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1. Plan

1.1. maximize communication abilities

1.2. avoid complication of stroke

1.3. maintain effective personal & family coping

1.4. maintain stable/improved LOC

1.5. Maximum physical functioning

1.6. maximum self-care abilities & skills

1.7. stable body functions (bladder control, etc.)

2. Monitor

2.1. Respiratory System

2.1.1. atelectasis

2.1.2. aspiration pneumonia

2.1.3. airway obstruction

2.1.4. endotracheal intubation & mechanical ventilation requirement

2.1.5. ineffective airway clearence

2.2. Neurological System

2.2.1. extension of stroke

2.2.2. increased intracranial pressure

2.2.3. vasospasm

2.2.4. Glasgow Coma Scale (GCS)

2.2.5. NIH Stroke Scale (NIHSS)

2.3. Cardiovascular System

2.3.1. vital signs

2.3.2. cardiac rhythm

2.3.3. intake & output

2.3.4. fluid intake

2.3.5. crackles & ronchi (pulmonary congestion)

2.3.6. murmurs or S3/S4

2.4. impaired physical mobility

2.5. impaired verbal communication

2.6. unilateral neglect

2.7. impaired urinary elimination

2.8. ineffective cerebral tissue perfusion

2.9. perceptual deficits

2.10. Warning Siigns

2.10.1. sudden weakness, paralysis or numbness of face, arm, leg; especially unilaterally

2.10.2. sudden dimness or loss of vision

2.10.3. sudden confusion, loss of speech or difficulty speaking or understanding speech

2.10.4. unexplained sudden dizziness, unsteadiness, loss of balance or coordination

2.10.5. sudden severe or unusual headache

3. Assess

3.1. current illness & initial symptoms

3.2. history of similar symptoms

3.3. current medications

3.4. history of risk factors & other illnesses

3.5. family history of stroke/cardiovascular disease

3.6. comprehensive neuro examination

3.6.1. LOC Glasgow Coma Scale (GCS) NIH Stroke Scale (NIHSS)

3.6.2. motor abilities

3.6.3. cognition

3.6.4. cranial nerve fucntion

3.6.5. sensation

3.6.6. proprioception

3.6.7. cerebellar function

3.6.8. deep tendon reflexes

3.6.9. pupillary response

4. What Is Stroke?

4.1. Stroke occurs when ischemia or hemorrhage into brain results in death of brain cells. It is the 3rd most common cause of death in Canada.

4.2. Ischemic Stroke

4.2.1. Inadequate blood flow to brain from partial/complete occlusion of artery (80% of all strokes)

4.2.2. 1. Transient Ischemic Attack: transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia

4.2.3. 2. Thrombotic Stroke: related to blood vessel injury & formation of blood clot -> narrow blood vessel

4.2.4. 3. Embolic Stroke: embolus lodges in & occlude cerebral artery -> infarction & edema of area supplied by that vessel

4.3. Hemorrhagic Stroke

4.3.1. From bleeding into brain tissue (intracerebral) or into subarachnoid space or ventricles (15% of all strokes)

4.3.2. 1. Intracerebral Hemorrhage: rupture of a vessel. It is often caused by hypertension and during periods of activity.

4.3.3. 2. Subarachnoid Hemorrhage: intracranial bleeding into cerebrospinal fluid-filled space between arachnoid & pia matter. It is commonly caused by rupture of cerebral aneurysm.

5. Collaborative Care

5.1. Stroke Prevention Therapy

5.1.1. Health Management Life style changes 1. BP Control 2. Blood gluclose control 3. Diet and Exercise 4. Smoking cessation 5. Limiting alcohol consumption 6. Routine health assessments

5.1.2. Management of modifiable risk factors to prevent a stroke

5.1.3. Drug Therapy Antiplatelet Drugs Purpose: To prevent the development of a thrombus or embolus to prevent further stroke Ex) Aspirin = most frequently used antiplatelet drug Antihypertensives Anticoagulants Ex) Warfarin Lipid-lowering Medications Ex) Statins

5.1.4. Surgical Therapy For pt with TIAs (Transient Ischemic Attacks) from carotid artery disease 1. Carotid endarterectomy 2. Transluminal angioplasty 3. Stenting 4. Extracranial-to-intracranial artery bypass

5.1.5. A summary of the above preventive measures

5.2. Acute Care

5.2.1. Focus is on (1) preserving life, (2) preventing further brain damage, (3) reducing disability Acute Care for Ischemic Stroke Drug Therapy Acute Care for Hemorrhagic Stroke Drug Therapy

5.3. Rehabilitation Care

5.3.1. Focus is on (1) lessening disability, (2) attaining optimal function Inpatient rehabilitation intervention Evidence-based mobility intervention was associated with improvements in mobility achievement, discharge functional outcomes, and quality of life for patients with hemorrhagic stroke. Activities in the intervention included progressive activities to improve coordination, strength, and range of motion. (Rand & Darbinian, 2015) Outpatient therapy Home care-based rehabilitation Neurologic Music Therapy targeting language rehabilitation

6. Risk Factors

6.1. Modifiable Risk Factors

6.1.1. Hypertension Hypertension is the most important modifiable risk factor that is often undetected and inadequately treated. Stroke risk can be significantly reduced through the adequate treatment and early diagnosis of hypertension.

6.1.2. Heart Disease

6.1.3. Diabetes Mellitus

6.1.4. Increased Serum Cholesterol

6.1.5. Obesity

6.1.6. Drug Abuse

6.1.7. Alcohol

6.1.8. Physical Inactivity

6.1.9. Smoking

6.2. Non-Modifiable Risk Factors

6.2.1. Age Stroke risk increases with age, doubling each decade after 55 years of age

6.2.2. Gender Strokes are more common in men, but more women die from stroke than men

6.2.3. Ethnicity and Race

6.2.4. Heredity/Family History

6.2.5. Low Birth Weight

7. Clinical Manifestations

7.1. Motor Deficits

7.1.1. Impairment of (1) mobility; (2) respiratory function; (3) swallowing and speech; (4) gag reflex; (5) self-care abilities

7.2. Communications

7.2.1. Aphasia Total loss of comprehension and use of language Due to damages to the dominant hemisphere of the brain

7.2.2. Dysphasia Difficulty related to the comprehension or use of language Due to partial disruption or loss

7.2.3. Dysarthria A disturbance in the muscular control of speech -> Impaired pronunciation, articulation, and/or phonation

7.3. Affect

7.3.1. Difficulty controlling their emotions

7.3.2. Depression and frustration associated with loss of function

7.4. Intellectual Function

7.4.1. Impaired memory and/or judgment

7.5. Spatial-perceptual Alterations

7.5.1. Anosognosia Deny their illnesses or their own body parts

7.5.2. Homonymous Hemianopsia Blindness occurs in the same half of the visual fields of both eyes -> Difficulties with spatial orientation

7.5.3. Agnosia Inability to recognize an object by sight, touch, or hearing In the video, she not only has difficulties in visually recognizing her glasses but also displays spatial orientation impairment.

7.5.4. Apraxia Inability to carry out learned sequential movements on command

7.6. Urinary and Bowel Elimination

7.6.1. Experiences frequency, urgency, and incontinence usually early on and temporarily

8. Right-Brain Damage Vs. Left-Brain Damage

9. Diagnostic Studies

9.1. Brain Imaging

9.1.1. Computed Tomography (CT) Scan Primary diagnostic test used after a stroke Indicates the size and location of the lesion Differentiates between ischemic and hemorrhagic stroke

9.1.2. MRI Used to determine the extent of brain injury

10. Implement

10.1. Respiratory System

10.1.1. airway potency & function

10.1.2. oxygenation

10.1.3. suctioning

10.1.4. patient mobility

10.1.5. positioning to prevent aspiration

10.1.6. deep breathing

10.2. Neurological Ssystem

10.2.1. closely monitor changes suggesting stroke, increased ICP, vasospasm or recovery from stroke symptoms

10.3. Cardiovascular System

10.3.1. maintain homeostasis/cardiac reserves

10.3.2. keep patient moving to prevent vein thrombosis

10.4. Musculoskeletal System

10.4.1. prevention of joint contractions & muscle atrophy

10.4.2. range of motion exercise & positioning

10.5. Integumentary System

10.5.1. monitor loss of sensation, decreased circulation & immobility

10.5.2. hygiene & emollient application

10.5.3. pressure relief

10.6. Bowel Management

10.6.1. stool softeners/fibres (psyllium)

10.6.2. avoid in-dwelling catheters

11. Health Promotion

11.1. Coping

11.1.1. emotionally & socially

11.1.2. changing roles & responsibilities

11.1.3. social service referral

11.2. Ambulatory & Home Care

11.2.1. education medication nutrition swallowing/gag reflex mobility exercises

11.2.2. demonstration

11.2.3. practice

11.2.4. evaluation of self-care skills

12. Research Article

12.1. Barriers to cardiovascular disease healthcare

12.1.1. Patient availability, access & costs knowledge, beliefs, memory

12.1.2. Healthcare Provider knowledge attitudes/behaviour

12.1.3. Health System & Policy financing system medical products & technologies leadership/governance health workforce service delivery Health information system & research

12.2. Resource effective strategies to prevent and treat cardiovascular disease

12.2.1. tobacco control

12.2.2. simplified screening & management algorithms for those at risk

12.2.3. availability and affordability of treatment regimens

12.2.4. simplified delivery of healthcare through task-sharing

12.2.5. optimizing self-management