STROKE (BRAIN ATTACK)
- A stroke or brain attack, formerly known as a cerebrovascular accident (CVA), is a sudden focal neurological deficit caused by cerebrovascular disease.
- A stroke is a syndrome in which the cerebral circulation is interrupted, causing neurological deficits.
- Cerebral anoxia lasting longer than 10 minutes causes cerebral infarction with irreversible change.
- Cerebral edema and congestion cause further dysfunction.
- Diagnosis is determined by a CT scan, electroencephalography, cerebral arteriography, and MRI.
- Transient ischemic attack may be a warning sign of an impending stroke
- The permanent disability cannot be determined until the cerebral edema subsides.
- The order in which function may return is facial, swallowing, lower limb, speech, and arms.
- Carotid endarterectomy is a surgical intervention used in stroke management; it is targeted at stroke prevention, especially in clients with symptomatic carotid stenosis.
- Hemorrhage from rupture of a vessel
- Anticoagulation therapy
- Diabetes mellitus
- Oral contraceptives
A critical factor in the early intervention and treatment of stroke is the accurate identification of stroke manifestations and establishing the onset of the manifestations. Stroke screening scales may be used to quickly identify stroke manifestations.
- Assessment findings depend on the area of the brain affected.
- Lesions in the cerebral hemisphere result in manifestations on the contralateral side, which is the side of the body opposite the stroke.
- Airway patency is always a priority.
- Pulse (may be slow and bounding)
- Respirations (Cheyne-Stokes)
- Blood pressure (hypertension)
- Headache, nausea, and vomiting
- Facial drooping
- Nuchal rigidity
- Visual changes
- Speech changes
- Decreased sensation to pressure, heat, and cold
- Bowel and bladder dysfunctions
Damage occurs in Broca’s area of the frontal brain.
The client understands what is said but is unable to communicate verbally.
Injury involves Wernicke’s area in the temporoparietal area.
The client is unable to understand the spoken and often the written word.
- Global or mixed: Language dysfunction occurs in expression and reception.
- Interventions for aphasia Provide repetitive directions. Break tasks down to one step at a time. Repeat names of objects frequently used. Allow time for the client to communicate. Use a picture board, communication board, or computer technology.
Interventions during the acute phase of stroke
- Maintain a patent airway and administer oxygen as prescribed.
- Monitor vital signs.
- Usually a blood pressure of 150/100 mm Hg is maintained to ensure cerebral perfusion.
- Suction secretions as prescribed, but never suction nasally or for longer than 10 seconds to prevent increased ICP.
- Monitor for increased ICP because the client is most at risk during the first 72 hours following the stroke.
- Position the client on the side, with the head of bed elevated 15 to 30 degrees as prescribed.
- Monitor level of consciousness, pupillary response, motor and sensory response, cranial nerve function, and reflexes.
- Maintain a quiet environment.
- Insert a Foley catheter as prescribed.
- Administer intravenous fluids as prescribed.
- Maintain fluid and electrolyte balance.
- Prepare to administer anticoagulants, antiplatelets, diuretics, antihypertensives, and anticonvulsants as prescribed.
- Establish a form of communication.
Interventions in the postacute phase of a stroke
- Continue with interventions from the acute phase.
- Position the client 2 hours on the unaffected side and 20 minutes on the affected side.
- Position the client in the prone position if prescribed, for 30 minutes three times daily.
- Provide skin, mouth, and eye care.
- Perform passive range-of-motion exercises to prevent contractures.
- Place antiembolism stockings on the client; remove daily to check skin.
- Measure thighs and calves daily for an increase in size.
- Monitor the gag reflex and ability to swallow.
- Provide sips of fluids and slowly advance diet to foods that are easy to chew and swallow.
- Provide soft and semisoft foods and flavored, cool or warm, thickened fluids rather than thin liquids because the stroke client can tolerate these types of food better; speech therapists may do swallow studies to recommend consistency of food and fluids.
- When the client is eating, position the client sitting in a chair or sitting up in bed, with the head and neck positioned slightly forward and flexed.
- Place food in the back of the mouth on the unaffected side to prevent trapping of food in the affected cheek.
Interventions in the chronic phase of stroke
- Neglect syndrome
Client is unaware of the existence of his or her paralyzed side (unilateral neglect), which places the client at risk for injury.
Teach the client to touch and use both sides of the body.
Client has blindness in half the visual field.
Homonymous hemianopsia is blindness in the same visual field of both eyes.
Encourage the client to turn the head to scan the complete range of vision; otherwise, he or she does not see half of the visual field.
- Approach the client from the unaffected side.
- Place the client’s personal objects within the visual field.
- Provide eye care for visual deficits.
- Place a patch over the affected eye if the client has diplopia.
- Increase mobility as tolerated.
- Encourage fluid intake and a high-fiber diet.
- Administer stool softeners as prescribed.
- Encourage the client to express her or his feelings.
- Encourage independence in activities of daily living.
- Assess the need for assistive devices such as a cane, walker, splint, or braces.
- Teach transfer technique from bed to chair and from chair to bed.
- Provide gait training.
- Initiate physical and occupational therapy for assessment and the need for adaptive equipment or other supports for self-care and mobility.
- Refer client to a speech and language pathologist as prescribed.
- Encourage the client and family to contact available community resources.