Chapter 62: Stroke Nursing Care

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Welcome to the Deep Dive.

Today we're tackling a really critical topic for anyone heading into nursing practice.

Stroke.

Some people call it a brain attack, and honestly that phrase captures the urgency perfectly.

So for you, our nursing student listeners, we're going to break down this complex condition from the emergency room all the way to long term care.

The goal here is to give you what you absolutely need for clinicals and yeah, for the NCLEX too.

Absolutely.

Stroke is such a dynamic challenge and nurses, well, you play a pivotal role right from the very beginning, recognizing signs through acute care and then guiding that long journey of rehabilitation.

We'll cover the core concepts today, the pathophysiology, the risk factors, different types, how it presents clinically, diagnostics, and really focus on those essential nursing interventions.

Okay, let's jump right in then.

What is a stroke?

Fundamentally, it boils down to the brain being deprived of blood flow.

That can happen two main ways, either ischemia basically, a blockage stopping blood flow, or hemorrhage, which is actual bleeding into or around the brain.

Both pathways, unfortunately, lead to brain cell death.

You'll hear the term CVA, cerebrovascular accident, but brain attack really drives home that emergency, you know?

Like a heart attack, but for the brain, time is everything.

It really is.

And the statistics are stark.

We're talking about 800 ,000 strokes every year in the US alone.

Around 7 million adults are living with the after effects.

And it's not just an older person's disease, about a third, maybe 34 % happen in people under 65.

It ranks fifth for cause of death, but, and this is key for nursing.

It's the leading cause of serious long -term disability.

Think about that.

15 to 30 % of survivors face permanent disability.

That's staggering.

And it goes way beyond just the physical symptoms we might see initially, right?

Oh, absolutely.

We're talking about things like hemiparesis, that's weakness on one side of the body, maybe inability to walk, needing help with basic activities,

aphasia, which is difficulty with communication, and often really significant depression.

It's a massive life change, not just for the patient, but for their whole family, their caregivers.

And as nurses, being truly mindful of that huge holistic impact is just, well, it's central to providing good care.

Okay.

So let's unpack the anatomy a bit.

How does blood actually get to the brain?

It's quite a setup.

You've got two main pairs of arteries acting like highways.

The internal carotid arteries handle the front part of the brain, supplying areas like the frontal, parietal, and temporal lobes.

And then the vertebral arteries run up the back, eventually merging to form the basilar artery.

These supply the back portions like the occipital lobes, the cerebellum, the brain stem.

Right.

And where these systems meet, at the base of the brain, there's this amazing structure called the circle of Willis.

You can think of it like a roundabout or an interchange connecting the anterior and posterior circulation.

It's basically a potential backup route.

If one major artery gets blocked, sometimes blood can be rerouted through this circle.

It's a critical safety mechanism, though its effectiveness can vary a lot between individuals.

A built -in insurance policy almost.

Kind of, yeah.

And the brain needs that backup because its demands are incredible.

It requires a constant uninterrupted supply of oxygen and glucose.

We're talking 750 to a thousand milliliters of blood flow every minute.

That's roughly 20 % of your total cardiac output going straight to your brain.

And here's the critical part for understanding stroke urgency.

Interrupt that flow and things happen fast.

Metabolism changes in just 30 seconds.

It stops completely in about two minutes.

And brain cells can start dying irreversibly in as little as five minutes.

Five minutes.

Wow.

That really underlines the time is brain mantra.

Exactly.

The brain also has this cool feature called cerebral autoregulation.

Normally it keeps blood flow steady, even if your body's blood pressure goes up or down within a certain range.

But during a stroke, especially ischemic, this system often fails.

So the brain suddenly becomes very dependent on systemic blood pressure.

Other factors influence flow too.

CO2 levels are a big one.

High CO2 dilates vessels, increasing flow.

Low CO2 constricts them.

Very low oxygen also increases flow.

Sometimes the brain can even develop collateral circulation over time like little detour routes for blood.

And we always have to think about intracranial pressure or ICP.

If that goes up, it can squash brain tissue and cut off blood flow even more.

So managing ICP is a huge priority after stroke.

Given how fast damage happens, prevention seems like the absolute best approach.

Hands down.

Most effective strategy there is.

So let's talk risk factors.

We usually split them into two groups, right?

Things you can't change and things you hopefully can.

Correct.

The non -modifiable ones include age risk doubles each decade after 55.

Gender plays a role.

Men have more strokes, but women have higher mortality, partly due to longer lifespans.

Ethnicity and race are significant too.

Black individuals have about twice the incidence and higher death rates, often linked to higher rates of hypertension, obesity, and diabetes.

Other groups like Hispanic, Native American, and Asian Americans also have higher rates than white individuals.

And of course, family history matters.

Okay, but the modifiable ones, this is where nursing interventions, patient education, it all comes into play because these can be changed.

This is where we can make a huge impact.

Top of the list has to be hypertension, right?

High blood pressure.

Absolutely.

It's the single most important modifiable risk factor.

Treating it effectively can slash stroke risk by up to 50%.

The AHA goal is generally a systolic pressure below 140 mmL of chitgene.

Other big ones are heart disease, especially atrial fibrillation or AFib, which is linked to about a quarter of all strokes.

Diabetes significantly increases risk, like five times higher.

Then there's smoking doubles, ischemic risk, quadruples hemorrhagic risk, excessive alcohol use, illicit drugs like cocaine, obesity, particularly abdominal obesity, lack of exercise.

It's a long list.

Even things like poor diet, certain older types of oral contraceptives, migraines with aura, and conditions like sickle -fill disease can increase risk.

It really highlights how much lifestyle impacts brain health.

It truly does.

And that ties directly into something incredibly important, recognizing the warning signs.

Let's talk about the transient ischemic attack, or TIA.

Ah yes, the mini -stroke.

But that term's a bit misleading, isn't it?

It is, because a TIA is a major warning.

It's a temporary episode where neurologic function is disrupted due to brief focal ischemia.

But, and this is key, without causing permanent brain damage or infarction.

Symptoms usually resolve within an hour.

So why is it such a medical emergency if it resolves on its own?

Because it's a huge red flag.

You have absolutely no way of knowing if that TIA is just a brief event, or if it's about to progress into a full devastating stroke.

About a third of people who have a TIA will eventually have a major stroke.

The symptoms mirror stroke symptoms, but are temporary.

Depending on the vessel, you might see transient vision loss, weakness on one side, numbness, slurred speech that could be the carotid system, or maybe vertigo, double vision, trouble swallowing, balance issues, possibly the vertebral arousal or system.

How do you assess that risk?

We use a tool called the ABCD2 score.

It helps predict the short -term risk of stroke after a TIA.

It assigns points based on age, blood pressure, clinical features like weakness or speech issues, duration of the symptoms, and presence of diabetes.

A higher score indicates a higher risk, and often means the patient should be admitted for observation and rapid workup.

Let's use that clinical scenario from the text.

You're at a family gathering, your uncle says he felt dizzy, had trouble talking, kind of blanked out earlier, but feels fine now.

As a nurse, what do you do?

You tell them to get to the ER right now.

No waiting.

Exactly.

Even if symptoms are gone, they need immediate evaluation.

That could have been a TIA, and it's a serious warning.

Okay, so TIAs are warnings.

What about when a full stroke actually occurs?

You mentioned ischemic and hemorrhagic earlier.

Right.

Those are the two main categories based on the underlying cause.

Ischemic strokes are the most common, about 87%.

They happen because of a blockage cutting off blood flow.

Within ischemic, you have thrombotic strokes.

This is where a clot forms right there in a brain artery, usually one already narrowed by atherosclerosis, often linked to hypertension, diabetes.

These might have TIAs beforehand and can develop more gradually.

Then you have embolic strokes.

An embolus, a clot, or piece of debris travels from somewhere else.

Often the heart, like an aphib, gets lodged in a brain artery and bam, sudden blockage.

These usually hit suddenly with severe symptoms.

And the other 13 % are hemorrhagic.

Correct.

Hemorrhagic strokes involve bleeding.

Intracerebral hemorrhage, ICH, is bleeding directly into the brain tissue itself, often caused by a ruptured blood vessel, frequently due to chronic hypertension.

Prognosis here is often poor.

Symptoms are usually sudden onset, severe headache, nausea, vomiting, declining consciousness, neurological deficits.

Where the bleed occurs really matters.

A bleed in the pons, for instance, can be catastrophic quickly.

And the other type of hemorrhagic.

That's supraacnoid hemorrhage.

This is bleeding into the space around the brain, the space filled with cerebrospinal fluid, CSF.

Most often, this is caused by a ruptured cerebral aneurysm, those little balloon -like outpouchings on arteries, often found in the Circle of Willis.

Sometimes people get warning headaches if an aneurysm leaks a bit.

But often the first sign is that sudden rupture, classically described as the worst headache of my life.

Stiff neck, loss of consciousness can also occur.

A major worry after SAH is cerebral vasospasm, where arteries constrict days later, potentially causing another stroke.

Let's revisit that scenario.

Your husband at the soccer game yells about the worst headache of his life.

Priority actions.

Okay, number one, call 911 immediately.

That's a potential SAH, a huge emergency.

Number two, assess and support his ABC's airway breathing circulation.

Number three, keep him calm, still, minimize any strain, and note the exact time symptoms started.

That time is crucial.

Got it.

Now, when someone has had a stroke, ischemic or hemorrhagic, how do the symptoms actually manifest?

Does it look different depending on the type?

Interestingly, the neurologic deficits themselves don't differ much based on ischemic versus hemorrhagic, because both ultimately damage brain tissue.

The key factor determining the symptoms is which part of the brain is affected.

Think about the left brain versus the right brain.

If someone has a stroke affecting the left side of their brain, you'll typically see deficits on the right side of their body, right hemiplegia or hemiparesis.

They're also very likely to have language problems, aphasia.

They might be slow, cautious, very aware of their problems, which can lead to anxiety and depression.

And right brain strokes.

If the right brain is damaged, you see left -sided hemiplegia or hemiparesis.

These patients often have issues with spatial perceptual tasks.

A really key feature is left -sided neglect.

They might completely ignore the left side of their body or their environment.

They also tend to be more impulsive, maybe deny or minimize their problems, have a short attention span.

This impulsivity creates major safety concerns.

So, besides the left -right general patterns, what specific functions get hit?

Motor is obvious.

Motor function is definitely the most visible.

Loss of skilled movement,

changes in muscle tone, often starting flaccid like weak and floppy,

then progressing to spasticity, which is increased muscle tone or stiffness.

And remember, its contralateral left brain stroke affects the right body.

Right brain stroke affects the left body.

Communication problems, aphasia, seem really common too, especially with left brain strokes.

Very common since the left hemisphere is usually dominant for language.

We talked about aphasia, that umbrella term.

There's Broca's aphasia, non -fluent, where people understand but struggle forming words.

It's frustrating for them.

Then Wernicke's aphasia, fluent, where they speak easily, but the words don't make sense and they have trouble understanding.

Global aphasia is severe difficulty across the board.

It's important to distinguish aphasia from dysarthria, which is purely a muscle control problem affecting speech clarity, not language itself.

What about emotional changes?

Effective changes are huge.

Patients might have trouble controlling emotions, crying, or laughing inappropriately.

This is called emotional alobity.

Depression is also very common after stroke.

Intellectually, memory and judgment can be impaired.

Right brain strokes often lead to impulsivity, while left brain strokes might cause more language -related memory issues.

And those spatial perceptual problems with right brain strokes, besides neglect, you might see agnosia, where they can't recognize familiar objects, or apraxia, where they can't perform learned movements on command, even if they have the physical ability.

Homonymous hemidopsia, blindness in the same half of each visual field, is also common and impacts safety and function.

Elimination issues too.

Yes, bladder and bowel problems are frequent initially.

Usually temporary or urinary incontinence or frequency.

Constipation is very common due to immobility and other factors.

Thinking about that businessman scenario, crying during meals, what's the key nursing approach there?

The key is education and support for the family.

Explain that the crying is likely emotional ability, a neurological effect, not him being deliberately difficult.

Teach strategies to create a calm environment, simplify tasks like eating, maybe use assistive devices, and offer consistent emotional support, validating their frustration, but managing the situation calmly.

That makes sense.

Okay, so we see these symptoms.

How do we definitively diagnose a stroke and figure out what kind it is?

Diagnosis starts immediately upon suspicion.

The absolute number one priority is confirming if it is a stroke, determining if it's ischemic or hemorrhagic, and identifying the cause if possible.

And I'll say it again,

the time of symptom onset is the most critical piece of history.

What are the go -to tests?

The initial essential tests are imaging,

a rapid non -contrast head CT or an MRI.

The CT is usually faster and is excellent for ruling out a hemorrhage immediately.

MRI might be better at visualizing an early ischemic stroke, but the speed of CT often makes it the first choice to guide urgent treatment like TPA.

What else might be done?

Lots of other tests help fill in the picture.

We might use CTA or MRA, that's angiography, using CT or MRI to get detailed views of the blood vessels.

Cardiac workup is vital ECG, echocardiogram, cardiac markers because the heart is a common source of embolai.

We can assess blood flow using carotid ultrasound or transcranial dobler.

And a full slate of lab work, coagulation studies, blood counts, electrolytes, glucose, lipids.

If SAH is suspected but the CT is negative, a lumbar puncture might show blood in the CSF, but we're cautious if ICP might be high.

So diagnosis leads to treatment.

Let's talk about interprofessional care, prevention, acute care, rehab, starting with prevention again.

Right, because it's so important.

We already hit on lifestyle modifications, diet, exercise, smoking cessation, managing hypertension, diabetes, AFib.

Drug therapy for prevention is key too, especially after a TIA or a prior stroke.

Antiplatelets like low -dose aspirin or clopidogrel are common.

Anticoagulants like warfarin or the newer direct oral anticoagulants, the OACs, like rivaroxaban are crucial for patients with AFib.

Statins help manage lipids.

Are there surgical or procedural options for prevention too?

Yes, for certain patients.

Carotid endarterectomy, CEA, is surgery to clean out plaque from a narrowed carotid artery.

Less invasively, angioplasty and stenting can be done, where a small mesh tube, a stent, is placed to keep the artery open.

Sometimes these stents have filters to catch debris during the procedure.

Post -procedure nursing involves careful neurochecks and BP management.

Okay, shifting gears to acute care.

Someone comes into the ED with stroke symptoms.

What happens?

Time is brain.

For ischemic stroke, the clock starts ticking from symptom onset.

Get them to a stroke center fast.

The goal is rapid assessment and treatment.

There are benchmarks, like door to needle, time for TPA.

Ideally within 60 minutes.

Initial nursing actions.

ABCs first, always.

Call a stroke code.

Get 5E access.

Monitor BP closely.

Guidelines are specific here.

We might allow permissive hypertension initially unless it's extremely high or TPA is planned.

Get that CT scan stat.

Draw baseline labs.

Position the head midline.

Elevate the head of the bed slightly.

Initiate seizure precautions.

Keep the patient NPO initially.

What about TPA?

That's the clot buster, right?

Recombinant tissue plasminogen activator, PPA, can dissolve the clot,

causing an ischemic stroke.

But it has a very narrow window, typically within 3 -4 .5 hours of symptom onset.

Strict criteria must be met, including ruling out hemorrhage on CT and checking for contraindications like recent bleeding or surgery.

If given, you're monitoring the patient very closely for any signs of bleeding, especially intracranially.

For some larger clots, endovascular therapy using stent retrievers is amazing.

They go in with a catheter, grab the clot, and pull it out.

This can be done up to 6 -24 hours in select patients.

And acute care for hemorrhagic stroke?

Totally different approach.

Completely different.

No anticoagulants.

No antiplatelets.

Definitely no TPA that would make bleeding worse.

The focus is on controlling blood pressure, usually keeping systolic below 160 mmHg.

Seizure precautions or prophylaxis might be needed.

Surgery might be an option to evacuate a large hematoma.

For ruptured aneurysms causing SAH, surgical clipping or endovascular coiling using those GDC coils,

aims to secure the aneurysm and prevent rebleeding.

After these procedures, we sometimes use therapy to intentionally raise blood pressure slightly to maintain brain perfusion.

And managing ICP, possibly with CSF drainage, is critical.

Pneumotipine is often given for SAH to prevent that dangerous phasospasm.

That really highlights how crucial it is to know the type of stroke.

Now let's focus on the nursing management throughout this process.

Assessment is key.

Absolutely.

Your initial assessment is rapid but thorough.

ABCs, neuro status using the NIH Stroke Scale, NIHSS.

That's a standardized tool you'll definitely use.

Get that history, especially time of onset.

Then your ongoing secondary assessments, track level of consciousness, cognitive function, motor strength, cranial nerves, sensation.

Detailed, frequent documentation is vital to catch any changes.

We anticipate common problems.

Altered neural status, risk for increased ICP, communication issues, aspiration risk, impaired mobility, risk for injury, coping difficulties.

How we translate that assessment into care, system by system.

Okay, let's break it down.

Respiratory is priority one.

High risk for aspiration pneumonia.

So interventions include oxygen, maybe airway support, suctioning as needed, encouraging deep breathing, meticulous oral care, keeping NPO until a swallow screen passes, positioning to prevent aspiration.

Neurologic, continuous monitoring using the NIHSS, checking pupils, LOC, motor function, watching for signs of increased ICP, cardiovascular.

Monitor vital signs, heart rhythm, manage fluids carefully, watch for VTE, so range of motion compression devices may be anticoagulants once safe.

What about musculoskeletal and skin?

Immobility is a big issue.

Huge.

For musculoskeletal, start passive range of motion early to prevent contractures.

Use proper positioning support limbs, prevent external rotation of the hip with a trochanter roll, maybe hand splints or cones.

Avoid pulling on a weak arm.

For integumentary, pressure injury prevention is massive.

Turn frequently, use pressure relieving surfaces, keep skin clean and dry, get them mobile as soon as possible, limit time on the affected side.

And GIGU?

GI.

Constipation is the enemy.

Push fluids, fiber, use stool softeners, maybe a bowel program, scheduled toileting often helps.

GU.

Manage incontinence, aim to avoid indwelling catheters.

Bladder retraining programs can work scheduled voiding, ensuring adequate intake.

Check post -void residuals with a bladder scanner.

Nutrition is tricky with following issues.

Vary.

NPO until cleared by speech therapy, usually within 24 hours.

Assess the gag reflex yourself, too.

If they can eat, it's often thickened liquids, curate or soft foods.

Position them upright, head flex slightly forward, place food on the unaffected side of the mouth.

Good oral care before eating is important.

If dysphagia persists, a PEG tube might be needed for long -term nutrition.

And communication for patients with aphasia.

Be patient supportive.

Assess their specific deficits.

Speak clearly, simply.

Use gestures, pictures, communication boards.

Give them time to respond.

Don't shout.

Don't pretend to understand if you don't.

Work closely with the speech therapist.

Treat them like the adults they are.

The sensory perceptual issues like neglect or hemianoxia need special attention, too.

Definitely.

For hemianoxia, teach the patient to scan their environment by turning their head towards the blind side.

Arrange the room accordingly.

For neglect, constantly reorient them to the affected side.

Encourage them to use it.

Position things on that side.

Safety is paramount.

Remove clutter.

Ensure good lighting.

Eye patches might help with double vision, diplopia, artificial tears for poor corneal reflexes.

This all leads into coping and rehabilitation.

Which starts on day one.

Stroke is a family crisis.

Fear, anger, depression.

Expect it all.

Provide clear information.

Emotional support.

Involve the family.

Address coping mechanisms.

Rehabilitation is a team effort.

PT, OT, speech therapy.

Goals are preventing complications.

Regaining function.

Physical therapy works on balance.

Transfers lead with the strong side.

Gait training.

Occupational therapy focuses on ADLs using assistive devices.

Speech therapy addresses communication and swallowing.

Constraint -induced movement therapy, coercing use of the weaker arm, can be effective.

It sounds incredibly complex but also rewarding when you see progress.

It truly is.

Addressing the emotional impact, the changes in roles, even things like sexual function, it's all part of holistic nursing care.

Helping patients and families find support groups and navigate community resources is also key for long -term success.

So wrapping this up, what are the absolute must -know takeaways for nursing students listening today?

Okay, number one.

Record now stroke, fast face, arms, speech, time.

Urgency is key.

Number two.

Know the difference between ischemic and hemorrhagic treatment depends on it.

Number three.

Master your neuro -assessments and anticipate the diverse clinical manifestations based on stroke location.

Number four.

Embrace the nursing process.

Assess, plan, intervene across all body systems, focusing on safety, preventing complications and promoting function.

And number five.

Remember the holistic approach care extends from prevention through acute management to long -term rehab and psychosocial support.

Excellent summary.

It really emphasizes the breadth and depth of the nurse's role.

And maybe one final thought to leave you with.

Stroke care is advancing rapidly.

New drugs, new devices, new rehab strategies.

As you move into practice, think about this.

What role will you play in interprofessional collaboration and patient advocacy to push those outcomes even further?

How can we as nurses best champion our patients through this evolving landscape?

That's a powerful question for our future colleagues to consider.

Thank you so much for walking us through this critical topic today.

And thank you for joining us on The Deep Dive.

Keep learning, stay curious, and we'll catch you next time.