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Stroke: Nursing Process (ADPIE)



Russell King is a 70-year-old male client who experienced an embolic stroke in his left middle cerebral artery. His wife says she found Russell slumped in his recliner, unable to get up. She noticed that his face looked like it was drooping on one side, and his speech was slurred. She called an ambulance, and he was brought to the emergency department, or ED, and was quickly diagnosed with a stroke and treated with thrombolytic therapy. After Russell recovered in the stroke unit, he was transferred to an inpatient rehabilitation facility where he will undergo rehabilitation therapy.

A stroke is when there’s a sudden neurological deficit because part of the brain loses its blood supply. There are factors that may put an individual at risk for stroke. Unfortunately, many of them are non-modifiable, including older age; male sex; history of prior stroke; and family history of stroke. On the other hand, modifiable risk factors include uncontrolled hypertension, dyslipidemia, diabetes, heart disease like atrial fibrillation, as well as obesity, lack of physical activity, diet high in saturated fats, and smoking or using drugs like cocaine or amphetamines.

Okay, now there are two main types of stroke: an ischemic stroke, in which a blocked artery reduces blood flow to the brain, and a hemorrhagic stroke, in which an artery in the brain breaks and creates a pool of blood that damages the brain. In this video, we are going to focus on ischemic strokes, which are much more common. Now, most ischemic strokes are caused by thrombosis, meaning that a clot forms over an atherosclerotic plaque. This is when a buildup of fat and cholesterol forms within a cerebral artery and starts to obstruct its blood flow. Another mechanism for ischemic stroke is an embolism. This happens when an embolus, which is a piece of blood clot or fatty deposit, breaks off from an atherosclerotic plaque from an artery outside the brain, most often from the heart or neck. The embolus then travels to the brain, where it gets lodged in a cerebral artery. Now, sometimes a small clot can block a cerebral artery for a short period of time, usually within minutes up to 24 hours, before dissolving and restoring normal blood flow. This is called a transient ischemic attack, or TIA for short. Although TIAs don’t cause permanent brain damage, they can be a warning sign for future strokes.

Stroke symptoms depend on the exact part of the brain that is affected, as well as the extent of damage and how long the brain suffers from reduced blood flow. Symptoms usually occur suddenly and can include numbness and sudden muscle weakness or paralysis on one side of the body. This can involve the face, with facial drooping, as well as the arms, or legs, leading to difficulty performing movements like walking. In addition, strokes may present with difficulty speaking or understanding speech; visual disturbances; loss of balance; as well as a sudden and severe headache, dizziness, and confusion. An acronym to remember some common stroke symptoms is to BE FAST, which stands for balance, eyes, face, arms and legs, speech, and time, which is a reminder to call emergency services as quickly as possible to minimize brain injury and maximize the chance of a full recovery.

Unfortunately, many clients who experience a stroke may develop complications, such as post-stroke pain associated with recurrent muscle spasms. Many clients also experience permanent weakness or paralysis of the involved area; difficulty talking or understanding speech, as well as difficulty swallowing. They can also develop problems with thinking or memory, emotional disturbances, and personality changes. In severe cases, these complications may cause clients to be unable to take care of themselves.

To diagnose and confirm the location of an ischemic stroke, brain imaging must be done. The first choice is usually a CT scan without contrast. However, a CT scan can detect a stroke that occured only after 6 to 24 hours. On the other hand, an MRI can detect a stroke that occurred within 3 to 30 minutes, but takes longer to perform. Other tests such as CT angiography, MR angiography, carotid and transcranial duplex ultrasonography, or conventional angiography can also be ordered and can help find the blocked artery. Laboratory tests are also done to monitor the client, and to identify risk factors that may have led to the stroke. These include a complete blood count, which may show an elevated platelet count; as well as coagulation tests, such as prothrombin time, or PT, and partial thromboplastin time, οr PTT, that may reveal a hypercoagulable condition; and lipid profile, which may show dyslipidemia. Blood glucose is also measured to rule out hyperglycemia or hypoglycemia, which can mimic a stroke. Additionally, a 12-lead electrocardiogram may detect a cardiac cause such as atrial fibrillation.

Okay, now, the immediate treatment of choice for ischemic stroke is thrombolysis to break down the clot and restore blood flow. After a stroke has occurred, there is an elevated risk of having additional strokes, so it’s important to minimize risk factors. The main way to do this is to quit smoking, have a healthy diet, and exercise regularly, as well as maintain a normal blood pressure, normal lipid profile, and control other diseases like diabetes or heart disease. Finally, clients may benefit from customized neurorehabilitation programs to practice and regain the ability to perform activities of daily living, and improve language function, as well as learning new ways to compensate for any remaining disabilities.

Alright, let’s get back to assess our client, Russell. You enter his room, introduce yourself, confirm his identity, and perform hand hygiene. His vital signs are tympanic temperature is 98℉ or 36.7°C, heart rate 70 beats per minute and regular, respiratory rate 18 breaths per minute with clear breath sounds bilaterally, oxygen saturation 94% on room air, blood pressure 130/85 mmHg. Peripheral pulses are equal and normal. You note that Russell is drowsy, but responds to verbal stimuli. His speech is slurred and he struggles to speak, and he is unable to swallow saliva. He has a visual deficit on his right side, and he has partial paralysis of the right side of his face, arms, and legs.