1. Types of Stroke
2. Evaluation
3. Implementation
4. Planning
5. Assessment
6. Ischemic Stroke- 80%
   1. Subtopic 1
7. Non-modifiable Risk Factors
8. Hemorrhagic Stroke- 20%
9. Transient Ischemic Attack (TIA)
   1. Transient episode of neurological dysfunction caused by cerebral ischemia without infarction
10. Hyperlipidemia
    1. Associated with metabolic syndrome
11. Heavy alcohol consumption
    1. Recommended max of 1-2 drinks/day
12. Heart disease
    1. Atrial fibrillation
    2. Previous myocardial infarction
13. Hypertension
    1. Associated with metabolic syndrome
14. Ethnicity
    1. Highest in Black and Hispanic populations
15. Heredity
    1. Family history
    2. Sickle cell anemia
    3. Bleeding disorder
16. Age
    1. Risk increases with age, greatest >80 years old
17. Obesity
    1. Associated with metabolic syndrome
18. Diabetes mellitus
    1. Doubles risk of stroke
19. Asymptomatic carotid stenosis
    1. Due to atherosclerosis
20. Nursing diagnosis
21. Nursing goals
    1. Maintain or improve LOC
    2. Maximum physical functioning
    3. Maximum self-care ability
    4. Maintain stable body functions
    5. Maximum communication skills
    6. Maintain adequate nutrition
22. Acute intervention
23. Nutrition
    1. Ability to swallow
    2. Proper nutritional intake
24. Collaborative care
25. Health promotion
    1. Modifiable risk factors
    2. Symptoms of stroke and when to seek care
26. Client centered care
    1. Client and family involved in planning
    2. Care goals and goal priority is client-directed
27. Objective Data
28. Subjective Data
29. Intracerebral Hemorrhage (ICH)- 17%
    1. Bleeding directly into the brain parenchyma
30. Embolic Stroke- 40%
    1. Debris originating outside the brain travels through blood stream and blocks cerebral vessel
31. Thrombotic Stroke- 40%
    1. In situ obstruction of arterial vessel
32. Subarachnoid Hemorrhage (SAH)- 3%
    1. Bleeding into the CSF in the subarachnoid space surrounding the brain
33. Clinical features and symptoms
34. Clinical features and symptoms
35. Severe headache
    1. Most common and characteristic symptom of SAH
    2. Often described as "worst headache ever experienced"
    3. Widespead headache that may radiate into the neck or down back of the legs
36. Digital subtraction angiography
    1. Gold standard to determine etiology of SAH
    2. Fluoroscopy technique used to visualize location of ruptured aneurysms
37. Often precipitated by physical activity
38. Reduced alertness
    1. Absence of focal neurological signs
    2. Death or deep coma occur in bleeding continues
    3. Neurological signs begin abruptly and are maximal at onset
39. Sudden onset of symptoms
    1. Bleeding usually only lasts seconds but rebleeding is common
    2. Due to blood speading rapidly in CSF and increasing intracranial pressure
40. Nausea and vomiting
    1. Present in 50% of cases
41. Headache and decreased level of consciousness
    1. Present in 50% of cases
    2. Headache develops gradually
    3. Headache due to increased intracranial pressure
42. Gradual progression of symptoms
    1. Focal neurological signs present
    2. Neurologic symptoms develop gradually over minutes to hours and are not maximal at onset
    3. Localized hematoma forms that slowly spreads through white matter
43. Nausea and vomiting
44. Meningsmus
    1. Photophobia
    2. Neck stiffness
45. Meningsmus
    1. Photophobia
    2. Neck stiffness
46. Demographic impacted
    1. Higher incidence in women than men
    2. Youngest median age of any stroke sub-type
47. Diagnosis of SAH
48. Causes of ICH
49. General
    1. Fever
    2. Lethargy
    3. Emotional lability
    4. Level of consciousness
50. GI Tract
    1. Dysphagia
    2. Constipation
    3. Loss of gag reflex
    4. Bowel incontinence
51. Cardiovascular
    1. Hypertension
    2. Tachycardia
    3. Carotid bruit
52. Neurological
    1. Aphasia
       1. Global
       2. Receptive
       3. Expressive
    2. Dysarthria
    3. Amnesia
    4. Visual deficits
    5. Weakness or paralysis
    6. Changes in personality
    7. Contralateral motor and sensory deficits
53. Respiratory
    1. Tachypnea
    2. Airway occlusions
    3. Loss of cough reflex
    4. Irregular respirations
    5. Rhonchi sounds present
54. Overall demeanor
    1. Fear
    2. Anxiety
    3. Depression
    4. Low self-esteem
55. Left-brain damage
    1. Paralyzed right side
    2. Impaired speech/aphasia
    3. Slow, cautious performance
    4. Tend to acknowledge deficits
    5. impaired comprehension of language and math
56. Right-brain damage
    1. Paralyzed left side
    2. Left-sided neglect
    3. Short attention span
    4. Spatial-perceptual deficits
    5. Impaired judgement, impulsive
    6. Tend to deny or minimize deficits
57. Contralateral visual and sensory loss
58. Verbal communication with client
59. Assess ROM
60. Canadian neurological scale
61. Glasgow coma scale
62. Nutrition Status
    1. Dysphagia
    2. Nausea and vomiting
63. Changes in excretion
    1. Changes in bowel movements
    2. Changes in urination
64. Neurological changes
    1. Fatigued
    2. Difficulty speaking
    3. Memory impairment
65. Health History
    1. TIA
    2. Medication use
    3. Environmental/occupational hazards
66. Musculoskeletal or nerve changes
    1. Weakness
    2. Numbness or tingling
    3. Loss of movement or sensation
67. Family History
    1. Stroke
    2. Hypertension
    3. Diabetes mellitus
68. Causes of SAH
69. Rupture of cerebral aneurysm
    1. Congenital vessel weakness
    2. Acquired vessel weakness
70. Cerebral amyloid angiopathy
    1. Most common etiology in the elderly
71. Head trauma
    1. Usually single event
    2. Most common cause of SAH
72. Brain magnetic resonance imaging (MRI)
    1. Uses a magnetic field and radio waves to create image of brain
    2. Very high sensitivity and accurate for determining ICH etiology
73. Bleeding disorder or anti-coagulant use
74. Genetic susceptibility
    1. Family history of SAH
    2. Polycystic kidney disease
75. Arteriovenous malformations
    1. Most common cause in children
76. Lumbar puncture (AKA spinal tap)
    1. Needle inserted into spine and CSF removed for diagnostic testing
       1. Mandatory when strong suspicion of SAH despite normal head CT
       2. Classic findings are elevated opening pressure and elevated RBC count
       3. Helpful when presenting with atypical symptoms of SAH
77. Non-contrast computed tomography (CT)
    1. Gold standard for ICH diagnosis
    2. Acute ICH present immediately on head CT
    3. X-ray procedure that combines may different views to give cross-section of brain
       1. Highly sensitive for cerebal hemorrhages
          1. Most sensitive the first 6-12 hours after SAH
       2. Useful for distinguishing between hemorrhagic and ischemic stroke
78. Non-contrast computed tomography (CT)
    1. Gold standard for SAH diagnosis
    2. X-ray procedure that combines may different views to give cross-section of brain
       1. Highly sensitive for cerebal hemorrhages
          1. Most sensitive the first 6-12 hours after SAH
       2. Useful for distinguishing between hemorrhagic and ischemic stroke
79. Illicit drug use
    1. Cocaine
    2. Amphetamines
80. Classification
    1. Small vessel disease
    2. Large vessel disease
81. No decreased level of consciousness
    1. First 24 hours post-stoke
82. May have neck bruit
83. Sudden onset of symptoms
    1. Onset unrelated to activity
    2. Neurological symptoms occur suddenly and are maximal at onset
       1. Involves sudden loss of focal brain function
84. Heart Disease
    1. Endocarditis
    2. Atrial fibrillation
    3. Prior myocardial infarction
85. Arteriosclerosis
    1. Large artery low flow TIA
    2. Focal neurological symptoms last minutes
86. Transient neurological symptoms
    1. <24 hours in length
    2. No infarction occurs
    3. Ischemia of focal brain, spinal cord or retina
87. Diffusion-weighted MRI
    1. Highly sensitive for infarction detection
88. Magnetic resonance angiogram (MRA)
    1. Indicates underlying pathophysiology of TIA
89. Hypertension
90. Small vessel transient ischemia
    1. Lacunar TIA
    2. Caused by stenosis of intracerebral vessels
91. Microemboli
    1. Discrete, single episode
    2. Focal neurological symptoms last hours
92. Blurry or decreased vision
    1. One or both eyes affected
93. Difficulty speaking or slurred speech
94. Demographics
    1. More common in adults >60 years old
95. Hand, arm, face, or leg weakness
96. Symptoms present <24 hours
    1. Often neurologic symptoms last less than 1 hour
97. Computed tomography (CT)
    1. Location and size of brain infarct helps differentiate between stroke subtypes
98. Magnetic resonance imaging (MRI)
    1. Location and size of brain infarct helps differentiate between stroke subtypes
99. Blood tests
    1. Blood lipids
    2. Complete blood count
    3. Blood clotting time
100. Blood tests
     1. Blood lipids
     2. Blood clotting time
     3. Complete blood count
101. Magnetic resonance imaging (MRI)
     1. Location and size of brain infarct helps differentiate between stroke subtypes
102. Cardiac testing
     1. Monitor for atrial fibrillation using 12 lead ECG
     2. Echocardiogram to identify source of embolism
     3. Most emboli causing embolic stroke originate from heart
103. Atherosclerosis
     1. Most important contributor to stroke occurence in older patients
104. Source of embolism
     1. Air
     2. Fat
     3. Cardiac
     4. Arterial
105. Clinical findings may quickly improve
     1. Emboli can migrate or lyse
106. History of TIA
     1. Previous TIA in 30-50% of patients with thrombotic stroke
     2. Strong indicator of local vascular lesion leading to thrombotic stroke
107. Demographic affected
     1. Higher incidence in men than women
108. Demographic affected
     1. Higher incidence in men than women
     2. Oldest median age of any stroke sub-type
109. Stuttering progression of symptoms
     1. Involves sudden loss of focal brain function
     2. Onset often during or immediately after sleep
     3. Symptoms vary between normal and abnormal with some periods of improvement
110. Bleeding disorder or anti-coagulant use
111. Diagnosis of ICH
112. Hypertension
     1. Most common etiology of spontaneous ICH
     2. Most important risk factor for ICH occurence
113. Rupture of cerebral aneurysm
     1. Acquired vessel weakness
     2. Congenital vessel weakness
114. Demographic impacted
     1. More common in Blacks and Asians than Caucasians
115. Often precipitated by physical activity
116. Seizure activity
     1. May occur in 29% of patients
117. Diagnosis of TIA
118. Diagnosis of embolic stroke
119. Clinical features and symptoms
120. Clinical features and symptoms
121. Cause of thrombotic stroke
122. Cause of TIA
123. Cause of embolic stroke
124. Diagnosis of thrombotic stroke
125. Reoccurrence is common
     1. Need to find underlying cause of stroke to prevent reoccurrence
126. Computed tomography (CT)
     1. Location and size of brain infarct helps differentiate between stroke subtypes
127. History of TIA uncommon
128. Artheriosclerosis
     1. Most important contributor to stroke occurence in older patients
     2. Hypertension and diabetes mellitus accelerate plaque formation in cerebral vessels
129. Cerebral artery dissection
130. Vasoconstriction
     1. Second most common cause
131. Traumatic occlusion
132. Fibromuscular dysplasia
133. Clinical features and symptoms
134. Clinical findings may quickly improve
     1. Emboli can migrate or lyse
135. Nursing Care
136. Stroke Demographics
     1. Stroke is the 3rd leading cause of death in Canada
     2. 40,000 - 50,000 people in Canada suffer a stroke each year
     3. 75% of the adult population has at least one of the modifiable risk factors of a stroke
137. Smoking
     1. Elevated risk of stroke
     2. Elevated risk disappears 4 years after smoking cessation
138. Diabetes mellitus
139. Modifiable Risk Factors
140. Traumatic Injury
141. Absent pulse upon physical examination
     1. Carotid pulse
     2. Radial pulse
     3. Pulse from inferior extremities
142. Urinary
     1. Urgency
     2. Frequency
     3. Incontinence
143. Gender
     1. Higher risk in men than women until >85 years old
     2. Women have higher mortality rate associated with stroke
144. Neurological
     1. Treat vasospasm
     2. Treat neurological stroke symptoms
     3. Reduce elevated intracranial pressure
145. Cardiovascular
     1. Restore normal heart rate
     2. Monitor cardiac rhythm
146. Respiratory
     1. Oxygenation
     2. Prevent aspiration
     3. Restore maximal function
     4. Treat airway obstruction
147. Integumentary
     1. Maintain good skin hygiene
     2. Maintain optimal sensation and circulation
     3. Frequent repositioning to prevent skin breakdown
148. Musculoskeletal
     1. Prevent joint contractures or muscle atrophy
     2. Perform active and passive ROM to maintain optimal function
149. Musculoskeletal
     1. Level of independence
     2. Ability to perform ADLs
150. Affect
     1. Coping abilities of client
     2. Level of family support
     3. Presence of emotional outbursts
151. Bowel and bladder function
     1. Presence of incontinence
     2. Effectiveness of stool softeners, laxatives
152. Use of other health care professionals
     1. Physicians
     2. Nutritionists
     3. Physiotherapists
     4. Respiratory therapists
     5. Occupational therapists
     6. Personal support workers
     7. Speech and language pathologists
153. Surgical therapy
     1. Vessel stenting
     2. Carotid endarterectomy
     3. Transluminal angioplasty
     4. Extracranial-intracranial bypass
154. Drug therapy
     1. Aspirin
     2. Clopidogrel
     3. Ticlopidine
     4. Dipyridamole
     5. Tisssue plasminogen activator (tPA)
155. Stroke prevention
     1. Patient education
     2. Manage modifiable factors
        1. Balanced and healthy diet
        2. Weight management
        3. Smoking cessation
        4. Limit alcohol consumption
        5. Regular exercise
     3. Routine health assessments
156. References
     1. Caplan, L. R. (2016). Etiology, classification, and epidemiology of stroke. Retrieved from http://www.uptodate.com/contents/etiology-classification-and-epidemiology-of-stroke?source=search_result&search=etiology+and+classification+of+stroke&selectedTitle=1~150
     2. Caplan, L. R. (2015). Overview of the evaluation of stroke. Retrieved from http://www.uptodate.com/contents/overview-of-the-evaluation-of-strokesource=search_result&search=clinical+diagnosis+of+stroke+subtypes&selectedTitle=2~150
     3. Caplan, L. R. (2013). Clinical diagnosis of stroke subtypes. Retrieved from http://www.uptodate.com/contents/clinical-diagnosis-of-stroke-subtypes?source=search_result&search=clinical+diagnosis+of+stroke+subtypes&selectedTitle=1~150
     4. Furie, K. L. & Ay, H. (2014). Patient information: Transient ischemic attack (Beyond the basics). Retrieved from http://www.uptodate.com/contents/transient-ischemic-attack-beyond-the-basics?source=search_result&search=patient+information+transient+ischemic&selectedTitle=2~150
     5. Leading causes of death, total population, by age group and sex, Canada (2015). Retrieved from http://www5.statcan.gc.ca/cansim/a26?lang=eng&id=1020561
     6. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. (2014). Medical-surgical nursing in Canada (3rd ed.). Toronto, Canada: Elsevier Canada.
     7. Rordorf, G. & McDonald, C. (2014). Spontaneous intracerebral hemorrhage: Treatment and prognosis. Retrieved from http://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-treatment-and-prognosis?source=search_result&search=spontaneous+intracerebral+hemorrhage&selectedTitle=1~150
     8. Sacco, R. L., Boden-Albala, B., Abel, G, Lin, I., Elkind, M., Hauser, A., …Shea, S. (2001). Race-ethic disparities in the impact of stroke risk factors. American Heart Association Journal, 32, 1725-1731. doi: 10.1161/01.str.32.8.1725
     9. Singer, R. J., Ogilvy, C. S., & Rordorf, G. (2013). Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage. Retrieved from http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-aneurysmal-subarachnoid hemorrhagesource=search_result&search=clinical+manifestations+and+diagnosis+of+aneurysmal+subarachnoid&selectedTitle=1~150
     10. Statistics (2015). Heart & Stroke Foundation. Retrieve from http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistics.htm
     11. Wojcik, J. B., Benns, M. V., Franklin, G. A., Harbrecht, B. G., Broughton-Miller, K. D., Frisbie, M. C., Bozeman, M. C. (2013). Traumatic injury may be a predisposing factor for cerebrovascular accident. Journal of Trauma Nursing, 20(3), 139-143. doi: 10.1097/JTN.0b013e3182a171cf
157. NURS 2522 Mind Map: Cerebral Vascular Accident
158. Irena Tin (214374391)
159. Kelsey Fallis (214486187)