nursing module for brain stroke

8/7/2019 Nursing module for brain stroke

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Nursing Care of the AcuteStroke Patient


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StrokeStroke Facts in AmericaFacts in America Third leading cause of

death in the United

States 750,000 Americans

suffer strokes eachyear

160,000 deaths eachyear

4,000,000 strokesurvivors


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StrokeStroke Facts in AmericaFacts in America A leading cause of

adult disability

Many strokes arepreventable

Every 45 seconds,someone suffers astroke

Twice as manywomen die fromstroke every year thanfrom breast cancer


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Types of Stroke

Ischemic: embolic or thrombotic

blocked blood flow to the brain Hemorrhagic: ICH, SAH, ruptured cerebral

aneurysm

TIA: This is a stroke, although symptomsresolve within an hour


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Signs and Symptoms of Stroke Sudden numbness or weakness of the face, arm

or leg, especially on one side of the body

Sudden confusion, trouble speaking orunderstanding

Sudden trouble seeing in one or both eyes

Sudden dizziness, loss of balance or coordination

or trouble walking

Sudden severe headache with no known cause


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Risk Factors

High blood pressure

Carotid artery disease

Physical inactivity

Excess alcohol intake

Atrial fibrillation

Diabetes

Heart disease

Smoking Family history

Prior stroke/TIA

High cholesterol

Obesity


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Brain Anatomy


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Treatment for Ischemic Stroke tPA=Thrombolytic agent

Document time of symptom

onset. (If awoke withsymptoms, must go by timewhen last seen normal)

Immediate head CT (checkfor blood)

Evaluate for tPAadministration (reviewexclusion/inclusion criteria)


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Treatment Cont If not a tPA candidate, ASA in ED. Rectal ASA

if fails swallow eval. or if swallow eval. notcomplete.

Keep NPO, until a formal swallow eval. isdone.

Admit as Inpatient and perform diagnostictesting: Carotid US, Echo, TEE, ECG

monitoring for a-fib, MRI, fasting Lipid,Clotting disorder blood work(Antiphospholipid, Factor V, Antithrombin III)

Rehabilitation


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tPA Administration Considerations

Must be startedbefore 3 hours fromonset

No blood on head CT Review patients

history for other riskfactors

Accurate weightrecorded Foley catheter prior to

tPA


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tPA Cont Consent explained and signed (BP>185/110) treat with

labetolol 10-20mg IV over 1-2min. May repeat x1 or nitropaste 1-2 inches. If treatmentdoes not lower BP, do not givetPA

NIH stroke scale showssignificant deficits to merittreatment.http://asa.trainingcampus.net


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tPA Contraindications Any recent surgery185/110)

Seizure at the onset of stroke Active internal bleeding (


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Contraindications Cont.. Intracranial neoplasm, AV malformation,

aneurysm Use of anticoagulants with PT>15 or INR >1.7 Platelet count


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Calculation and Documentation of tPA

0.9 mg/kg Do not exceed the 90 mg max dose Mix 100 mg in 100 ml of sterile water, subtract pt

dose from 100 ml and discard the difference.Final concentration 1mg/1ml Withdraw 10% and give IV bolus over 1 minute,

followed by the remainder over 60 min. Double check for correct dose (MD, RN) Document bolus dose and drip dose over 1 hr


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Example of tPA Calculation Patient wt 80 kg

Chart:

0800 tPA bolus 7.2

mg 0801 tPA infusion

64.8 mg in 64.8 mlgiven over 60minutes

0.9mg/kg = 72

72mg in 72 ml

(total dose)

- 10% = 7.2 mg orml (bolus dose)

72 -7.2 = 64.8mg(infusion dose)


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During tPA Administration Check BP every 15 min for 2 hours

Treat hypertension/hypotension as ordered

Monitor Neuro status every 30 min x4

Watch for bleeding puncture sites, urine, stooletc.

Know signs/symptoms of IntracerebralHemorrhage: Any acute neurologicaldeterioration, new HA, N/V, sudden HTN


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Hemorrhage Suspected STOP TPA INFUSION, call MD

immediately

Stat head CT without contrast

Draw blood for PT, PTT, plt ct,fibrinogen, and type and hold

Prepare for administration of cryo andor platelets


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Post tPA Continue to monitor for signs/symptoms of

intracerebral hemorrhage

Therapy/Rehab physician evaluation, if needed

No unnecessary blood draws or invasive proceduresfor 12 hours after tPA

Repeat CT scan 24 hours after tPA to evaluate forbleeding (STAT if suspect intracerebral hemorrhage)

No aspirin, heparin, warfarin, or other antithromboticor antiplatelet drugs 24 hours after tPA


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Other Treatment Options for

Ischemic Strokes

If symptom onset is

greater than 3 hrsconsider: Other interventions (IA,

corkscrew, stenting)

Other trials

(thrombolytics,neuroprotective,hyperglycemia)


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Hemorrhagic Stroke Treatment Do not give antithrombotics

or anticoagulants

Monitor and treat blood

pressure greater than150/105 (Table 6, 2005Guidelines update)

NPO, until swallow eval iscompleted

Anticipate Neurosurgicalconsult

Possible administration ofblood products


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In-patient Considerations Nursing Issues

Started on stroke prevention medications? Clinical pathway followed?

Blood pressure within appropriate parameters? Know signs of suspected Intracranial Hemorrhage

and actions to take DVT prophylaxis addressed by day 2?

IPCs/Lovenox/heparin SQ per orders

Therapies seeing patient? Review PT/OT/STrecommendations


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Inpatient Cont IV fluids (Normal Saline or LR)?

Nutrition? Dietary evaluation. Assistive devices for

feeding. Calorie Counts as ordered. Fever? Treat if greater than 99 F with Tylenol

Blood glucose within appropriate parameters?Obtain sliding scale if necessary.

Positioning? Pillows under affected limbs. TurnQ2hours. Accommodate limitations

Rehab consults as soon as possible, if needed


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JCAHO Guidelines Deep Vein Thrombosis (DVT) Prophylaxis

Discharged on Antithrombotics

Patients with Atrial Fibrillation ReceivingAnticoagulation Therapy

Tissue Plasminogen Activator (t-PA)Considered/Administered

Antithrombotic Medication Within 48 Hours ofHospitalization


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JCAHO Cont Lipid Profile During Hospitalization

Screen for Dysphagia

Stroke Education Smoking Cessation

A Plan for Rehabilitation was Considered

From JCAHO.org website Primary Stroke Center

Standardized measures


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JCAHO Expectations for ED Stroke Team and written protocols to quickly

evaluate and treat stroke patients

Stroke education: 8 hours/year for Stroke TeamMembers

Head CT within 25 min. of being ordered

CT interpretation within 45 min. of order

Lab and (ECG as needed) complete within 45min. of order


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Reference/Recommended Reading

(articles available online)

http://stroke.ahajournals.org/cgi/content/full/34/4/1056 (Stroke. 2003;34:1056.)

2003 American Heart Association, Inc.ASA Scientific Statement

Guidelines for the Early Management of Patients WithIschemic Stroke : A Scientific Statement From the StrokeCouncil of the American Stroke AssociationHarold P. Adams, Jr, MD, Chair; RobertJ. Adams, MD; Thomas Brott,MD; Gregory J. del Zoppo, MD; Anthony Furlan, MD; Larry B. Goldstein,MD; Robert L. Grubb, MD; Randall Higashida, MD; Chelsea Kidwell,MD; Thomas G. Kwiatkowski, MD; John R. Marler, MD George J.

Hademenos, PhD, (ex-officio member) http://www.americanheart.org/presenter.jhtml?identifier=3023366 (Stroke. 2005;36:916-921) 2005 Guidelines Update, Adams, H; Adams,

R; Del Zoppo, Goldstein, LB


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Helpful Information Montana Stroke Initiative:

http://montanastroke.org

State-wide protocols and guidelines Evidence based practice

Stroke education for physicians, primaryproviders, nurses and EMS providers

Mission: To develop a state-wide strokesystem of care that allows patients access tothe best stroke care regardless of where theylive in Montana

nursing module for brain stroke

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