Clinical Pathway

of Acute Stroke
Renz Darwin C. Castañaday
 INTRODUCTION

What is Stroke?
-A stroke occurs when the blood supply to part of
your brain is interrupted or reduced, depriving brain tissue
of oxygen and nutrients. Within minutes, brain cells begin
to die.
-A stroke is a medical emergency. Prompt treatment
is crucial. Early action can minimize brain damage and
potential complications.
 Types Of Acute Stoke
1. Ischemic Stoke
2. Hemorrhagic Stroke
3. Transient ischemic attack
 Ischemic Stroke
-Ischemic strokes occur when the arteries to
your brain become narrowed or blocked,
causing severely reduced blood flow
(ischemia).
-Most common ischemic stroke
a. Thrombotic stroke
b. Embolic Stroke
Ischemic Stroke
 Thrombotic stroke
-A thrombotic stroke
occurs when a blood clot
(thrombus) forms in one of
the arteries that supply
blood to your brain. A clot
may be caused by fatty
deposits (plaque) that build
up in arteries and cause
reduced blood flow
(atherosclerosis) or other
artery conditions.
 Embolic stroke
An embolic stroke
occurs when a blood
clot or other debris
forms away from your
brain — commonly in
your heart — and is
swept through your
bloodstream to lodge in
narrower brain arteries.
This type of blood clot is
called an embolus.
 Hemorrhagic Stroke
Hemorrhagic stroke occurs
when a blood vessel in your
brain leaks or ruptures. Brain
hemorrhages can result from
many conditions that affect
your blood vessels.These
include uncontrolled high
blood pressure
(hypertension),
Overtreatment with
anticoagulants (blood
thinners), Weak spots in your
blood vessel walls
(aneurysms)
 Types Of Hemorrhagic Stroke
Intracerebral hemorrhage
-In an intracerebral hemorrhage, a blood vessel in the brain bursts and spills
into the surrounding brain tissue, damaging brain cells. Brain cells beyond the leak are
deprived of blood and are also damaged.
High blood pressure, trauma, vascular malformations, use of blood-thinning
medications and other conditions may cause an intracerebral hemorrhage.
Subarachnoid hemorrhage
In a subarachnoid hemorrhage, an artery on or near the surface of your brain bursts and
spills into the space between the surface of your brain and your skull. This bleeding is
often signaled by a sudden, severe headache.
A subarachnoid hemorrhage is commonly caused by the bursting of a small sack-shaped
or berry-shaped aneurysm. After the hemorrhage, the blood vessels in your brain may
widen and narrow erratically (vasospasm), causing brain cell damage by further limiting
blood flow.
 Types Of Hemorrhagic Stroke

Intracerebral hemorrhage Subarachnoid hemorrhage

 Transient Ischemic Attack
A transient ischemic attack (TIA) —
sometimes known as a ministroke —
is a temporary period of symptoms
similar to those you'd have in a
stroke. A temporary decrease in blood
supply to part of your brain causes
TIAs, which may last as little as five
minutes.
Like an ischemic stroke, a TIA occurs
when a clot or debris blocks blood
flow to part of your nervous system —
but there is no permanent tissue
damage and no lasting symptoms.
 Risk Factors
Many factors can increase your stroke risk. Some factors can also increase your
chances of having a heart attack. Potentially treatable stroke risk factors include:
Lifestyle risk factors
•Being overweight or obese
•Physical inactivity
•Heavy or binge drinking
•Use of illicit drugs such as cocaine and methamphetamines
Medical risk factors
•Blood pressure readings higher than 120/80 millimeters of mercury (mm Hg)
•Cigarette smoking or exposure to secondhand smoke
•High cholesterol
•Diabetes
•Obstructive sleep apnea
 Risk Factors
• Cardiovascular disease, including heart failure, heart defects, heart infection
or abnormal heart rhythm
• Personal or family history of stroke, heart attack or transient ischemic attack.

Other factors associated with a higher risk of stroke include:

• Age —People age 55 or older have a higher risk of stroke than do younger
people.
• Race — African-Americans have a higher risk of stroke than do people of
other races.
• Sex — Men have a higher risk of stroke than women. Women are usually
older when they have strokes, and they're more likely to die of strokes than
are men.
• Hormones — use of birth control pills or hormone therapies that include
estrogen, as well as increased estrogen levels from pregnancy and childbirth.
MANAGEMENT OF STROKE
Asessment
 Diagnosis
Computerized Tomography Scan- A CT scan uses a series of X-rays to
create a detailed image of your brain.A CT scan can show a hemorrhage,
tumor, stroke and other conditions. Doctors may inject a dye into your
bloodstream to view your blood vessels in your neck and brain in greater
detail (computerized tomography angiography). There are different types
of CT scans that your doctor may use depending on your situation.
Echocardiogram- An echocardiogram uses sound waves to create
detailed images of your heart. An echocardiogram can find a source of
clots in your heart that may have traveled from your heart to your brain
and caused your stroke.
Blood tests- You may have several blood tests, which tell your care team
how fast your blood clots, whether your blood sugar is abnormally high or
low, whether critical blood chemicals are out of balance, or whether you
may have an infection. Managing your blood's clotting time and levels of
sugar and other key chemicals will be part of your stroke care.
 Treatment
Ischemic stroke
Medication
Intravenous injection of tissue plasminogen activator (tPA). This
injection of recombinant tissue plasminogen activator (tPA), also called
alteplase, is considered the gold standard treatment for ischemic stroke.
This drug restores blood flow by dissolving the blood clot causing your
stroke, and it may help people who have had strokes recover more fully.
Your doctor will consider certain risks, such as potential bleeding in the
brain, to determine if tPA is appropriate for you.
 Treatment
Surigcal Procedure
Emergency endovascular procedures. Doctors sometimes
treat ischemic strokes with procedures performed directly
inside the blocked blood vessel.
Removing the clot with a stent retriever. Doctors may use
a catheter to maneuver a device into the blocked blood
vessel in your brain and trap and remove the clot. This
procedure is particularly beneficial for people with large clots
that can't be completely dissolved with tPA, though this
procedure is often performed in combination with intravenous
tPA.
Stent Retriever
 Treatment
Other procedures;
Carotid endarterectomy. In a carotid endarterectomy, a surgeon
removes plaques from arteries that run along each side of your neck to
your brain (carotid arteries). In this procedure, your surgeon makes an
incision along the front of your neck, opens your carotid artery and
removes plaque that blocks the carotid artery. Your surgeon then repairs
the artery with stitches or a patch made from a vein or artificial material
(graft). The procedure may reduce your risk of ischemic stroke. However,
a carotid endarterectomy also involves risks, especially for people with
heart disease or other medical conditions.
Carotid endarterectomy
 Treatment
Hemorrhagic stroke
Emergency measures.
If you take warfarin (Coumadin, Jantoven) or anti-platelet drugs such as
clopidogrel (Plavix) to prevent blood clots, you may be given drugs or
transfusions of blood products to counteract the blood thinners' effects. You may
also be given drugs to lower pressure in your brain such as osmotic diuretics
(intracranial pressure), lower your blood pressure, prevent vasospasm or prevent
seizures.
Once the bleeding in your brain stops, treatment usually involves supportive
medical care while your body absorbs the blood. Healing is similar to what
happens while a bad bruise goes away. If the area of bleeding is large, your doctor
may perform surgery to remove the blood and relieve pressure on your brain.
 Treatment
Surgical procedure
Surgical clipping- A surgeon places a tiny clamp at the base of the aneurysm, to stop
blood flow to it. This clamp can keep the aneurysm from bursting, or it can prevent re-
bleeding of an aneurysm that has recently hemorrhaged.
Coiling (endovascular embolization)- A surgeon inserts a catheter into an artery in your
groin and guides it to your brain using X-ray imaging. Tiny detachable coils are guided into
the aneurysm (aneurysm coiling). The coils fill the aneurysm, which blocks blood flow into
the aneurysm and causes the blood to clot.
Surgical AVM removal- Surgeons may remove a smaller AVM if it's located in an
accessible area of your brain, to eliminate the risk of rupture and lower the risk of
hemorrhagic stroke. However, it's not always possible to remove an AVM if its removal
would cause too large a reduction in brain function, or if it's large or located deep within
your brain.
Stereotactic radiosurgery- Using multiple beams of highly focused radiation, stereotactic
radiosurgery is an advanced minimally invasive treatment used to repair vascular
malformations.
 Nursing Management
Nursing Assessment:
During the acute phase, a neurologic flow sheet is maintained to
provide data about the following important measures of the patient’s
clinical status:
• Change in level of consciousness or responsiveness.
• Presence or absence of voluntary or involuntary movements of
extremities.
• Stiffness or flaccidity of the neck.
• Eye opening, comparative size of pupils, and pupillary reaction to
light.
• Color of the face and extremities; temperature and moisture of the
skin.
• Ability to speak.
• Presence of bleeding.
• Maintenance of blood pressure.
 Nursing Management

Nursing Assessment:
During the postacute phase, assess the following functions:

•Mental status (memory, attention span, perception, orientation, affect,

speech/language).
•Sensation and perception (usually the patient has decreased awareness
of pain and temperature).
•Motor control (upper and lower extremity movement); swallowing ability,
nutritional and hydration status, skin integrity, activity tolerance, and
bowel and bladder function.
•Continue focusing nursing assessment on impairment of function in
patient’s daily activities.
 Nursing Management
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses for a
patient with stroke may include the following:

•Impaired physical mobility related to hemiparesis, loss of balance and

coordination, spasticity, and brain injury.
•Acute pain related to hemiplegia and disuse.
•Deficient self-care related to stroke sequelae.
•Disturbed sensory perception related to altered sensory reception,
transmission, and/or integration.
•Impaired urinary elimination related to flaccid bladder, detrusor
instability, confusion, or difficulty in communicating.
•Disturbed thought processes related to brain damage.
•Impaired verbal communication related to brain damage.
 Nursing Management

Nursing Diagnosis
•Risk for impaired skin integrity related to hemiparesis or hemiplegia
and decreased mobility.
•Interrupted family processes related to catastrophic illness and
caregiving burdens.
•Sexual dysfunction related to neurologic deficits or fear of failure.
 Nursing Management

Planning & Goals

The major goals for the patient and family may include:
• Improve mobility.
• Avoidance of shoulder pain.
• Achievement of self-care.
• Relief of sensory and perceptual deprivation.
• Prevention of aspiration.
• Continence of bowel and bladder.
• Improved thought processes.
• Achieving a form of communication.
• Maintaining skin integrity.
• Restore family functioning.
• Improve sexual function.
• Absence of complications.
 Nursing Management

Nursing Intervention
Nursing care has a significant impact on the patient’s recovery. In
summary, here are some nursing interventions for patients with stroke:
Positioning. Position to prevent contractures, relieve pressure, attain good body
alignment, and prevent compressive neuropathies.
Prevent flexion. Apply splint at night to prevent flexion of the affected extremity.
Prevent adduction. Prevent adduction of the affected shoulder with a pillow placed
in the axilla.
Prevent edema. Elevate affected arm to prevent edema and fibrosis.
Full range of motion. Provide full range of motion four or five times a day to
maintain joint mobility.
Prevent venous stasis. Exercise is helpful in preventing venous stasis, which may
predispose the patient to thrombosis and pulmonary embolus.
Regain balance. Teach patient to maintain balance in a sitting position, then to
balance while standing and begin walking as soon as standing balance is achieved.
Personal hygiene. Encourage personal hygiene activities as soon as the patient can
sit up.
 Nursing Management
Nursing Intervention

Manage sensory difficulties. Approach patient with a decreased field

of vision on the side where visual perception is intact.
Visit a speech therapist. Consult with a speech therapist to evaluate
gag reflexes and assist in teaching alternate swallowing techniques.
Voiding pattern. Analyze voiding pattern and offer urinal or bedpan on
patient’s voiding schedule.
Be consistent in patient’s activities. Be consistent in the schedule,
routines, and repetitions; a written schedule, checklists, and audiotapes
may help with memory and concentration, and a communication board
may be used.
Assess skin. Frequently assess skin for signs of breakdown, with
emphasis on bony areas and dependent body parts.
 Prevention
• Controlling high blood pressure (hypertension).
• Lowering the amount of cholesterol and saturated fat in
your diet.
• Quitting tobacco use.
• Controlling diabetes.
• Maintaining a healthy weight.
• Eating a diet rich in fruits and vegetables.
• Exercising regularly.
• Drinking alcohol in moderation, if at all.
• Treating obstructive sleep apnea (OSA).
• Avoiding illegal drugs.
 Maintenance medication
Beta-Blockers for controlling Hypertension
ACE Inhibitors for better blood flow
Anticoagulant and Antiplatelet to prevent
blood from clotting