Question

1. What are the modifiable and non-modifiable risk factors for Stroke?
2. Describe the action, side effects and nursing implications for the medications Dilantin and Keppra.

Answer 1

Modifiable risk factors:-

1)Hypertension

Hypertension is the most important modifiable risk factor for stroke, with a strong, direct, linear, and continuous relationship between blood pressure and stroke risk.

2)Diabetes

It is an independent risk factor for stroke with a 2-fold increased risk in stroke for diabetic patients, and stroke accounts for approximately 20% of deaths in diabetics. Pre-diabetics are also at increased risk of stroke.

3)Atrial fibrillation and atrial cardiopathy

Atrial fibrillation (AF) has long been recognized to be a major risk factor for stroke, and this has only increased with the aging of the US population.

The association between AF and stroke has long been assumed to be due to stasis of blood in the fibrillating left atrium causing thrombus formation and embolization to the brain.

4)Dyslipidemia

The relationship between dyslipidemia and stroke risk is complex, with an increased risk for ischemic stroke with increased total cholesterol, and a decreased risk for ischemic stroke with elevated HDL cholesterol.

5)Physical inactivity

It is associated with many poor health effects, including stroke.

6)Diet

It influences the risk of stroke as well as the risk of other stroke risk factors such as diabetes, hypertension, and dyslipidemia.

7)Body weight and obesity

They are the risk factors for stroke, although the specific ways in which they increase stroke risk continue to be debated.

Obesity is related to stroke risk factors such as hypertension and diabetes.

8) Metabolic syndrome

The concept of Metabolic Syndrome incorporates obesity, dyslipidemia, pre-hypertension and pre-diabetes.

9)Alcohol consumption

Alcohol consumption has a more direct linear relationship with hemorrhagic stroke, such that consumption of even small amounts of alcohol appear to increase risk of hemorrhage. Heavy alcohol consumption is linked to hypertension, as well as poor blood pressure control in hypertensive patients who consume alcohol.

10)Abuse

Abuse of illicit substances, including cocaine, heroin, amphetamines, and ecstasy, is associated with an increased risk of ischemic and hemorrhagic subtypes of strokes.

11)Cigarette smoking

It remains a major risk factor for stroke, nearly doubling the risk with a dose response relationship between pack-years and stroke risk.

12) Inflammation and infection

Levels of inflammatory biomarkers have been associated with increased risk of stroke, just as they have been associated with risk of other cardiovascular diseases and all-cause mortality.

Non-modifiable risk factors:-

1)age

2)sex

3)race-ethnicity

4)genetics.

In general, stroke is a disease of aging. The incidence of stroke increases with age, with the incidence doubling for each decade after age 55.

At young ages, women have as high or higher risk of stroke as men, though at older ages, the relative risk is slightly higher for men.The higher stroke risk among women at younger ages likely reflects risks related to pregnancy and the post-partum state, as well as other hormonal factors, such as use of hormonal contraceptives.

African Americans are at twice the risk of incident stroke when compared to their white counterparts, and have higher mortality associated with stroke.

Genetic factors - with parental history and family history increasing the risk of stroke.

Dilantin and Keppra:-

Actions

Dilantin (phenytoin) and Keppra (levetiracetam) are anti-epileptic drugs used to control seizures.

Phenytoin is believed to protect against seizures by causing voltage-dependent block of voltage gated sodium channels. This blocks sustained high frequency repetitive firing of action potentials.

Dilantin (phenytoin) is an anti-epileptic drug, also called an anticonvulsant. It works by slowing down impulses in the brain that cause seizures.

Precisely how Keppra works to prevent seizures is not fully understood, but it is thought to possibly “calm the brain” by preventing nerve cells from becoming hyperactive and to do so without affecting normal electrical impulses.

Keppra is indicated as adjunctive therapy in the treatment of myoclonic seizures in adults and adolescents 12 years of age and older with juvenile myoclonic epilepsy.

Keppra is indicated as adjunctive therapy in the treatment of primary generalized tonic-clonic seizures in adults and children 6 years of age and older with idiopathic generalized epilepsy.

Side effects

serious side effects:-

• Liver problems.
• Low blood count which could increase your chance of getting infections, bruising, bleeding and increased fatigue.
• Osteopenia, osteoporosis, osteomalacia and fractures.
• Hyperglycemia
• High levels of DILANTIN in your blood that could cause confusion also known as delirium, psychosis or a more serious condition called encephalopathy.

most common side effects:-

• Irregular movement of the eye (nystagmus)
• Problems with movement and balance (ataxia)
• Slurred speech
• Decrease in coordination
• Drowsiness
• Confusion.

Nursing considerations

Assessment

• History: Hypersensitivity to hydantoins; sinus bradycardia, AV heart block, Stokes-Adams syndrome, acute intermittent porphyria, hypotension, severe myocardial insufficiency, diabetes mellitus, hyperglycemia, pregnancy, lactation.
• Physical: skin color, lesions; lymph node palpation; orientation, affect, reflexes, vision examination; BP; R, adventitious sounds; bowel sounds, normal output, liver evaluation; periodontal examination; LFTs, urinalysis, CBC and differential, blood proteins, blood and urine glucose, EEG and ECG

Interventions

• Use only clear parenteral solutions; a faint yellow color may develop, but this has no effect on potency. If the solution is refrigerated or frozen, a precipitate might form, but this will dissolve if the solution is allowed to stand at room temperature.
• WARNING: Administer IV slowly to prevent severe hypotension; the margin of safety between full therapeutic and toxic doses is small. Continually monitor patient’s cardiac rhythm and check BP frequently and regularly during IV infusion.
• Monitor injection sites carefully; drug solutions are very alkaline and irritating.
• WARNING: Monitor for therapeutic serum levels of 10–20 mcg/mL.
• Give oral drug with or without food in a consistent manner. Give with food if patient complains of GI upset.
• Recommend that the oral phenytoin prescription be filled with the same brand each time; differences in bioavailability have been documented.
• Suggest that adult patients who are controlled with 300-mg extended phenytoin capsules try once-a-day dosage to increase compliance and convenience.
• WARNING: Reduce dosage, discontinue phenytoin, or substitute other antiepileptic medication gradually; abrupt discontinuation may precipitate status epilepticus.
• Phenytoin is ineffective in controlling absence seizures.
• WARNING: Discontinue drug if rash, depression of blood count, enlarged lymph nodes, hypersensitivity reaction, signs of liver damage, or Peyronie’s disease .
• Monitor hepatic function periodically during long-term therapy; monitor blood counts and urinalysis monthly.
• Monitor blood or urine sugar of patients with diabetes mellitus regularly. Adjustment of dosage of hypoglycemic drug may be needed because antiepileptic may inhibit insulin release and induce hyperglycemia
• Monitor blood proteins to detect early malfunction of the immune system (eg, multiple myeloma).
• Arrange instruction in proper oral hygiene technique for long-term patients to prevent development of gum hyperplasia.

Teaching points

• Take this drug exactly as prescribed, with food to reduce GI upset, or without food—but maintain consistency in the manner in which you take it. Be especially careful not to miss a dose if you are on once-a-day therapy.
• Do not discontinue this drug abruptly or change dosage, except on the advice of your health care provider.
• Maintain good oral hygiene (regular brushing and flossing) to prevent gum disease; arrange frequent dental checkups to prevent serious gum disease.
• Arrange for frequent checkups to monitor your response to this drug.
• Monitor your blood or urine sugar regularly, and report any abnormality to your health care provider if you have diabetes.
• This drug is not recommended for use during pregnancy. It is advisable to use some form of contraception other than hormonal contraceptives.
• Wear a medical alert tag so that any emergency medical personnel will know that you have epilepsy and are taking antiepileptic medication.
• You may experience these side effects: Drowsiness, dizziness, confusion, blurred vision (avoid driving or performing other tasks requiring alertness or visual acuity; alcohol may intensify these effects); GI upset (take drug with food, eat frequent small meals).
• Report rash, severe nausea or vomiting, drowsiness, slurred speech, impaired coordination (ataxia), swollen glands, bleeding, swollen or tender gums, yellowish discoloration of the skin or eyes, joint pain, unexplained fever, sore throat, unusual bleeding or bruising, persistent headache, malaise, any indication of an infection or bleeding tendency, abnormal erection, pregnancy.