Wednesday, 21 January 2015

Student Nurse Perspective: Stroke Care


Seeing as my first job as a qualified nurse is going to be on a stroke unit. I thought for my own sake that I write a little about strokes. With that I thought I'd tie in with a little bit of information about thrombolysis. Mostly I am writing this as a refresher for myself and at the moment this looks like to be my last Student Nurse Perspective article. Due to be renamed Icelandic Metal Nurse. But I do hope that it will be useful for others as well, I will try my best to write it in such a way that everyone can read it and understand it (well, hopefully).

Haemorrhagic Stroke
Stroke (Apparently called Brain Attack in the US) is the common name for Cerebrovascular Accident (CVA). Every year around 100,000 strokes occur in the UK. It mostly occurs in people who are over 65. But it can affect everyone. It is a very debilitating condition and depending on which area of the brain it happens the symptoms vary. Mostly the effects are irreversible. Symptoms vary between what part of the brain is affected, and the larger the stroke the more areas of cognitive ability it will affect. Stroke accounts for over 46,000 deaths per year making it the third largest cause of deaths in the UK and it is the most common cause of adult disability.  There are big financial implications for society as a whole, total costs to the NHS is over £4.4 billion per year and to society due to lost income and informal care it is £9 billion.

Survival rates from a stroke is currently 20-30% after one month and 30-40% after one year, but those numbers do not mean a lot to the individual. Generally in terms of better prognosis is based on severity of the stroke, age of the patient, what type of stroke, ethnicity and co-morbidities. Physical recovery is based on how much function the patient has in terms of activities of daily living and it usually reaches it's peak six months post stroke.  Whilst we have come a long way in treating acute strokes and hospital rehabilitation for stroke patients, we have not progressed very well in terms of long term management and community based treatment for stroke patients who suffer from some of the more long term affects of strokes like psychological and social problems.

Ischaemic Stroke
Strokes fall into two categories, ischaemic strokes and haemorrhagic strokes. Ischaemic strokes accounts for 85-90% of all strokes. Ischaemic stroke occurs when there is a blood clot occluding any blood flow to a portion of the brain. Haemorrhagic stroke is when an artery in the brain has burst and blood leaks into the brain tissue. Haemorrhagic stroke can also be further divided into Intracerebral haemorrhage (bleeding in the brain tissue) and subarachnoid haemorrhage (bleeding on the surface of the brain). There are also some conditions that are sometimes known as stroke mimics, for example hypoglycaemia, epileptic seizures, severe migraine attack, encephalopathy and Transient Ischaemic Attacks. There are certain lifestyle factors that increase your risk of having a stroke such as smoking, alcohol consumption, poor diet, lack of exercise, obesity and drug use. There are also certain medical conditions that will raise that risk such as  high cholesterol, high blood pressure, atherosclerosis, diabetes and atrial fibrillation.
  • There are of course plenty of actions you can take to reduce your risk of getting a stroke. If you are a smoker then there is nothing better you could do than to quit smoking. I mean seriously. Just stop. Now. That stuff is bad for you.
  • Reduce your alcohol consumption. Those cans/wine glasses add up, especially when you are pairing gluten free German beer with French wine as smorgaswine.
  • Lay of those drugs. Or at least reduce your usage drastically. Please.
  • Pick up regular exercise. It doesn't have to be anything major. Just get of that sofa and go for a nice brisk 30-45 minute walk every day. Get a dog or failing that get a ferret.
  • Increase your intake of fruit and vegetables. The importance of a good diet cannot be underestimated. Sure go for the occasional fast food, but don't forget to include some salad with it.
  • Lose some weight. No I am not saying that you have to look like a sculptured Greek god/dess. I am saying that that apron you have around your waist needs to go.
  • If you're diabetic make sure that you keep your blood sugar ticking between 4-10 mmol/l. Fluctuating blood sugar can be a little disastrous. 

F.A.S.T.
Thankfully due to the excellent FAST campaign most people know what signs to look out for if someone is having a stroke. But I'll go over it briefly again just to recap. When stroke begins the symptoms are pretty quick to show, first thing to notice will be if the face is drooping to one side (can they smile), if they can raise both arms and keep them raised for say 10 seconds or so and if their speech is slurred. Time is of essence here so if you suspect that a loved one is having a stroke phone the emergency services as soon as possible (999, 112 or 911, depending on your location). While there are lots more signs and symptoms those are the ones you should look out for. Symptoms also vary depending on where the damage is happening in the brain, if the symptoms are visible on the right side of the body then the left side of the brain is affected and vice versa.

Carotid Artery
If you've been found to be in a particular risk group then your doctor might decide to put you on some medications in order to reduce that risk. This is mostly medication based using drugs like statins, these are used to control and lower your cholesterol. Anti-platelet, such as aspirin or clopidogrel, are also per standard. These work by inhibiting platelets forming clots. Quite possibly the most important one, or possibly the most well known, you will also be prescribed a tablet from the anti-coagulation group, most likely Warfarin. Like the anti-platelets these work by reducing clot forming usually by inhibiting vitamin k production. As far as side effects are concerned there is the risk of bleeding. If you were diagnosed with high blood pressure you would also be put on either beta blockers or ACE inhibitors.  All of these drugs would also be used as a secondary prevention. If you had suffered from Transient Ischaemic Attacks your doctor might suggest that you have what is called Carotid Endarterectomy, this procedure is used to remove plaque from the carotid arteries. If this procedure is done in a timely manner post TIA's then lives can be saved and strokes averted. Not only that it is also sometimes a suggested operation to prevent another stroke from occurring and again time is of the essence. The sooner this operation is done the better outcome there is for the patient.

Recombinant Tissue
Plasminogen Activator
If ischaemic stroke is caught soon enough and time of onset is known then this type of stroke can be partially reversed or at least contained using a medical treatment called Thrombolysis. The alternative name for it is Alteplase and this is made from recombinant tissue plasminogen activator. It is biotechnology at its finest. This treatment is a bit of a controversial one, mainly due to the perceived ineffectiveness, the risk and the price.  About 1 in 7 actually benefits from it and there is the danger that it might turn an ischaemic stroke into a haemorrhagic one. In order to qualify for the procedure you have to have a CT/MRI scan to confirm what kind of stroke you have had. The time of onset has to be known and has to be within 4 hours, though the treatment is said to work better if it is within 3 hours. And the patient has to be weighed. If it has gone over 4 and half hours then you are in danger of damaging the brain even further. When it is effective then it is very effective, a study found that after three months from treatment around 30% of patients were back to normal or at least near normal neurologically and a further 30% had mild to moderate neurological deficit. Up to 50% had become independent in activities of daily living and 15% were moderately independent. But on the other side of things it also found that it up to 9% of patients who had received this treatment had died due to intracranial haemorrhage.

So in conclusion. Regarding strokes time, is of the essence so if you suspect that a loved one (or a stranger for that matter) is having a stroke get your phone out. Don't waste your time taking pictures, and phone for the emergency services. But it isn't just important to get them into the hospital for treatment it is also important to make sure that they end up in a specialist stroke unit as their chances of recovery are much better on there than on a general medical ward. The multi-disciplinary team on there should be made up from (besides nurses) Occupational Therapists, physiotherapists, Clinical Stroke Specialist Nurse, medical consultant and a registrar. Ideally after the hospital stay there should be an outreach team to assist with activities of daily living and further rehabilitation.
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