Acute Ischemic Stroke
You are an AGACNP practicing as a hospitalist in a tertiary care center. You are tasked with admitting a patient with a chief complaint of an acute neurological disease state. Please choose from one of the following and try to avoid duplicating posts.
Transient Ischemic Attack (TIA)
Ischemic and Hemorrhagic Stroke
Seizures
Intracranial Hypertension
Encephalitis
Meningitis
Encephalopathy
Space-Occupying Lesions
Peripheral Neuropathy
Parkinson's Disease
Alzheimer's Disease
Closed Head Injuries With and Without Chronic Anticoagulation
Multiple Sclerosis
Amyotrophic Lateral Sclerosis
Outline a typical presentation for the disease state you have chosen. List appropriate diagnostic testing, admission orders, and referrals and consultations. Include appropriate screening tools, identify potential risks, and list appropriate interventions to minimize risk and provide preventative care, including tertiary prevention. Highlight differences in presentation of adult versus geriatric patients with neurological emergencies. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources.
Acute Ischemic Stroke
Typical Presentation:
A patient with an acute ischemic stroke may present with sudden-onset focal neurological deficits. Common symptoms include:- Hemiparesis or hemiplegia (weakness or paralysis) on one side of the body.
- Hemisensory loss (numbness or tingling) on one side of the body.
- Facial droop (weakness or asymmetry of the facial muscles).
- Aphasia (difficulty speaking or understanding language) if the stroke affects the dominant hemisphere.
- Visual field deficits or vision loss in one eye.
Diagnostic Testing:
- Non-contrast CT scan of the brain: To determine if the stroke is ischemic or hemorrhagic and assess the extent of brain damage.
- CT angiography or MR angiography: To evaluate the blood vessels and identify any occlusions or stenosis.
- Laboratory tests: Including complete blood count, coagulation profile, comprehensive metabolic panel, lipid profile, and cardiac markers (troponin) to assess for potential underlying causes of the stroke.
Admission Orders:
- Neurological monitoring: Frequent neurological assessments including Glasgow Coma Scale (GCS), pupil checks, and vital signs.
- Continuous cardiac monitoring: To detect any arrhythmias or changes in ECG.
- IV access and hydration: To maintain adequate fluid status.
- NPO status: Until a swallowing evaluation is performed to assess for dysphagia.
- Aspirin 325 mg PO (if not contraindicated): Unless the patient received thrombolytic therapy or there is a clear contraindication.
- Thrombolytic therapy (if eligible): If the patient presents within the appropriate time window and meets criteria for intravenous alteplase administration.
Referrals and Consultations:
- Neurology consult: To assist with further evaluation, management, and determination of appropriate interventions.
- Physical therapy, occupational therapy, and speech-language pathology: To assess and initiate rehabilitation as early as possible.
Screening Tools and Interventions for Risk Minimization and Preventative Care:
- NIH Stroke Scale (NIHSS): To assess stroke severity and guide treatment decisions.
- Swallowing evaluation: To assess for dysphagia and determine appropriate dietary modifications to prevent aspiration pneumonia.
- Fall risk assessment: To identify patients at risk for falls and implement preventive measures such as bed alarms, non-slip footwear, and assistive devices.
Differences in Presentation of Adult versus Geriatric Patients:
Geriatric patients may present with atypical symptoms or have delays in seeking medical attention. They may have more subtle neurological deficits or non-specific symptoms such as confusion, dizziness, or generalized weakness. Comorbidities such as hypertension, diabetes, and atrial fibrillation are more prevalent in this population and may contribute to the development of ischemic strokes. Geriatric patients may also have age-related changes that affect treatment decision-making, such as increased bleeding risk with anticoagulation therapy. Rehabilitation interventions should be tailored to address age-related functional decline and consider factors like frailty and cognitive impairment.Summary and Recommendations:
Admitting a patient with an acute ischemic stroke requires prompt evaluation and management to minimize brain damage and prevent complications. Diagnostic testing, including a non-contrast CT scan of the brain, is crucial to determine the type and extent of the stroke. Admission orders should include neurological monitoring, cardiac monitoring, hydration, and consideration of thrombolytic therapy if eligible. Referrals to neurology and rehabilitation services are essential for comprehensive care. Screening tools such as the NIH Stroke Scale can aid in assessing stroke severity and guiding treatment decisions. Swallowing evaluations and fall risk assessments should be performed to minimize complications. The presentation of ischemic stroke in geriatric patients may vary, necessitating careful evaluation and consideration of comorbidities. Age-related factors should be taken into account when deciding on treatment options and planning rehabilitation interventions. References:- Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., … & Tirschwell, D. L. (2018). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50(12), e344-e418.
- Winstein, C. J., Stein, J., Arena, R., Bates, B., Cherney, L. R., Cramer, S. C., … & Lang, C. E. (2016). Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 47(6), e98-e169.