There is an old saying about diagnostics: When you hear thundering hooves, think horses, not zebras. When Julia*, a 28-year-old event organizer, arrived in the ED complaining of a severe headache on the left side of her head, the staff heard she had attended a wedding the night before and diagnosed dehydration. As she was signing her discharge form, she told them it was hard to write, but the staff dismissed it. Two days later, she returned to the ED and an MRI revealed an ischemic stroke. Everyone was thinking horses Julia was riding a zebra.
Not Your Typical Stroke
Strokes are much more common among the elderly, but the American Stroke Association reports annually about 15,000 people have their first cerebral infarctions by the age of 45. A study presented at the ASA 2009 International Stroke Conference indicated that the problem in younger people often is initially misdiagnosed, costing valuable time.
Sandra Goodman, RN, CPNP, clinical coordinator of the division of pediatric neurology at Maimonides Medical Center in Brooklyn, N.Y., says any symptoms that appear suddenly should be taken seriously. If youre thinking complex migraine, you should think stroke, she says. Goodman says the availability of MRIs, the gold standard for differentiating between hemorrhagic and ischemic strokes, aids in making the diagnosis.
Strokes in young adults are not common, but the possibility should always be in the back of the clinicians mind during assessment, says Claudine Rosiecki, RN, BSN, CCRN, stroke unit coordinator at The Valley Hospital in Ridgewood, N.J.
Rosiecki notes that the type of stroke dictates the most appropriate treatment, and when diagnosing, speed is of the essence. Tissue plasminogen activator (tPA), a powerful thrombolytic medication, is appropriate during the first three to 4 1/2 after the onset of symptoms during an ischemic stroke but is not used once that time window closes. There also are several mechanical devices that are introduced through the vascular system to remove clots, but they also only are appropriate during those first six to nine hours. Hemorrhagic strokes may be treated by surgical intervention.
Younger patients may have a history or lifestyle that puts them at risk. She notes some basic factors; any one should be a red flag for investigation when associated with a sudden onset of symptoms:
History of oral contraceptive use
History of tobacco use
Illicit drug use
Increased cholesterol level
History of hypertension
Any blood-clotting disorder
Building a New LifeAmy Colombo, RN
The first days after the event lay the groundwork for the eventual recovery of the patient, says Mary Burke, RN, BSN, CCRN, charge nurse of the neurological ICU at NewYork-Presbyterian Hospital in New York City. Rehabilitative therapy often starts in the NICU as soon as the patient is stable. Family is involved immediately, and a variety of educational material is available to help them understand what has happened. Sometimes the material offers a basis for more questions and triggers a discussion of fears and concerns.
After the acute phase, the work of rehabilitation begins in earnest. At Kessler Institute for Rehabilitation in West Orange, N.J., there is a multidisciplinary approach to getting the individual back into life. In rehabilitation, we are all about teaching, says Amy Colombo, RN, BSN, CRRN, clinical coordinator of the stroke unit. They offer a Medication Management Program geared specifically for these patients because most never have been on the kinds of medication they will be taking after their strokes. Patients meet twice a week with a nurse, pharmacist and occupational therapist to review the interactions and safety issues involved with their medications. Physical therapy is intense and focuses on increasing function, including driver re-education whenever possible.
Colombo says that these patients typically suffer from reactive depression. The stressors they cope with are daunting, and include everything from intimacy and sexuality to financial problems that come from the loss of family income. Psychological services are available and encouraged, and family therapy often is initiated to address everyones concerns.
We have a focus on determining future goals with the patient, Colombo says. This includes helping them reach an understanding of their family situation, and helping them determine a way to return to their former roles in some capacity. We refer them to a vocational counselor for return-to-work questions.
Before going home, the family is referred to community resources and assisted with initiating applications for benefits and services. Everyone is offered membership in the monthly Stroke Before 60 support group. There also is an outpatient cognitive rehabilitation program that focuses on return-to-work goals.
The New Normal
When these patients arrive home, they often still are struggling with the devastation of impairments and limitations. Home care nurses such as Julia Smith-Dorsey, RN, a visiting staff nurse at Patient Care Inc. in Denville, N.J., are there to assist the patient and family in making the difficult transition to a new normal.
Smith-Dorsey says her approach is determined by the way the family is reacting to the patients disability. As the family struggles to rebuild itself to accommodate the new roles everyone plays, the home care team is particularly well-situated to assist them in redefining themselves. Including the family in the care at home helps as everyone redefine their roles.
* Name changed to protect privacy.