Stroke conditions cause a significant number of deaths and disability conditions across the world. According to the Ministry of Health of Singapore (2009), an estimated 15 million individuals suffer from stroke annually, out of whom a third die and another a third are permanently disabled. In Singapore, stroke is ranked the fourth highest cause of death among persons aged 50 years or more and the dominant cause of lifelong disability. Generally, stroke refers to a situation where the brain cells fail to function normally due to an interruption in blood supply. The most common types of stroke are ischaemic and haemorrhagic stroke. Ischaemic stroke occurs in case of blockage of blood flow to the brain cells, while a haemorrhagic stroke occurs if a blood vessel rupture and leads to bleeding in the brain (Palm et l., 2012). According to Venketasubramanian et al. (2011), ischaemic stroke accounts for an estimated 74 percent of stroke cases registered in Singapore compared to 26 percent of haemorrhagic stroke cases. There are multiple causes and risk factors of stroke.
Causes of stroke either lead to blockage or leak in an artery supplying blood to the brain. Fatty deposits in blood vessels are the main cause of blocking of arteries or severe reduction in the blood supply to the brain (Johnson et al., 2016). Sometimes, blood clots form in regions where arteries are narrow hence limiting oxygen and nutrients supply to the brain. Haemorrhagic stroke results from a burst of an artery due to various reasons such as uncontrolled blood pressure, prolonged treatment with anticoagulants, bulging of an artery in a frail region, the impact of an injury such as due to car accident, weakness of blood vessel due to deposition of proteins, and abnormally thin arteries (Party, 2012). According to the Ministry of Health of Singapore (2009), a patient suffers from stroke if the signs and symptoms persist for more than 24 hours. If the symptoms continue for less than 24 hours, the condition is referred to as a transient ischaemic attack and only results in a temporary decline in blood flow to the brain (Ministry of Health of Singapore, 2009). Managing the avoidable risk factors may help reduce the chances of stroke or transient ischaemic attack.
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Identifying the risk factors and adopting a healthy lifestyle may help significantly in reducing stroke cases. Although a number of the risk factors such as old age, genetic factors, and history of stroke are constant, modifying certain characteristics may minimize the risk of stroke (Johnson et al., 2016). Examples of manageable risk factors include hypertension, overweight, diabetes, abuse of drugs such as cocaine and methamphetamine ( Warlow, 1998), unhealthy diet, physical inactivity, obesity, use of tobacco, and other cardiovascular diseases such as coronary artery disease (Palm et al., 2012). Most of the activities involved in reducing the risk of stroke aim at lowering cholesterol levels and maintaining appropriate blood sugar levels to reduce the damage of blood vessels and nerves and avoid blockages due to the accumulation of fats (Chimowitz et al., 1997). The prevention of stroke entails maintaining heart-healthy life changes.
Pathophysiology
The blood supply system to the brain and spinal cord are connected and mainly flows from the heart through the dorsal aorta. Before reaching the brain, the dorsal aorta branches into the internal carotid and vertebral arteries (Beal, 2010). The branching occurs in the neck region before the arteries move into the cranium, where they form the Circle of Willis, which is responsible for supplying blood to a significant portion of the cerebrum. The internal carotid arteries (ICA) enter the brain through the carotid artery and do not branch further to supply any part of the face or neck. The ICA branches into the ophthalmic artery, posterior communicating artery, anterior choroidal artery, and anterior cerebral artery. The ophthalmic artery nourishes the orbit structure. The posterior communicating artery connects the Circle of Willis, while the anterior choroidal artery nourishes the brain part in control of the motor and vision. As the name suggests, the anterior cerebral artery nourishes a section of the cerebrum, and the other portions of the cerebrum are supplied by the middle cerebral artery (Beal, 2010). The vertebral arteries branch from the subclavian and ascend the neck into the cranial cavity before branching into the meningeal branch, spinal arteries, and posterior inferior cerebellar artery (Beal, 2010). The meningeal branch, the spinal and the cerebellar arteries nourish the falx cerebelli, the entire length of the spinal cord, and the cerebellum, respectively. The risk of stroke is elevated by atherosclerosis.
Atherosclerosis condition only affects arteries that transport oxygenated blood, and nutrients to the tissues and cells. The process of atherosclerosis refers to the process in which the arteries narrow due to the accumulation of plaque on the inner walls (Berliner et al., 1995). The process of atherosclerosis is slow and may begin as early as the adolescent stage but is more common in middle age. The process is initiated LDL cholesterol which crosses endothelium to create plaque. The immune system then responds to the formation of plaque by sending white blood cells to eliminate the toxins. Over the years, the accumulated combination of plaque and macrophages tends to cause the hardening of the arteries (Berliner et al., 1995). Unhealthy behaviour such as smoking, a sedentary lifestyle, and excessive use of alcohol enhances the formation of plaque (Lusis, 2000). Once the plaque is formed, particles may break off from the walls of the arteries, after which they are transported through the bloodstream and may either attach to the walls or cause the formation of a blood clot called a thrombus (Lusis, 2000). The narrowing of arteries or the formed blood clots may block the blood flow to the brain and hence the risk of ischaemic stroke. The narrowing of arteries also causes an increase in blood pressure and the risk of haemorrhagic stroke. Arteries supplying blood to the brain may burst if pressure increases in regions where the artery walls are frail to cause bleeding into the brain parenchyma. The signs and symptoms of stroke are related to the damage to the disease.
Symptoms
Stroke manifests through a wide range of signs and symptoms, some of which are distinct while others are shared with other conditions. The common symptoms associated with stroke normally appear suddenly and include numbness of the face, leg, or arm mostly on one side of the body, troubled speech and understanding, problems walking due to loss of balance and lost coordination, severe headache, difficulty while swallowing, trouble seeing with one or both eyes, loss of consciousness, vomiting and coma (Beal, 2010 and Party, 2012). The most distinctive sign and symptoms for stroke are interrelated and include a drooped face on one side if the patient smiles, one arm becoming suddenly numb, inconsistent speech. The symptoms connect to the impaired functioning of the brain as a result of a blocked supply of blood or rupture of an artery. The cerebrum consists of the right and left hemispheres which are joined by the corpus callosum to facilitate the transmission of messages to either side (Beal, 2010). Since each of the hemispheres regulate the opposite side, stroke affecting either side has an effect on the respective side hence causing dropping off the face and numbness of arm and leg on that side.
Additionally, the brain plays an important role in coordinating speech and eyesight. For instance, the cerebrum plays a crucial role in the interpretation of the vision, speech, touch, emotions, learning, and coordination of movement (Beal, 2010). Stroke causes deprivation of oxygen and nutrients to key parts of the brain and hence damage or death of brain cells. Depending on the area of the brain that is affected, a patient may experience difficulty in comprehending concepts, thinking clearly, applying reason, judging circumstances, and stroke patients may also exhibit memory loss. Due to the role of the brain in muscle coordination, patients may lose control of throat and mouth muscles hence making it difficult to talk, chew or swallow Party, 2012). Subarachnoid haemorrhage results from the bursting of leakage of blood vessels supplying the cerebrum or clots in the region between the pial and arachnoid areas Party, 2012). The effect triggers a severe headache, neurological effects on vision, and sometimes unconsciousness.
There are specific parts of the brain that produce particular signs and symptoms if damaged by the effects of stroke. The left hemisphere is, for example, responsible for speech in most individuals, although some left-handed persons use the right hemisphere (Beal, 2010). Slurred speech, therefore, suggests damage on the left hemisphere, although confirmation is necessary if the patient is left-handed. Speech disturbance is referred to as aphasia and may influence speech, reading, and writing. Damage of the Broca’s area, which is the left frontal lobe, may cause challenges in the movement of the tongue and facial muscles (Beal, 2010). If the Wernicke’s area is in the left temporal lobe, a patient creates long, meaningless sentences and may sometimes create new words (Beal, 2010). Such patients also have difficulty in comprehending speech and are hence oblivious of their communication errors.
Evaluation of One Assessment Tool
Various prehospital and hospital evaluation tools are available for use by personnel working outside hospitals and clinicians. Since Singapore is an urban city-nation with the third biggest population density globally, the emergency medical systems are designed to quickly identify possible stroke patients who are then transported to predetermined hospitals Xu et al., 2020). The emergency services consist of members of the Singapore defense forces who are trained to use the Cincinnati Prehospital Stroke Scale (CPSS) before ferrying suspected patients to designated healthcare facilities equipped to deal with stroke cases (Xu et al., 2020). One noticeable advantage of CPSS is the ease of performance in the prehospital setting and possible enhancement of the emergency response systems (Maddali et al., 2018). Efficient emergency services play a critical role in enhancing the outcomes, given that the treatment of stroke is reliant of time to prevent the death of a high number of neurons (Test, 2021). The CPSS is a highly simplified evaluation tool that focuses on identifying three main stroke symptoms including lack of facial palsy, impaired speech and weakness of one arm. If one out of the three symptoms is confirmed, it means that the possibility of stroke is above 70% while presence of all the three signs indicate that the chances of stroke are above 85%.
Table 1
Cincinnati Prehospital Stroke Scale (CPSS) (Test, 2021).
|
Cincinnati Prehospital Stroke Scale (CPSS) |
|||
| Sign/Symptom | Test | Normal | Abnormal |
| Facial droop | Ask the patient to smile or show their teeth | If the movements are the same on either side of the face | If one side of the face fails to move as the other |
| Arm drift | Ask the patient to extend both arms straight for 10 seconds while closing their eyes | If there is an equal movement of the arms or no movement at all | If one arm fails to move or drifts below the other |
| Speech | The patient is asked to say the statement, “The sky is blue in Cincinnati” | If the words are said correctly without slurring | If the patient is unable to speak, slurs, or says the statement wrongly |
The management of stroke requires a fast and effective evaluation tool like the CPSS. Despite taking less than an estimated one minute, the CPSS has a high sensitivity and specificity rate of approximately 69 and 78 percent, respectively (Crowe et al., 2021). The main disadvantage of the CPSS evaluation tool relies on the use of few symptoms as the basis for establishing stroke (Maddali et al., 2018). As a result, there are potential shortfalls in the identification of posterior blood flow stroke whose specificity depends on different symptoms, which include vomiting, dizziness, and severe headache (Test, 2021). However, the importance of the tool remains solid that given that posterior circulation stroke accounts for a lower proportion of stroke cases recorded in an estimated range of between 5 and 10% (Test, 2021). Additionally, the tool is most appropriate in out-of-hospital settings and improves the efficacy of the emergency response while providing an opportunity for further analysis using hospital evaluation tools.
Nursing Management of Stroke
Nurses play a crucial role in the different stages of stroke management. The effort of nurses emerges within the first 3 to 24 hours and may commence in the prehospital environment or in the emergency section. During this phase, the nurses ought to focus on patient stabilization to maintain open airways and ensure breathing and circulation (Summers et al., 2009). Nurses also initiate the process of signs and symptoms analysis to confirm stroke. Once stroke is identified, the nurses should ensure registering of last known time, evaluation of sugar levels, avoid administration of sugar-containing fluids other than in the case of hypoglycaemia, quick initiation of treatment and liaison with the multidisciplinary team to initiate treatment such as the use of rtPA (recombinant tissue plasminogen activator) (Summers et al., 2009). In the first phase, nurses must prioritize timely treatment.
The second phase of nursing management care focuses on the stabilisation of the patient. Key areas that nurses ought to concentrate on include regulating the blood sugar level, managing fever, and continued engagement with the team members from various disciplines (Summers et al., 2009). Nurses play an important role in coordinating the activities of the medical team by continually monitoring and consulting about possible deteriorations or complications. Examples of possible complications include respiratory challenges, mainly among patients with pneumonia or a history of smoking, high blood pressure, cerebral edema, low blood sugar, and dehydration (Ashcraft et al., 2021). Nurses ought to rely on clinical pathways and physician standing orders as a guide for the management of stroke patients. In so doing, nurses can make use of the appropriate diagnostic tests and therapies. The aim of nurses should be to minimize readmission, time of stay in the hospital, and costs of care and enhance the quality of the patient outcome.
Evidence suggests that a significant proportion of the stroke patients are likely to worsen with the initial 24 hours (Summers et al., 2009). Consequently, nurses coordinating care after certain treatment procedures must focus engage in close monitoring of patients. Nurses ought to be aware of higher risks of elevated ICP as a result of large stroke lesions after thrombolysis and should be ready to deploy the necessary neurological evaluation tools to swiftly identify a change in patient condition. Nurses must also maintain a close evaluation of bleeding in the next 24 to 36 hours after the administration of rtPA (Summers et al., 2009). According to Summers et al., (2009), an estimated 6.4% of treated stroke patients manifested symptomatic ICH, which is partly related to the worsening patient condition. Although studies show an unavoidable rate of haemorrhagic translation among ischaemic stroke patients, thrombolysis is proved to enhance the risk of haemorrhage, especially if there are any treatment protocol guidelines are omitted (Ashcraft et al., 2021). Key indicators of haemorrhagic translation include an increase in blood pressure, a shift in alertness, worsening motor control, vomiting, and reintroduced headache. Any signs of worsening require immediate discontinuation of the rtPA infusion procedure. Control of ICH requires orders from a physician, meaning that a nurse should immediately notify in case of such escalation. Possible physician recommendations to curb ICH include frequent brain imaging and laboratory examinations such as prothrombin time, thromboplastin time, platelets blood count, administration of cryoprecipitate.
Other than their role in emergency response and treatment, nurses also play a crucial role in educating patients on self-care prior to discharge. Although a proportion of the stroke patients are discharged into long term care facilities, a significant proportion of the discharged patients go back home and are expected to take charge of their day to day activities such as eating, mobility, bathing, personal hygiene, dressing, and sitting (Aslani et al., 2016). Meanwhile, some still experience stroke-related challenges such as lowered mental capacity, imbalance, lack of coordination, and weakness of arm or leg. Most of these patients have reported feeling unready to handle self-care upon discharge. Therefore, nurses play an essential role in patient education, training, and rehabilitation (Zimmermann-Schlatter et al., 2008). Part of the task involves psychological counselling to cultivate the right attitude about their situation and create hope for future improvements. Patients need to understand the nature of their complications and the appropriate interventions such as physical activities and nutrition. The rehabilitation of stroke patients entails activities required to relearn lost abilities due to brain damage. Often stroke survivors are prone to emotional disturbances such as fear, anxiety, grief, and anger. Nurses ought to monitor post-stroke patients for personality changes and clinical depression. Psychological counselling works well before setting in on depression, but administration of antidepressant drugs may be necessary in severe cases (Aslani et al., 2016). Involving family members and friends in the post-stroke care also helps to create a supportive environment and enhance adaptation to the changes in a patient’s life.
Conclusion
Stroke is a major cause of death and permanent disability conditions in Singapore and across the world. There are two broad categorizations of stroke: ischaemic and haemorrhagic stroke. Ischaemic stroke results due to obstruction of blood flow to the brain cells due to formation of blood clots or narrowing of arteries. If the blood pressure is high, haemorrhagic stroke may occur as a result of a rupture that causes bleeding in the brain (Palm et l., 2012). Ischaemic stroke accounts for more than 70% of the total cases reported per annum compared to below 30% of haemorrhagic stroke cases. There are multiple causes and risk factors of stroke. Commencing stroke treatment within a short time helps to save more brain cells for permanent damage.
Nursing practice knowledge has the potential to enhance timely treatment among stroke patients. The nurses have crucial knowledge about the factors that must be closely monitored during the emergency response, such as accurate recording of last known time, sugar levels, and hypertension. Also, nurses may conduct certain lifesaving procedures such as administration of sugar-containing fluids in case of hypoglycaemia or even the initiation of treatment using rtPA infusion (Summers et al., 2009). During treatment, nurses have to continually monitor a patient to ensure that their condition does not deteriorate. To successfully achieve their role, the nurses check on specific measures such as blood pressure, a shift in alertness, worsening motor control, vomiting, and reintroduced headache. In post-discharge care, nurses help patients to ensure that they can independently conduct their day-to-day activities such as eating, mobility, bathing, personal hygiene, dressing, and sitting (Aslani et al., 2016). The main tools available to a nurse include patient education, training, and rehabilitation (Zimmermann-Schlatter et al., 2008). Psychological counselling also helps to cultivate the right attitude about their situation and to create hope, although antidepressants may be necessary for severe conditions. Nurses also ought to engage medical in practices meant to prevent conditions such as urinary tract infections, pneumonia, injuries resulting from falls, or clots in large veins (Aslani et al., 2016). Neurorehabilitation programs, for example, involve repeated practices such as sports or computer games to regain impaired skills such as coordination, speech problems, and ability to grasp. Well-coordinated practice may help relocate the functions from a previously damaged part of the brain to another (neuroplasticity) (Zimmermann-Schlatter et al., 2008). A lot of training and refresher courses are required to help enhance the capacity of nurses.
Intense stroke education is necessary among nurses at every phase of stroke treatment. Such education must concentrate on enhancing their abilities in patient assessment and continued monitoring to avoid deterioration. Quick assessment enhances the efficiency of treatment to save the loss of brain cells due to deprivation from oxygen and nutrients (Aslani et al., 2016). Achieving accurate diagnosis among nurses may also provide an opportunity for initiation of the rtPA infusion procedure for severe situations that may not wait for arrival in a healthcare facility where a multidisciplinary team is available (Summers et al., 2009). Other than the medical training, nurses need education on the rehabilitation of patients and psychological counselling required to successfully integrate patients into their new life without fuelling depression. Since subsequent stroke attacks are possible, sufficient emphasis must be channelled towards encouraging a healthy lifestyle.
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