Unraveling Ischemic Stroke: Pathophysiology, Reperfusion, Nursing Care, and Shared Decision-Making

QUESTION

1. Explain the underlying pathophysiology related to the clinical manifestations of Ischaemic Stroke.
2. Discuss the importance of reperfusion in the management of a patient presenting with an Ischaemic Stroke.
3. Identify evidence-based strategies when caring for a patient presenting with Ischaemic Stroke.
4. Justify and prioritise the nursing care related to the case study.
5. Promote shared decision-making processes collaborating with family and the health care team.

Case Study ISBAR Handover:

Introduction: Mrs Mary Fenech is a 78-year-old lady with no known allergies (NKA)

Situation: She arrived in the Emergency Department at 09:30 hrs with slurred speech and right sided weakness since 0530 hrs while at home.

Findings from the CT perfusion assessment using Mean Transit Time (MTT) and Time to Peak (TTP) images showed reduced blood flow in the left middle cerebral artery (MCA) vascular territory extending from the medial cerebellum to the deep white matter at the centrum semiovale above the lateral ventricle. A CT angiogram showed an acute left Internal Carotid Artery (ICA) occlusion. Thrombolysis with Alteplase was administered at 11:30hrs

Background: Atrial Fibrillation (AF), Hypertension (HTN), Type 2 Diabetes Mellitus (IDDM), No head trauma, no prior stroke within the previous 3 months

Regular medications–

Atenolol 50mg daily, Aspirin 100mg daily, Lipitor 40mg daily, Magnesium 200mg daily, Amlodipine 5mg daily, Perindopril 5mg daily, NovoRAPID insulin

Assessment: 

• Airway: slight inspiratory stridor
• Breathing: Respiratory rate 24, bilateral air entry, clear sounds. SpO₂ 90% on room air
• Circulation: BP 149/69, irregular rate – 80 bpm
• Disability: GCS 12 (E 4, V 3, M 5) Pupils equal and reacting to light (PEARL). Sluggish eye gaze. Temp 36.9
• Exposure: x2 IVC in Right & Left cubital fossa
• Fluid: IV Compound sodium lactate (Hartman’s) at 20 mL /hr TKVO
• Glucose blood level: 9.5mmol/L 
• Weight approx. 86kg

Stroke Assessment:

F: Face- Right sided facial droop 

A: Arms- Right sided weakness

S: Speech- Aphasia 

T: Time of onset 0530hrs, Time of thrombolysis 1130hrs, time of ECR planned at 1300hrs, Door-to-Needle time 150 minutes, Symptom to needle time 390 minutes 

Results:  A diagnosis of left MCA stroke with totally occluded left Internal Carotid Artery (ICA)

Nursing Interventions: 

• Initiate Stroke Pathway
• Keep in resuscitation bay (Triage category 2)
• Connect to continuous cardiac monitoring
• Record a 12 lead Electrocardiograph (ECG)
• Initiate supplemental oxygen if SpO2 < 93%
• Monitor airway patency
• Record Glasgow Coma Scale hourly
• Prepare for endovascular clot retrieval (ECR) to restore blood flow
• Arrange for a Speech Pathology consult
• Maintain head of the bed elevated to 30 degrees
• Insert a nasogastric tube
• Maintain nil by mouth
• Collect requested pathology
• Monitor for haematemesis, melaena and haematuria

Blood tests:

Coagulation profile and cross match (PT, APTT, INR), FBC, LFT, EUC,

Medications:

• Alteplase (IV)
• Heparin 5000iu (IV)
• Labetalol
• Insulin NovoRAPID (SC)

ANSWER

Unraveling Ischemic Stroke: Pathophysiology, Reperfusion, Nursing Care, and Shared Decision-Making

Introduction

Ischemic stroke is a critical neurological event caused by reduced blood flow to a specific brain area. Prompt management is crucial to minimize damage and improve outcomes. This essay delves into the pathophysiology of ischemic stroke, the significance of reperfusion, evidence-based nursing strategies, and prioritized care for a case study patient. The importance of shared decision-making involving the family and healthcare team is also highlighted.

Pathophysiology of Ischemic Stroke

Ischemic stroke results from the interruption of blood supply to a brain region, primarily caused by thrombotic or embolic occlusion of cerebral arteries. In Mrs. Mary Fenech’s case, a left Internal Carotid Artery (ICA) occlusion has led to reduced blood flow in the left middle cerebral artery (MCA) territory. This insufficient blood flow deprives brain cells of oxygen and nutrients, leading to cellular dysfunction, injury, and death.

Reperfusion: A Vital Management Approach

Reperfusion therapy is crucial in ischemic stroke management. The administration of Alteplase, a tissue plasminogen activator (tPA), as thrombolysis, aims to dissolve the obstructive clot and restore blood flow. Timely reperfusion minimizes tissue damage and enhances the likelihood of recovery. Mrs. Fenech’s case showcases the Door-to-Needle time of 150 minutes, highlighting the urgency of reperfusion.

Evidence-Based Nursing Strategies for Ischemic Stroke Care

Continuous Cardiac Monitoring: Monitoring cardiac rhythms aids in early detection of arrhythmias or complications.
Neurological Assessment: Regular Glasgow Coma Scale assessments track neurological changes, guiding interventions.
Supplemental Oxygen: Maintaining SpO2 above 93% ensures adequate tissue oxygenation.
Head Elevation: Elevating the head to 30 degrees minimizes cerebral edema and improves perfusion.
Nasogastric Tube Insertion: A nasogastric tube prevents aspiration, especially in patients with swallowing difficulties.
Speech Pathology Consult: Collaboration with speech pathologists facilitates early assessment and intervention for aphasia.
Coagulation Profile Monitoring: Regular coagulation tests monitor potential bleeding risks associated with anticoagulation therapy.

Prioritized Nursing Care for Mrs. Fenech

Immediate Stroke Pathway Initiation: Promptly activating the stroke pathway expedites evidence-based care delivery.
Continuous Monitoring: Ensuring continuous cardiac and oxygen saturation monitoring prevents potential complications.
Reperfusion Therapy and Monitoring: Administering Alteplase and monitoring for bleeding complications is a priority.
Elevated Head Position: Maintaining head elevation supports cerebral perfusion and minimizes complications.
Consultation and Assessment: Engaging speech pathology for aphasia assessment facilitates early intervention.
Communication and Shared Decision-Making: Regular communication with the family and healthcare team ensures collaborative decision-making aligned with Mrs. Fenech’s best interests.

Shared Decision-Making: Collaborating with Family and Healthcare Team

Shared decision-making involves Mrs. Fenech, her family, and the healthcare team in collaborative care planning. Discussions regarding treatment options, potential risks, and expected outcomes allow informed choices aligned with Mrs. Fenech’s values and preferences. Open communication fosters a supportive environment, promoting holistic patient-centered care.

Conclusion

Understanding the pathophysiology of ischemic stroke, the significance of reperfusion, and evidence-based nursing strategies are pivotal in optimizing patient outcomes. The prioritized nursing care for Mrs. Fenech showcases a comprehensive approach that considers the urgency of interventions while ensuring patient safety and comfort. Shared decision-making fosters collaboration, enhancing patient and family engagement in care planning and decision-making processes.