Ischemic Stroke

Carolyn Klempay & Ariana Kulinczenko

Background

 Ischemic Stroke vs. Hemorrhagic Stroke   80% of all strokes Third leading cause of death in United States  Blood circulation stops   cells die 4-10 minutes, lack of oxygen and glucose

Risk Factors

Modifiable         Hypertension Cardiovascular disease Diabetes Mellitus Dyslipidemia Cigarette smoking Physical inactivity Obesity Diet** Unmodifiable    Age Gender Race

Signs and Symptoms

    Loss of vision or speech Paralysis Muscle weakness Change in mental status  Coma, memory changes, confusion

Diagnosis

  National Institute of Health Stroke Scale      Level of consciousness Visual loss Neurological status Sensory loss Language  Motor skills CT scans and Magnetic Resonance Imaging (MRI)

Client & History

    Ruth Noland 77 y.o. Female 5’2”, 165 lbs (75 kg) Right side partial paralysis and slurred speech    Hypertension 10 years Hyperlipidemia 2 years BMI 30.0 kg/m2

Symptoms

        Weakness of right side, arm, and leg Impaired sensation of left side Dysarthria and tongue deviation Impaired cranial nerves Loss of motor function tone and strength Plantar reflex decreased Normal blink reflex Normal respiration

Diagnosis

  Ischemic Stroke NIH Stroke Scale Score 14

Intervention

        Administer 0.6 mg/kg intravenous rtPA   Total dose: 67.5 mg 0.9 NS at 75 cc/hr Check vital signs Consciousness levels (NIH Stroke Scale) Continuous cardiac monitoring NPO diet 24 hours, except medications Acetaminophen for pain treatment Swallowing assessment Administer dysphagia diet

Dysphagia

     Dysphagia is termed as the inability or difficulty swallowing. Swallowing is an extremely complicated process of that is controlled by the central nervous system. It requires multiple parts of the brain to be in cohesion.

If this area of the brain is damaged from stroke, serious implications are necessary to follow Difficulty swallowing can affect food consumption, due to dehydration, malnutrition and secondary illnesses. The primary nutrition complications are weight loss and subsequent development of nutrition deficiencies that result from the inadequate nutrient intake.

Bedside Swallowing Assessment

 The bedside swallowing assessment was created to provide data for use in diagnosis and treatment planning.

1. The first part is the preparatory exam with no swallowing involved. 2. The second part is the initial swallowing exam where the physiology of swallowing is observed.  A speech-language pathologist evaluates, performs the diagnosis and treats swallowing disorders in the oral pharyngeal phases.

Dysphagia Swallowing Levels

 A. Oral preparation: This phase is when food or liquid is chewed and mechanically manipulated in the mouth for the preparation of swallowing. Movement patterns in this phase depend on the consistency of the material swallowed.  B. Oral transit: This phase is where the tongue propels food or liquid to the back of the mouth. This is the phase that triggers the swallowing response. Once it is pushed to the back of the mouth, the swallowing response begins.

 C. Pharyngeal:This phase begins when food or liquid is quickly passed through the pharynx and straight into the esophagus for swallowing.

 D. Esophageal:This final phase is where food or liquid from the previous phases passes through the esophagus and moves into the stomach.

Energy Requirements

    TEE for Overweight and Obese Females Aged 19 Years and Older:

TEE = 448 – 7.95 x age (yrs) + PA (1.16 low active) x (11.4 x wt (kg) + 619 x ht (m))

TEE = 448 – 7.95 x 77yrs + 1.16 x (11.4 x 75kg + 619 x 1.58m) TEE = 1962 kcal = 1,900 kcal – 2,000 kcal      Protein Requirements:

1.0 – 1.2 g/kg body weight

1.0 g x 75 kg = 75 g 1.2 g x 75 kg = 90 g

= 75 grams – 90 grams protein

Fluid Requirements



Weight:

   100 mL fluid per kg body weight for the first 10 kg 50 mL per kg body weight for next 10 kg 20 mL per kg body weight for each kg above 20kg (55kg)  Age and Weight: Standard fluid needs for people ages 65-85 years: 25-30 mL per kg  Reasonable range: 2,250 mL – 2,600 mL

Planning A Dysphagia Diet

Three levels of solid foods:

 1) Pureed. These foods have a pudding-like texture and are very cohesive. They require little to no chewing. Some examples of the pureed level are foods similar to milk and dairy products, applesauce, gravies and sauces.

  2) Mechanically altered . These foods are very moist and are in semisolid forms that require little chewing. 3) Advanced. These include soft foods that require a little more chewing than the previous level. This level is usually presented to patients with improved dysphagia.

Planning A Dysphagia Diet

Four Levels of fluid consistency:



Measured in CentiPoise; a dynamic viscosity measurement. This unit measures the fluids force per unit or internal resistance.

  1) Thin. This is 1-50 centiPoise. The thin consistency includes all liquids, jell-o, sorbet, Italian ice and ice cream. 2) Nectar-like. This is between 51-350 cP. Examples of the nectar phase include an apricot juice consistency.   3) Honey-like. This is between 351-1,750 cP. This includes liquids that can still be poured, but very slowly.

4) Spoon-thick. This is greater than 1,750 cP and includes liquids that are spoon-able that will not stay upright when a spoon is held vertically.

Foods in the Dysphagia Diet



To maintain or attain normal nutritional status while reducing danger of aspiration and choking, the texture (of foods) and/or viscosity (of fluids) are personalized for a patient with dysphagia.

1) Consistency

 The uniformity and coherence among things or parts within a food or substance Pureed Consistency in a dysphagia diet. Pureed is described as smooth and pudding-like. Ex: applesauce, gravies, pudding.

2) Texture

 The composition or structure of a food or substance Adding corn flour to a substance to create a more gritty and thicker texture

3) Viscosity

 The resistance to flow or alteration of shape by any substance as a result of molecular cohesion Applied to the resistance liquids have when swallowed, of a fluid to flow because of a shearing force. Ex: Honey-like 351-1750cP

Dysphagia Diet

   Mrs. Noland’s dysphagia is centered in the esophageal transit phase. She is having trouble passing food from the esophagus to the stomach. Mrs. Noland is experiencing reduced esophageal peristalsis, which indicates she cannot handle foods of thick consistencies. For food to pass through to the stomach, Mrs. Noland will need to stick to a pureed and thin liquid diet because liquids have the quickest transit time.

Mrs. Noland’s Altered Diet

               Orange Juice: no pulp Raisin Bran: cream of wheat, breakfast cereal, warm and pureed, easily swallowed Milk: thin liquid Banana: pureed until completely smooth Coffee: thin liquid Sweetener: dissolve in the liquid and can be swallowed with the liquid Chicken Tortellini soup: puree the entire soup and strain Saltine Crackers: puree this with her soup and strain Canned Pears: substitute with applesauce or puree the pears for easier swallowing Iced Tea: thin liquid Baked Chicken: mix with liquid and puree Baked Potato: mashed Steamed broccoli: puree or substitute with vegetable juice or v8 Margarine: acceptable Canned Peaches: puree, thin fruit smoothie, substitute for a fruit pudding, or yogurt.

Enteral Products

 

Mrs. Noland should also consider a nutritional supplement, such as nutritional shakes, Ensure High Protein, to ensure proper and sufficient nutrient and energy intake. Mrs. Noland needs a nutritional supplement drink that provides an adequate amount of protein because it will be difficult for her to include high protein foods in her diet. No consumption of: pulp, cottage cheese, eggs, peanut butter, nuts or seeds

 Ensure High Protein Nutrition Shake Milk Chocolate : 1 serving: 414 mL, 210 kcal, 25 g protein, 2.5 g Fat, 23 g Carbs, 3 g Fiber .

Nutrition Upon Discharge

   Mrs. Noland will still struggle with many problems once she is released from the hospital. It is important for her husband to be aware of these potential conditions to prevent problems from occurring or worsening. Mrs. Noland will still be struggling to swallow many foods and will need to eat very soft foods, with a pureed consistency.

She will slowly be able to make progress to denser foods with thicker consistencies, but that progress will be very gradual and cannot be implemented until her speech pathologist allows her. Mr. and Mrs. Noland should go through nutrition counseling so that they may become educated over proper nutrition, preparation and purchasing techniques that will aid in her recovery and prevent a future stroke from occurring.

Lab Data

Chemistry Normal Range

Cholesterol (mg/dL) 120-199 HDL-C (mg/dL) LDL (mg/dL) >55 <130 LDL/HDL ratio <3.22

Triglycerides (mg/dL) 35-135

August 12

210 40 155 3.875

198

PES Statements

 1. Obesity (NC-3.3) related to excessive energy intake and physical inactivity as evidence by BMI of 30.0 kg/m infrequent physical activity.

2 , elevated cholesterol levels of 210 mg/dL, low HDL of 40 mg/dL, high LDL of 155 mg/dL, elevated LDL/HDL ratio at 3.875, elevated triglyceride levels at 198 mg/dL, relation to hypertension development, and  2. Excessive Fat Intake (NI-5.6.2) related to food and nutrition related knowledge deficit as evidence by elevated cholesterol levels of 210 mg/dL, low HDL of 40 mg/dL, high LDL of 155 mg/dL, elevated LDL/HDL ratio at 3.875, elevated triglyceride levels at 198 mg/dL, hyperlipidemia, and BMI at 30.0 kg/m 2 .

Goals

 Acute Period:      Initiate dysphagia diet, pureed foods and thin liquids Maintain energy intake 1,800 kcal – 2,000 kcal Weight maintenance, appropriate calorie, protein, and fat levels Initiate (minimum) 5 cups fluid to meet fluid requirements Nutrition education to client and husband on dysphagia diet   Record weight changes, hydration status, and fluid loss Add enteral nutrition supplement product, rich in protein

Goals

 Post-Rehabilitation:     Use adjusted weight to initiate weight reduction Initiate 1,600 kcal – 1,800 kcal energy intake Decrease fat intake (31%), increase protein intake (14%) Initiate physical activity

Monitoring & Evaluation

       Track food intake and evaluate food log Track foods she has difficulties swallowing and which are easily consumed, so that they can either be continued or discontinued in her diet Monitor fat levels and reassess lipid profile to see if any improvements have been made Protein intake Appetite and tolerance Weight, to determine whether her intake is sufficient. Recommendation of admission to a stroke rehabilitation center should be considered

Questions?

Resources

     Anatomy & Physiology of Swallowing. (2011). Anatomy & Physiology of Swallowing. Retrieved November 25, 2013, from http://www.d.umn.edu/~mmizuko/5200/anat.htm

Chidester, J. (1997, June). Result Filters. National Center for Biotechnology Information. Retrieved December 1, 2013, from http://www.ncbi.nlm.nih.gov/pubmed/8990413 Clinic, M. (2012, July 3). Definition. Mayo Clinic. Retrieved November 12, 2013, from http://www.mayoclinic.com/health/stroke/DS00150/DSECTION=tr eatments-and-drugs Definition: 'Viscosity'. (2006). Viscosity. Retrieved December 1, 2013, from http://www.medilexicon.com/medicaldictionary.php?t=99155 Dysphagia. (2013). Dysphagia. Retrieved December 1, 2013, from https://ehealth.gov.mt/HealthPortal/rehabilitation/speech_language_ pathology/conditions_that_may_affect_sl/dysphagia.aspx

Resources

     Heart Association. (2012, December 10). What Your Cholesterol Levels Mean. What Your Cholesterol Levels Mean. Retrieved November 24, 2013, from http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholeste rol/What-Your-Cholesterol-Levels-Mean_UCM_305562_Article.jsp

Nelms, M. N. (2013). Nutrition Therapy and Pathophysiology 2/e. Belmont, CA, Wadsworth.

NIH. (2011). NIH Stroke Scale. National Institutes of Health. Retrieved November 12, 2013, from http://www.nihstrokescale.org/docs/HospitalStrokeScales.pdf

Office of the Professions. (1998, January). NYS Speech-Language Pathologists & Audiologists: Fiberoptic Endoscope. Retrieved December 1, 2013, from http://www.op.nysed.gov/prof/slpa/speechguidefiberoptic.htm

U.S. Bureau of Labor Statistics. (2013, November 20). U.S. Bureau of Labor Statistics. Retrieved November 30, 2013, from http://www.bls.gov/