General Care After Stroke, Including Stroke Units and Prevention and Treatment of Complications of S - PowerPoint PPT Presentation

Loading...

PPT – General Care After Stroke, Including Stroke Units and Prevention and Treatment of Complications of S PowerPoint presentation | free to view - id: 100822-ODMyN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

General Care After Stroke, Including Stroke Units and Prevention and Treatment of Complications of S

Description:

Concentrate admissions to a specialized facility with ... If necessary, consider enteral feedings. Initial Management of Acute Stroke. Early mobilization ... – PowerPoint PPT presentation

Number of Views:253
Avg rating:3.0/5.0
Slides: 31
Provided by: heathe110
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: General Care After Stroke, Including Stroke Units and Prevention and Treatment of Complications of S


1
General Care After Stroke, Including Stroke
Units and Prevention and Treatment of
Complications of Stroke
2
Reasons for Admission
  • Serious illness
  • Potentially life-threatening disease
  • Risk for medical or neurological complications
  • Neurological deterioration
  • Observation, evaluation and treatment

3
Organization of Stroke Care
  • Acute Stroke Units
  • Concentrate admissions to a specialized facility
    with skilled care and monitoring.
  • Shorten hospitalizations and reduce death and
    disability.
  • Reduce complications and promote rehabilitation.

4
Organization of Stroke Care
  • Stroke Teams
  • Coordinated teams of health care professionals to
    coordinate efficient and effective care for
    stroke patients.
  • Stroke Teams play a part in the hyperacute, the
    acute and the rehabilitation phases of stroke
    care.
  • Involve the multidisciplinary team.

5
Stroke Centers
  • Primary Stroke Centers
  • Use the cardiac/trauma model of delivering care.
  • Major elements patient care and support
    services.
  • Define institutions where appropriate care can be
    given.

6
Goals of Treatment After Admission
  • Continue care started in emergency department.
  • Observe for and prevent or control neurological
    and medical complications.
  • Start rehabilitation and discharge planning.
  • Evaluate for cause of stroke and start therapies
    to prevent recurrent stroke.

7
Neurological Complications
  • Progression of thrombosis
  • Recurrent embolism
  • Brain edema
  • Hydrocephalus
  • Increased intracranial pressure
  • Hemorrhagic transformation
  • Seizures

8
Medical Complications
  • Myocardial infarction Pneumonia
  • Congestive heart failure Airway obstruction
  • Cardiac arrhythmias Hypertension
  • Deep vein thrombosis Bladder infections
  • Pulmonary embolus Depression
  • Gastrointestinal bleeding Electrolyte
    disturbance

9
After Admission
  • Initially treated with bed rest mobilization
    begins as soon as the patients condition is
    stable
  • Pulse oximetry first 24-48 hours
  • Cardiac monitoring first 24 hours

10
After Admission
  • Frequent assessments of vital signs and
    neurological status by nursing staff.
  • Protection of airway, especially if depressed
    consciousness or signs of brain stem dysfunction.
  • Supplemental oxygen if patient is hypoxic.
  • Assessment for cause of hypoxia.

11
Heart Disease and Stroke
  • Heart disease often is the cause of stroke.
  • Most patients with stroke have heart disease.
  • Stroke, especially intracranial hemorrhage, can
    cause myocardial ischemia or cardiac arrhythmias.
  • Many persons will have cardiac arrhythmias or
    electrocardiographic abnormalities after stroke.

12
Heart Disease and Stroke
  • Sinus bradycardia Sinoatrial arrhythmia
  • Ventricular tachycardia Atrial fibrillation
  • Ventricular fibrillation PVC
  • Idioventricular rhythms PSVT
  • Torsades de pointes AV block

13
ECG Changes and Stroke
  • ST-T segment elevation/depression
  • Pathological Q waves
  • Negative T waves
  • Abnormal U waves
  • QT prolongation

14
Hypertension in Stroke
  • Arterial hypertension is common among persons
    with stroke
  • risk factor for stroke
  • consequence of stroke
  • Usually declines spontaneously
  • Secondary to pain, vomiting, stress, anxiety
  • Secondary to increased intracranial pressure

15
Treatment of Arterial Hypertension
  • Oral agents preferred
  • Continue or re-institute antihypertensive
    medications
  • Goal of lowering pressure by 15 during first 24
    hours
  • If parenteral medications are used, prefer
    short-acting drugs

16
Initial Management of Acute Stroke
  • Treat fever and search for the cause of fever
    suspect pulmonary or urinary tract infections
  • Maintain hydration with intravenous fluids
  • Treat hyperglycemia and hypoglycemia
  • Assess swallowing before starting oral feedings
  • If necessary, consider enteral feedings

17
Mobilization After Stroke
  • Early mobilization
  • positive for morale
  • expedites rehabilitation
  • lessens risk of pulmonary, skin, musculoskeletal
    complications
  • Watch for hypotension or neurological worsening
  • Protect against falls

18
Prevention of DVT and Pulmonary Embolism
  • Mobilization
  • Heparin
  • LMW heparins/heparinoids
  • Oral anticoagulants
  • Aspirin
  • Alternating pressure stockings

19
Brain Edema and Increased Intracranial Pressure
  • Peaks within one week of stroke
  • Earlier with hemorrhagic stroke
  • A leading cause of death
  • Seen with large multi-lobar strokes
  • Can be secondary to hydrocephalus or mass effect
    of a hematoma

20
Brain Edema and Increased Intracranial Pressure
  • Common cause of neurological worsening
  • progression of stroke
  • secondary brain ischemia
  • herniation syndromes
  • Hallmark is depression of consciousness
  • Vital signs unstable and arterial hypertension

21
Management of Brain Edema and Increased
Intracranial Pressure
  • Restrict fluids moderately
  • Avoid hypo-osmolar fluids
  • Control fever, hypoxia, hypercarbia
  • Elevate head of bed by 30
  • Monitor intracranial pressure

22
Trial of Dexamethasone for Supratentorial
Intracerebral Hemorrhage
  • Dexamethasone Placebo
  • n46 n47
  • Good Recovery 8 5
  • Poor Survivor 17 21
  • Dead 21 21
  • Infectious Complications 13 6
  • Pougvarin, et al. New England Journal of
    Medicine 19873161229-1233..

23
Intracranial Pressure
  • Hyperventilation to a pCO2 of approximately 28-30
    mm Hg
  • Corticosteroids are not recommended
  • Mannitol, 0.25-1 g/kg intravenously given every 6
    h maximum osmolarity 310
  • Furosemide 40 mg intravenously

24
Surgical Management of Brain Edema and ICP
  • Drainage of CSF fluid
  • Evacuation of hematoma
  • Resection of infarcted tissue
  • Hemicraniectomy

25
Evaluation for Cause of Stroke
  • Magnetic resonance imaging of brain
  • Magnetic resonance angiography
  • Spiral CT imaging
  • Carotid duplex
  • Transcranial Doppler
  • Transthoracic echocardiography
  • Transesophageal echocardiography

26
Prevention of Recurrent Stroke Cardioembolic
Stroke
  • Oral anticoagulants
  • prosthetic valves INR 2.5-3.5
  • other causes INR 2.0-3.0
  • Stroke despite adequate anticoagulation
  • add aspirin
  • add dipyridamole
  • Contraindication for anticoagulation
  • Aspirin

27
Prevention of Recurrent Stroke
  • Carotid endarterectomy if ipsilateral high-grade
    stenosis, acceptable risk, and skilled surgeon
  • Antiplatelet aggregating drugs
  • Aspirin
  • Ticlopidine
  • Aspirin and dipyridamole

28
Rehabilitation
  • Critical part of care after stroke
  • Begin as soon as patient is stable and while the
    patient is still in an acute care bed
  • Tailor to individual patients needs
  • Progress in a step-wise progression
  • Maximize patients independence

29
Decisions About Rehabilitation Influence
Discharge Planning
  • In-patient rehabilitation unit
  • attached to acute hospital
  • free-standing hospital
  • Outpatient care
  • Home care
  • Skilled nursing facility

30
Discharge Planning Considerations
  • Cognitive and functional status
  • Family and caregivers support
  • Financial resources
  • Patient and family education
  • Follow-up medical care, rehabilitation
  • Identify safe place of residence
  • Community support or resources
About PowerShow.com