Final Icu Presentation

Stroke The 3rd leading cause of death in the US 795,000 US residents have a stroke annually Approximately 610,000 are first attacks Approximately 185,000 are recurrent attacks

In 2005 Stroke accounted for approximatelty 1 of every 17 deaths in the United States

Care through Primary & Secondary Prevention Treatment of established disease risk factors –

Management of hypertension lipid levels Diabetes Atrial fibrillation

Evidence-Based Guidelines Utilization provides a standardized approach in which appropriate therapies are initiated Use all available resources to ensure optimal stroke care

The Joint Commission Stroke Indicators

Clinical Practice Guidelines Institute for Clinical Systems Improvement Health Care Guideline: Diagnosis and Initial Treatment of Ischemic Stroke American Heart Association/American Stroke Association Guidelines for the Early Management of Adults with Ischemic Stroke Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack Guidelines for Management of Spontaneous Intracerebral Hemorrhage in Adults

BGMC Policies l Nursing

Management of the Patient with a Suspected Stroke l Nursing Management of the Patient with Ischemic Stroke Receiving Fibrinolytic Therapy, tPA (Activase, Alteplase) l Brain Attack

BGMC Brain Attack Process – – – – –

NIHSS CT Lab EKG Alteplase (t-PA) consideration

BGMC Standing orders Brain Attack Alteplase Administration – Ischemic Stroke/TIA – Hemorrhagic Stroke –

–

Standardized stroke orders improve adherence to best practice for stroke patients

Alteplase (t-PA) 3 hour window from the time the person was last known normal or witnessed onset

The goal of pharmacologic therapy of stroke is revascularization of the ischemic brain

Joint Commission Performance Measures for Stroke Patients

# 4 Tissue Plasminogen Activator (t-PA) Administered Patients for whom IV thrombolytic therapy is initiated at the hospital within 3 hours of last known well

Time is Brain: Save the Penumbra Penumbra is zone of reversible ischemia around the core of irreversible infarctionsalvageable in first few hours after ischemic stroke onset

Time is Brain: Save the Penumbra l Penumbra – – – –

is damaged by:

Seizure Hypotension Hyperglycemia Fever

Time is Brain: Save the Penumbra

l Patient

symptoms due to both infarcted core and ischemic penumbra l One cannot determine by exam how much brain can still be saved

Transient Ischemic Attack (TIA) l Approximately

15% of all strokes are heralded by a TIA l Among TIA patients who go to the ED – – –

5% have stroke within 2 days 10% have stroke within 3 months 25% have recurrent “event” within 3 months

Transient Ischemic Attack (TIA) l Ischemic – – –

Stroke without sequelae

Angina of the brain Most common cause thromboembolism Secondary prevention depends on source of clot

Transient Ischemic Attack (TIA) l Prevention

recommendations for patients with ischemic stroke are now broadly applied to those with TIA l Recognition of common etiologies and the urgent need for treatment

ABCD2 Score ABCD2 score is a clinical risk assessment tool to improve the prediction of stroke risk after TIA

ABCD2 Score

Risk factor A

B

Age

Age > 60 Age < 60

BP @ assessment

C

D

Category

Clinical Features

Duration

Diabetes TOTAL

Score 1 0

SBP >140 or DBP >90 Other

1 0

Unilateral weakness Speech disturbance Other 0 >60 minutes 10-59 minutes < 10 minutes ____1 __ 0-7

2 1

2 1 0

Stroke begets Stroke Second Stroke risk is highest in the 7 days following the event Approximately 25% of Stroke patients worsen within 24-48 hours after onset

Cerebral Cortex The occipital lobe is an observatory scrutinizing the visual world. The parietal lobe an architect's office where space is mapped. The frontal lobe is home to a cabinet of war plotting our actions. The temporal lobe is a monumental library equipped to catalogue, store, and retrieve the experiences of a lifetime.

Zeman, A. Tales from the Temporal Lobes NEJM 352;2 pg 120

Brain Function-Frontal Lobe The Major function is initiation of motor activity and voluntary movement Personality and mood, initiative, “executive function”, planning, concentration, insight, social behavior, speech, conscious thought, abstract thinking and judgment

Brain Function-Frontal Lobe Key Functions: l Memory (for habits and motor activities) l Executive functions (task initiation, motivation, planning and self monitoring) l Concentration/reasoning l Judgment/problem solving

Associated Dysfunctions: l Inability to attend to task l Inability to sequence complex tasks (i.e. getting dressed) l Impaired judgment, decreased ability to problem solve

Brain Function-Parietal Lobe Region in which general sensory information from the opposite side of the body is processed Localization of sensory information to the body surface Ability of familiar objects to be recognized based on holding or touching them, largely based on experience (Most commonly involved areas for strokes)

Brain Function-Parietal Lobe Key Functions: l l l

Visual Attention Touch perception Integration of different sensory input

Associated Dysfunctions: l

l l l

Difficulty focusing visual attention or attending to more than one object at a time Inability to perceive objects normally Neglect or inattention to part of body or space Denial of deficits

Brain Function-Temporal Lobe The major function of the temporal lobe is located in the primary auditory area Receives inputs from the auditory pathway and is involved in the processing of auditory information

Brain Function-Temporal Lobe Key Functions: Integration of visual, auditory, and somatic info Memory (storage, retrieval of words, experiences)

Associated Dysfunctions:

Difficulty recognizing faces Difficulty attending to input Short term memory loss Disturbance of long term memory

Brain Function-Occipital Lobe Primary Visual Cortex for the perception and interpretation of visual input from the eyes

Brain Function-Occipital Lobe Key Functions: Visual Spatial organization and interpretation of visual info Visual reflexes

Associated Dysfunctions:

Visual field cuts Diplopia Agnosias – inability to recognize familiar objects, words, colors or movement of an object

Carotid Arteries Right Common Carotid originates in the neck from the brachiocephalic trunk Left Common Carotid arises from the aortic arch in the thoracic region The common carotid arteries bifurcate at the level of third cervical vertebra into the internal and external carotid arteries The internal carotid artery branches to form the opthalmic artery and the anterior circulation of the brain – –

Anterior Cerebral Artery Middle Cerebral Artery

Vertebral Arteries l The

Vertebral arteries are branches of the subclavian l The 2 Vertebral arteries join up to form the basilar artery at the base of the medulla oblongata at the level of the pons l Vertebrobasilar system supplies the posterior circulation of the brain via the Circle of Willis

Neurodiagnostics:MR Angiography

Cerebral cortex: Vascular Territories

ar m face

le g

face ar m le g

Anterior Cerebral Artery (ACA) Supplies: Medial and Superior aspects of frontal and parietal lobes Least common area for stroke due to occlusion or stenosis

ACA Stroke Dysfunction: Motor – Contralateral hemiparesis, in foot and leg deficits > than arm – Footdrop, gait disturbances Sensory – Contralateral hemisensory alterations Visual or Ocular – Deviation of eyes toward affected side

ACA Stroke Dysfunction: l

Speech – expressive aphasia

l

Cognition - Impaired attention span - Perseveration - Amnesia

l

Perception – Apraxia – Inability to carry out purposeful movements in nonaffected side

Middle Cerebral Artery (MCA) Supplies: Lateral aspect of frontal and parietal lobes Approximately 90% of all strokes involve the MCA

MCA Stroke Dysfunction: l

Motor – Contralateral hemiparesis or hemiplegia, face and arm deficits > than leg

l

Sensory – Contralateral hemisensory alterations – Neglect of involved extremities

l

Visual or Ocular – Homonymous hemianopia – Inability to turn eyes toward affected side

MCA Stroke Dysfunction: l

Speech – Dyslexia, dysgraphia, aphasia

l

Cognition - Lack of judgment/ poor insight

l

Perception – Neglect - Difficulty w/spatial relationships - Apraxia

Posterior Cerebral Artery (PCA) Supplies: Medial and Inferior aspects of right temporal and occipital lobes

PCA Stroke Dysfunction: Motor – Mild contralateral hemiparesis (with thalmic or subthalmic involvement) Sensory – Diffuse sensory loss (thalmic) Visual or Ocular – Pupillary dysfunction (brainstem) – Loss of Conjugate gaze, nystagmus – Loss of depth perception – Cortical blindness – Homonymous hemianopia

PCA Stroke Dysfunction: Speech – Perseveration - Dyslexia Cognition - Memory impairment Perception – Impaired right vs. left discrimination - Difficulty w/spatial relationship - Visual agnosia

Primary motor cortex (M1) Posterior parietal cortex

Supplementary motor cortex (SMA)

Principal Motor

Premotor cortex (PMA)

Principal Motor Domains The primary motor cortex (M1) lies along the precentral gyrus, and generates the signals that control the execution of movement. Secondary motor areas are involved in motor planning.

Motor

Primary motor cortex (M1)

Hip Trunk

Arm

Hand

Foot

Face

Tongue

Larynx

Motor homunculus l Body

parts with complex repertories of fine movement, like the hand, require more cortical space in M1, while body parts with relatively simpler movements, like the hip, require less cortical space.

Right Hemispheric Stroke

If the Stroke occurs on the right side, the left side of the body will be affected, which could produce any or all of the following:

Contralateral face, arm and leg weakness or hemiparesis Contralateral arm and/or leg sensory loss or extinction Hemispatial neglect or inattention

Left Hemispheric Stroke

If the Stroke occurs on the left side, the right side of the body will be affected, which could produce any or all of the following:

Contralateral face, arm and leg weakness or hemiparesis Contralateral arm and/or leg sensory loss Aphasia, alexia, agraphia

Right Hemispheric Stroke

Left Hemispheric Stroke

(continued)

If the Stroke occurs on the right side, the left side of the body will be affected, which could produce any or all of the following:

Deficit and/or neglect of the left visual field Right gaze preference Impulsive or overestimation of abilities (risk for injury)

If the Stroke occurs on the leftt side, the right side of the body will be affected, which could produce any or all of the following:

Deficits in right visual field Left gaze preference Slow and cautious behavior

Cerebral Hemispheres

Cerebrovascular Disease: Stroke Subtype Hemorrhagic Stroke Intracerebral Hemorrhage

Ischemic Stroke Atherothrombotic Cerebrovascular Disease

Cryptogenic Embolism Subarachnoid Hemorrhage Lacunar Small vessel disease

Albers GW, et al. Chest. 1998;114:683S-698S. Rosamond WD, et al. Stroke. 1999;30:736-743.

Cerebrovascular Disease: Stroke Subtype

(cont.)

Stroke Types l Ischemic – –

Stroke (87%)

Diminished blood supply to focal area of the brain Mostly thromboembolism

l Hemorrhagic – –

Stroke (13%)

Blood vessel rupture within skull not due to trauma Intracerebral (10%) or subarachnoid (3%)

Ischemic Stroke Most common cause: thromboembolism Possible sources of Clot: l Heart l Large artery (to brain) l Small artery (in brain) l Blood itself

3 types of Ischemic Strokes 1. Thrombotic strokes Occur when a clot blocks the flow of arterial blood to the brain. The clot is usually the result of arteriosclerosis, originating within the brain.

3 types of Ischemic Strokes 2. Embolic strokes Also are the result of a clot formation However, these clots form elsewhere in the body, usually the heart or the neck, and travel to the brain and cause an occlusion of cerebral blood flow.

3 types of Ischemic Strokes 3. Systemic hypoperfusion Occurs when the systemic blood pressure becomes too low and in turn causes a decrease in cerebral blood flow.

Findings l Cardiac

murmurs l Cardiac arrhythmias l Asymmetry of blood pressure between the two upper extremities l Asymmetry of peripheral pulses l Cervical or cranial bruits May be the cause of an ischemic stroke or detect a cardiac complication from the cerebrovascular event

2 types of Hemorrhagic Strokes 1. Subarachnoid hemorrhage Occurs when a blood vessel ruptures in the subarachnoid space, between the brain and the skull.

2 types of Hemorrhagic Strokes 2. Intracerebral hemorrhage

Occurs when a blood vessel within the brain itself ruptures.

5 Major Stroke Syndromes

Features of Ischemic or Hemorrhagic Stroke Focal Neurologic Symptoms: Cognitive impairments (i.e. aphasia) Weakness or incoordination of limbs Facial weakness Numbness of limbs and/or face Cranial nerve palsies

Distinguishing Features: Hemorrhagic Stroke vs. Ischemic Stroke Features suggesting Ischemic Stroke l Stepwise deterioration or progressive worsening l Waxing and waning of findings l Focal neurologic impairments in pattern of single blood vessel l Signs point to a focal cortical or subcortical lesion.

Distinguishing Features: Hemorrhagic Stroke vs. Ischemic Stroke

Hemorrhagic Stroke l Early

and prolonged loss of consciousness l Prominent headache, nausea and vomiting l Retinal hemorrhages l Nuchal rigidity l Focal signs do not fit the anatomic pattern of a single blood vessel

Clinical Assessment Critical First Actions Assess and support cardiorespiraoty function Assess and support oxygenation and ventilation Assess and support blood glucose Assess neurologic function Determine precise time of symptom onset Determine essential medical information

Nursing Care of the Acute Ischemic/Hemorrhagic Stroke Vital signs and neurologic assessments as ordered and more frequently if needed Check oxygen level if hypoxic, give supplemental oxygen Cardiac monitor DVT prevention Anticoagulation (only for the Ischemic Stroke) or compression stockings for the bedridden

Nursing Care of the Acute Ischemic/Hemorrhagic Stroke

l Bladder/Bowel

care ( to include I/O) l Frequent turning or change in position and skin care l Range of motion exercises l Activity –

Bedest progressing to full activity as tolerated

Joint Commission Performance Measures for Stroke Patients 

#1 DVT prophylaxis initiated by end of Hospital Day Two (Ischemic and Hemorrhagic stroke patients)



 

Use of heparin, heparinoids and/or Sequential Compression Device (SCD) for patients who are nonambulatory or need assistance from another individual

DVT prophylaxis Pulmonary embolism accounts for 10% of deaths after stroke The complication may be detected in 1% of the patients who have had a stroke

Symptomatic DVT slows recovery and rehabilitation after Stroke

Joint Commission Performance Measures for Stroke Patients

# 7 Screen for Dysphagia Before any foods, fluids or medications a dysphagia screen should be performed on all stroke patients (Ischemic/Hemorrhagic)

Nursing Care of the Acute Ischemic/Hemorrhagic Stroke

Hydration/Nutrition

–

-IV fluids – Swallowing assessment – Diet as tolerated – NG tube feedings Assess for future need for enteral feeding

Nursing Care of the Acute Ischemic/Hemorrhagic Stroke

Medications Symptomatic medications Medications for concomitant diseases – Continue treatment for stroke –

–

Joint Commission Performance Measures for Stroke Patients

# 5 Antithrombotic Medication Initiated by End of Hospital Day # 2 Ischemic Stroke or TIA patients to receive antithrombotic medication by end of hospital day # 2

Antithrombotic within 48 hours of Event

Two large trials, CAST and IST, each showed a reduction in death and disability with aspirin initiated within 48 hours of stroke A small increase in bleeding complications was noted

Stroke Prevention - Non-cardioembolic ASA 2006 Recommendations l For

Patients with noncardioembolic ischemic stroke or TIA, antiplatelet agents are recommended rather than oral anticoagulation to reduce the risk of recurrent stroke and other cardiovascular events (Class I, Evidence A)

Antiplatelets ASA 2006 Recommendations Compared to ASA alone, both the combination of aspirin and extended-release dipyridamole and clopidogrel are safe The combination of aspirin and extended-release dipyridamole is suggested instead of Aspirin alone (Class II, Level A) Clopidogrel is suggested instead of aspirin alone based on direct comparison trials (Class IIb, Level B)

Ischemic Stroke Prevention Large Artery Atherosclerosis Endarterectomy

Patient after stroke or TIA

Consult with patient and patient’s MD

Candidate for endarterectomy? NO

Carotid stenosis stenosis >60%

YES

Candidate for angioplasty?

YES

NO

Antiplatelet therapy indicated

Joint Commission Performance Measures for Stroke Patients

# 2 Discharged on Antithrombotics TIA or Ischemic Stroke Patients should be prescribed antithrombotic therapy @ d/c unless contraindicated

Joint Commission Performance Measures for Stroke Patients

# 3 Patients with Atrial Fibrillation Receiving Anticoagulation Therapy Patients with an Ischemic Stroke with A-fib discharged on anticoagulation therapy unless it is contraindicated

Anticoagulation for Atrial Fibrillation

More than 75,000 cases of Stroke are attributed to A-fib

Atrial Fibrillation (AF)ASA 2006 Recommendations l For

patient with ischemic stroke or TIA with persistent or paroxysmal (intermittent) AF anticoagulation with adjusted-dose warfarin (target INR 2.5, range 2.0 to 3.0) is recommended (Class I, Evidence A). l For patients unable to take oral anticoagulants, aspirin 325 mg per day is recommended (Class I Evidence A).

Ischemic Stroke Prevention Cardioembolic Stroke

Patient after stroke or TIA Cardioembolic stroke

Contraindication NO Initiate warfarin to warfarin? therapy YES Initiate antiplatelet therapy

Nursing Care of the Acute Ischemic/Hemorrhagic Stroke l Diagnostic –

testing

Ascertain the cause of the stroke and to plan for therapies to prevent recurrent stroke

l Consultations – – – –

Physical therapy Speech therapy Occupational therapy Social services

Lipid Profile 36.6 million Americans have cholesterol levels > 240 Cholesterol goals: total Cholesterol < 200 HDL > 40 LDL < 100 (w/ hx. Of CHD) Lipid lowering therapy was associated with a 17% risk reduction rate in stroke

Joint Commission Performance Measures for Stroke Patients

# 6 Discharged on Statin Medication Ischemic Stroke/TIA Patients with an LDL > 100 OR who were on cholesterol reducing medication prior to hospitalization

Joint Commission Performance Measures for Stroke Patients

# 10 Assessed for Rehabilitation All Stroke (Ischemic/Hemorrhagic) patients assessed for or received rehabilitation services

Rehabilitation Rehabilitation is the primary treatment modality for patients recovering from Stroke All stroke patients should be assessed for rehabilitation during the initial hospitalization

Stroke patients should be referred to – – –

Inpatient facility Outpatient facility Home care services for rehabilitation

Nursing Care of the Acute Ischemic/Hemorrhagic Stroke Information delivery

Provide information to patient and family about stroke, its complications, its treatment, and plans for future care

Joint Commission Performance Measures for Stroke Patients

# 8 Stroke Education All Stroke (Ischemic & Hemorrhagic) and TIA patients and/or caregivers should receive stroke education and/or resources

Educate about Modifiable Risk Factors Elevated BP is probably the single most important factor promoting long-term disposition to stroke The relationship between BP and stroke is linear One study showed a decrease of 5mm/Hg in diastolic and a 10mm/HG in systolic was associated with 34% and 28% fewer strokes

ACE inhibitors proved effective in Stroke prevention in the HOPE study, the PROGRESS study and the LIFE study

Education @ BGMC FAST pamphlet Booklets – Stroke Life after a Stroke Patient Information – Stroke Caregivers Helpful Information

Hospital Channel 95 Brain Attack a Survival Guide

Hospital Channel 99 Stroke Education in Spanish

Joint Commission Performance Measures for Ischemic/ Hemorrhagic Stroke & TIA Patients # 9 Smoking Cessation Adult smoking cessation advise/counseling for all Stroke (Ischemic/Hemorrhagic) or TIA patients

Smoking Cessation Estimated 35.1 million men and 20.9 million women smoke

Ask about tobacco use status Assess the tobacco user’s willingness to quit Assist with counseling Prescribe medication for smoking cessation

How does the hemorrhagic stroke differ from ischemic stroke?

Nursing Care of the Hemorrhagic Stroke

May be similar to that of an ischemic stroke, however, there are some major differences; related to bleeding and the increased intracranial pressure caused by the bleeding

Nursing Care of the Hemorrhagic Stroke

Lifesaving measures might be needed within the first 24 hours, including surgical evacuation of a large hematoma.

Nursing Care of the Hemorrhagic Stroke

Aggressive blood pressure management may be needed in order to prevent the risk of continued bleeding.

Nursing Care of the Hemorrhagic Stroke

A patient who develops new focal neurologic signs, headache or altered consciousness and is on an anticoagulant, antiplatelet aggregating agent or thrombolytic agent, intracranial hemorrhage should be suspected

Nursing Care of the Hemorrhagic Stroke

Intracranial hemorrhage is the most frequent fatal complication of long-term use of oral anticoagulants.

Nursing Care of the Hemorrhagic Stroke

Medications – – – –

Stop all anticoagulant, antiplatelet aggregating agent or thrombolytic agent Symptomatic medications Medications for concomitant diseases Continue treatment for stroke

Nursing Care of the Hemorrhagic Stroke

Diagnostic testing – –

PT/INR, aPTT, platelet count Ascertain the cause of the stroke and to plan for therapies to prevent recurrent stroke

Aneurysmal Subarachnoid Hemorrhagic Stroke Treatment of aneurysm Clipping – Coiling Trapping or wrapping aneurysm –

–

Nursing Care of the Aneurysmal Subarachnoid Hemorrhagic Stroke General and Symptomatic Treatment Absolute bedrest in quiet, dark environment Medications Sedative if agitated – Anticonvulsants – Analgesics, including opiates, for headache; avoid aspirin and other nonsteroidal anti-inflammatory agents because of their antiplatelet effects – Antihypertensives –

Nursing Care of the Aneurysmal Subarachnoid Hemorrhagic Stroke

Treat dehydration and hyponatremia Avoid fluid restriction Administer intravenous fluids containing sodium – Administer colloid solutions –

–

Vasospasm HHH therapy l Hemodilution –

Hct 30-35%

l Hypertension – –

Phenylephrine/Norepinephrine BP titration to CPP

l Hypervolemia – –

Colloid/crystalloid PCWP / CVO 12 or more

Cerebral Perfusion Pressure l CPP

= MAP-ICP l MAP = [( 2 x daistolic) + systolic] / 3 l Normal CPP = 70 – 100mm/Hg CPP should be kept above 60mm/Hg to avoid hypoperfusion and ischemic injury

Improving Outcomes The cause and symptoms of stroke are a multitude of complex origins. The nursing care in the acute stroke patient demands fine tuned critical thinking skills. Sound nursing assessment is essential to reduce stroke mortality and morbidity in the acute setting.

Improving Outcomes

Dedicated stroke units can reduce a patient’s risk of death by 40%!