MANAGEMENT OF A PATIENT WITH STROKE

INTRODUCTION

A stroke, or brain attack, is a medical emergency where blood flow to part of the brain is cut off,
causing brain cells to die within minutes due to lack of oxygen, leading to lasting damage or
death; it's mainly caused by a blockage (ischemic stroke, ~90%) or a burst blood vessel
(hemorrhagic stroke).

DEFINITION

In the 1970s the World Health Organization (W.H.O) defined "stroke" as a "neurological deficit
of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours.

CLASSIFICATION OF STROKE

Stroke can be classified into two major categories:

1. Ischemic stroke: Ischemic stroke is caused by interruption of the blood supply to the
brain, during ischemic stroke, blood supply to part of the brain is decreased, leading to
dysfunction of the brain tissue in that area. There are four reasons why this might happen:

 Thrombosis (obstruction of a blood vessel by a blood clot forming locally)

 Embolism (obstruction due to an embolus from elsewhere in the body),[2]
 Systemic hypoperfusion (general decrease in blood supply, e.g., in shock)[23]
 Cerebral venous sinus thrombosis.
 Lacunar stroke or lacunar cerebral infarct (LACI) is the most common type
of ischemic stroke, resulting from the occlusion of small penetrating arteries that provide
blood to the brain's deep structures. Patients who present with symptoms of a lacunar
stroke, but who have not yet had diagnostic imaging performed, may be described as
having lacunar stroke syndrome (LACS).

2. HEMORRHAGIC STROKE: Hemorrhagic stroke results from the rupture of a blood

vessel or an abnormal vascular structure.

There are two main types of hemorrhagic stroke:

  Intracerebral hemorrhage, which is bleeding within the brain itself (when an artery in the
brain bursts, flooding the surrounding tissue with blood), due to either intraparenchymal
hemorrhage (bleeding within the brain tissue) or intraventricular hemorrhage (bleeding
within the brain's ventricular system).
 Subarachnoid hemorrhage, which is bleeding that occurs outside of the brain tissue but
still within the skull, and precisely between the arachnoid mater and pia mater (the
delicate innermost layer of the three layers of the meninges that surround the brain).
3. SILENT STROKE: is stroke that does not have any outward symptoms, and people are
typically unaware they had experienced stroke. Despite not causing identifiable
symptoms, silent stroke still damages the brain and places the person at increased risk for
both transient ischemic attack and major stroke in the future. Conversely, those who have
had major stroke are also at risk of having silent stroke.
4. Lacunar stroke:

CAUSES OF STROKE IN OLD AGE

The cause of stroke in aging is based on the type of stroke:

Thrombotic stroke

In thrombotic stroke, a thrombus (blood clot) usually forms around atherosclerotic plaques. Since
blockage of the artery is gradual, onset of symptomatic thrombotic stroke is slower than that of
hemorrhagic stroke. A thrombus itself (even if it does not completely block the blood vessel) can
lead to an embolic stroke (see below) if the thrombus breaks off and travels in the bloodstream,
at which point it is called an embolus.

PATHOPHYSIOLOGY

A stroke can occur when blood flow to the brain is blocked or there is sudden bleeding in the
brain. There are two types of strokes. A stroke that occurs because blood flow to the brain is
blocked is called an ischemic stroke. The brain cannot get oxygen and nutrients from the blood.
Without oxygen and nutrients, brain cells begin to die within minutes. A stroke that occurs
because of sudden bleeding in the brain is called a hemorrhagic stroke. The leaked blood results
in pressure on brain cells, damaging them just under 90% of strokes involve blocked blood
vessels (ischemic), and the rest involve internal bleeding (hemorrhagic). Strokes are further
classified based on where in the brain the blockage or bleeding occurs. A stroke is a medical
emergency. A stroke can cause lasting brain damage, long-term disability, or even death. Signs
of a stroke can range from mild weakness to paralysis or numbness on one side of the face or
body. Other signs may include a sudden and severe headache, sudden weakness, blurred vision
and aphasia or understanding speech. Martin G (2009).

CLINICAL MANIFESTATION OF STROKE

A stroke occurs when blood flow to the brain is disrupted, causing brain cells to die. The clinical
manifestations of a stroke include:

 Sudden weakness or numbness: This can occur in the face, arm, or leg, usually on one
side of the body

 Sudden confusion: This can include difficulty speaking or understanding speech

 Sudden vision problems: This can include dimness, loss of vision, or double vision in
one or both eyes

 Sudden dizziness or balance problems: This can include trouble walking or lack of
coordination

 Sudden severe headache: This can occur with no known cause

 Other symptoms: This can include drowsiness, nausea or vomiting, fainting, or seizure.

RISK FACTOR
Major risk factors for stroke include controllable lifestyle factors like high blood pressure,
smoking, high cholesterol, diabetes, and poor diet, as well as non-modifiable factors like age,
family history, and certain ethnicities. Other risk factors include obesity, physical inactivity,
heart conditions such as atrial fibrillation, and a previous stroke or transient ischemic attack
(TIA)

GENERAL INVESTIGATION
A general investigation for a stroke includes a physical exam, medical history, and a series of
tests. The goal of these tests is to determine the type of stroke, its location, and the extent of
brain damage.

Physical examination

 Check for mental alertness

 Check for coordination and balance

 Check for numbness or weakness in the face, arms, and legs

 Check for vision problems

 Check for difficulty speaking

 Medical history Ask about any previous medical conditions.
 Tests

DIAGNOSTIC INVESTIGATION

 Brain imaging: A CT scan or MRI can show brain damage or bleeding.

 Blood tests: A complete blood count (CBC) can help identify blood problems.

 Heart tests: An electrocardiogram (EKG) or echocardiogram can check for heart

problems or blood clots.

 Blood flow tests: A CTA or MRA can show blood flow in the brain or neck.

 Ultrasound: A carotid ultrasound can show if the carotid arteries are blocked.

COMPLICATIONS
 Paralysis: Loss of muscle movement, which can affect one side of the body or specific
muscles

 Dysphagia: Difficulty swallowing, which can include food going down the wrong pipe,
choking, or feeling like something is stuck in the throat
  Urinary tract infections (UTIs): A common complication that can occur after prolonged
use of a catheter during a hospital stay

 Blood clots: Deep vein thrombosis or pulmonary embolism can cause severe pain or
cramping in the leg, swelling, and skin redness

 Falls: Falls can occur due to mobility issues

 Pressure sores: Can develop as a result of falls or other complications

 Emotional complications

 Depression: People who have had strokes may have more trouble controlling their
emotions or develop depression

 Anxiety: A common complication that can remain after a stroke

 Cognitive complications

 Memory loss: Many people who have had strokes experience some memory loss

 Confusion: patient may have poor reasoning, making judgments, and understanding
concepts.

NURSING MANAGEMENT

 Admission of patient
 Monitor vital signs with emphasis on blood pressure
 Reassure patient before medication administration
 Serve medication as prescribed
 Patient encouraged to rest.
 Supported patient not to fall
 Observation of vital signs
 Check for cerebral palsy
 Observe other signs

ASSIGNMENT
Make a nursing care plan for an 80 years old woman with stroke. State any six diagnosis and
solve any four.

To be submitted in our next class.