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Blood Pressure Management – Stroke Nursing Care in ICU

by Rhonda Lawes

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    00:01 I want to dig a little deeper in this blood pressure management because we teach patients all the time that normal blood pressure is < 120/80 mm Hg, right, since we changed the numbers a little bit.

    00:11 But blood pressure management in acute ischemic stroke is different than acute hemorrhagic stroke.

    00:18 Okay. So, pretty much the takeaway point, blood pressure management post stroke is different.

    00:25 Just right there. You've got that. And then you can break that down, it's even different between an ischemic stroke and an acute hemorrhagic stroke. So, we're talking about the acute phase of stroke because there's also differences in the management of blood pressure in the acute and chronic phases of both strokes. Okay. So, if I don't have you confused enough, let me explain it a little better. See, Mr. Johnson's blood pressure, let's use that as an example. Mr. Johnson had an ischemic stroke and he got alteplase, which is a thrombolytic drug.

    00:57 A clot -- boom -- it's a clot buster. So, for the first 24 hours after his thrombolytic alteplase, the Critical Care nurse is going to monitor and maintain his blood pressure at or below, 180/105 mm Hg. Okay, so if it gets above that, here's an example of 3 medications that might be used: labetalol, nicardipine, and clevidipine.

    01:21 So, those are 3 medications that might be used. Remember, Mr. Johnson's health care provider is going to order specific medications for the nurse to use, but we wanted to give you 3 examples that might be used or considered. So those are the 3 medications just that are examples of that. Now, if Mr. Johnson had not received alteplase, right, his hypertension wouldn't have been treated, unless it was extreme. So, if he had not received alteplase, we really would let his blood pressure, it'd have to be > 220/120 mm Hg before we would treat it. Now, remember for Mr. Johnson, we're keeping it below 180/105 mm Hg because he had the alteplase.

    02:04 If he hadn't had the alteplase, we wouldn't treat it unless it was > 220/120 mm Hg.

    02:11 And those represent systolic blood pressure, SBP, or diastolic blood pressure, DBP.

    02:17 So, unless Mr. Johnson had some other comorbidities -- why, I keep giving you these caveats, don't I? Right. Normally, that would be our measurement, not > 220 mm Hg or 120 mm Hg if he had not received alteplase.

    02:30 But if Mr. Johnson had some other comorbidities, like he was also having ischemic heart disease, or he was in heart failure, or we're worried about his aorta dissecting, meaning that it was splitting apart and leaking, we would run a lower BP. But you wouldn't be the one who decided that.

    02:48 The health care provider would write very specific orders on the safe range of blood pressure. We're just giving you kind of an idea of where health providers would write those orders or what they would be thinking about when they set the ranges. Okay. Let's review.

    03:02 You're going to see how smart you feel. Why is a higher blood pressure allowed for patients with ischemic stroke who do not receive alteplase? Okay. Here's the answer. In ischemic stroke, the perfusion pressure after the obstructed vessels is low, and the vessels are dilated.

    03:24 Okay. That's a lot of words. Let's break it down. So, if I've had an ischemic stroke which some days, the way my mouth works, I think I have, but if I've had an ischemic stroke, the perfusion pressure after the obstructed vessel is low. So let's say the clot was right here, okay? So, this is blocked off right here. So the pressure after the blockage is low, and the vessels are dilated. Okay. So, my brain wouldn't be able to effectively auto-regulate these dilated vessels. So those vessels that are dilated are dependent on my systemic blood pressure for perfusion.

    04:06 Okay. I don't want to speak through this point because I want you to feel comfortable why we allow a higher blood pressure.

    04:13 So, I got a clot here. So what are the vessels like after the clot? Right. They're dilated which drops pressure, and so the perfusion pressure after the blockage is usually low.

    04:28 The brain can effectively auto regulate that. The brain says, "Hey, I know you're not getting enough perfusion here, but there's nothing I can do about it." So the only way we can have this brain well-perfused is if the total systemic blood pressure is higher. That's why we allow a higher blood pressure after an ischemic stroke.

    04:49 Now, how is blood pressure treated in a hemorrhagic stroke? We got the ischemic stroke part, but what about a hemorrhagic stroke? And when we say hemorrhagic stroke, that means you're bleeding in your head, okay? So that's why we're going to treat that differently.

    05:04 So, for blood pressure management in acute bleeding or hemorrhagic stroke, the patient's blood pressure is often already elevated. And so, an acute stroke, like 150-220 mm Hg systolic, if that's what the patient is running, where they've got a systolic pressure running between 150 mm Hg and 220 mm Hg, our goal and our target is to lower that systolic pressure to < 140 mm Hg, We found out there's really no clear benefit to getting it lower than 140 mm Hg in the first few hours of the acute phase. So our goal is to get it just like right to 140 mm Hg. We're not going to push them all the way down to 120 mm Hg because it really doesn't do that much benefit for the patient. So, we're talking about an acute hemorrhagic stroke, right? Usually, the blood pressure we see like 150 mm Hg to 220 mm Hg. We just want them a little bit below 140 mm Hg and we'll be really happy. Now, if I have an acute stroke with a blood pressure > 220 mm Hg, we're going to get real aggressive. It's game on like Donkey Kong, so we are going to get super aggressive with that blood pressure.

    06:09 Now we're not giving oral meds, we're giving an IV infusion of antihypertensives. And we're monitoring that blood pressure every 5 minutes. Because you can imagine, we've got a problem. If you have a bleed in your head and your blood pressure is super high, you're just a fountain squirting inside your skull and nobody needs that.

    06:28 So, if you're that high, if you're > 220 mm Hg, we're going to give you IV infusion and be checking your blood pressure every 5 minutes trying to get your systolic blood pressure down to 140/60 mm Hg. Okay, so before we go on, I want you to make sure that you know those key numbers to give you a frame of reference of a general idea of how we treat blood pressure management.

    06:52 Now stop and think how is this different than an ischemic stroke? Compare the 2 sets of numbers so you have a good feel.

    07:02 Make sure, before we go on, that you pause the video and think through, hat kind of blood pressure would I maintain if I had someone who had an ischemic stroke? What kind of blood pressure would I want to maintain if someone had a hemorrhagic stroke? What's the rationale why I have a lower blood pressure in ischemic stroke? How does someone with an ischemic stroke rely on systemic blood pressure? Why do they need to? Okay. Those are just some pause and recall questions. Let's keep going.


    About the Lecture

    The lecture Blood Pressure Management – Stroke Nursing Care in ICU by Rhonda Lawes is from the course Neurology Case Study: Nursing Care of Stroke Patient.


    Included Quiz Questions

    1. Labetalol
    2. Nicardipine
    3. Clevidipine
    4. Mannitol
    5. Lasix
    1. 220/120 mm Hg if alteplase was not administered
    2. 180/105 mm Hg if alteplase was administered
    3. 180/105 mm Hg if alteplase was not administered
    4. 220/120 mm Hg if alteplase was administered
    5. 120/80 mm Hg is a goal blood pressure with or without alteplase administration.
    1. Because the perfusion pressure after the obstructed vessel is low, and an increased blood pressure will help increase pressure to perfuse this area for the brain
    2. Because the perfusion pressure after the obstructed vessel is high, and an increased blood pressure will help decrease pressure to perfuse this area for the brain
    3. Because the diffusion pressure after the obstructed vessel is high, and an increased blood pressure will help decrease pressure to diffuse this area for the brain
    4. Because the diffusion pressure after the obstructed vessel is low, and an increased blood pressure will help increase pressure to diffuse this area for the brain
    1. If the client's systolic blood pressure (SBP) is between 150 and 220 mm Hg, the target is to lower the SBP to 140 mm Hg or lower.
    2. If the client's systolic blood pressure (SBP) is greater than 220 mm Hg, the target is to lower the SBP to 140–160 mm Hg.
    3. If the client's systolic blood pressure (SBP) is between 150 and 220 mm Hg, the target is to lower the SBP to 140–160 mm Hg.
    4. If the client's systolic blood pressure (SBP) is greater than 220 mm Hg, the target is to lower the SBP to 140 mm Hg or lower.
    5. The target blood pressure for all acute hemorrhagic strokes is 120–80 mm Hg.

    Author of lecture Blood Pressure Management – Stroke Nursing Care in ICU

     Rhonda Lawes

    Rhonda Lawes


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