STROKESTROKE

Presenter:Presenter:Abdul MajidAbdul Majid

Aga Khan University HospitalAga Khan University HospitalDate:Date: 19 Jan 2015 19 Jan 2015

LEARNING OBJECTIVESLEARNING OBJECTIVES

• Define Stroke, And Its Types?Define Stroke, And Its Types?• What Is TIA?What Is TIA?• Discuss Causes & Risk Factor Of Discuss Causes & Risk Factor Of

Stroke?Stroke?• Assess Sign & Symptom Of Stroke?Assess Sign & Symptom Of Stroke?• Discuss The Diagnosis & Management.Discuss The Diagnosis & Management.• Nursing Diagnosis & Consideration.Nursing Diagnosis & Consideration.• Complication Of Stroke.Complication Of Stroke.

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How Serious Is Stroke in the USHow Serious Is Stroke in the US??

• About 700,000 strokes occur each About 700,000 strokes occur each year. year. • Over 167,000 deaths each year.Over 167,000 deaths each year.• #3 killer.#3 killer.• A leading cause of serious long-term A leading cause of serious long-term disability in adults.disability in adults.• 4.7 million stroke survivors.4.7 million stroke survivors.

Relative Incidence of Atherothrombotic Relative Incidence of Atherothrombotic Stroke and MI by Age and GenderStroke and MI by Age and Gender

STROKESTROKEA stroke is caused by the interruption ofA stroke is caused by the interruption ofthe blood supply to the brain, usuallythe blood supply to the brain, usuallybecause a blood vessel bursts or isbecause a blood vessel bursts or isblocked by a clot. This cuts off theblocked by a clot. This cuts off thesupply of oxygen and nutrients, causingsupply of oxygen and nutrients, causingdamage to the brain tissue.damage to the brain tissue.

Also called “Also called “brain attackbrain attack”, cerebral”, cerebralinfarction, cerebral hemorrhage,infarction, cerebral hemorrhage,ischemic stroke or strokeischemic stroke or stroke

TYPES:TYPES:

1) ISCHEMIC STROKE1) ISCHEMIC STROKEOccurs when a clot or a mass clogs a bloodOccurs when a clot or a mass clogs a bloodvessel, cutting off the blood flow to brain cells.vessel, cutting off the blood flow to brain cells.The underlying condition for this type ofThe underlying condition for this type ofobstruction is the development of fatty depositsobstruction is the development of fatty depositslining the vessel walls. This condition is calledlining the vessel walls. This condition is calledatherosclerosis.atherosclerosis.Almost 85% of strokes are ischemicAlmost 85% of strokes are ischemic

ATHEROSCLEROSISATHEROSCLEROSIS It’s the process in which deposits of fatty It’s the process in which deposits of fatty

substances, cholesterol, cellular waste products, substances, cholesterol, cellular waste products, calcium and other substances build up in the inner calcium and other substances build up in the inner lining of an artery. This buildup is called plaque.lining of an artery. This buildup is called plaque.

2) HEMORRHAGIC STROKE 2) HEMORRHAGIC STROKE • Results from a weakened vessel that ruptures and Results from a weakened vessel that ruptures and

bleeds into the surrounding brain. The blood bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain accumulates and compresses the surrounding brain tissue.tissue.

• About 15% of all strokes but responsible for 30% of About 15% of all strokes but responsible for 30% of stroke deathsstroke deaths

TWO (02) TYPESTWO (02) TYPES SUBARACHNOID HEMORRHAGE (SAH)SUBARACHNOID HEMORRHAGE (SAH)

occurs when a blood vessel on the surface of the brainoccurs when a blood vessel on the surface of the brainruptures and bleeds into the space between the brain and theruptures and bleeds into the space between the brain and theskullskull

INTRACEREBRAL HEMORRHAGE (ICH)INTRACEREBRAL HEMORRHAGE (ICH)Occurs when a blood vessel bleeds into the tissue deep withinOccurs when a blood vessel bleeds into the tissue deep withinthe brain.the brain.

Two Major Types of StrokeTwo Major Types of Stroke

Transient Ischemic Stroke Transient Ischemic Stroke (TIA)(TIA)

• When blood flow to part of the brain stops for When blood flow to part of the brain stops for a short period of time, also called transient a short period of time, also called transient ischemic attack (TIA). These symptoms ischemic attack (TIA). These symptoms appear and last less than 24 hours before appear and last less than 24 hours before disappearing. While TIAs generally do not disappearing. While TIAs generally do not cause permanent brain damage, they are a cause permanent brain damage, they are a serious warning sign that a stroke may serious warning sign that a stroke may happen in the future and should not be happen in the future and should not be ignored.ignored.

• When people use the term "ministroke," what When people use the term "ministroke," what they're really often referring to is a transient they're really often referring to is a transient ischemic attack (TIA) — a temporary ischemic attack (TIA) — a temporary interruption of blood flow to part of the brain. interruption of blood flow to part of the brain.

Up to approximately 30% of people who suffer Up to approximately 30% of people who suffer transient attacks (TIAs) will develop a stroke transient attacks (TIAs) will develop a stroke within 5 years.within 5 years.

DIRECT CAUSES:DIRECT CAUSES:

• CEREBRAL THROMBOSISCEREBRAL THROMBOSIS• a blood clot or plaque blocks an artery that a blood clot or plaque blocks an artery that

supplies a vital brain centersupplies a vital brain center• CEREBRAL HEMORRHAGE/ANEURYSMCEREBRAL HEMORRHAGE/ANEURYSM• an artery in the brain bursts, weakens the an artery in the brain bursts, weakens the

aneurysm wall; severe rise in BP causing aneurysm wall; severe rise in BP causing hemorrhage and ischemiahemorrhage and ischemia

• CEREBRAL EMBOLISMCEREBRAL EMBOLISM• a blood clot breaks off from a thrombus elsewhere a blood clot breaks off from a thrombus elsewhere

in the body, lodges in a blood vessel in the brain in the body, lodges in a blood vessel in the brain and shuts off blood supply to that part of the brain and shuts off blood supply to that part of the brain

• RISK FACTORS:RISK FACTORS:• Being over age 55 Being over age 55 • Being an African-AmericanBeing an African-American• Having diabetesHaving diabetes• Having a family history of strokeHaving a family history of stroke

• MEDICAL STROKE RISKMEDICAL STROKE RISK• Previous strokePrevious stroke• Previous episode of transient ischemic attack (TIA)Previous episode of transient ischemic attack (TIA)• High cholesterolHigh cholesterol• High blood pressureHigh blood pressure• Heart diseaseHeart disease

Risk Factors for Stroke That Risk Factors for Stroke That Cannot Be ChangedCannot Be Changed

• Increased age Increased age • Being male Being male • Race (e.g., African-Americans) Race (e.g., African-Americans) • Diabetes mellitus Diabetes mellitus • Prior stroke/transient ischemic attacks Prior stroke/transient ischemic attacks • Family history of stroke Family history of stroke • Asymptomatic carotid bruitAsymptomatic carotid bruit

Risk Factor For Stroke: Risk Factor For Stroke: TreatableTreatable

Major Major • Hypertension Hypertension • Heart disease, esp. atrial fibrillation Heart disease, esp. atrial fibrillation • Cigarette smoking Cigarette smoking • Transient ischemic attacksTransient ischemic attacks• DyslipidemiaDyslipidemia• Physical inactivityPhysical inactivity• ObesityObesity

     

Common STROKE symptomsCommon STROKE symptomsWeakness or paralysis Weakness or paralysis Numbness, tingling, decreased sensationNumbness, tingling, decreased sensationVision changesVision changesSpeech problemsSpeech problemsSwallowing difficulties or droolingSwallowing difficulties or droolingLoss of memoryLoss of memoryVertigo (spinning sensation)Vertigo (spinning sensation)Loss of balance and coordinationLoss of balance and coordinationPersonality changesPersonality changesMood changes (depression, apathy)Mood changes (depression, apathy)Drowsiness, lethargy, or loss of consciousnessDrowsiness, lethargy, or loss of consciousnessUncontrollable eye movements or eyelid Uncontrollable eye movements or eyelid

droopingdrooping

ACT F.A.S.TACT F.A.S.TF – FACEF – FACE

• Ask the person to smile. Does one side of the face droop?Ask the person to smile. Does one side of the face droop?

A – ARMSA – ARMS• Ask the person to raise both arms. Does one arm drift Ask the person to raise both arms. Does one arm drift

downward?downward?

S – SPEECHS – SPEECH• Ask the person to repeat a simple sentence. Does the Ask the person to repeat a simple sentence. Does the

speech sound slurred or strange?speech sound slurred or strange?

T – TIMET – TIME• Call 911 ImmediatelyCall 911 Immediately

ASSESSMENTASSESSMENT

Monitor for signs and symptomsMonitor for signs and symptoms• Symptoms will vary based on the area of the brain Symptoms will vary based on the area of the brain

that is not adequately supplied with oxygenated bloodthat is not adequately supplied with oxygenated blood• Assess/Monitor Airway patencyAssess/Monitor Airway patency• Swallowing ability/aspiration riskSwallowing ability/aspiration risk• Level of consciousnessLevel of consciousness• Neurological statusNeurological status• Motor, sensory and cognitive functionsMotor, sensory and cognitive functions• Glasgow Coma Scale scoreGlasgow Coma Scale score

Left and Right Hemisphere Stroke: Left and Right Hemisphere Stroke:

Left (Dominant) Left (Dominant) Hemisphere Stroke: Hemisphere Stroke:

Right (Non-dominant) Right (Non-dominant) Hemisphere Stroke: Hemisphere Stroke:

• Aphasia Aphasia • Right hemiparesis Right hemiparesis • Right-sided sensory loss Right-sided sensory loss • Right visual field defect Right visual field defect • Poor right conjugate gaze Poor right conjugate gaze • Dysarthria Dysarthria • Difficulty reading, writing, Difficulty reading, writing,

or calculating or calculating

• Neglect of left visual field Neglect of left visual field • Extinction of left-sided Extinction of left-sided

stimuli stimuli • Left hemiparesis Left hemiparesis • Left-sided sensory loss Left-sided sensory loss • Left visual field defect Left visual field defect • Poor left conjugate gaze Poor left conjugate gaze • Dysarthria Dysarthria • Spatial disorientation Spatial disorientation

STROKE PREVENTIONSTROKE PREVENTION

• Get screened for high BP.Get screened for high BP.• Have your cholesterol level checked. Have your cholesterol level checked.

LDL should be lower than 70 mg/dL.LDL should be lower than 70 mg/dL.• Follow a low-fat diet.Follow a low-fat diet.• Quit smoking!Quit smoking!• Exercise!Exercise!• Limit alcohol intake!Limit alcohol intake!

DiagnosisDiagnosis

• HistoryHistory• Examination. Examination. • (whooshing sound over neck, (whooshing sound over neck,

which may indicate which may indicate hardening or hardening or narrowing narrowing (atherosclerosis) of the (atherosclerosis) of the carotid carotid arteries.)arteries.)

• use an ophthalmoscope to use an ophthalmoscope to check check for signs of tiny for signs of tiny cholesterol crystals cholesterol crystals or clots in or clots in the blood vessels at the the blood vessels at the back back of your eyes.of your eyes.

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Cholestrol level:Cholestrol level:

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Continue. . Continue. .

• Computerized tomography (CT) scan.Computerized tomography (CT) scan.• Magnetic resonance imaging (MRI).Magnetic resonance imaging (MRI).• Carotid ultrasound.Carotid ultrasound.• Cerebral angiogram.Cerebral angiogram.• Echocardiogram.Echocardiogram.

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TreatmentTreatment

• Anticoagulants (Heparin, Warfarin)Anticoagulants (Heparin, Warfarin)• Antiplatelets (aspirin, clopidogrelAntiplatelets (aspirin, clopidogrel• StatinStatin• ARB (-sartan), or ACE inhibitor + HCTZARB (-sartan), or ACE inhibitor + HCTZ• Carotid endarterectomy if indicatedCarotid endarterectomy if indicated• Carotid or intracranial stent.Carotid or intracranial stent.• Risk factor control!!!Risk factor control!!!

NURSING DIAGNOSISNURSING DIAGNOSIS

• Ineffective tissue perfusion (cerebral)Ineffective tissue perfusion (cerebral)• Disturbed sensory perceptionDisturbed sensory perception• Impaired physical mobilityImpaired physical mobility• Risk for injuryRisk for injury• Self-care deficitSelf-care deficit• Impaired verbal communicationImpaired verbal communication• Impaired swallowingImpaired swallowing

NURSING CONSIDERATIONSNURSING CONSIDERATIONS• Maintain patent airwayMaintain patent airway• Monitor for changes in the client’s level ofMonitor for changes in the client’s level of consciousnessconsciousness• Assist with communication skills if the client’sAssist with communication skills if the client’s

speech is impaired. speech is impaired. • Assist with safe feeding.Assist with safe feeding.

• Assess swallowing reflexes.Assess swallowing reflexes.• Thicken liquid to avoid aspiration. Thicken liquid to avoid aspiration. • Eat in an upright position and swallow with the head and neck Eat in an upright position and swallow with the head and neck

flexed slightly forward.flexed slightly forward.• Place food in the back of the mouth on the unaffected side.Place food in the back of the mouth on the unaffected side.• Suction on standby.Suction on standby.

Continue. . . Continue. . .

• Maintain skin integrity.Maintain skin integrity.• Encourage PROM every 2 hr to the affected extremities Encourage PROM every 2 hr to the affected extremities

and AROM every 2 hr to the unaffected extremities.and AROM every 2 hr to the unaffected extremities.• Elevate the affected extremities to promote venous Elevate the affected extremities to promote venous

return and to reduce swelling.return and to reduce swelling.• Maintain a safe environment to reduce the risks of falls.Maintain a safe environment to reduce the risks of falls.• Provide care to prevent deep-vein thrombosis Provide care to prevent deep-vein thrombosis

(sequential compression stockings, frequent position (sequential compression stockings, frequent position changes, mobilization)changes, mobilization)

ComplicationsComplications

• Loss of Muscle Control/ParalysisLoss of Muscle Control/Paralysis• Speech ProblemsSpeech Problems• Swallowing DifficultiesSwallowing Difficulties• Cognitive ImpairmentsCognitive Impairments• NumbnessNumbness• PainPain• Loss of IndependenceLoss of Independence• Personality and Mood ChangesPersonality and Mood Changes• DepressionDepression• Shortened Life SpanShortened Life Span

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THAT’S it..!!THAT’S it..!!THANK YOU FOR THANK YOU FOR

LISTENING! LISTENING!