Cerebrovascular Accident Nursing Care Plan

 

Nursing Diagnosis
  • Ineffective Cerebral Tissue Perfusion

May be related to

  • Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vaso­spasm, cerebral edema

Possibly evidenced by

  • Altered level of consciousness; memory loss
  • Changes in motor/sensory responses; restlessness
  • Sensory, language, intellectual, and emotional deficits
  • Changes in vital signs
Desired Outcomes
  • Maintain usual/improved level of consciousness, cognition, and motor/sensory function.
  • Demonstrate stable vital signs and absence of signs of increased ICP.
  • Display no further deterioration/recurrence of deficits
Nursing Interventions
  • Assess factors related to individual situation for decreased cerebral perfusion and potential for increased ICP.
    • Rationale: Assessment will determine and influence the choice of interventions. Deterioration in neurological signs or failure to improve after initial insult may reflect decreased intracranial adaptive capacity requiring patient to be transferred to critical area for monitoring of ICP, other therapies. If the stroke is evolving, patient can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence.
  • Closely assess and monitor neurological status frequently and compare with baseline.
    • Rationale: Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression of damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA.

Monitor vital signs: 

  • changes in blood pressure, compare BP readings in both arms.
    • Rationale: Fluctuations in pressure may occur because of cerebral injury in vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse). Increased ICPmay occur because of tissue edema or clot formation. Subclavian artery blockage may be revealed by difference in pressure readings between arms.
  • Heart rate and rhythm, assess for murmurs.
    • Rationale: Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (stroke after MI or from valve dysfunction).
  • Respirations, noting patterns and rhythm (periods of apnea after hyperventilation), Cheyne-Stokes respiration.
    • Rationale: Irregularities can suggest location of cerebral insult or increasing ICP and need for further intervention, including possible respiratory support.
  • Evaluate pupils, noting size, shape, equality, light reactivity.
    • Rationale: Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined by balance between parasympathetic and sympathetic innervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves.
  • Document changes in vision: reports of blurred vision, alterations in visual field, depth perception.
    • Rationale: Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions.
  • Assess higher functions, including speech, if patient is alert.
    • Rationale: Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate deterioration or increased ICP.
  • Position with head slightly elevated and in neutral position.
    • Rationale: Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion.
  • Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit duration of procedures.
    • Rationale: Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage.
  • Prevent straining at stool, holding breath.
    • Rationale: Valsalva maneuver increases ICP and potentiates risk of rebleeding.
  • Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity.
    • Rationale: Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may reflect increased ICP or cerebral injury, requiring further evaluation and intervention.
  • Administer supplemental oxygen as indicated.
    • Rationale: Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema formation.

Administer medications as indicated: 

  • Alteplase (Activase), t-PA;
    • Rationale: Thrombolytic agents are useful in dissolving clot when started within 3 hr of initial symptoms. Thirty percent are likely to recover with little or no disability. Treatment is based on trying to limit the size of the infarct, and use requires close monitoring for signs of intracranial hemorrhage. Note: These agents are contraindicated in cranial hemorrhage as diagnosed by CT scan.
  • Anticoagulants: warfarin sodium (Coumadin), low-molecular-weight heparin (Lovenox);
    • Rationale: May be used to improve cerebral blood flow and prevent further clotting when embolism and/or thrombosis is the problem.
  • Antiplatelet agents:  aspirin (ASA), dipyridamole (Persantine), ticlopidine (Ticlid);
    • Rationale: Contraindicated in hypertensive patients because of increased risk of hemorrhage.
  • Antifibrinolytics: aminocaproic acid (Amicar);
    • Rationale: Used with caution in hemorrhagic disorder to prevent lysis of formed clots and subsequent rebleeding.
  • Antihypertensives
    • Rationale: Chronic hypertension requires cautious treatment because aggressive management increases the risk of extension of tissue damage.
  • Peripheral vasodilators: cyclandelate (Cyclospasmol), papaverine (Pavabid), isoxsuprine (Vasodilan).
    • Rationale: Transient hypertension often occurs during acute stroke and resolves often without therapeutic intervention.Used to improve collateral circulation or decrease vasospasm.
  • Steroids: dexamethasone (Decadron).
    • Rationale: Use is controversial in control of cerebral edema.
  • Neuroprotective agents: calcium channel blockers, excitatory amino acid inhibitors, gangliosides.
    • Rationale: These agents are being researched as a means to protect the brain by interrupting the destructive cascade of biochemical events (influx of calcium into cells, release of excitatory neurotransmitters, buildup of lactic acid) to limit ischemic injury.
  • Phenytoin (Dilantin), phenobarbital.
    • Rationale: May be used to control seizures and/or for sedative action. Note: Phenobarbital enhances action of antiepileptics.
  • Stool softeners.
    • Rationale: Prevents straining during bowel movement and corresponding increase of ICP.
  • Prepare for surgery, as appropriate: endarterectomy, microvascular bypass, cerebral angioplasty.
    • Rationale: May be necessary to resolve situation, reduce neurological symptoms of recurrent stroke.
  • Monitor laboratory studies as indicated:  prothrombin time (PT) and/or activated partial thromboplastin time (aPTT) time, Dilantin level.
    • Rationale: Provides information about drug effectiveness and/or therapeutic level.
Nursing Diagnosis
  • Impaired Physical Mobility

May be related to

  • Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic paralysis
  • Perceptual/cognitive impairment

Possibly evidenced by

  • Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength/control
Desired Outcomes
  • Maintain/increase strength and function of affected or compensatory body part.
  • Maintain optimal position of function as evidenced by absence of contractures, foot drop.
  • Demonstrate techniques/behaviors that enable resumption of activities.
  • Maintain skin integrity.
Nursing Interventions
  • Assess extent of impairment initially and on a regular basis. Classify according to 0–4 scale.
    • Rationale: Identifies strengths and deficiencies that may provide information regarding recovery. Assists in choice of interventions, because different techniques are used for flaccid and spastic paralysis.
  • Change positions at least every 2 hr (supine, side lying) and possibly more often if placed on affected side.
    • Rationale: Reduces risk of tissue injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown.
  • Position in prone position once or twice a day if patient can tolerate.
    • Rationale: Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe.
  • Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head.
    • Rationale: Prevents contractures and footdrop and facilitates use when function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side.
  • Use arm sling when patient is in upright position, as indicated.
    • Rationale: During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and shoulder-hand syndrome.
  • Evaluate need for positional aids and/or splints during spastic paralysis:
    • Rationale: Flexion contractures occur because flexor muscles are stronger than extensors.
  • Place pillow under axilla to abduct arm
    • Rationale: Prevents adduction of shoulder and flexion of elbow.
  • Elevate arm and hand
    • Rationale: Promotes venous return and helps prevent edema formation.
  • Place hard hand-rolls in the palm with fingers and thumb opposed.
    • Rationale: Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in a functional position.
  • Place knee and hop in extended position;
    • Rationale: Maintains functional position.
  • Maintain leg in neutral position with a trochanter roll;
    • Rationale: Prevents external hip rotation.
  • Discontinue use of footboard, when appropriate.
    • Rationale: Continued use (after change from flaccid to spastic paralysis) can cause excessive pressure on the ball of the foot, enhance spasticity, and actually increase plantar flexion.
  • Observe affected side for color, edema, or other signs of compromised circulation.
    • Rationale: Edematous tissue is more easily traumatized and heals more slowly.
  • Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary.
    • Rationale: Pressure points over bony prominences are most at risk for decreased perfusion. Circulatory stimulation and padding help prevent skin breakdown and decubitus development.
  • Begin active or passive ROM to all extremities (including splinted) on admission. Encourage exercises such as quadriceps/gluteal exercise, squeezing rubber ball, extension of fingers and legs/feet.
    • Rationale: Minimizes muscle atrophy, promotes circulation, helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. Note: Excessive stimulation can predispose to rebleeding.
  • Assist patient with exercise and perform ROM exercises for both the affected and unaffected sides. Teach and encourage patient to use his unaffected side to exercise his affected side.
  • Assist patient to develop sitting balance by raising head of bed, assist to sit on edge of bed, having patient to use the strong arm to support body weight and move using the strong leg. Assist to develop standing balance by putting flat walking shoes, support patient’s lower back with hands while positioning own knees outside patient’s knees, assist in using parallel bars.
    • Rationale:Aids in retraining neuronal pathways, enhancing proprioception and motor response.
  • Get patient up in chair as soon as vital signs are stable, except following cerebral hemorrhage.
    • Rationale:Helps stabilize BP (by restoring vasomotor tone), promotes maintenance of extremities in a functional position and emptying of bladder, reducing risk of urinary stones and infections from stasis. Note: If stroke is not completed, activity increases risk of additional bleed.
  • Pad chair seat with foam or water-filled cushion, and assist patient to shift weight at frequent intervals.
    • Rationale: To prevent pressure on the coccyx and skin breakdown.
  • Set goals with patient and SO for participation in activities and position changes.
    • Rationale: Promotes sense of expectation of improvement, and provides some sense of control and independence.
  • Encourage patient to assist with movement and exercises using unaffected extremity to support and move weaker side.
    • Rationale: May respond as if affected side is no longer part of body and needs encouragement and active training to “reincorporate” it as a part of own body.
  • Provide egg-crate mattress, water bed, flotation device, or specialized beds, as indicated.
    • Rationale: Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown and decubitus formation. Specialized beds help with positioning, enhance circulation, and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia.
  • Position the patient and align his extremities correctly. Use high-top sneakers to prevent footdrop and contracture and convoluted foam, flotation, or pulsating mattresses or sheepskin.
    • Rationale: These are measures to prevent pressure ulcers.
Nursing Diagnosis
  • Communication, impaired verbal [and/or written]

May be related to

  • Impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle tone/control; generalized weakness/fatigue

Possibly evidenced by

  • Impaired articulation; does not/cannot speak (dysarthria)
  • Inability to modulate speech, find and name words, identify objects; inability to comprehend written/spoken language
  • Inability to produce written communication
Desired Outcomes
  • Indicate an understanding of the communication problems.
  • Establish method of communication in which needs can be expressed.
  • Use resources appropriately.
Nursing Interventions
  • Assess extent of dysfunction: patient cannot understand words or has trouble speaking or making self understood. Differentiate aphasia from dysarthria.
    • Rationale: Helps determine area and degree of brain involvement and difficulty patient has with any or all steps of the communication process. Patient may have receptive aphasia or damage to the Wernicke’s speech area which is characterized by difficulty of understanding spoken words. He may also have expressive aphasia or damage to the Broca’s speech areas, which is difficulty in speaking words correctly, or may experience both. Choice of interventions depends on type of impairment. Aphasia is a defect in using and interpreting symbols of language and may involve sensory and/or motor components (inability to comprehend written and/or spoken words or to write, make signs, speak). A dysarthric person can understand, read, and write language but has difficulty forming and pronouncing words because of weakness and paralysis of oral musculature. Patient may lose ability to monitor verbal output and be unaware that communication is not sensible.
  • Listen for errors in conversation and provide feedback.
    • Rationale: Feedback helps patient realize why caregivers are not understanding or responding appropriately and provides opportunity to clarify meaning.
  • Ask patient to follow simple commands (“Close and open your eyes,” “Raise your hand”); repeat simple words or sentences;
    • Rationale: Tests for receptive aphasia.
  • Point to objects and ask patient to name them.
    • Rationale: Tests for expressive aphasia. Patient may recognize item but not be able to name it.
  • Have patient produce simple sounds (“Dog,” “meow,” “Shh”).
    • Rationale: Identifies dysarthria, because motor components of speech (tongue, lip movement, breath control) can affect articulation and may or may not be accompanied by expressive aphasia.
  • Ask patient to write his name and a short sentence. If unable to write, have patient read a short sentence.
    • Rationale: Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia.
  • Write a notice at the nurses’ station and patient’s room about speech impairment. Provide a special call bell that can be activated by minimal pressure if necessary.
    • Rationale: Allays anxiety related to inability to communicate and fear that needs will not be met promptly.
  • Provide alternative methods of communication: writing, pictures.
    • Rationale: Provides communication needs of patient based on individual situation and underlying deficit.
  • Anticipate and provide for patient’s needs.
    • Rationale: Helpful in decreasing frustration when dependent on others and unable to communication desires.
  • Talk directly to patient, speaking slowly and distinctly. Phrase questions to be answered simply by yes or no. Progress in complexity as patient responds.
    • Rationale: Reduces confusion and allays anxiety at having to process and respond to large amount of information at one time. As retraining progresses, advancing complexity of communication stimulates memory and further enhances word and idea association.
  • Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Avoid pressing for a response.
    • Rationale: Patient is not necessarily hearing impaired, and raising voice may irritate or anger patient. Forcing responses can result in frustration and may cause patient to resort to “automatic” speech (garbled speech, obscenities).
  • Encourage SO/visitors to persist in efforts to communicate with patient: reading mail, discussing family happenings even if patient is unable to respond appropriately.
    • Rationale: It is important for family members to continue talking to patient to reduce patient’s isolation, promote establishment of effective communication, and maintain sense of connectedness with family.
  • Discuss familiar topics, e.g., weather, family, hobbies, jobs.
    • Rationale: Promotes meaningful conversation and provides opportunity to practice skills.
  • Respect patient’s preinjury capabilities; avoid “speaking down” to patient or making patronizing remarks.
    • Rationale: Enables patient to feel esteemed, because intellectual abilities often remain intact.
  • Consult and refer patient to speech therapist.
    • Rationale: Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits/therapy needs.
Nursing Diagnosis
  • Disturbed Sensory Perception

May be related to

  • Altered sensory reception, transmission, integration (neurological trauma or deficit)
  • Psychological stress (narrowed perceptual fields caused by anxiety)

Possibly evidenced by

  • Disorientation to time, place, person
  • Change in behavior pattern/usual response to stimuli; exaggerated emotional responses
  • Poor concentration, altered thought processes/bizarre thinking
  • Reported/measured change in sensory acuity: hypoparesthesia; altered sense of taste/smell
  • Inability to tell position of body parts (proprioception)
  • Inability to recognize/attach meaning to objects (visual agnosia)
  • Altered communication patterns
  • Motor incoordination
Desired Outcomes
  • Regain/maintain usual level of consciousness and perceptual functioning.
  • Acknowledge changes in ability and presence of residual involvement.
  • Demonstrate behaviors to compensate for/overcome deficits.
Nursing Interventions
  • Review pathology of individual condition.
    • Rationale: Awareness on the type and areas of involvement aid in assessing specific deficit and planning of care.
  • Observe behavioral responses: crying, inappropriate affect, agitation, hostility, agitation, hallucination.
    • Rationale: Individual responses are variable, but commonalities such as emotional lability, lowered frustration threshold, apathy, and impulsiveness may complicate care.
  • Establish and maintain communication with the patient. Set up a simple method of communicating basic needs. Remember to phrase your questions so he’ll be able to answer using this system. Repeat yourself quietly and calmly and use gestures when necessary to help in understanding.
    • Rationale: Note: even an unresponsive patient may be able to hear, so don’t say anything in his presence you wouldn’t want him to hear and remember.
  • Eliminate extraneous noise and stimuli as necessary.
    • Rationale: Reduces anxiety and exaggerated emotional responses and confusion associated with sensory overload.
  • Speak in calm, comforting, quiet voice, using short sentences. Maintain eye contact.
    • Rationale: Patient may have limited attention span or problems with comprehension. These measures can help patient attend to communication.
  • Ascertain patient’s perceptions. Reorient patient frequently to environment, staff, procedures.
    • Rationale: Assists patient to identify inconsistencies in reception and integration of stimuli and may reduce perceptual distortion of reality.
  • Evaluate for visual deficits. Note loss of visual field, changes in depth perception (horizontal and/or vertical planes), presence of diplopia (double vision).
    • Rationale: Presence of visual disorders can negatively affect patient’s ability to perceive environment and relearn motor skills and increases risk of accident and injury.
  • Approach patient from visually intact side. Leave light on; position objects to take advantage of intact visual fields. Patch affected eye if indicated.
    • Rationale: Helps the patient to recognize the presence of persons or objects and may help with depth perception problems. This also prevents patient from being startled. Patching the eye may decrease sensory confusion of double vision.
  • Assess sensory awareness: dull from sharp, hot from cold, position of body parts, joint sense.
    • Rationale: Diminished sensory awareness and impairment of kinesthetic sense negatively affects balance and positioning and appropriateness of movement, which interferes with ambulation, increasing risk of trauma.
  • Stimulate sense of touch. Give patient objects to touch, and hold. Have patient practice touching walls boundaries.
    • Rationale: Aids in retraining sensory pathways to integrate reception and interpretation of stimuli. Helps patient orient self spatially and strengthens use of affected side.
  • Protect from temperature extremes; assess environment for hazards. Recommend testing warm water with unaffected hand.
    • Rationale: Promotes patient safety, reducing risk of injury.
  • Note inattention to body parts, segments of environment, lack of recognition of familiar objects/persons.
    • Rationale: Agnosia, the loss of comprehension of auditory, visual, or other sensations, may lead result to unilateral neglect, inability to recognize environmental cues, considerable self-care deficits, and disorientation or bizarre behavior.
  • Encourage patient to watch feet when appropriate and consciously position body parts. Make patient aware of all neglected body parts: sensory stimulation to affected side, exercises that bring affected side across midline, reminding person to dress/care for affected (“blind”) side.
    • Rationale: Use of visual and tactile stimuli assists in reintegration of affected side and allows patient to experience forgotten sensations of normal movement patterns.