Stroke Nursing Care

Aug 26, 2023

Stroke Nursing Care

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Stroke nursing care and assessment for nursing students. This video covers how to assess and care for a stroke patient for nurses and nursing students.

Learn the difference between ischemic and haemorrhagic strokes and how management of these patients differs.

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Content

0 -> Now, working on neurological ICU, so I see a lot of stroke patients. But what I am trying

6.2 -> to do here is just keep it really simple and give you the basics of stroke and kinda what

11.16 -> you need to know to pass nursing exams and the NCLEX without going into it very much

16.54 -> or too deep here. So, a stroke is essentially, it s a neurological deficit caused by decreased

23.28 -> blood flow to a portion of the brain. Okay. Now we have Ischemic versus Hemorrhagic stroke

30.96 -> and we re gonna dive into this quite a bit here. And lack of blood flow greater than

33.2 -> 10 minutes can cause irreversible damage. What you see here is you see an ischemic stroke

40.34 -> several days after the initial stroke here. So, this will be the right side of the brain,

46 -> and this will be the left because images are reversed on CT. So, this will be a large right

52.9 -> sided stroke here and this would be the ventricles of the brain. So, this patient has a massive

63.12 -> stroke here, right? So, basically, though, regardless if it s ischemic or hemorrhagic,

68.93 -> what we re concerned about here is this decreased blood flow to the portion of the brain, much

73.369 -> like a heart attack, if one of those vessels becomes occluded or if one of the vessels

79.369 -> ruptures, we have that issue or blood flow, they re not progressing beyond that point.

84.6 -> And without the blood flow, it s not getting oxygen and we have tissue death, right? Okay,

90.32 -> so that s what a stroke essentially is.

92.229 -> Now, let s talk Ischemic verus Hemorrhagic. When we talk about an ischemic stroke, we

97.77 -> re talking about, of course, a blood clot. This makes out about 87% of all strokes and

104.229 -> it s not initially identifiable on a CT. So, what happens is, is a patient comes in with

109.329 -> stroke-like symptoms, right? Altered levels of consciousness, facial droop, and things

116.31 -> like that. And so, we, automatically are concerned that it could be an ischemic stroke and we

123.709 -> begin interventions for that. So, that s kinda what the concern there. With hemorrhagic strokes,

129.64 -> what we have is, we have a bleed. We have weak blood vessel ruptures and the patient

134.28 -> will generally call it the worst headache of their life. So, a lot of times, what we

137.459 -> ll have is, is we ll have like an aneurysm on one of the vessels in the brain and this

143.29 -> portion of the aneurysm here is generally the weakest part. And so, what will happen

148.379 -> is, eventually, that could rupture, and then, that would cause blood flow out of here and

152.959 -> then we d lose blood flow distal to that. And so that, of course is a huge concern as

158.349 -> well. Both of these, as you can see, are limiting blood flow beyond that point. Okay, so here

163.689 -> s a ischemic stroke with a blood clot and this will be like a hemorrhagic stroke with

167.78 -> blood being lost into cerebral space. Okay, so, with hemorrhagic stroke, though, this

173.6 -> is identifiable on CT immediately, because we d see all this blood inside the cerebral

182.469 -> space, okay.

185.61 -> So, some of the risk factors, what do we need to watch out for the patient who maybe at

190.44 -> risk for stroke. Now, this is gonna be similar risk factors for many things that we talked

194.469 -> about, right? Because our risk factors are Hypertension, Diabetes, Atheroclerosis. And

200.341 -> so, with all these here, we re talking about vascular issues, right? So, these are making

207.409 -> our vessels weaker and they re making our vessels less adaptable to blood flow and things

213.36 -> like that. So, blood is less able to flow, vessels become weaker, and then atherosclerosis,

219.859 -> of course, can lead to clots. We could also have cardiac dysrhythmias. We can have Afib

227.56 -> even, that can cause clots to dislodge and head up to the brain. Substance abuse, a lot

233.65 -> of times, we ll see patients with cocaine abuse that can lead to stroke. Obesity, of

239.76 -> course, we re also talking about vascular issues there, as well as, build up of fat

245.25 -> within the vessels and lead to ischemic stroke. Oral contraceptives actually have, pose a

250.769 -> risk factor for hemorrhagic stroke, okay. And an anticoagulant therapy, of course, if

257.769 -> a patient, pertaining to a patient s blood, we get their INR up to like our goal level

263.22 -> of 2, or whatever, or 2.5, whatever their goal is, that makes them more of a candidate

268.86 -> for bleeding. So, if it s an elderly patient who is, has less balance and things like that,

273.3 -> they fall, that puts them in a big risk for like a subarachnoid hemorrhage with blood

277.9 -> collecting in the cerebral space or subdural hematomas, something like that.

282.979 -> Okay. So, how do we assess this? First of all is clinical assessment. Like I said, we

288.81 -> have to be able to assess for stroke symptoms, facial droop, they re not talking right, they

295.36 -> have altered mental status. We can do a CT and initially, that will help us be able to

299.87 -> find, like I said, a hemorrhagic stroke, or like an ischemic stroke a couple of days after.

308.81 -> We can also run an MRI, it s gonna be a little bit more conducive to see a stroke. We can

315.17 -> do a cerebral angiogram that s this here, we could actually inject the dye up into the

319.169 -> cerebral space and this is what would be done with it, within a ischemic stroke. If we see

323.6 -> an ischemic stroke, the physician will go in there, the neurosurgeon or interventional

327.52 -> neurologist would go in there and would be able to inject this dye and will be able to

330.669 -> see where the stroke is and then be able to, a clot isn t be able to remove it. And we

335.32 -> ll get into that in just a minute.

337.009 -> So, again, our assessment. Altered levels of consciousness, contralateral manifestations

343.05 -> (opposite side of a stroke), now, and again, this is going to be dependent upon where the

347.95 -> stroke is, whether it s basal ganglia, whether it s pontine, whether it s super supratentorial.

356.97 -> So, based on where the stroke is, is gonna kinda tell us some of the assessment findings.

362.69 -> But for our purposes, we really just need to keep in mind these: facial droop, arms

367.99 -> - does one arm drift?, meaning, does it fall down? If it s lifted up, are they not able

372.449 -> to lift it. Or, speech problems, so, they are just acting different, okay? A lot of

376.569 -> times, patients will come in and they ll just say grandma was talking funny after dinner

380.28 -> or something like that. And then we can also do what s called the NIH Stroke Scale. This

383.98 -> gives you a score basically grading how significant the stroke is, up to 40 or so. And, the higher

392.59 -> the score, the more significant the stroke was. And so, we kinda judge our size, we judge

397.879 -> our ability to read, their orientation, and then we give them a score based on that, of

402.97 -> how significant the stroke was.

408.62 -> Okay, so, some things you need to keep in mind here. You ll hear a lot about these aphasia,

413.669 -> apraxia, hemianopsia, dysphagia. So, what are these things? Aphasia is speech difficulty,

419.58 -> and there s a couple of different kinds: there s expressive, receptive, global. And, so,

424.099 -> some of the things, with expressive, it s gonna be, they understand but they re not

427.199 -> able to express themselves, right? With receptive, they re not able to comprehend, so, they re

432.51 -> not receiving, they re not receptive of what you re saying. With global, that s language

438.15 -> dysfunction. Okay, and so, this can be like, the first time we actually see a patient who

441.949 -> has this, it can be very surprising kinda to hear these patients talk and they really

446.919 -> believe they re making sense but they re rally making no sense at all, or you show them like

453.849 -> a picture of a glove and they call it a key, and they really just believe they re saying

458.479 -> the right things. So, the best thing we can do for these patients is provide adequate

461.8 -> time for the client to respond. Okay, we need to not be rushing them through assessments,

465.729 -> we need to make sure they re able to have the time they need to respond, we need to

469.351 -> repeat names of individuals and objects frequently, we need to repeat ourselves. My name is Jon,

473.75 -> I m your nurse, remember, I m gonna be taking care of you. We can use a picture board that

478.361 -> a lot of hospitals will have. We can provide only one instruction at a time, so don t say

483.8 -> let s go to the bathroom, let s get back down, let s watch the TV, here s your cola. You

487.68 -> need to do things very slowly for these patients, okay? Apraxia would be the inability to perform

494.81 -> tasks. So, you would ask them to write their name and they re not able to do it. Hemianopsia

500.639 -> is blindness in half of the vision field an this is one of the test we do with our NIH

505.3 -> Stroke Scale, is we ll show them a picture, that kinda has some thing happen at one side

511.27 -> of the picture and something happen on the other side of the picture and we ask them

513.49 -> to just tell us what they see in the picture and so we ll have a picture. It s actually

520.329 -> a picture of a mom over here doing dishes and then over here, there s a couple of kids

525.39 -> kinda grabbing into a cookie jar. And so, people with hemianopsia, they ll only be able

529.709 -> to see one half of the picture. They actually, this other half becomes just completely absent

536.04 -> and they just can t see it at all. So, what we can do here, is we can instruct the client

539.38 -> to turn their head to capture the entire vision field, so, they really be only be able to

543.64 -> see from one side, we need to tell them to make sure they re looking around everywhere.

549.48 -> We approach them for the unaffected side and we provide food and objects to the unaffected

553.82 -> side. We re not trying to trick our clients here and we re not trying to cure them with

558.34 -> hemanopsia, then we might not be able to do that. But, teaching them to adapt to that

562.73 -> is what we re trying to do. And then, dysphagia is difficulty of swallowing. Okay, so, keeping

567.43 -> those things in mind.

568.71 -> Some things that we can do for ischemic stroke. With ischemic stroke, we actually allow for

575.36 -> permissive hypertension. So, we ll allow their blood pressure up to 220/110. And the reason

583.8 -> for that, is remember, we have this clot here, right? And so, blood is not flowing as it

588.2 -> should. So, we want to pump up that blood pressure to try to get as much perfusion as

593.34 -> we can. Okay, and so, it s always fun with neuro assist to watch them freak out when

598.46 -> they see a blood pressure of 180 on an ischemic stroke patient. We re gonna get that blood

603.17 -> pressure up and try to perfuse as much a possible. It can also provide anti-thrombotic therapy.

608.49 -> This will be like TPA. And with a patient with TPA, we actually bring that blood pressure

612.589 -> down a bit because there s a huge risk for bleeding out with TPA. So, what a TPA actually

617.269 -> does, is it goes in, so it s antithrombotic, right? So, we have this thrombus in our vessel

624.48 -> and a TPA actually goes in them and bam it, bust that up, okay. It s pretty cool. And

628.77 -> then, we have our carotid endarterectomy, so let s say, here s our patient, here s our

635.16 -> carotid artery, let s say you have a clot here, they can actually open this up, and

641.26 -> pull that clot out. Okay, so, pulling that clot out there will then allow blood flow

646.389 -> back up into the brain. There s thrombectomy as well. With thrombectomy, that s kinda when

653.76 -> the CTA would be used, the patient will go into interventional neurology, and the physician

659.23 -> will actually go up to that clot in case it can pull it out. Okay, so, it s pretty cool

664.86 -> watching that. And, so, that would restore blood flow. And then obviously, we re going

670.389 -> to monitor neurological status.

673.72 -> With our hemorrhagic stroke patients, remember, this is completely different. What we ll do

677.11 -> here is we can do coiling or clipping of an aneurysm. So, remember, we have an aneurysm

682.13 -> here, so the physician will go in here with like a little wire and they can actually throw

689.05 -> wires in here to coil that. And what will happen is, that will actually start to clot

696.2 -> over and then blood flow is restored and we re not worried about this rupturing anymore.

701.209 -> So, that will strengthen all that, that aneurysm there. So, that would be with coiling. With

706.43 -> clipping, they actually go in and do a crane-y, they ll open this goal, and they ll actually

714.529 -> clip this off. Okay. So, that s kinda the difference with coiling and clipping.

718.149 -> With these patients, one of our biggest concerns is going to be to be, to prevent spasming

723.86 -> of these vessels, okay, we want these vessels to continue to keep the blood flow as they

728.73 -> should. And so, after we do this coiling and the clipping, we kinda get their blood pressure

735.41 -> up, just to tie it again and make sure that they re getting enough blood flow. So, we

738.61 -> dilute their blood, we give them more volume, an we make sure they re getting all of the

743.829 -> blood they need, the blood flow volume that they need. Okay, so that s how we kinda manage

748.7 -> those patients.

749.899 -> Also, we wanna monitor for seizure precautions, with blood, anytime blood comes in contact

754.449 -> with other vessels and things, we can have seizures. We wanna monitor neurological status,

758.42 -> are they improving? Are they getting worse? Trying to make sure I don t get into this

763.37 -> too much here. We wanna make sure that they re not getting more. So, to monitor neurological

767.51 -> status, one thing that we re gonna do, is we re gonna assess pupils, make sure this

772.18 -> will be like unequal pupils here. We wanna of course, we re looking for Perla. Pupils,

776.51 -> Equal, Round, Reactive to Light and Accommodate. We wanna maintain a quiet, calm environment.

781.37 -> We wanna assess for need for assistive devices. We can get physical therapy and occupational

785.269 -> therapy involved. And, then, we wanna get speech therapy involved to make sure they

788.481 -> ll able to take their foods and their medications as needed.

791 -> Okay, so that s just the basics of stroke, of course, we can go into this much more.

Source: https://www.youtube.com/watch?v=cUwn_4S3lBc