop complications of immobility:

12 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

Stroke patients may be initially kept on bed rest but should be mobilized when they
are hemodynamically stable.
Assess for neglect.
Provide active or passive range of motion to all extremities every shift.
Establish splinting routine to affected extremities.
Monitor daily blood glucose.
Instruct in mobility aids; instruct in strategies of fall prevention.

N.B. Complications from immobility account for up to 51% of

deaths in the first 30 days after ischemic stroke. Early
mobilization reduces risk of atelectasis, pneumonia, DVT, and
pulmonary embolism.

o Patient will establish an effective method of communication:

Assess ability to speak and to follow simple commands.
Arrange for consultation with speech language pathologist to differentiate
language disturbances.
Use communication aids such as picture cards and pantomime to enhance
communication.
Provide a calm, unrushed environment. Listen attentively to the patient. Speak in a
normal tone.

c. Gastrointestinal
o Patient will receive adequate caloric intake and will not experience
decrease in weight from baseline.
o Patient will be free from aspiration.
Obtain admission weight.
Perform cranial nerve assessment (including ability to swallow) to identify deficits.

13 Management of stroke patient

 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

Obtain consultation from speech–language pathologist to see if patient is safe to

eat orally.
Provide proper diet and assist with feeding as needed.
Provide N/G or PEG feeding
Monitor caloric intake; implement calorie count if necessary.
Obtain dietary consultation to obtain recommendation for supplements.

d. Genitourinary
o The patient will achieve urinary/ bowel continence
Perform assessment of usual patterns and habits.
Establish a toileting schedule using a bedpan, urinal, or bedside commode every 2
hours during waking hours and every 4 hours at night.
Monitor for the development of urinary retention or urinary tract infection.
Use bladder scanner to evaluate contents of bladder.
Avoid use of indwelling catheter to prevent infection.
Allow patient to assume a normal position for voiding unless contraindicated to
promote complete bladder emptying.
I & O chart.
Limit oral fluid intake in the evening to decrease possibility of nighttime
incontinence
If urinary incontinence persists:
1.Consult physician about intermittent catheterization, insertion of indwelling
catheter, or use of external catheter.
2. Initiate a bladder training program.
3. Provide emotional support.

If bowel incontinence persists:

1. Establish & adhere to bowel training program.
2. Provide client with liner for underwear or
3. Utilize room deodorizers as necessary
4. Provide emotional support.

e. Cardiovascular
o Patient will not experience any arrhythmias
Monitor vital signs closely.
14 Management of stroke patient
 University of Dammam
College of Nursing
Critical Care Nursing Course (1610 – 412)

Manage blood pressure carefully; avoid sharp drops in blood pressure that could
result in hypotension and cause an ischemic event secondary to hypotension.
During cardiac monitoring phase, identify arrhythmias.
Treat arrhythmias to maintain adequate cerebral perfusion pressure and reduce
chance of neurological impairment.

4. Rehabilitation
 Physiotherapy.
 Speech therapy & dysphasia care.
 Occupational therapy.

15 Management of stroke patient