Focus on Stroke: Nursing Management
Stroke: NURSING MANAGEMENT Zoya Minasyan, RN, MSN-Edu Structures and Functions of Nervous System Left hemisphere of cerebrum, lateral surface, showing major lobes and areas of the brain. Structures and Functions of Nervous System Structural features of neurons: dendrites, cell body, and axons. Structures and Functions of Nervous System Major divisions of the central nervous system (CNS). Structures and Functions of Nervous System The cranial nerves are numbered according to the order in which they leave the brain. Structures and Functions of Nervous System Arteries of the head and neck. Brachiocephalic artery, right common carotid artery, right subclavian artery, and their branches. The major arteries to the head are the common carotid and vertebral arteries. Structures and Functions of Nervous System Arteries at the base of the brain. The arteries that compose the circle of Willis are the two anterior cerebral arteries joined to each other by the anterior communicating cerebral artery and to the posterior cerebral arteries by the posterior communicating arteries. Structures and Functions of Nervous System The vertebral column (three views). Stroke Stroke occurs when ischemia or hemorrhage into the brain results in death of brain cells. Also known as a brain attack Functions are lost or impaired Such as movement, sensation, or emotions that were controlled by the affected area of the brain Severity of the loss of function varies according to the location and extent of the brain involved. Risk Factors Most effective way to decrease the burden of stroke is prevention. Risk factors can be divided into non modifiable and modifiable risks. Risk Factors Modifiable Hypertension Metabolic syndrome Heart disease Heavy alcohol consumption Poor diet Drug abuse Sleep apnea Obesity Physical inactivity Smoking Non modifiable Age Gender Race Heredity/family history Types of Stroke Strokes are classified on the basis of underlying pathophysiologic findings. Ischemic Thrombotic Embolic Hemorrhagic Major Types of Stroke Ischemic Stroke Ischemic strokes result from Inadequate blood flow to the brain from partial or complete occlusion of an artery 80% of all strokes are ischemic strokes. Ischemic strokes can be Thrombotic Embolic Ischemic Stroke Thrombotic stroke Thrombosis occurs in relation to injury to a blood vessel wall and formation of a blood clot. Result of thrombosis or narrowing of the blood vessel Most common cause of stroke • Lacunar strokes • • a stroke from occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue. thrombotic strokes are associated with hypertension or diabetes mellitus, both of which accelerate atherosclerosis Pathogenesis of Atherosclerosis A, Damaged endothelium. B, Diagram of fatty streak and lipid core formation. C, Diagram of fibrous plaque. Raised plaques are visible: some are yellow, others are white. D, Diagram of complicated lesion: thrombus is red, collagen is blue. Plaque is complicated by red thrombus deposition. Pathogenesis of Atherosclerosis Developmental stages: Fatty streaks Fibrous plaque Earliest lesions Characterized by lipid-filled smooth muscle cells Potentially reversible Beginning of progressive changes in the arterial wall Lipoproteins transport cholesterol and other lipids into the arterial intima. Fatty streak is covered by collagen, forming a fibrous plaque that appears grayish or whitish. Result = Narrowing of vessel lumen Complicated lesion Continued inflammation can result in plaque instability, ulceration, and rupture. Platelets accumulate and thrombus forms. Increased narrowing or total occlusion of lumen Ischemic Stroke Embolic stroke Occurs when an embolus lodges in and occludes a cerebral artery Results in infarction and edema of the area supplied by the involved vessel Second most common cause of stroke Patient with an embolic stroke commonly has a rapid occurrence of severe clinical symptoms. Onset of embolic stroke is usually sudden and may or may not be related to activity. Patient usually remains conscious, although he may have a headache. Ischemic Stroke Transient ischemic attack Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain Symptoms last <1 hour • Most TIAs resolve • encourage patients to go to the emergency room at symptom onset since once a TIA starts, one does not know if it will persist and become a true stroke, or if it will resolve. • In general, one third of individuals who experience a TIA will not experience another event, one third will have additional TIAs, and one third will progress to stroke. Hemorrhagic Stroke • • Result from bleeding into the brain tissue itself or into the subarachnoid space or ventricles Often a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding Intracerebral hemorrhage Bleeding within the brain caused by rupture of a vessel Hypertension is the most important cause. Hemorrhage commonly occurs during periods of activity. Hemorrhagic Stroke Massive hypertensive hemorrhage rupturing into a lateral ventricle of the brain. Hemorrhagic Stroke Intracerebral hemorrhage Manifestations Neurologic deficits Headache Nausea and/or vomiting Decreased levels of consciousness Hypertension Hemorrhagic Stroke Subarachnoid hemorrhage Intracranial bleeding into cerebrospinal fluid–filled space between the arachnoid and pia mater Commonly caused by rupture of a cerebral aneurysm Majority of aneurysms are in the circle of Willis. “Worst headache of one’s life” Other causes of subarachnoid hemorrhage include trauma and illicit drug (cocaine) abuse. people who have a hemorrhagic stroke due to a ruptured aneurysm can die during the first episode or die from subsequent bleeding. increases with age, higher in women than men. Loss of consciousness may or may not occur. focal neurologic deficits (including cranial nerve deficits), nausea, vomiting, seizures, and stiff neck. Most frequent surgical procedure to prevent re bleeding is clipping of the aneurysm. Clinical Manifestations Affects many body functions Motor activity Elimination Intellectual function Spatial-perceptual Personality Affect Sensation Communications Clinical Manifestations Motor Function Most obvious effect of stroke Include impairment of Mobility Respiratory function Swallowing and speech Gag reflex Self-care abilities Loss of skilled voluntary movement Alterations in muscle tone Alterations in reflexes Clinical Manifestations Motor Function An initial period of flaccidity (also known as hypotonicity is a condition characterized by a decrease or loss of normal muscle tone due to the deterioration of the lower motor nerve cells). May last from days to several weeks Related to nerve damage Spasticity of the muscles follows the flaccid stage. (an abnormal increase in muscle tension and a reduced ability of a muscle to stretch) Related to interruptions in upper motor neuron influence Clinical Manifestations Communication Patient may experience aphasia when a stroke damages the dominant hemisphere of the brain. Aphasia is the total loss of comprehension and use of language. Dysphasia refers to difficulty related to the comprehension or use of language and is due to partial disruption or loss. Types of Aphasia Broca’s Wernicke’s Damage to frontal lobe, speak in short phrases that makes sense but with great effort. “Walk doge””Book –book table”. They are aware of it and become frustrated. Left temporal lobe damage. Long sentences with no meaning, difficult to understand the meaning of the speech. They are not aware of it. Global Severe communication difficulties, limited in ability to speak. A massive stroke may result in global aphasia, in which all communication and receptive function are lost. Clinical Manifestations Communication Many patients experience dysarthria. Disturbance in the muscular control of speech Dysarthria does not affect the meaning of communication or the comprehension of language, but it does affect the mechanics of speech. Some patients experience a combination of aphasia and dysarthria. Impairments may involve Pronunciation Articulation Phonation Clinical Manifestations Affect • Patients who suffer a stroke may have difficulty controlling their emotions. • Depression and feelings associated with changes in body image and loss of function can make this worse. • Patients may also be frustrated by mobility and communication problems. Emotional responses may be exaggerated or unpredictable. • An example of unpredictable affect is as follows: •A well-respected lawyer has returned home from the hospital following a stroke. During meals with his family, he becomes frustrated and begins to cry because of difficulty getting food into his mouth and chewing, something that he was able to do easily before his stroke. Clinical Manifestations Intellectual Function Both memory and judgment may be impaired as a result of stroke. A left-brain stroke is more likely to result in memory problems related to language. Clinical Manifestations Spatial–Perceptual Alterations Stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation. However, this may occur with left-brain stroke. An example of behavior with right-brain stroke is the patient who tries to rise quickly from a wheelchair without locking the wheels or raising the footrests. The patient with a left-brain stroke would move slowly and cautiously from the wheelchair. Clinical Manifestations Spatial-Perceptual Alterations Spatial-perceptual problems may be Incorrect perception of self and illness perception of self in space Inability to recognize an object by sight, touch, or hearing Inability to carry out learned sequential movements on command A stroke on the right side of the brain is more likely to cause problems in spatial-perceptual orientation, although this can also occur with left-brain stroke as well. Clinical Manifestations Elimination Most problems with urinary and bowel elimination occur initially and are temporary. When a stroke affects one hemisphere of the brain, the prognosis for normal bladder function is intact partial sensation of bladder and voluntary urination is present Initially, the patient may experience frequency, urgency, and incontinence. • Constipation is associated with immobility, weak abdominal muscles, dehydration, and diminished response to the defecation reflex. Diagnostic Studies When symptoms of a stroke occur, diagnostic studies are done to Confirm that it is a stroke Identify the likely cause of the stroke CT is the primary diagnostic test used after a stroke. A CT scan can rapidly distinguish between ischemic and hemorrhagic stroke and help determine the size and location of the stroke. Serial CT scans may be used to assess the effectiveness of treatment and to evaluate recovery. Diagnostic Studies CTA MRI, MRA Intraarterial digital subtraction angiography (DSA) reduces the dose of contrast material, uses smaller catheters, and shortens the length of the procedure compared with conventional angiography Transcranial Doppler ultrasonography Angiography can identify cervical and cerebrovascular occlusion, atherosclerotic plaques, and malformation of vessels Digital subtraction angiography MRI is used to determine the extent of brain injury Angiography may detect vascular lesions and blocksges Cerebral angiography CT angiography (CTA) provides visualization of cerebral blood vessels Transcranial Doppler (TCD) ultrasonography is a noninvasive study that measures the velocity of blood flow in the major cerebral arteries. Lumbar puncture LICOX system The LICOX system may be used as a diagnostic tool for evaluating the progression of stroke, brain O2 and temperature, page 1432 LICOX catheter The LICOX brain tissue oxygen system involves a catheter inserted through an intracranial bolt , placed in white matter of the brain. (A). The system measures oxygen in the brain (PbtO2), brain tissue temperature, and intracranial pressure (ICP) (B). Diagnostic Studies of Nervous System Normal images of the brain. A, CT scan. B, MRI. 38 Diagnostic Studies of Nervous System Cerebral angiogram illustrating an arteriovenous malformation (arrow). Collaborative Care Prevention Goals of stroke prevention include Health promotion Education and management of modifiable risk factors Patients with known risk factors require close management. Diabetes mellitus Hypertension Obesity High serum lipids Cardiac dysfunction Collaborative Care Prevention Antiplatelet drugs are usually the chosen treatment • Aspirin is the most frequently used as antiplatelet agent. • Common dose for aspirin is 81 to 325 mg/day. • Other drugs include ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine), and combined dipyridamole and aspirin (Aggrenox). • Oral anticoagulation using warfarin is the treatment of choice for individuals with atrial fibrillation. Collaborative Care Prevention Surgical interventions Carotid end-arterectomy (tube inserted above and below the blockage, remove the plaque, stitch the artery close, remove the tube) Transluminal angioplasty (insertion of balloon to open artery in the brain and to improve blood flow) Stenting (inflate the balloon cath, imlpant the stent, deflate the balloon and remove, leave the stent permanently in place holding the artery open to improve the blood flow) Extracranial-intracranial bypass (EC-IC) anastomosing (surgically connecting) external artery to internal arterysuperficial temporal to middle cerebral artery Carotid End-arterectomy Carotid endarterectomy is performed to prevent impending cerebral infarction. A, A tube is inserted above and below the blockage to reroute the blood flow. B, Atherosclerotic plaque in the common carotid artery is removed. C, Once the artery is stitched closed, the tube can be removed. A surgeon may also perform the technique without rerouting the blood flow. Brain Stent Brain stent used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant the stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery and then inflated. The stent expands due to the inflation of the balloon. C, The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery open and improving the flow of blood. Collaborative Care Acute Care Goals for collaborative care during the acute phase are Preserving life Preventing further brain damage Reducing disability Begins with managing the ABCs Airway Breathing Circulation Collaborative Care Acute Care Causes Sudden vascular compromise causing disruption of blood flow to the brain Thrombosis Trauma Aneurysm Embolism Hemorrhage Collaborative Care:Acute Care Assessment findings Altered level of consciousness Weakness, numbness, or paralysis Speech or visual disturbances Severe headache ↑ or ↓ heart rate Respiratory distress Unequal pupils Hypertension Facial drooping on affected side Difficulty swallowing Seizures Bladder or bowel incontinence Nausea and vomiting Vertigo Collaborative Care Acute Care Interventions Ensure patent airway. Call stroke code or stroke team. Remove dentures. Perform pulse oximetry. Maintain adequate oxygenation. Obtain IV access. Maintain BP. Obtain CT scan immediately. Perform baseline laboratory tests. Position head midline. Elevate head of bed 30 degrees if no symptoms of shock or injury occur. Institute seizure precautions. Anticipate thrombolytic therapy for ischemic stroke. Collaborative Care Acute Care Watch for hypertension post stroke. Drugs to lower BP are used only if BP is markedly increased. (metoprolol, cardene) Fluid and electrolyte balance must be controlled carefully. Adequate hydration promotes perfusion and decreases further brain injury. Adequate fluid intake during acute care via oral, intravenous (IV), or tube feedings should be 1500 to 2000 mL/day. Overhydration may compromise perfusion by increasing cerebral edema. Collaborative Care Acute Care Interventions Monitor Level vital signs and neurologic status. of consciousness Monitor sensory function Pupil size and reactivity O2 saturation Cardiac rhythm Collaborative Care: Acute Care Recombinant tissue plasminogen activator (tPA) Used to reestablish blood flow through a blocked artery to prevent cell death in patients with acute onset of ischemic stroke symptoms Must be administered within 3 to 4.5 hours of onset of clinical signs of ischemic stroke Pt screened before tPA can be given: non contrast CT or MRI scan to rule out hemorrhagic stroke blood tests for coagulation disorders screening for recent history of gastrointestinal bleeding, stroke, or head trauma within the past 3 months, or major surgery within 14 days. Collaborative Care Acute Care Aspirin is used within 24 to 48 hours of stroke. Platelet inhibitors and anticoagulants may be used in thrombus and embolus stroke patients after stabilization. • Contraindicated for patients with hemorrhagic stroke • • • • The use of anticoagulants (e.g., heparin) in the emergency phase following an ischemic stroke generally is not recommended because of the risk for intracranial hemorrhage. Dose of aspirin is 325 mg. Common anticoagulants include warfarin (Coumadin). Platelet inhibitors include aspirin, ticlopidine (Ticlid), clopidogrel (Plavix), and dipyridamole (Persantine). Collaborative Care Acute Care Surgical interventions for stroke Ischemic stroke Hemorrhagic stroke MERCI (mechanical embolus removal in cerebral ischemia) Immediate evacuation of aneurysm-induced hematomas Cerebellar hematomas >3 cm After stroke has stabilized for 12 to 24 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning. Patient may be transferred to a rehabilitation unit, outpatient therapy, or home care–based rehabilitation. Merci Embolus Retriever in Cerebral Ischemic Stroke The MERCI retriever removes blood clots in patients who are experiencing ischemic strokes. The retriever is a long, thin wire that is threaded through a catheter into the femoral artery. The wire is pushed through the end of the catheter up to the carotid artery. The wire reshapes itself into tiny loops that latch onto the clot and the clot can then be pulled out. To prevent the clot from breaking off, a balloon at the end of the catheter inflates to stop blood flow through the artery. Clipping and Wrapping of Aneurysms GDC Coil: Gugleilmi detachable coils A, A coil is used to occlude an aneurysm. Coils are made of soft, spring like platinum. The softness of the platinum allows the coil to assume the shape of irregularly shaped aneurysms while posing little threat of rupture of the aneurysm. B, A catheter is inserted through an introducer (small tube) in an artery in the leg. The catheter is threaded up to the cerebral blood vessels. C, Platinum coils attached to a thin wire are inserted into the catheter and then placed in the aneurysm until the aneurysm is filled with coils. Packing the aneurysm with coils prevents the blood from circulating through the aneurysm, reducing the risk of rupture. Nursing Management Nursing Assessment If the patient is stable, obtain Description of the current illness with attention to initial symptoms History of similar symptoms previously experienced Current medications History of risk factors and other illnesses Family history of stroke or cardiovascular disease Nursing Management Nursing Assessment Comprehensive neuro examination Level of consciousness Cognition Motor abilities Cranial nerve function Sensation Deep tendon reflexes Nursing Management Nursing Diagnoses Risk for ineffective cerebral tissue perfusion Ineffective airway clearance Impaired physical mobility Impaired verbal communication Impaired urinary elimination Impaired swallowing Situational low self-esteem Nursing Management Planning Goals are that the patient will Maintain stable or improved level of consciousness Attain maximum physical functioning Maximize self-care abilities and skills Maintain stable body functions Maximize communication abilities. Avoid complications of stroke. Maintain effective personal and family coping. Nursing Management Nursing Implementation Health promotion To reduce the incidence of stroke, the nurse should focus teaching toward stroke prevention. Particularly in persons with known risk factors Education about hypertension control and adherence to medication Teaching Early patients and families about symptoms Stroke TIA When to seek health care for symptoms Nursing Management Nursing Implementation Respiratory system Management of the respiratory system is a nursing priority. Risk for atelectasis Risk for aspiration pneumonia Risks for airway obstruction May require tracheal intubation and mechanical ventilation Nursing Management Nursing Implementation Neurologic system Monitor closely to detect changes suggesting Extension ↑ of the stroke ICP Vasospasm Recovery from stroke symptoms Table 58-8, page 1472 the NIH Stroke Scale (NIHSS)national institutes of health stroke scale . Nursing Management: Nursing Implementation Cardiovascular system Goals aimed at maintaining homeostasis Many patients with stroke have decreased cardiac reserves from the secondary diagnoses of cardiac disease. Monitoring vital signs frequently Monitoring cardiac rhythms Calculating intake and output, noting imbalances Regulating IV infusions Adjusting fluid intake to the individual needs of the patient Monitoring lung sounds for crackles and rhonchi (pulmonary congestion) Monitoring heart sounds for murmurs After stroke, patient is at risk for deep vein thrombosis. Related to immobility, loss of venous tone, and ↓ muscle pumping in leg Most effective prevention is keeping the patient moving. Nursing Management Nursing Implementation Musculoskeletal system Goal is to maintain optimal function. prevention of joint contractures and muscular atrophy range-of-motion exercises and positioning are important. Paralyzed or weak side needs special attention when positioned. Avoidance of pulling the patient by the arm to avoid shoulder displacement Hand splints to reduce spasticity Nursing Management Nursing Implementation Integumentary system Susceptible to breakdown related to Loss of sensation Decreased circulation Immobility Compounded by patient age, poor nutrition, dehydration, edema, and incontinence Pressure relief by position changes, special mattresses, or wheelchair cushions Good skin hygiene Early mobility Position patient on the weak or paralyzed side for only 30 minutes. Nursing Management Nursing Implementation Gastrointestinal system Stress of illness. Constipation. Patients may be placed on stool softeners. Physical activity promotes bowel function. Urinary system promote normal bladder function. Avoid the use of indwelling catheters. Nursing Management Nursing Implementation Nutrition Nutritional needs require quick assessment and treatment. May initially receive IV infusions to maintain fluid and electrolyte balance May require nutritional support First feeding should be approached carefully. Test swallowing, chewing, gag reflex, and pocketing before beginning oral feeding. Feedings must be followed by oral hygiene. Nursing Management Nursing Implementation Communication Nurse’s role in meeting psychologic needs of the patient is primarily supportive. Patient is assessed for both the ability to speak and the ability to understand. Speak slowly and calmly, using simple words or sentences. Gestures may be used to support verbal cues. Nursing Management Nursing Implementation Sensory-perceptual alterations Blindness in same half of each visual field is a common problem after stroke. Known as homonymous hemi anopsia A neglect syndrome (decrease in safety, increase risk for injury) Other visual problems may include Diplopia (double vision) Ptosis (drooping eyelid) Homonymous Hemianopsia (Food on left side is not seen) Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemi anopsia Shows that food on the left side is not seen and thus is ignored. Nursing Management Nursing Implementation Coping Affects family Emotionally Socially Financially Changing roles and responsibilities Explain What has happened Diagnosis Therapeutic procedures Should be clear and understood by patient. social services referral is often helpful. Nursing Management: Nursing Implementation Ambulatory and home care Patient is usually discharged to home, an intermediate or long-term care facility, or a rehabilitation facility. discharge planning with the patient and family starts early in the hospitalization and promotes a smooth transition from one care setting to another. prepare the patient and family for discharge through Education Demonstration Practice Evaluation of self-care skills Rehabilitation to promote optimal functioning. Physical, mental, and social well-being Loss of Postural Stability Loss of postural stability is common after stroke. The patient is unable to sit upright and tends to fall sideways. Appropriate support with pillows or cushions should be provided. Nursing Management Nursing Implementation Ambulatory and home care (cont’d) Musculoskeletal interventions Bobath method Balance training Transferring from bed to chair Therapists and nurses use the Bobath approach to encourage normal muscle tone, normal movement, and promotion of bilateral function of the body. An example is to have the patient transfer into the wheelchair using the weak or paralyzed side and the stronger side to facilitate more bilateral functioning. CIMT is a more recent approach. Constraint-induced movement therapy (CIMT) encourages the patient to use the weakened extremity by restricting movement of the normal extremity. This approach is challenging, and the ability of patients to comply may limit its use. Nursing Management Nursing Implementation Ambulatory and home care (cont’d) After acute phase, a dietitian can assist in determining appropriate daily caloric intake based on the patient’s Size Weight Activity level Nurse and speech therapist must assess ability of patient to swallow solids and fluids and must adjust the diet appropriately. Inability to feed oneself can be frustrating and may result in malnutrition and dehydration. Assistive Devices for Eating A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips are helpful for some persons. B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the other. C, Plate guards help keep food on the plate. D, Cup with special handle. Nursing Management Nursing Implementation Implement a bowel management program for problems with Bowel control Constipation Incontinence High-fiber diet and adequate fluid intake Nursing Management Nursing Implementation Patients with stroke on right side of brain Difficulty in judging position, distance, and movement Impulsive, impatient, and denying problems related to stroke Respond best to directions given verbally Patients Slower with stroke on left side of brain in organization and performance of tasks Impaired spatial discrimination Have fearful, anxious response to stroke Respond well to nonverbal cues Nursing Management Nursing Implementation Interventions for atypical emotional response Distract the patient. Explain that emotional outbursts may occur. Maintain a calm environment. Avoid shaming. Patients with a stroke may be coping with many losses Often go through the process of grief Some patients experience long-term depression Support communication between the patient and family. Discuss lifestyle changes. Discuss changing roles within the family. Be an active listener. Include family in goal planning and patient care. Support family conferences. Nursing Management Nursing Implementation Family members must cope with Recognition of behavioral changes resulting from neurologic deficits that are not changeable Responses to multiple losses by both the patient and the family. Behaviors that may have been reinforced during the early stages of stroke as continued dependency Stroke support groups within rehab facilities and community are helpful. Mutual sharing Education Coping Understanding Nursing Management Nursing Implementation Speech, comprehension, and language deficits are the most difficult problem for the patient and family. Speech therapists can assess and formulate a plan to support communication. Nurses can be a role model for patients with aphasia. Question #1 A patient with right-sided paresthesias and hemiparesis is hospitalized and diagnosed with a thrombotic stroke. Over the next 72 hours, the nurse plans care with the knowledge that the patient: 1. Is ready for aggressive rehabilitation. 2. Will show gradual improvement of the initial neurologic deficits. 3. May show signs of deteriorating neurologic function as cerebral edema increases. 4. Should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits. Question #2 While performing health screening at a health fair, the nurse identifies which of the following individuals at greatest risk for experiencing a stroke? 1. A 46-year-old white female with hypertension and oral contraceptive use for 10 years. 2. A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dL. 3. A 42-year-old African American female with diabetes mellitus who has smoked for 30 years. 4. A 62-year-old African American male with hypertension who is 35 pounds overweight. Answer #2 Answer: 4 Rationale: Option 4: This individual has five risk factors: age, African American, male, hypertension, and overweight. Option 1: This individual has two risk factors: hypertension and oral contraception use. Option 2: This individual has two risk factors: male and increased cholesterol level. Option 3: This individual has three risk factors: African American, diabetes mellitus, and smoking. Answer #2 Nonmodifiable risk factors include age, gender, ethnicity/race, and family history/heredity. Stroke risk increases with age, doubling each decade after 55 years of age. Two thirds of all strokes occur in individuals >65 years. Strokes are more common in men, but more women die from stroke than men. Because women tend to live longer than men, they have more opportunity to suffer a stroke. African Americans have a higher incidence of stroke, as well as a higher death rate from stroke than whites. A family history of stroke, a prior transient ischemic attack, or a prior stroke also increases the risk of stroke. Modifiable risk factors are those that can potentially be altered through lifestyle changes and medical treatment, thus reducing the risk of stroke. Modifiable risk factors include hypertension, increased cholesterol, elevated blood lipid levels, heart disease, smoking, excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, and drug abuse. Early forms of birth control pills that contained high levels of progestin and estrogen increased a woman’s chance of experiencing a stroke, especially if she also smoked heavily. Newer, lowdose oral contraceptives have lower risks for stroke except in those individuals who are hypertensive and smoke. Other conditions that may increase stroke risk include migraine headaches, inflammatory conditions. Sickle cell disease is another known risk factor for stroke. Question #3 A patient with a stroke has dysphagia. Before allowing the patient to eat, which of the following actions should the nurse take first? 1. Check the patient’s gag reflex. 2. Request a soft diet with no liquids. 3. Place the patient in high-Fowler’s position. 4. Test the patient’s ability to swallow with a small amount of water. Answer #3 Answer: 1 Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding, and begin exercises to stimulate swallowing. To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated), and give the patient a small amount of crushed ice or ice water to swallow. Case Study 73-year-old man was admitted to the hospital with right-sided paresis and expressive aphasia. He had been experiencing periods of confusion, right-sided weakness, and slurred speech for the past several weeks. These episodes were brief and resolved completely within an hour. No treatments were sought. Case Study 1 History of COPD, MI 15 years prior, and atrial fibrillation Over the first 24 hours of admission, his neurologic deficits gradually progressed. By day 2 of admission, he had right-sided flaccid paralysis and global aphasia. Discussion Questions Case Study 1. What is probably the cause of his stroke? 2. Could this stroke have been prevented? Discussion Questions Case Study 3. 4. What are the priority nursing interventions for him? What teaching will you need to do for him and his family?
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