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Topics About 'Stroke'.

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  1. I recently had a situation where I noticed my patient was becoming increasingly agitated, word salad was present, and left sided weakness was present. The patient had a head CT without contrast completed approximately 3 hours prior that was negative for stroke. Despite the recent negative head CT, I was concerned that my patient may be actively having a stroke. I made my charge nurse aware of the situation. She assessed the patient and also suspected stroke. At this point we sent a STAT page out to the hospitalist. 15 minutes passed by and there was no response (per my hospital policy, 15 minutes is the time frame a hospitalist is expected to return a STAT page). My charge nurse called the house supervisor at this point and made them aware of the situation. The house supervisor made the decision to ask a provider from the emergency department to assess my patient for possible stroke. The emergency department doctor came, assessed the patient, felt that the patient was having a stroke, and ordered a head CT with contrast. This CT came back positive for stroke. Around the time all of this was happening, the hospitalist (who I had tried to page at the start of all of this) arrived on the floor and stated that he did not feel the patient had a significant change in condition and that it was wrong to call a stroke alert and involve the ED doctor. He stated that it made his night harder and that we should have just paged him a second time. Although the patient did come in with word salad and left sided weakness it was, in my opinion, worsening. The patient was also becoming agitated which was new. I feel that I was looking out for the best interest of my patient and I don’t know what I should have done differently. I’m a relatively new nurse so I just wanted an opinion from someone who has more experience than myself.
  2. The experience of aphasia is often described as imprisonment, loss of self, loneliness and a lack of presence in daily life. June is National Aphasia Month and an opportunity to learn more about this disorder that affects the ability to speak, read, write and listen. What is Aphasia? Aphasia is a communication disorder that impairs a person’s ability to communicate and understand others. Aphasia may also make it difficult to read, write, gesture or use numbers. However, aphasia does not affect a person’s intelligence. Someone with aphasia still has thoughts and ideas, however, it is difficult to communicate these through language. Head injury, infection, brain tumors or other neurological conditions can cause aphasia. However, the most common cause is stroke. Facts and Figures About one-third of strokes result in aphasia At least 2,000,000 people in the U.S. live with aphasia It is more common than Parkinson’s disease, cerebral palsy or muscular dystrophy There is no medical cure Aphasia affects everyone differently Communication can improve overtime, especially with speech therapy Is most common among older population Occurs in people of all ages, gender, races and nationalities Awareness Statistics The National Aphasia Association conducted a survey on aphasia awareness in 2016. The survey found 84.5% of people have never heard of aphasia and 34.7% either have aphasia or know someone that does. Only 8.8 % of people surveyed have heard of aphasia and can identify it as a language disorder Types of Aphasia The types of aphasia depend on what language areas in the brain have been damaged. Wernicke’s Aphasia (Receptive Aphasia) This type affects the temporal lobe of the brain and characteristics include: Stringing together meaningless words to form long sentences Adding made-up or unnecessary words to sentences Being unaware of spoken mistakes Difficulty understanding speech Example: “You know that sludder that you take to before and webster on together maybe.” Broca’s Aphasia (Expressive Aphasia) This is the most common type of aphasia and primarily affects the brain’s frontal lobe. Characteristics include: May accompany right-sided weakness or paralysis Knowing what they want to say but unable to express in sentence form Speaking in short phrases and omitting small words (i.e. is, and, the) Using words that are close to what they want to say, but not the exact word (i.e. using “dog” for “cat”) Example: “Glasses aides table” for “My glasses and hearing aides are on the table.” Global Aphasia Global aphasia occurs with extensive damage to different language areas in the brain. Characteristics may include: Severe communication difficulties Very limited in ability to speak or comprehend language Repeating the same words or phrases over and over Treatment For Aphasia The brain has a tremendous ability to recover, therefore, people with aphasia often see dramatic improvements within the first few months. In fact, language improvements may occur even after long periods of time. However, many people have some difficulty after the recovery period. The goal of aphasia therapy is to use remaining language abilities to improve the ability to communicate. Learning new ways of communicating, such as gestures, pictographs and the use of electronic devices can significantly improve quality of life. What Research is Being Done? New types of speech-language therapies are being researched in both recent and chronic aphasia to identify new methods of helping with improving word retrieval and other aspects of speech. One of these methods is activities stimulating the mental representation of sounds, words and sentences for easier access and retrieval. Other research includes: Exploring drug therapies that affect chemical neurotransmitters in the brain to use in combination with speech-language therapy Using functional magnetic resonance imaging (MRI) to better understand language reorganization after a brain injury Studying the use of noninvasive brain stimulation in combination with speech language therapy to temporarily alter brain activity to help people re-learn language use. Make the Effort to Connect In recognition of Aphasia Awareness Month, take time to step up your ability to simplify your language, encourage communication and make a difference. Be sure to check out the National Aphasia Association’s website for tips and tools to help with communication and much more. The website is also a great resource for people with aphasia, as well as, family, friends and caregivers. What have you done or plan to do for better communication with aphasic patients? Additional Resource: American Stroke Association Aphasia Education American Stroke Association: Aphasia and Stroke
  3. J.Adderton

    Heat, Humidity and Protecting the Heart

    The hot and humid “dog days of summer” can cause heat stress in healthy people. For those with existing heart disease, typical summer weather can be downright dangerous. Studies have shown heat and humidity are hard on the heart. Heart disease, especially heart failure and ventricular dysfunction, make it harder for the body to cool in summer weather. According to the American Heart Association, a heat wave lasting just 2 days increases the likelihood of a premature heart-associated death. Heat and Heart Stress The body sheds extra heat through the involuntary process of radiation and evaporation. This process cools the body but adds some stress to the heart. In individuals with heart disease, the stress can be significant. Radiation (Circulation) Heat naturally moves from warm to cooler areas. If the air around us is cooler, our bodies use radiation to release heat into the air. This transfer will stop when air temperature reaches body temperature. The heart has to pump harder and faster to reroute blood flow to the skin for heat release. Evaporation (Heat) Sweat cools the body through evaporation. Just one teaspoon of sweat can cool the body by 2 degrees a day with low humidity. Evaporation is less effective on humid days when the air is heavy with water vapor. This process of cooling places additional strain on the heart. Sweat pulls sodium, potassium and other minerals needed for water balance out of the body. To counter this loss, the body holds onto water by retaining fluid. Heart Problems and Problems Coping Healthy people most likely adjust to hot summer days without missing a beat. However, those with heart disease may have difficulty coping with the added physical stress. The following factors may further contribute: Heart muscle damage can decrease the heart’s ability to circulate enough blood to adjust to hot weather. Narrowed arteries can limit blood flow to the skin Common heart medications may interfere with the ability to regulate heat. Beta blockers slow heart rate and blood may not circulate fast enough for effective heat exchange. Diuretics may worsen dehydration Some antihistamines and antidepressants reduce or block sweating In certain conditions (i.e. dementia, Alzheimer’s Disease, Parkinson’s Disease) thirst signals may not be sent due to the brain’s slow response to dehydration. Balancing Heat and Diuretics Congestive heart failure brings additional strain on hot days. Since the heart is weaker, the body has a harder time cooling. The risk for heat stroke, heat exhaustion and dehydration is greater with heart failure. Also, diuretics may increase the risk for dehydration and high sodium levels. Patient education should include compliance with physician instructions for fluid intake during hot weather. Diuretics and fluid intake may need to be adjusted to compensate for increased sweating and water loss. What to Watch For Nurses have a responsibility to educate heart patients on what to watch for during hot weather. Weakness and/or dizziness Nausea and vomiting Cool skin Headaches Dark urine Muscle cramps High fever* Uncharacteristic behavior* Confusion* Rapid respirations* Rapid pulse* Seizures and unconsciousness* *May indicate heat stroke Be Proactive and Safe Nurses are the constant across all areas of healthcare. Therefore, nurses carry the responsibility of educating heart patients on precautions to take on hot days. Patient education may include: Avoid activity outdoors during the hottest part of the day Consider exercising indoors or try out a water work-out in the pool Talk to your physician about guidelines for staying hydrated, especially if fluid intake is restricted When sweating, drink sports drinks to replace electrolytes Don’t wait until you are thirsty to drink Consider other sources of hydration such as popsicles or fruit juice Avoid alcohol and caffeine to reduce risk of dehydration Wear loose, light-weight and light-colored clothing If going outdoors, use sunblock Talk to your doctor about your specific self-care needs during hot weather Keep informed of you local humidity levels Check on a friend or neighbor and ask them to do the same for you Patient education should also include tips on maintaining a cool environment. Stay indoors with air-conditioning as much as possible. Don’t rely on fans as the primary source of cooling If your home is not air-conditioned, contact your local health department to locate a local air-conditioned shelter Limit the use of stove and oven for cooking and laundry dryers Cool down with cool baths or showers If time must be spent outdoors, avoid the hottest part of the day and find a shady area Conclusion Hot and humid weather can be dangerous for anyone, but the risk is greater for those with heart disease. Be prepared to educate your patients on how to prevent over-stressing the heart while beating the dog days of summer. Protect Your Heart CDC Information Related to Extreme Heat Heat is hard on the heart: Simple precautions can ease the strain
  4. For individuals diagnosed with AFib, the risk of stroke is very real. In fact, a person with Afib is 5x more likely to suffer a stroke than someone with a regular heart rhythm. In order to order to understand how the implant works, you must first be familiar with the basics of Afib. In Afib, the heart’s atria flutter and send erradic electrical signal to the ventricles. As a result, blood pools and clots in the heart’s left atrial appendage (LAA). In non-valvular Afib, more than 90% of blood clots resulting in a stroke are formed in the LAA. A stroke occurs when these clots travel to the brain and prevent adequate blood flow. Afib is more common after age 50 and often occurs without symptoms. Watch an animation of Afib from the American Heart Association The goal of Afib treatment is to prevent clots from forming, control pulse rate and restore normal heart rhythm. Anticoagulants (warfarin, others) are given to prevent blood clots and reduce the risk of stroke. There are individuals that require blood thinners long-term. The risk of bleeding is higher when taking blood thinners. The Watchman implant is an alternative to long-term anticoagulant therapy for stroke prevention when the risk of bleeding outweighs the medication’s benefit. The WATCHMAN device is for people meeting the following criteria: Diagnosed with Afib not caused by a heart valve problem Diagnosed with Afib and physician is recommending blood thinners Are able to take warfarin but need an alternative ***Individuals may need an alternative to warfarin for the following: History of serious bleeding while taking blood thinners Are at risk for major bleeding to due lifestyle, occupation or physical condition Take warfarin but have difficulty maintaining therapeutic PT/INR, have difficulty getting regular blood tests or cannot take a different type of anticoagulant The WATCHMAN device is not for patients: Who are unable to take warfarin, aspirin or clopidogrel Who should not or cannot have a heart catheterization Allergic to the device materials With a LAA that is too large or small for the device to fit appropriately Doing well and expect to continue doing well on anticoagulants. "Ed is a 74-year-old patient with a long history of Afib. Over the years, Ed has undergone multiple cardioversions and cardiac ablations. Due to Ed’s high stroke risk, he was placed on warfarin and has been taking for several years. Ed has had multiple falls and remains a high fall risk secondary to vertigo. When Ed visits his cardiologist, he expresses fear of causing a major bleed because of his falls. However, he wants to continue to be active with his grandchildren and occasionally golf. The cardiologist explains the WATCHMAN procedure to Ed as an alternative to warfarin." How It Works The actual Watchman implant is about the size of a quarter and fits directly into the LAA. The implant permanently closes the LAA- preventing clots from leaving the heart and entering into the bloodstream. Since the implant is permanent, placed once and does not have to be replaced. The Watchman procedure is minimally invasive and typically performed in a heart catheterization lab. The procedure is monitored by the medical team and utilizes imaging to visually guide the device in place. A thin catheter is inserted through a vein in the groin and guided into the heart’s right atrium. A second puncture is made in the muscle wall between the right and left atrium. The catheter is then advanced into the left atrium. The physician uses imaging to advance a smaller inner catheter, with the compressed device enclosed, into the LAA. Once the implant is in the right place, the implant will open- much like an umbrella. Within 45 days, a thin layer of tissue will grow over the implant. Always a Risk Any medical procedure carries risks and the Watchman is no exception. Review common risks here. Clinical Studies and Evidence The Food and Drug Administration approved the Watchman implant in 2016 based on long-term data from clinical trials. The trials ( PREVAIL study, PROTECT AF study and CAP Registry) included over 2400 patients and >8000 patient-years of follow-up. Data from the trials supporting FDA approval include: Device successfully implanted in 95% of patients 45 days after implantation, 92% of patients were no longer taking blood thinners >99% were no longer taking blood thinners by 1 year Significant decrease in disabling and fatal strokes (largely due to the reduction in hemorrhagic stroke) Demonstrated similar ischemic stroke reduction when compared to warfarin Reduced major bleeding events vs warfarin by 72% at 6 months In addition to clinical trials, the Watchman procedure has been performed over 20,000 times worldwide. It is the only device of its kind approved by the U.S. Food and Drug Administration. What new and emerging advances in stroke prevention have you seen in your area of practice? For additional information, visit www.watchman.com