Cerebrovascular Accident Nursing Care Plan Notes

Definition

A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a sudden loss of brain function resulting from Cerebral Vascular Accident (Ischemic Stroke) a disruption of the blood supply to a part of the brain.

Description

Stroke is the primary cerebrovascular disorder in the United States.
Strokes are usually hemorrhagic (15%) or ischemic/nonhemorrhagic (85%).
Ischemic strokes are categorized according to their cause: large artery thrombotic strokes (20%), small penetrating artery thrombotic strokes (25%), cardiogenic embolic strokes (20%), cryptogenic strokes (30%), and other (5%).
Cryptogenic strokes have no known cause, and other strokes result from causes such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.
The result is an interruption in the blood supply to the brain, causing temporary or permanent loss of movement, thought, memory, speech, or sensation.

Risk Factors

Nonmodifable

Advanced age (older than 55 years)
Gender (Male)
Race (African American)

Modifable

Hypertension
Atrial ﬁbrillation
Hyperlipidemia
Obesity
Smoking
Diabetes
Asymptomatic carotid stenosis and valvular heart disease (eg, endocarditis, prosthetic heart valves)
Periodontal disease

Pathophysiology

Clinical Manifestations

General signs and symptoms include numbness or weakness of face, arm, or leg (especially on one side of body); confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; loss of balance, dizziness, difﬁculty walking; or sudden severe headache.

Motor Loss

Hemiplegia, hemiparesis
Flaccid paralysis and loss of or decrease in the deep tendon reﬂexes (initial clinical feature) followed by (after 48 hours) reappearance of deep reﬂexes and abnormally increased muscle tone (spasticity)

Communication Loss

Dysarthria (difﬁculty speaking)
Dysphasia (impaired speech) or aphasia (loss of speech)
Apraxia (inability to perform a previously learned action)

Perceptual Disturbances and Sensory Loss

Visualperceptual dysfunctions (homonymous hemianopia [loss of half of the visual ﬁeld])
Disturbances in visualspatial relations (perceiving the relation of two or more objects in spatial areas), frequently seen in patients with right hemispheric damage
Sensory losses: slight impairment of touch or more severe with loss of proprioception; difﬁculty in interrupting visual, tactile, and auditory stimuli

Impaired Cognitive and Psychological Effects

Frontal lobe damage: Learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reﬂected in a limited attention span, difﬁculties in comprehension, forgetfulness, and lack of motivation.
Depression, other psychological problems: emotional lability, hostility, frustration, resentment, and lack of cooperation.

Assessment and Diagnostic Methods

History and complete physical and neurologic examination
Noncontrast CT scan
12lead ECG and carotid ultrasound
CT angiography or MRI and angiography
Transcranial Doppler ﬂow studies
Transthoracic or transesophageal echocardiography
Xenonenhanced CT scan
Single photon emission CT (SPECT) scan

Prevention

Help patients alter risk factors for stroke; encourage patient to quit smoking, maintain a healthy weight, follow a healthy diet (including modest alcohol consumption), and exercise daily.
Prepare and support patient through carotid endarterectomy.
Administer anticoagulant agents as prescribed (eg, lowdose aspirin therapy).

Medical Management

Recombinant tissue plasminogen activator (tPA), unless contraindicated; monitor for bleeding
Anticoagulation therapy
Management of increased intracranial pressure (ICP): osmotic diuretics, maintain PaCO2 at 30 to 35 mm Hg, position to avoid hypoxia (elevate the head of bed to promote venous drainage and to lower increased ICP)
Possible hemicraniectomy for increased ICP from brain edema in a very large stroke
Intubation with an endotracheal tube to establish a patent airway, if necessary
Continuous hemodynamic monitoring (the goals for blood pressure remain controversial for a patient who has not received thrombolytic therapy; antihypertensive treatment may be withheld unless the systolic blood pressure exceeds mm Hg or the diastolic blood pressure exceeds 120 mm Hg)
Neurologic assessment to determine if the stroke is evolving and if other acute complications are developing

Management of Complications

Decreased cerebral blood ﬂow: Pulmonary care, maintenance of a patent airway, and administration of supplemental oxygen as needed.
Monitor for UTIs, cardiac dysrhythmias, and complications of immobility.

Nursing Assessment

During Acute Phase (1 to 3 days)

Weigh patient (used to determine medication dosages), and maintain a neurologic ﬂow sheet to reﬂect the following nursing assessment parameters:

Change in level of consciousness or responsiveness, ability to speak, and orientation
Presence or absence of voluntary or involuntary movements of the extremities: muscle tone, body posture, and head position
Stiffness or ﬂaccidity of the neck
Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position
Color of face and extremities; temperature and moisture of skin
Quality and rates of pulse and respiration; ABGs, body temperature, and arterial pressure
Volume of ﬂuids ingested or administered and volume of urine excreted per 24 hours
Signs of bleeding
Blood pressure maintained within normal limits

Postacute Phase

Assess the following functions:

Mental status (memory, attention span, perception, orientation, affect, speech/language).
Sensation and perception (usually the patient has decreased awareness of pain and temperature).
Motor control (upper and lower extremity movement); swallowing ability, nutritional and hydration status, skin integrity, activity tolerance, and bowel and bladder function.
Continue focusing nursing assessment on impairment of function in patient’s daily activities.

Diagnosis

Nursing Diagnoses

Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
Acute pain related to hemiplegia and disuse
Deﬁcient selfcare (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke sequelae
Disturbed sensory perception (kinesthetic, tactile, or visual) related to altered sensory reception, transmission, and/or integration
Impaired swallowing
Impaired urinary elimination related to ﬂaccid bladder, detrusor instability, confusion, or difﬁculty in communicating
Disturbed thought processes related to brain damage
Impaired verbal communication related to brain damage
Risk for impaired skin integrity related to hemiparesis or hemiplegia, decreased mobility
Interrupted family processes related to catastrophic illness and caregiving burdens
Sexual dysfunction related to neurologic deﬁcits or fear of failure

Collaborative Problems/Potential Complications

Decreased cerebral blood ﬂow due to increased ICP; inadequate oxygen delivery to the brain; pneumonia.

Planning and Goals

The major goals for the patient (and family) may include improved mobility, avoidance of shoulder pain, achievement of selfcare, relief of sensory and perceptual deprivation, prevention of aspiration, continence of bowel and bladder, improved thought processes, achieving a form of communication, maintaining skin integrity, restored family functioning, improved sexual function, and absence of complications. Goals are affected by knowledge of what the patient was like before the stroke.

Nursing Interventions

Improving Mobility and Preventing Deformities

Position to prevent contractures; use measures to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies.
Apply a splint at night to prevent ﬂexion of affected extremity.
Prevent adduction of the affected shoulder with a pillow placed in the axilla.
Elevate affected arm to prevent edema and ﬁbrosis.
Position ﬁngers so that they are barely ﬂexed; place hand in slight supination. If upper extremity spasticity is noted, do not use a hand roll; dorsal wrist splint may be used.
Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times a day.

Establishing an Exercise Program

Provide full range of motion four or ﬁve times a day to maintain joint mobility, regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. If tightness occurs in any area, perform rangeofmotion exercises more frequently.
Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.
Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (eg, shortness of breath, chest pain, cyanosis, and increasing pulse rate).
Supervise and support patient during exercises; plan frequent short periods of exercise, not longer periods; encourage patient to exercise unaffected side at intervals throughout the day.

Preparing for Ambulation

Start an active rehabilitation program when consciousness returns (and all evidence of bleeding is gone, when indicated).
Teach patient to maintain balance in a sitting position, then to balance while standing (use a tilt table if needed).
Begin walking as soon as standing balance is achieved (use parallel bars and have wheelchair available in anticipation of possible dizziness).
Keep training periods for ambulation short and frequent.

NURSING ALERT: Initiate a full rehabilitation program even for elderly patients.

Preventing Shoulder Pain

Never lift patient by the ﬂaccid shoulder or pull on the affected arm or shoulder.
Use proper patient movement and positioning (eg, ﬂaccid arm on a table or pillows when patient is seated, use of sling when ambulating).
Rangeofmotion exercises are beneﬁcial, but avoid overstrenuous arm movements.
Elevate arm and hand to prevent dependent edema of the hand; administer analgesic agents as indicated.

Enhancing Self Care

Encourage personal hygiene activities as soon as the patient can sit up; select suitable selfcare activities that can be carried out with one hand.
Help patient to set realistic goals; add a new task daily.
As a ﬁrst step, encourage patient to carry out all selfcare activities on the unaffected side.
Make sure patient does not neglect affected side; provide assistive devices as indicated.
Improve morale by making sure patient is fully dressed during ambulatory activities.
Assist with dressing activities (eg, clothing with Velcro closures; put garment on the affected side ﬁrst); keep environment uncluttered and organized.
Provide emotional support and encouragement to prevent fatigue and discouragement.

Managing Sensory Perceptual Difﬁculties

Approach patient with a decreased ﬁeld of vision on the side where visual perception is intact; place all visual stimuli on this side.
Teach patient to turn and look in the direction of the defective visual ﬁeld to compensate for the loss; make eye contact with patient, and draw attention to affected side.
Increase natural or artiﬁcial lighting in the room; provide eyeglasses to improve vision.
Remind patient with hemianopsia of the other side of the body; place extremities so that patient can see them.

Assisting with Nutrition

Observe patient for paroxysms of coughing, food dribbling out or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids.
Consult with speech therapist to evaluate gag reﬂexes; assist in teaching alternate swallowing techniques, advise patient to take smaller boluses of food, and inform patient of foods that are easier to swallow; provide thicker liquids or pureed diet as indicated.
Have patient sit upright, preferably on chair, when eating and drinking; advance diet as tolerated.
Prepare for GI feedings through a tube if indicated; elevate the head of bed during feedings, check tube position before feeding, administer feeding slowly, and ensure that cuff of tracheostomy tube is inﬂated (if applicable); monitor and report excessive retained or residual feeding.

Attaining Bowel and Bladder Control

Perform intermittent sterile catheterization during period of loss of sphincter control.
Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
Assist the male patient to an upright posture for voiding.
Provide highﬁber diet and adequate ﬂuid intake (2 to 3 L/day), unless contraindicated.
Establish a regular time (after breakfast) for toileting.

Improving Thought Processes

Reinforce structured training program using cognitiveperceptual retraining, visual imagery, reality orientation, and cueing procedures to compensate for losses.
Support patient: Observe performance and progress, give positive feedback, convey an attitude of conﬁdence and hopefulness; provide other interventions as used for improving cognitive function after a head injury.

Improving Communication

Reinforce the individually tailored program.
Jointly establish goals, with patient taking an active part.
Make the atmosphere conducive to communication, remaining sensitive to patient’s reactions and needs and responding to them in an appropriate manner; treat patient as an adult.
Provide strong emotional support and understanding to allay anxiety; avoid completing patient’s sentences.
Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes may help with memory and concentration; a communication board may be used.
Maintain patient’s attention when talking with patient, speak slowly, and give one instruction at a time; allow patient time to process.
Talk to aphasic patients when providing care activities to provide social contact.

Maintaining Skin Integrity

Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.
Employ pressurerelieving devices; continue regular turning and positioning (every 2 hours minimally); minimize shear and friction when positioning.
Keep skin clean and dry, gently massage healthy dry skin, and maintain adequate nutrition.

Improving Family Coping

Provide counseling and support to family.
Involve others in patient’s care; teach stress management techniques and maintenance of personal health for family coping.
Give family information about the expected outcome of the stroke, and counsel them to avoid doing things for patient that he or she can do.
Develop attainable goals for patient at home by involving the total health care team, patient, and family.
Encourage everyone to approach patient with a supportive and optimistic attitude, focusing on abilities that remain; explain to family that emotional lability usually improveswith time.

Helping the Patient Cope with Sexual Dysfunction

Perform indepth assessment to determine sexual history before and after the stroke.
Interventions for patient and partner focus on providing relevant information, education, reassurance, adjustment
of medications, counseling regarding coping skills, suggestions for alternative sexual positions, and a means of sexual expression and satisfaction.

Teaching Points

Teach patients about the “act FAST” Campaign
Teach patient to resume as much selfcare as possible; provide assistive devices as indicated.
Have occupational therapist make a home assessment and recommendations to help patient become more independent.
Coordinate care provided by numerous health care professionals; help family plan aspects of care.
Advise family that patient may tire easily, become irritable and upset by small events, and show less interest in daily events.
Make referral for home speech therapy. Encourage family involvement. Provide family with practical instructions to help patient between speech therapy sessions.
Discuss patient’s depression with physician for possible antidepressant therapy.
Encourage patient to attend communitybased stroke clubs to give a feeling of belonging and fellowship with others.
Encourage patient to continue with hobbies, recreational and leisure interests, and contact with friends to prevent social isolation.
Encourage family to support patient and give positive reinforcement.
Remind spouse and family to attend to personal health and wellbeing.

Evaluation

Expected Patient Outcomes

Achieves improved mobility.
Has no complaints of pain.
Achieves selfcare; performs hygiene care; uses adaptive equipment.
Demonstrates techniques to compensate for altered sensory reception, such as turning the head to see people or objects.
Demonstrates safe swallowing.
Achieves normal bowel and bladder elimination.
Participates in cognitive improvement program.
Demonstrates improved communication.
Maintains intact skin without breakdown.
Family members demonstrate a positive attitude and coping mechanisms.
Develops alternative approaches to sexual expression.