MANAGEMENT OF ACUTE STROKE, Study notes of Nursing

Download MANAGEMENT OF ACUTE STROKE and more Study notes Nursing in PDF only on Docsity! MANAGEMENT OF ACUTE STROKE Presented by: Garden City Hospital Professional Nursing Development Garden City Hospital is an approved provider of continuing nursing education by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation Management of Acute Stroke Purpose of Activity: To demonstrate increased knowledge relative to the management of cerebrovascular disease and to remain current with advancements in the identification and treatment of acute stroke. Objectives of the Program: 1. Differentiate the signs/symptoms of acute ischemic stroke versus acute hemorrhagic stroke. 2. Describe changes and conditions that necessitate rapid response interventions. 3. Define strategies to prevent stroke related complications. 4. Application of National Institute of Health Stroke Scale. 5. Recall management of acute stroke treatment modalities. 6. List modifiable risk factors to prevent secondary stroke. Target Audience: Registered Nurses and Licensed Practical Nurses. Date: September 1, 2011 5.5 Contact Hours awarded if completion of entire educational activity, passing score of >80% on post-test, and completion/submission of evaluation form. Must be completed by June 22, 2014 to receive contact hours. Planning Committee/Presenters: Susan Karasinski RN MSN, Fawn Covert RN BSN, Allison Mardeusz RN BSN, Vicki Ashker RN MSA CCRN, Nancy VanCleave RN BSN CNOR, Adriana Comsa RN, Yvonne Cleaver RN Garden City Hospital is an approved provider of continuing nursing education by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation Causes of ICH:  Arteriovenous malformation  Aneurysm rupture  Cerebral venous thrombosis  Coagulopathies  Eclampsia  Infection  Neonatal germinal matrix or subependymal hemorrhage  Sickle Cell disease  Illicit or sympathomimetic drug abuse  Trauma  Vasculitis Signs and Symptoms of ICH:  Headache (Extremely painful)  Altered Level of Consciousness (same as AIS)  Nausea and vomiting (same as AIS)  Seizures  Light intolerance  Neck pain  Gaze preference (same as AIS)  Visual field deficits (same as AIS) Differentiation of Ischemic VS Hemorrhagic Stroke Although presenting symptoms can be similar, with the exception of the severe headache associated with a hemorrhagic stroke, radiologic imaging studies will provide the clinician with the differential. CT scan is the first diagnostic tool to evaluate for the difference between ischemic or hemorrhagic stroke. It can locate the site of bleeding and indicate any displacement of tissue, hemorrhage or hematoma. If bleeding is present on the CT scan, the patient is disqualified as a candidate for tissue plasminogen activator (tPA). If blood is present, a Neurosurgery consult is completed to determine whether the patient is a candidate for surgical intervention. If no bleeding is present on CT scan, it is termed “CT Negative”; treatment for reversal of stroke will continue as this ONLY refers to the absence of blood NOT the absence of stroke. An MRI can provide the same valuable information; however the CT scan can be completed more rapidly and does not have the same amount of contraindications as MRI. If a study of vascular formation within the brain tissue is necessary, angiography studies can be completed, though not as a first line study. If a clinician is concerned with ruling out meningitis, a lumbar puncture can be performed as well. Condition Changes Requiring Rapid Response Intervention (Sudden Onset of Symptomatology) Decreased Level of Consciousness: Patient’s that have a sudden onset of symptoms that would include the inability to remain awake, inability to focus attention without any other reasonable cause need to be considered for stroke assessment. Facial Droop: Acute onset of facial droop can indicate stroke, having the patient attempt to smile to assess for symmetry can provide an indicator to the clinician that the patient may need to be evaluated for stroke. Facial droop is often categorized as a motor deficit. Change in Speech Patterns: Dysphonia-whispering or hoarse speech, complete inability to speak, slurred speech, Aphasia-difficulty saying or expressing words clearly, Dysarthria-problems using language or inappropriate speech. Motor Changes: Often described as ‘weakness’, ‘heaviness’ or ‘clumsiness’. The patient may concurrently experience sensory symptoms such as numbness. Complaints of generalized weakness should be taken into consideration when assessing the patient as both sides can experience motor symptoms simultaneously. Downward drifting of the patients outstretched/pronated arm are indicative of a hemiparesis and should be taken very seriously. The anatomical extent of the motor deficit is and important factor for determining the patient’s prognosis in the acute phase. Strategies to Prevent Stroke Related Complications DVT: Deep venous thrombosis (DVT) of the legs is common in patients with a recent stroke, particularly older patients with a severe hemiplegia who are immobile. DVT’s are most often asymptomatic, or unrecognized, but my a still lead to further complications and must be prevented and/or investigated in the post-stroke population. DVT should be suspected if a patient’s leg becomes swollen, hot or painful or if the patient develops a fever. It can be difficult to assess if the patients paretic leg becomes swollen as the effects of gravity and immobility will cause the leg to swell. If the patient develops swelling while the patient is still being nursed in bed DVT is the likely cause because the dependent effects of gravity have not affected the extremity. Stroke patients who have communication deficits may not be express the discomfort associated with acute DVT so the diligent assessment of the multidisciplinary team will be the key in early diagnosis. PE: Pulmonary embolism (PE) Maneuvers to reduce the risk of DVT and PE include:  Early mobilization: Avoidance of prolonged bedrest, evaluation and treatment utilizing physical and occupational therapy when patient is stabilized.  Hydration/Fluids: An elevated urea, likely indicating dehydration, is associated with higher risk of DVT. Additionally, hydration is generally indicated in part because acute stroke patients are often unable to take in adequate fluids orally.  Full-length graduated compression stockings: Patients undergoing surgery have shown a significant reduction in DVTs with the application of stocking prior to surgery. Unlike surgery, stockings cannot be applied before the onset of insult, so there is a chance the patient will develop a DVT prior to stocking application. When utilized stockings should be fitted in accordance with the manufacturers guidelines and removed daily to check for skin problems.  Aspirin: When started within 48hours of ischemic stroke it has been shown to reduce relative risk of PE and improves patients’ overall outcome.  Heparin: It has been shown to reduce the risk of DVT in ischemic stroke, but can complicate treatment if hemorrhagic complications arise. Low molecular weight heparin (LMWH) has been used in populations with a very low likelihood of hemorrhage after ischemic stroke yet remains at extremely high risk for DVT/PE. Examples of patients that meet this criteria would be patients with severe leg weakness and immobility, cancer, thrombophilia or previous venous thromboembolism.  External pneumatic compression: Studies have shown that when coupled with the use of graded compression stockings, they can greatly reduce the incidence of DVT/PE related complications post stroke. Hypertension (HTN): Blood pressure is generally higher with hemorrhagic stroke patients rather than ischemic stroke patients. Patients that have a history of hypertension tend to have higher blood pressures post infarct; the acute on chronic hypertensive effect. Extremely high blood pressure after stroke has been associated with poorer outcomes independent of age and stroke severity. During the first few days after stroke blood pressure should be monitored and treated only if end organ damage is evident. Conditions that would necessitate lowering of blood pressure immediately post stroke include: Papilloedema or retinal hemorrhage and exudates, marked renal failure with microscopic hematuria and proteinuria, left ventricular failure diagnosed on clinical features and supported by evidence from chest X-ray and/or echocardiogram, features of hypertensive encephalopathy (seizures, reduced conscious level), or aortic dissection. Hypertension must be managed very carefully because an acute reduction in cerebral perfusion can further increase cerebral ischemic damage. When lowering blood pressure the target should be to gradually lower the pressure over hours-days, not minutes. that a HgbA1C be completed to distinguish diabetes from stroke induced hyperglycemia.  Hypoglycemia: Hypoglycemic symptoms can mimic that of a transient ischemic attack (TIA) and should be ruled out once suspected in the stroke population. Patients are less likely to suffer from hypoglycemia as a cause of stroke but may be placed at risk by clinicians when trying to correct hyperglycemia. If a patient has a diagnosis of diabetes and has a reduced oral intake due to complications of stroke they too may be placed at higher risk for hypoglycemia. Blood glucose in this population should be regularly monitored and recorded to evaluate and trend fluctuations. Skin Breakdown: Stroke patients are at risk for skin breakdown because of loss of sensation and impaired circulation, older age, decreased level of consciousness, and inability to move themselves because of paralysis. Related complications such as incontinence can accelerate skin breakdown. Patients should be examined for skin breakdown after being repositioned or sitting. Special care should be taken when moving patients to avoid excessive friction or pressure. Patients should not be left in any single position for longer than 2 hours. The skin must be kept clean and dry, and special mattresses should be used where indicated (Summers et al, 2009) Airway Obstruction: Patients with a decreased level of consciousness, impaired bulbar function or those who have aspirated may have an obstructed or partially obstructed airway. Central cyanosis, noisy airflow with grunting, snoring or gurgling, an irregular breathing pattern and retracting of the suprasternal area and intercostal muscles may indicate an obstruction. Transient obstruction is common in the acute phase of stroke during sleep and it is important that apneic spells due to an obstructed airway are not mistakenly attributed to periodic respiration and so ignored. If an obstructed airway is suspected, the oropharynx should be cleared of any foreign matter with a gloved finger sweep, the patient’s jaw pulled forward and the neck extended to stop the tongue from falling back and occluding the airway. Placement of an oropharyngeal or nasopharyngeal airway may be necessary and the patient should be evaluated for potential intubation. Seizures: A small percentage of stroke patients will have a seizure within the first week or two of their stroke; these are referred to as ‘onset seizures’, most occurring within the first 24 hours. Onset seizures are more common in severe strokes, hemorrhagic strokes and strokes involving the cerebral cortex. Diagnosis of seizure should be done utilizing an accurate description from the patient, any witnesses and may require confirmation via electroencephalography (EEG). Anti- epileptic drugs should be used in their usual fashion to treat seizures, though there is no evidence to support the use of anti-epileptic drugs on at risk populations with no evidence of seizure. Precautionary measures at the bedside include: Padding the bedrails and fall prevention guidelines. Application of the National Institute of Heath Stroke Scale (NIHSS) The National Institutes of Health Stroke Scale (NIHSS) is a user-friendly, valid and reliable tool for the assessment of brain attack. It is utilized for defining stroke severity and measuring the effects of interventions. It includes an evaluation of eye movement, visual fields, coordination, motor strength, sensation and it also detects the presence of aphasia and neglect. The scale’s 11 categories are listed in the first column. In column 2, the observer selects –from a choice of 3 to 6 numbered descriptors for each item- the one that best depicts the patient’s response. Results are then totaled. A score of zero is considered normal, and 42 is the worst possible examination, reflecting the most severe neurologic deficits. (See example scale below) Category Description Score Date/Time/Initials 1a. Level of consciousness Alert Drowsy Stuporous Coma 0 1 2 3 1b. LOC, questions (month, age) Answers both correctly Answers one correctly Incorrect 0 1 2 1c. LOC, commands (Open/close eyes, make fist, let go) Obeys both correctly Obeys one correctly Incorrect 0 1 2 2. Best gaze (Eyes open-patient follows examiner’s finger or face) Normal Partial gaze palsy Forced deviation 0 1 2 3. Visual (Introduce visual stimulus/threat to pt’s visual field quadrants) No visual loss Partial hemianopia Complete hemianopia Bilateral hemianopia 0 1 2 3 4. Facial palsy (Show teeth, raise eyebrows, squeeze eyes shut) Normal Minor Partial Complete 0 1 2 3 5a. Motor arm-Left (Elevate extremity to 90˚ and score drift/movement) No drift Drift Can’t resist gravity No effort against gravity No movement Amputation, joint fusion etc. 0 1 2 3 4 X 5b. Motor arm-Right (Elevate extremity to 90˚ and score drift/movement) No drift Drift Can’t resist gravity No effort against gravity No movement Amputation, joint fusion etc. 0 1 2 3 4 X 6a. Motor leg-Left (Elevate extremity to 30˚ and score drift/movement) No drift Drift Can’t resist gravity No effort against gravity No movement Amputation, joint fusion etc. 0 1 2 3 4 X 6b. Motor leg-Right (Elevate extremity to 30˚ and score drift/movement) No drift Drift Can’t resist gravity No effort against gravity No movement Amputation, joint fusion etc. 0 1 2 3 4 X 7. Limb ataxia (Finger-nose, heel down shin) Absent Present in one limb 0 1 Present in two limbs 2 8. Sensory (Pin prick to face, arm, trunk, and leg-compare side to side) Normal Partial loss Severe loss 0 1 2 9. Best Language (Name item, describe a picture and read sentences) No aphasia Mild to moderate aphasia Severe aphasia Mute 0 1 2 3 10. Dysarthria (Evaluate speech clarity by pt repeating listed words) Normal articulation Mild to moderate dysarthria Near to unintelligible or worse Intubated or other physical barrier 0 1 2 X 11. Extinction and inattention (Use information from prior testing to identify neglect or double simultaneous stimuli testing) No neglect Partial neglect Complete neglect 0 1 2 Total Score *(Criddle, Bonnono, and Fisher, 2003) Advanced Cardiovascular Life Support (ACLS) Treatment Algorhythm Goals set forth by the American Heart Association (AHA) regarding stroke identification and management are as follows: 1. Immediate general assessment by the stroke team, emergency physician, or another expert within 10 minutes of arrival; order urgent non-contrast CT scan. 2. Neurologic assessment by the stroke team or designee and CT scan performed within 25 minutes of hospital arrival. 3. Interpretation of the CT scan within 45 minutes of ED arrival. 4. Initiation of fibrinolytic therapy in appropriate patients (those without contraindications) within 1 hour of hospital arrival and 3 hours from symptom onset. 5. Door-to-admission time of 3 hours. (AHA, 2010) Refer to American Heart Association: Adult Suspected Stroke Algorithm, 2011. Exclusion Criteria:  Evidence of ICH on CT scan  Clinical presentation suggestive of SAH  Active internal bleeding  Intracranial surgery, serious head trauma or previous stroke within 3 months  Any history of ICH, arteriovenous malformation (AVM) or aneurysm  Blood Pressure: If blood pressure cannot be controlled after two attempts o Systolic > 185 o Diastolic > 110  Glucose < 50 per blood glucose monitor  Known bleeding diathesis including: o Platelet count < 100,000 o On heparin (within 48 hours) & elevated PTT o INR > 1.7 o Low molecular weight heparin administered in the past 24 hours at therapeutic doses (Excludes prophylactic doses) Additional Exclusion Criteria 3 hours to 4.5 hours:  Age > 80  Major neurological deficits with a NIHSS greater than 25  History of stroke AND diabetes  Receiving anticoagulant therapy regardless of INR, PT/PTT Dosing: tPA is based on the patient’s weight  0.9 mg/kg  Maximum dose ANY patient can receive is 90 mg  Two-part administration process o IV Bolus o 1 hour infusion Administration:  1st part: o 10% of the total dose is administered as an IV bolus o Bolus administration occurs over 1 minute  2nd part: o Remaining 90% is infused over 60 minutes o Must be administered via IV pump Vital signs and NIHSS to be completed by nursing every 15 minutes during administration. Complications and Side Effects: The most common complication with tPA administration is bleeding. Bleeding is further broken down into two broad categories.  Internal o Intracranial o Retroperitoneal o GI o GU o Respiratory tracts  Superficial: o Venous cut downs o Arterial and venous puncture sites o Catheter insertion sites o Needle puncture sites o Sites of recent surgical intervention Precautions:  Avoid IM injections  Use extreme caution with venipunctures; only perform as required  If arterial puncture is needed during infusion or after, utilize upper extremity. Manual compression will be required. o Pressure to be applied for 30 minutes o Pressure dressing to be applied to site o Frequent checks of the puncture site  Pt must be placed on seizure precautions  Bedrest x 24 hours  HOB at 30 degrees, place tPA sign above bed  NPO until evaluated by Speech Therapy or Neurology Post tPA Assessment and Documentation:  Vital signs and NIHSS by nurses o Q 15 minutes X 2 hours from start of tPA o Q 30 minutes X 6 hours o Q hour X 16 hours  Temperature Q 4 hours X 24 hours  Continuous pulse oximetry  Blood glucose (may require tight glycemic control) o Upon admission o Q 6 hours if NPO o AC & HS once patient has resumed meal consumption o Notify physician if blood glucose > 140 Increased Intracranial Pressure (ICP): In the event of ischemia or infarction of the brain tissue, there are structural changes that occur causing a decrease in the collagen and connective tissues of the brain. This loss of vascular structure causes the breakdown of the blood brain barrier and contributes to cerebral edema. With the increase in brain tissue size, CSF and blood should get displaced allowing space for the increasing size of the brain tissue. Only so much space is allotted and the brain will eventually press against the skull causing an increased ICP. Early Signs of Increased ICP:  Change (decrease) in LOC: o Lethargy, confusion, disorientation, restlessness or apathy  Headache  Change in verbal/motor responses: o Slurred speech o Inability to move extremity o Facial droop  Vomiting without nausea  Pupils: o Pupillary changes on one side o Sluggish reaction to light bilaterally o Pupillary inequality  Motor response: o Sudden weakness o Positive pronator drift  Ocular palsies: Paralysis of the muscles used to move the eyes  Papilledema: Swelling of the optic disc leading to blurred vision and blind spots Late Signs of Increased ICP:  Unarousable  Pupils fixed and dilated  Motor response: Profound weakness  Abducens Palsies: Nerve problem resulting in double vision  Cushings Triad: Increased systolic blood pressure, bradycardia, respiratory irregularity  Widened Pulse Pressure: An increased distance between systolic and diastolic BP numbers Nursing Interventions for Treating Increased ICP: Clustering activities is recommended to reduce the amount of prolonged time with increased ICP. Let your patient rest between activities to allow their ICP to return to baseline. Timely intervention for fevers is important as well to reduce the metabolic (oxygen) demands of the injured brain tissue. To improve venous return, keep the patient’s head and neck aligned and keep the head of the bed above 30 degrees, but below 90 degrees (prolonged hip flexion can increase ICP). If your patient is intubated and/or mechanically ventilated, make sure that tracheostomy ties are not too tight. Limit suctioning to 2 passes with an insertion time of less than 10 seconds each; reduce cough stimulation when possible due to a risk for increasing the patient’s ICP. Hypertension (HTN): Hypertension aggravates atherosclerosis and increases vascular resistance (vasoconstriction) within the brain.