STROKE ..........

Assessment of the secerity of stroke

The level of stroke severity as measured by NIHSS scoring system:

·                     0 – No stroke

·                     1 to 4 – Minor stroke

·                     5 to 15 – Moderate stroke

·                     16 to 42 – Severe stroke

1a	Level of Consciousness
	Alert	0
	Drowsy	1
	Stuporous	2
	Coma	3
1b	LOC questions
	Answers both questions correctly	0
	Answers one question correctly	1
	Answers neither correctly	2
1c	LOC commands
	Performs both task correctly	0
	Performs one task correctly	1
	Performs neither task correctly	2
2	Best Gaze
	Normal	0
	Partial gaze palsy	1
	Forced deviation	2
3	Visual
	No visual loss	0
	Partial hemianopia	1
	Complete hemianopia	2
	Bilateral hemianopia (Blind including cortical blindness)	3
4	Facial palsy
	Normal (Symmetrical movement)	0
	Minor paralysis (flattened nasolabial fold, asymmetry in smiling)	1
	Partial paralysis (total or near total paralysis of lower face)	2
	Complete paralysis of one or both sides	3
5	Motor arm	5a left		5b right
	No drift (Holds limb for 45 or 90 degrees for full 10 seconds)	0		0
	Drift (Holds limb 45 or 90 degrees, but drifts down before 10 sec)	1		1
	Some effort against gravity	2		2
	No effort against gravity	3		3
	No movement	4		4
	Amputation joint fusion explain	A		A
6	Motor leg	5a left		5b right
	No drift (Holds limb for 45 or 90 degrees for full 10 seconds)	0		0
	Drift (Holds limb 45 or 90 degrees, but drifts down before 10 sec)	1		1
	Some effort against gravity	2		2
	No effort against gravity	3		3
	No movement	4		4
	Amputation joint fusion explain	A		A
7	Limb ataxia
	Absent	0
	Present in one limb (Right Arm Yes/No; Left Arm Yes/No)	1
	Present on both limbs	2
	Amputation or Joint fusion	A
8	Sensory
	Normal (No sensory loss)	0
	Mild to moderate sensory loss (Patient feels pinprick is less sharp or dull on the affected side; is aware of being touched)	1
	Severe to total loss (is not aware of being touched)	2
9	Best language
	No aphasia	0
	Mild to Moderate (Some obvious loss of fluency)	1
	Severe aphasia (All communication through expression)	2
	Mute or global aphasia	3
10	Dysarthria
	Normal	0
	Mild to Moderate	1
	Severe	2
	Intubated or other physical barrier explain	A
11	Extinction and Inattention
	No abnormality		0
	Visual, tactile auditory, spatial (Inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities)		1
	Profound hemi attention/ Hemi inattention to more than one sensory modality (Does not recognize on hand or oriented to only one side of the body)		2

. National Institute of Health Stroke Scale (NIHSS)

Modified Rankin scale is another tool used to assess the severity of stroke .

0	No symptoms at all
1	No significant disability despite symptoms; is able to carry out all usual duties and activities
2	Slight disability; Unable to carry out all previous activities; but able to look after own affairs w/o assistance
3	Moderate disability; require some help, but able to walk w/o assistance
4	Moderately severe disability; unable to walk w/o assistance and unable to attend own bodily needs w/o assistance
5	Severe disability; Bed-ridden, incontinent and requiring constant nursing care and attention
6	Dead

 Modified Rankin scale

Investigations

1.  Blood studies: complete blood cell count (CBC), electrolytes, coagulation profile,
random blood sugar, renal function tests, liver function tests.

2.   CT Scan/ CT angiography

3.   ECG

4.   MRI brain with magnetic resonance angiography (MRA)

5.   Transcranial doppler study

6.   Ultrasonography

7.   Cardiac evaluation

Treatment

Emergency treatment

Intravenous thrombolysis: Recombinant tissue plasminogen activator (rtPA) for ischemic stroke if the window period (the time period calculated from the time the patient was last seen well until found to have deficits) is < 4.5 hrs and if there are no contra-indications for rtPA.

Intra-arterial thrombolytics (Urokinase): This is the treatment option if the window period is between 4.5-6 hrs and if there are no contraindications for Urokinase

Decompressive craniectomy: For massive cerebral infarct the treatment of choice is surgical decompression.

 Medical management

Antiedema measures includes administration of mannitol, diuretics, and hyperventilation. Management of hypertension is another goal of medical management.

Secondary prevention

1.  Antiplalelets-Aspirin/Clopidogrel

2.  Statins

3.  Aggressive physiotherapy and general supportive care

4.  Treatment for Deep vein thrombosis (DVT)

5.  Carotid endarterectomy

6.  Treat cardiac causes if any.

Protocol for thrombolytic therapy

The administration of rtPA improves the outcome after stroke when given very early, and within 4.5 hours of onset of stroke in carefully selected persons. If the 4.5 hour time window can be met, treatment can be beneficial irrespective of patient's age, gender, ethnicity, or presumed cause of stroke. A significant increase in improvement at 24 hours and favorable outcomes at 3 months were noted among persons treated with rtPA.The administration of thrombolytic drugs to persons with acute ischemic stroke can be complicated by bleeding. Symptomatic intracranial hemorrhage was significantly increased with treatment but despite the hemorrhage, the rate of death or severe disability was less in the actively treated groups. The benefit of intravenous rtPA for acute ischemic stroke beyond 4.5 hours from the onset of symptoms is not established and cannot be recommended. Intravenous rtPA is not recommended when the time of onset of stroke cannot be ascertained reliably, including strokes recognized upon awakening (“wake up stroke”).

Contraindications

·      Age less than 18 years

·      Evidence of intracranial hemorrhage on pretreatment CT.

·      Coma or severely altered sensorium.

·      Symptoms rapidly improving or minor (not measurable by the NIHSS).

·      Known bleeding diathesis, including but not limited to:

1.        Platelet count < 100,000

2.        Current use of oral anticoagulants or,

3.        Prothrombin time (PT) > 15 sec, INR > 1.7,

4.        Use of heparin in the previous 48 hours and a prolonged partial thromboplastin time (PTT).

·      Serious head trauma or previous stroke within 3 months.

·      Seizure at the onset of stroke.

·      Major surgery or major trauma within 14 days.

·      Arterial puncture at a noncompressible site or lumbar puncture within 7 days.

·      Gastro Intestinal or urinary tract bleeding within 21 days.

·      Pretreatment systolic blood pressure (SBP) > 185 or diastolic blood pressure (DBP) > 110, despite simple measures.

·      History of intracranial hemorrhage.

·      Abnormal blood glucose (< 50 or > 400 mg/ dL)

·      Recent myocardial infarction complicated by pericarditis.

·      Pregnant or lactating females (menstruation is not a contraindication).

·      Early changes on CT such as sulcal effacement, mass effect, or edema are not absolute contraindications. If these signs are present, then it suggests a longer interval between stroke onset and the CT scan than 3 hours. Immediate efforts must be made to re-establish the time of onset of neurological symptoms.

For patients presenting with new onset stroke

Determine exact time of onset of symptoms and document in medical record.

Activate the Acute Stroke Service and act promptly.

1.   Order non-contrast head CT immediately. CT Scan will be read by a neurologist or radiologist.

2.   Obtain blood samples for CBC, electrolytes, (BUN), creatinine, glucose, PT, PTT, INR, fibrinogen and blood group. Write "STROKE STAT" on lab slips to expedite handling and processing for faster turn around time of lab results.

3.   Obtain urine for human chorionic gonadotropin in all women of child-bearing age.

4.   Obtain ECG and chest X-ray.

5.   Insert 2 large peripheral intravenous lines (18 gauge).

Administration of rtPA

The neurologist will check all inclusion and exclusion criteria on the thrombolysis check list for ischemic stroke, sign it, and put in medical record. Informed consent is necessary. Because of the risk of major bleeding, the risks and benefits of treatment should be discussed with the patient and/or family prior to administration of rtPA. Document the discussions.

Total rtPA dose = 0.9 mg/ kg (max 90 mg). 10% is given as a bolus over 60 seconds and then the remaining is infused over one hour. Example: A 100 kg patient would receive a 9mg bolus in the first minute followed by 81mg over the next hour via. infusion pump. Do not move the patient until infusion is complete unless absolutely necessary. 

Monitoring and care during and after rtPA infusion

Vital signs should be checked  every 15 minutes for 2 hours after starting infusion. Then every 30 minutes for 6 hours. Then every hour until 24 hours after starting infusion. Maintain SBP between 110 and 185mm Hg. Insertion of indwelling Foley’s catheter should be avoided during the infusion and for at least 30 minutes after infusion ends. Insertion of a nasogastric tube should be avoided, if possible, during the first 24 hours. Central venous access, arterial punctures and intramuscular injections should be avoided. NPO except medicines for 24 hours. Test all urine, stool, and emesis for occult blood. Prophylactic H2 blockers are strongly recommended. No anticoagulants or anti inflammatory drugs should be administered for 24 hours. After 24 hours, if anticoagulant or antiplatelet therapy is to be given, a follow up CT scan or MRI should be free of hemorrhage. Ahead CT for any worsening of neurologic condition is very necessary.

If hemorrhage is suspected, stop infusion of the thrombolytic drug

If the patient develops severe headache, acute hypertension, nausea or vomiting; discontinue the infusion and prepare for an emergency CT/ MRI scan, blood investigations, blood product transfusion and possible transfer for surgical intervention. Send repeat CBC, platelet, INR, PTT, PT, fibrinogen, D-dimer. Prepare for administration of 6 to 8 units of cryoprecipitate containing factor VIII and 6 to 8 units of platelets. Plan for non-contrast CT in 24 hours. Document all vital signs, assessment, medication intervention and response to interventions in the medical records.

Nursing management

This can be dealt with in the following categories:

1.   High risk for ineffective breathing pattern related to
hypoxia, neuro muscular impairment

       To overcome the problem, maintain a patent airway. Monitor respiratory functions and provide respiratory support. Position the patient on his side and give chest physiotherapy and suctioning whenever required. Frequent assessment of vital
signs including neurological signs, and hemodynamic status is essential.

2.   High risk for aspiration related to reduced level of consciousness, depressed cough and gag reflex and presence of tracheotomy or endotracheal tube

       Provide suction whenever necessary. Assess the gag reflex and provide nasogastric feeding as necessary. Elevate head of bed at least 300 and keep patient upright for 30-45 min after feeding. Assist patient with oral intake to detect abnormalities early.

3.   Impaired physical mobility

       Change position every 2 hours and take care of pressure points by gentle massage. Provide pressure relieving devices. Keep side rails up to promote safe environment. Encourage and facilitate early ambulation and other activities of daily living.

4.   High risk for impaired verbal communication

       Anticipate the patient needs. Modulate personal communication by using body language and simple directions. Encourage family to attempt communication with patient. Visual aids like writings, picture boards and gestures will be helpful at times.

5.   Impaired nutrition related to inadequate intake

       Consult dietician regarding diet planning. Assist patient with meals as needed. Prevent dehydration and constipation. Nasogastric tube feeding may be required.

6.   Self care deficit

       Anticipate and meet all the basic needs in bedridden patients. Assist in feeding, grooming, bathing and toiletry needs. Preserve and protect all functions.

7.   Impaired coping related to anxiety

       Provide thorough explanation and demonstrations before any procedure. Continuous reassurance and psychological support helps to develop positive attitude. Orient to any new environment. Provide positive feedback and repetition when the patient is trying to re-learn a skill.

8.   High risk for infection/injury

       Maintain aseptic precautions in all invasive procedures. Ensure hand hygiene to prevent health care associated infection. Ensure twice daily catheter care to prevent urinary tract infection. Frequent change of position prevent pressure ulcers, and thrombophlebitis. Keep the side rails up to prevent falls. Keep head end elevation of at least 300 to prevent ventilator associated pneumonia. Ensure regular bowel elimination. Maintain oral hygiene. Take measures to prevent exposure keratitis and other eye infection.

9 .  Rehabilitation within the hospital

       Focus on restoration of function and initiate bowel and bladder retraining.  Initiate physical therapy to restore functions, and passive range of motion exercises to prevent contractures. Occupational and speech therapy helps the client speedy return to productive life. Provide nutrition counseling, life style modification hints and need to control blood pressure and compliance with medication to prevent future stroke.

10.       Discharge planning

       Teach the family members about feeding and nutrition, physiotherapy and mobility, diversion and sleep, preventing falls, pressure ulcers and infection. Discharge to a nursing home or a rehabilitation center is recommended for those who require additional care.

CONCLUSION

Brain attack or stroke leads to lasting cognitive and emotional consequences in more than half of the patients. They experience high levels of morbidity. Every minute is precious when someone is developing a stroke. Most effective nursing care is required in the initial period of stroke.

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