STROKE

Prevent it
Make healthy lifestyle your choice
Stroke is a global health problem and is the second commonest cause of death and a leading cause of adult disability worldwide. But in Malaysia,Stroke is the third largest cause of death. Yet, it is one of the most preventable life-threatening health problem
A stroke is a brain attack and occurs when the blood supply to the brain is disrupted. The
brain is the nerve centre of the body, controlling every thing we do or think, as well as controlling automatic functions like breathing. In order to work, the brain needs a constant blood supply which carries vital oxygen and nutrients. When a blood vessel in your brain bursts or gets clogged, the blood supply stops and the brain cells are deprived of oxygen and nutrients. That part of the brain starts to die. You have a stroke. Very quickly. Very silently. Brain damage affects your senses, your speech and understanding of language. One side of your body may be paralyzed, your behaviour, thought and memory patterns are altered.

What is a STROKE ?
If the blood supply in only a small part of the brain is cut off for only a very short time, the stroke is likely to be mild and temporary. However, if blood supply to a large part of the brain is cut off for a long time, the effects will be more severe and are likely to be permanent. In some cases, a stroke can cause death.

What causes a STROKE ?

Blood is brought to the brain by blood vessels called arteries. A stroke happpens when an artery to the brain is blocked or bursts. A blocked artery causes an ischaemic stroke while a burst artery causes a haemorrhagic stroke.

Ischaemic stroke
An ischaemic stroke occurs when an artery in the brain, which has been narrowed by fatty

deposit (atherosclerosis), is completed blocked. The artery in the brain can also be blocked by blood clots and other substances formed in other parts of the body. These clots can break off and be carried by the bloodstream to the brain.

Haemorrhagic stroke
A haemorrhagic stroke is often caused by an artery which has burst under very high blood pressure. Sometimes, part of an artery weakens over time, becomes abnormally thin (ananeurysm) , and suddenly bursts

Complication of STROKE ?
The effects of a stroke vary from person to person, depending on which part of the brain is damaged and the extent of that damage. Some complications happen as a direct result of injury to the brain due to stroke, or because of a change in the patient s abilities for example, being unable to move freely can result in bedsores The most common problems after stroke are : Aspiration Pneumonia Shoulder pain Pressure sore Urinary tract infection Other pain Falls

Aspiration Pneumonia
causes breathing problems, a complication of many major illnesses

Shoulder pain
stems from lack of support of an arm due to hemiplegia or exercise of an arm. This usually is caused when the affected arm hangs resulting on pulling of the arm on the shoulder
Lack of support or exercise of an arm can result in shoulder pain, a common complication of stroke.

Pressure sore
Pressure ulcers that result from decreased ability to move and pressure on areas of the body because of immobility

Urinary tract infection

An infection that can happen anywhere along the urinary tract usually bacteria that enter the urethra and then the bladder that caused by germs,

Other pain
Pain that include other part of body such as back pain.

Falls
Any falls that occurred due to stroke.

Fa

Stroke patient

Prevention of complication
What can be done?
sudden numbness or weakness, usually on one side of the body sudden confusion or a fit difficulty speaking or understanding sudden difficulty seeing in one or both eyes sudden difficulty in walking sudden severe giddiness, loss of balance or coordination sudden severe headache with no known cause difficulty in swallowing loss of concentration and memory loss of control of passing urine or passing motion

Every stoke is different. The symptoms depending on which part of the brain affected and how much damage there is.

is

What are the symptoms ?

A stroke is an emergency. If you think that you are having a stroke, you need to contact emergency medical services /hospital immediately. The longer a stroke goes untreated, the greater the damage. Once a part of the brain dies, it cannot be repaired and the effects are permanent.

1. How to prevent aspiration pneumonia?

Positioning during feeding

Swallowing therapy Diet modification Assess patient with feeding tubes by appropriate insertion of the tube and confirmation feeding tube placement ( ryle s tube )

Positioning during feeding

i) Elevate head of bed by put the patient in up right position. 30 40 will help to prevent aspiration pneumonia because the effect of gravity will gastroesopagheal reflux or aspiration pneumonia.

degree reduce

ii) Head down/chin-tuck position will lowering the head so neck is flexed and chin is approximately three fourths of way down to ward chest. It will provide better airway protection and de crease the risk of aspiration iii)Keep the patient upright for 30 mins after the meal to decrease reflux. esophageal

Swallowing therapy

i) Supraglottic swallow -If using food, place food in mouth -Have patient inhale & hold breath -Ask patient to swallow while holding breath -Have patient cough or clear throat after swallowing without again -Repeat 10 times, 3-4 times per day Benefit of Supraglottic swallow: -Increases voluntary airway protection, voluntary closure of

in

haling

glottis before and

during

swallow, ensures pulmonary air

vol

ume for throat clearing.

ii) Mendelson Maneuver -Ask patient to place hand on larynx -Have patient swallow and feel larynx left at its highest posi tion. -If using food, ask patient to place food in mouth -Have patient swallow and again hold larynx in highest posi tion swallow, patient then releases hold. -Repeat 3-5 times per day Benefit of Mendelson Maneuver -Allows voluntary increase in laryngeal elevation time and cricopharyngeal sphincter, prolongs airway closure

during

the

opening

of

Diet modification

i) Encourage to take thick liquids -Thick liquid move more slowly than thin liquid -Its suggest to patient with incomplete larynxgeal elevation and closure because a thick liquid is less likely to penetrate the unpro tected larynx -Hot and cold liquids maybe thickened by adding a comercial thickening agent or household food product such as instant potato flakes and instant baby rice cereal.

Ii) Modifying the bolus size to a small volume may assist the pa tient prone to aspiration due to pharyngeal swallow delay because a small bolus will not enter the pharynx as quickly as a large bolus

RYLES TUBE

Purpose:

For feeding & drainage of gastric

contents

Equipments: Clinically clean tray Nasogastric tube that has been stored in a deep freeze for at least half an hour before the procedure is to begin, to ensure a rigid tube that will allow for easy passage. Topical gauze Lubricating jelly Hypoallergenic tape 20ml syringe Indicator strips, eg: pH Fix Receiver Spigot Glass of water

Procedure Explain and discuss the procedure with the patient Arrange a signal by which the patient can communicate if he/she wants the nurse to stop, eg: by raising his/her hand Assist the patient to sit in a semi-upright position in the bed/chair. Support the patient s head with pillows Mark the distance which the tube is to be passed by measuring the distance on the tube from the patient s ear lobe to the bridge of the nose plus the distance form the ear lobe to the bottom of xiphisternum. Wash hands with bactericidal soap and water or bactericidal alcohol hand rub, assemble the equipment required. Check the patient s nostrils are patent by asking him/her to sniff with one nostril closed. Repeat with the other nostril. Lubricate about 15-20 cm of the tube with a thin coat of lubricating jelly that has been

placed on a topical swab. Insert the proximal end of the tube into clearer nostril and slide it backwards and inwards along the floor of the nose to the nasopharynx. If an obstruction is felt, withdraw the tube and try again in a slightly different direction or use the other nostril. As the tube passes down into nasopharynx, ask the patient to start swallowing and sipping water, enabling the tube to pass into the esophagus. Advance the tube through the pharynx as the patient swallows until the tape-marked tube reaches the point of entry into the external nares. If the patient shows signs of distress ( cyanosis, grasping ), remove the tube immediately. Secure the tube to the nostril with the adherent dressing tape.

Check the position of the tube to confirm that it is in following methods:

the stomach

by using the

Taking an X-ray of chest and upper abdomen Aspirating 2ml of stomach contents and testing with pH indicator strips. When aspirating fluid for pH testing, wait at least 1 hour after a feed or medication has been administered. Before aspirating, flush the tube with 20 ml of air to clear other substances. A pH level of 5.5 in unlikely to be pulmonary aspirate and is considered appropriate to proceed to feed through the tube. If a pH of 6.0 or above is obtained or there is doubt over the result in the range of pH 5-6 then feeding must not commence. The nasogastric tube may need to be repositioned or checked with an X-ray.

Stroke patients are particularly prone to pain, most commonly associated with the musculoskeletal ramifications of paralysis and immobility, and particularly involving the hemiplegic shoulder.

2. How to prevent shoulder and other pain ? Shoulder Pain

Encourage or assisted to mobilize or change position at frequent interval.

Encourage to practice range of motion exercise which is active & passive movement, in

order to : i) Maintain full joint range Ii) Maintain full muscle length and extensibility Iii) Assist venous return Iv) Maintain sensation of normal movement Positioning in the bed To promote optimal recovery by modulating mus cle tone, provid ing appropriate sensory information and increasing spatial awareness and to prevent complications such as pressure sores, contrac tures, pain and respiratory problems and assist safer eating. The five main positions recommended : -lying on the unaffected side, -lying on the affected side -lying supine -sitting up in bed -sitting up in a chair.

Range of motion exercises POSITIONING

Positioning is about maintain body alignment. Its indicated for patients who are acutely ill or required bed rest when normal functioning is impaired. Fowler s Semi setting position Head of bed elevated to 45 60 degrees Knees slightly elevated

Indications : Promotes comfort Improves respiratory problems Encourage post-operative drainage

Fowler s position

Dorsal recumbent ( Supine ) Back lying position Head & shoulder may be slightly raised

Promotes comfort

Supine position

Prone Facedown position Head is turned to one side

Helps prevent contracture of hips and knees Promotes drainage from mouth

Lateral Side lying position Lateral aspects of lower scapula and lower ilium support most of body weight

Promotes comfort Relieve Pressure on sacrum and heels

Prevent aspiration Reduces pressure on sacrum and greater tronchanter of hip Promotes drainage from mouth
Lateral position

Sims Semiprone position Upper arm is flexed at shoulder and elbow, lower arm is positioned behind patient Both legs flexed in front of patient with more flexion in upper leg Promotes comfort especially in pregnant clients

Prevent aspiration Reduces pressure on sacrum and greater tronchanter of hip Promotes drainage from mouth
Sim s position

3. How to prevent Pressure Sore ? Risk factors for developing Pressure Ulcers
The conditions most commonly identified as risk factors for pressure ulcer development are: Altered sensory function or level of consciousness ( i.e; inability to recognize or respond to ischemic signals ) Altered activity and mobility ( e..g: client who is bed-bound or chair-bound and who lacks the ability to respond to ischemic signals with appropriate repositioning ) Excessive moisture ( e.g: the client who is diaphoretic or incontinent and therefore at

greater risk for superficial skin damage ) Malnutrition ( possibly due to soft tissue wasting and reduced ability to distribute weight evenly, as well as compromised immune system function ) Exposure to shear and friction ( a common problem with any client who is unable to reposition effectively, since such individuals are at increased risk for dragging or sliding injuries ) General debilitation ( e.g: hypovolemic conditions, hyperthermic conditions, and other conditions that compromise tissue perfusion or increase the tissue metabolic demands ) One of the most common effects of a stroke is not being able to move part or all of your body. Not being able to move can increase the chance of pressure ulcers forming. With adequate nursing resources and expertise, pressure ulcers should not develop during immobility after stroke. Nursing intervention is to promote, maintain and manage skin integrity target three primary aspects of care; prevention strategies, treatment considerations and patient education

Recommendations for skin care and early treatment of pressure ulcers

Inspect the skin of all at- risk individuals at least once a day, but ideally with every patient turn for erythema or areas of break down, pay particular attention to bony prominences. Document results of skin inspection Cleanse the skin at the time soiling and at routine intervals; indi vidualize the frequency of skin cleansing according to need and/ or patient preference. Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness of the skin. During cleansing, take care to mimimize the force and friction ap plied to the skin. Minimize environmental factors leading to skin drying, such as low humidity (less than 40%) and exposure to cold; treat dry skin with moisturizers. Avoid massage over bony prominences. Minimize skin exposure to moisture due to incontinence, perspire tion, or wound drainage. Minimize skin injury due to friction and shear forces through proper positioning, transferring, and turning techniques; friction injuries may be reduced by the use of lubricants, protective films, protective dressings, and protective padding. When apparently well-nourished patients develops an inadequate dietary intake of protein or calories, first atrempt to discover the factors compromising

intake and offer support, including nutria tional supplements, as needed; for nutritionally compromised indi vuals, implement a plan of nutritional support and/ or supplementation.

Additional recommendations for prevention and treatment of pressure are mechanical loading and support surfaces, and educational programs for the prevention of pressure ulcers. Recommendations for Management of Mechanical Loading and Support Surfaces
Reposition any individual in bed who is assessed to be at risk for developing pressure ulcers at least every 2 hours; teach patients using wheelchairs to shift their weight every 15 minutes. For individuals in bed, use positioning devices such as pillows or foam wedges to keep bony prominences from direct contact with one another. Maintain the head of the bed at the lowest degree of elevation con sistent with medical condition and other restrictions; limit the amount of time the head of the bed is elevated. Use lifting devices such as a trapeze or bed linen to move (rather than drag) individuals in bed who cannot assist during transfer and position changes. Place any individual at risk for developing pressure ulcers on a pressure reducing device such as foam, static air, alternating air, gel, water mattress, when he or she is lying in bed. Apply bed- making for each individual.

Recommendations for Educational Programs for the Prevention of Pressure Ulcers

Be structured, organized, comprehensive, and di rected at all level of providers, patients and family caregivers. Include information on cause and risk factors for pressure ulcers selection and/or use of support surfaces, demonstra tion of

health

care

formation, positioning to

decrease tissue breakdown and development and implementation of and individualized program of skin care. Identify persons responsible for pressure ulcer prevention and be appropriate to the audience in terms of level of information presented and ex pected participation.

4. How to prevent urinary tract infection ? Shoulder Pain

UTI are a leading cause of morbidity and health care expenditures in person of all ages. UTI are the leading cause of systemic infection in older adult.

Catheterization predisposes to urinary tract infection for the following reasons: The introduction of the catheter through the urethra provides a direct route for microorganisms to travel up the urinary tract to the bladder. Catheter-induced local irritation to the urethra or bladder predisposes to infection. The catheter interferes with the most important defense against bacterial urinary tract infection, the unobstructed flow of urine throughout the urinary tract and regular, complete evacuation of the bladder. Clients who require catheterization often have diseases or other conditions that interfere with the body s immune system, thereby decreasing the efficiency of urinary tract s reaction to bacteriuria. Preventions Encourage patient to drink plenty of fluids, unless contraindicated. Teach patient appropriate hygiene ( careful cleaning of perineal area after each voiding and bowel movement, wiping front to back Observe urine for color, odor, amount, and frequency Use strict asepsis with catheter insertion and maintenance unless clean technique is indicated. ( intermittent clean catheterization is recommended for long term

maintenance at home when a catheter is required for bladder emptying.

Recommendation for hand hygiene

If hands are visibly soiled or contaminated with blood or other body fluid:

Wash hands with either a nonantimicrobiol soap and water or an antimicrobial soap and water. Wash hands before eating and after using the rest-room Use warm, not hot water to prevent further irritation to skin.

If hands are not visibly soiled, use an alcohol-based handrub to decontaminate hands. Decontaminate hands before having direct contact with patients, after having direct contact with a patient, before donning sterile gloves for a procedure, and after removing gloves. Decontaminate hands also after contact with inanimate objects surrounding the patient, and if moving hands from a contaminated site to a clean site on a patient s body during patient care Perform decontamination also after contact with body fluids or excretions, mucous membrane, non intact skin and wound dressings, Alternatively, wash hands with antimicrobial soap and water. Preventing falls is a team effort. All people that take care of patients and residents must make sure that their patients and residents are safe. They must make sure that no patient or resident falls. EVERY patient and resident must be safe. Frequent monitoring and observation to prevent falls Sturdy, non skid shoes and footwear Instruction about changing position slowly and being alert to safety risks Their bed at the lowest possible level Toileting, fluid and food needs anticipated for and promptly met A bedside commode nearby so they can safely use it Adequate and easy to reach assistive devices, such as walkers or canes. If the patient needs assistance with these devices, nurses and nursing assistants must give them the help

they need. Ramps to safely enter and leave a building without using stairs. In the home, wheelchair lifts are sometimes used if the person lives in a two-story house.

5. How to prevent falls ?