Now, working on neurological ICU, so I see a lot of stroke patients. But what I am trying
to do here is just keep it really simple and give you the basics of stroke and kinda what
you need to know to pass nursing exams and the NCLEX without going into it very much
or too deep here. So, a stroke is essentially, it s a neurological deficit caused by decreased
blood flow to a portion of the brain. Okay. Now we have Ischemic versus Hemorrhagic stroke
and we re gonna dive into this quite a bit here. And lack of blood flow greater than
10 minutes can cause irreversible damage. What you see here is you see an ischemic stroke
several days after the initial stroke here. So, this will be the right side of the brain,
and this will be the left because images are reversed on CT. So, this will be a large right
sided stroke here and this would be the ventricles of the brain. So, this patient has a massive
stroke here, right? So, basically, though, regardless if it s ischemic or hemorrhagic,
what we re concerned about here is this decreased blood flow to the portion of the brain, much
like a heart attack, if one of those vessels becomes occluded or if one of the vessels
ruptures, we have that issue or blood flow, they re not progressing beyond that point.
And without the blood flow, it s not getting oxygen and we have tissue death, right? Okay,
so that s what a stroke essentially is.
Now, let s talk Ischemic verus Hemorrhagic. When we talk about an ischemic stroke, we
re talking about, of course, a blood clot. This makes out about 87% of all strokes and
it s not initially identifiable on a CT. So, what happens is, is a patient comes in with
stroke-like symptoms, right? Altered levels of consciousness, facial droop, and things
like that. And so, we, automatically are concerned that it could be an ischemic stroke and we
begin interventions for that. So, that s kinda what the concern there. With hemorrhagic strokes,
what we have is, we have a bleed. We have weak blood vessel ruptures and the patient
will generally call it the worst headache of their life. So, a lot of times, what we
ll have is, is we ll have like an aneurysm on one of the vessels in the brain and this
portion of the aneurysm here is generally the weakest part. And so, what will happen
is, eventually, that could rupture, and then, that would cause blood flow out of here and
then we d lose blood flow distal to that. And so that, of course is a huge concern as
well. Both of these, as you can see, are limiting blood flow beyond that point. Okay, so here
s a ischemic stroke with a blood clot and this will be like a hemorrhagic stroke with
blood being lost into cerebral space. Okay, so, with hemorrhagic stroke, though, this
is identifiable on CT immediately, because we d see all this blood inside the cerebral
space, okay.
So, some of the risk factors, what do we need to watch out for the patient who maybe at
risk for stroke. Now, this is gonna be similar risk factors for many things that we talked
about, right? Because our risk factors are Hypertension, Diabetes, Atheroclerosis. And
so, with all these here, we re talking about vascular issues, right? So, these are making
our vessels weaker and they re making our vessels less adaptable to blood flow and things
like that. So, blood is less able to flow, vessels become weaker, and then atherosclerosis,
of course, can lead to clots. We could also have cardiac dysrhythmias. We can have Afib
even, that can cause clots to dislodge and head up to the brain. Substance abuse, a lot
of times, we ll see patients with cocaine abuse that can lead to stroke. Obesity, of
course, we re also talking about vascular issues there, as well as, build up of fat
within the vessels and lead to ischemic stroke. Oral contraceptives actually have, pose a
risk factor for hemorrhagic stroke, okay. And an anticoagulant therapy, of course, if
a patient, pertaining to a patient s blood, we get their INR up to like our goal level
of 2, or whatever, or 2.5, whatever their goal is, that makes them more of a candidate
for bleeding. So, if it s an elderly patient who is, has less balance and things like that,
they fall, that puts them in a big risk for like a subarachnoid hemorrhage with blood
collecting in the cerebral space or subdural hematomas, something like that.
Okay. So, how do we assess this? First of all is clinical assessment. Like I said, we
have to be able to assess for stroke symptoms, facial droop, they re not talking right, they
have altered mental status. We can do a CT and initially, that will help us be able to
find, like I said, a hemorrhagic stroke, or like an ischemic stroke a couple of days after.
We can also run an MRI, it s gonna be a little bit more conducive to see a stroke. We can
do a cerebral angiogram that s this here, we could actually inject the dye up into the
cerebral space and this is what would be done with it, within a ischemic stroke. If we see
an ischemic stroke, the physician will go in there, the neurosurgeon or interventional
neurologist would go in there and would be able to inject this dye and will be able to
see where the stroke is and then be able to, a clot isn t be able to remove it. And we
ll get into that in just a minute.
So, again, our assessment. Altered levels of consciousness, contralateral manifestations
(opposite side of a stroke), now, and again, this is going to be dependent upon where the
stroke is, whether it s basal ganglia, whether it s pontine, whether it s super supratentorial.
So, based on where the stroke is, is gonna kinda tell us some of the assessment findings.
But for our purposes, we really just need to keep in mind these: facial droop, arms
- does one arm drift?, meaning, does it fall down? If it s lifted up, are they not able
to lift it. Or, speech problems, so, they are just acting different, okay? A lot of
times, patients will come in and they ll just say grandma was talking funny after dinner
or something like that. And then we can also do what s called the NIH Stroke Scale. This
gives you a score basically grading how significant the stroke is, up to 40 or so. And, the higher
the score, the more significant the stroke was. And so, we kinda judge our size, we judge
our ability to read, their orientation, and then we give them a score based on that, of
how significant the stroke was.
Okay, so, some things you need to keep in mind here. You ll hear a lot about these aphasia,
apraxia, hemianopsia, dysphagia. So, what are these things? Aphasia is speech difficulty,
and there s a couple of different kinds: there s expressive, receptive, global. And, so,
some of the things, with expressive, it s gonna be, they understand but they re not
able to express themselves, right? With receptive, they re not able to comprehend, so, they re
not receiving, they re not receptive of what you re saying. With global, that s language
dysfunction. Okay, and so, this can be like, the first time we actually see a patient who
has this, it can be very surprising kinda to hear these patients talk and they really
believe they re making sense but they re rally making no sense at all, or you show them like
a picture of a glove and they call it a key, and they really just believe they re saying
the right things. So, the best thing we can do for these patients is provide adequate
time for the client to respond. Okay, we need to not be rushing them through assessments,
we need to make sure they re able to have the time they need to respond, we need to
repeat names of individuals and objects frequently, we need to repeat ourselves. My name is Jon,
I m your nurse, remember, I m gonna be taking care of you. We can use a picture board that
a lot of hospitals will have. We can provide only one instruction at a time, so don t say
let s go to the bathroom, let s get back down, let s watch the TV, here s your cola. You
need to do things very slowly for these patients, okay? Apraxia would be the inability to perform
tasks. So, you would ask them to write their name and they re not able to do it. Hemianopsia
is blindness in half of the vision field an this is one of the test we do with our NIH
Stroke Scale, is we ll show them a picture, that kinda has some thing happen at one side
of the picture and something happen on the other side of the picture and we ask them
to just tell us what they see in the picture and so we ll have a picture. It s actually
a picture of a mom over here doing dishes and then over here, there s a couple of kids
kinda grabbing into a cookie jar. And so, people with hemianopsia, they ll only be able
to see one half of the picture. They actually, this other half becomes just completely absent
and they just can t see it at all. So, what we can do here, is we can instruct the client
to turn their head to capture the entire vision field, so, they really be only be able to
see from one side, we need to tell them to make sure they re looking around everywhere.
We approach them for the unaffected side and we provide food and objects to the unaffected
side. We re not trying to trick our clients here and we re not trying to cure them with
hemanopsia, then we might not be able to do that. But, teaching them to adapt to that
is what we re trying to do. And then, dysphagia is difficulty of swallowing. Okay, so, keeping
those things in mind.
Some things that we can do for ischemic stroke. With ischemic stroke, we actually allow for
permissive hypertension. So, we ll allow their blood pressure up to 220/110. And the reason
for that, is remember, we have this clot here, right? And so, blood is not flowing as it
should. So, we want to pump up that blood pressure to try to get as much perfusion as
we can. Okay, and so, it s always fun with neuro assist to watch them freak out when
they see a blood pressure of 180 on an ischemic stroke patient. We re gonna get that blood
pressure up and try to perfuse as much a possible. It can also provide anti-thrombotic therapy.
This will be like TPA. And with a patient with TPA, we actually bring that blood pressure
down a bit because there s a huge risk for bleeding out with TPA. So, what a TPA actually
does, is it goes in, so it s antithrombotic, right? So, we have this thrombus in our vessel
and a TPA actually goes in them and bam it, bust that up, okay. It s pretty cool. And
then, we have our carotid endarterectomy, so let s say, here s our patient, here s our
carotid artery, let s say you have a clot here, they can actually open this up, and
pull that clot out. Okay, so, pulling that clot out there will then allow blood flow
back up into the brain. There s thrombectomy as well. With thrombectomy, that s kinda when
the CTA would be used, the patient will go into interventional neurology, and the physician
will actually go up to that clot in case it can pull it out. Okay, so, it s pretty cool
watching that. And, so, that would restore blood flow. And then obviously, we re going
to monitor neurological status.
With our hemorrhagic stroke patients, remember, this is completely different. What we ll do
here is we can do coiling or clipping of an aneurysm. So, remember, we have an aneurysm
here, so the physician will go in here with like a little wire and they can actually throw
wires in here to coil that. And what will happen is, that will actually start to clot
over and then blood flow is restored and we re not worried about this rupturing anymore.
So, that will strengthen all that, that aneurysm there. So, that would be with coiling. With
clipping, they actually go in and do a crane-y, they ll open this goal, and they ll actually
clip this off. Okay. So, that s kinda the difference with coiling and clipping.
With these patients, one of our biggest concerns is going to be to be, to prevent spasming
of these vessels, okay, we want these vessels to continue to keep the blood flow as they
should. And so, after we do this coiling and the clipping, we kinda get their blood pressure
up, just to tie it again and make sure that they re getting enough blood flow. So, we
dilute their blood, we give them more volume, an we make sure they re getting all of the
blood they need, the blood flow volume that they need. Okay, so that s how we kinda manage
those patients.
Also, we wanna monitor for seizure precautions, with blood, anytime blood comes in contact
with other vessels and things, we can have seizures. We wanna monitor neurological status,
are they improving? Are they getting worse? Trying to make sure I don t get into this
too much here. We wanna make sure that they re not getting more. So, to monitor neurological
status, one thing that we re gonna do, is we re gonna assess pupils, make sure this
will be like unequal pupils here. We wanna of course, we re looking for Perla. Pupils,
Equal, Round, Reactive to Light and Accommodate. We wanna maintain a quiet, calm environment.
We wanna assess for need for assistive devices. We can get physical therapy and occupational
therapy involved. And, then, we wanna get speech therapy involved to make sure they
ll able to take their foods and their medications as needed.
Okay, so that s just the basics of stroke, of course, we can go into this much more.