Management Of Patients Presenting With Stroke

Treatment options vary, depending on the type of stroke the patient experiences.
Early medical diagnosis of the type of stroke coupled with new drug treatments can greatly reduce the long-term disability secondary to ischemia.
Surgery performed to improve cerebral circulation for patients with thrombotic or embolic stroke includes an endarterectomy (the removal of atherosclerotic plaque from the inner arterial wall) or a microvascular bypass (the surgical anastomosis of an extracranial vessel to an intracranial vessel).

Medications useful in treating stroke include:

• alteplase (recombinant tissue plasminogen activator), effective in emergency treatment of embolic stroke
• (Patients with embolic or thrombotic stroke who aren’t candidates for alteplase [3 to 6 hours poststroke] should receive aspirin or heparin.)
• long-term use of aspirin or ticlopidine, used as antiplatelet agents to prevent recurrent stroke
• anticoagulants (heparin, warfarin), which may be required to treat crescendo TIAs not responsive to antiplatelet drugs
• antihypertensives, antiarrhythmics, and antidiabetics, which may be used to treat risk factors associated with recurrent stroke.

Early supportive therapy
Frequently assess neurologic status, using the National Institutes of Health (NIH) Stroke Scale to determine deficits.

• If the patient has been treated with alteplase, monitor him for signs of hemorrhage.
• Monitor blood pressure frequently; give labetalol for severe hypertension.
• Use acetaminophen and hypothermia blankets to control fever.
• Maintain a patent airway and oxygenation status; intubate and ventilate the patient as needed.
• Monitor blood glucose levels.
• Monitor electrocardiogram results, and treat arrhythmias as early as possible.
• If the patient develops a headache, administer an analgesic.

Ongoing care

• Watch for signs and symptoms of pulmonary emboli, such as chest pain, shortness of breath, dusky color, tachycardia, fever, and changed sensorium.
• If the patient is unresponsive, monitor his blood gas levels often, looking for increased partial pressure of carbon dioxide or decreased partial pressure of arterial oxygen.
• Watch for signs of other complications, such as infection, cerebral edema, hydrocephalus, seizures, aspiration pneumonia, deep vein thrombosis, pressure ulcers, urinary tract infections, contractures, and subluxation.
• Offer the urinal or bedpan every 2 hours. If the patient is incontinent, he may need an indwelling urinary catheter, but this should be avoided, if possible, because of the risk of infection.
• Ensure adequate nutrition.
• Check the patient’s gag reflex before offering small oral feedings of semisolid foods. (A speech pathologist should assess the patient to determine his needs and specific feeding strategies for dysphagia.) Place the food tray within the patient’s visual field. If oral feedings aren’t possible, insert a nasogastric tube.
• To prevent aspiration pneumonia, position the patient in an upright, lateral position to allow secretions to drain.
• Turn the patient frequently.
• Position the patient and align his extremities correctly to prevent external rotation. Use high-topped sneakers to prevent footdrop when the patient is sitting up and his feet are on the floor. Avoid subluxation of the affected shoulder through proper support and positioning.
• Provide range-of-motion exercises throughout the day. Consult a physical therapist for additional positioning and transfer strategies and splinting devices.
• Consult a physical therapist, an occupational therapist, and a speech therapist for short- and long-term rehabilitative care goals.
• A multidisciplinary approach is necessary to help minimize long-term disability.

Deficits can include motor weakness, coordination and balance problems, diminished corneal reflex, visual field deficits, dysarthria, dysphasia, impaired memory and concentration, and pain.

• Establish and maintain communication with the patient. If he’s aphasic, set up a simple method of communicating basic needs. Remember to phrase your questions so he’ll be able to answer using this system. Repeat yourself quietly and calmly, and use gestures, if necessary, to help him understand. Even the unresponsive patient can hear, so don’t say anything in his presence you wouldn’t want him to hear and remember.
• Provide psychological support. Set realistic short-term goals. Involve the patient’s family in his care when possible, and explain his deficits and strengths.
• Establish rapport with the patient. Spend time with him, and provide a means of communication. Simplify your language, asking questions that can be answered with a yes or no whenever possible. Don’t correct his speech or treat him like a child. Remember that building rapport may be difficult because of mood changes that may result from brain damage or as a reaction to being dependent.
• If necessary, teach the patient to comb his hair, dress, and wash. With the aid of a physical therapist and an occupational therapist, obtain appliances, such as walking frames, hand
• bars for the toilet, and ramps, as needed.
• If speech therapy is indicated, encourage the patient to begin as soon as possible and follow through with the speech therapist’s suggestions.
• To reinforce teaching, involve the patient’s family in all aspects of rehabilitation. With their cooperation and support, devise realistic discharge goals, and let them help decide when the patient can return home.

Before discharge, 

• warn the patient and his family to report any premonitory signs or symptoms of stroke, such as severe headache, drowsiness, confusion, and dizziness. Emphasize the importance of regular follow-up visits.
• If aspirin has been prescribed to minimize the risk of embolic stroke, tell the patient to watch for GI bleeding related to ulcer formation. Make sure the patient realizes that he can’t substitute acetaminophen for aspirin.