A cerebrovascular accident (CVA) more commonly known as a stroke, occurs when blood flow to the brain is blocked. There are two main types of strokes: ischemic and hemorrhagic.
Ischemic strokes are caused by a blockage, usually, a clot that blocks blood flow to the brain. Hemorrhagic strokes are sudden bleeding in the brain such as when an artery bursts. This can be caused by an aneurysm, high blood pressure, or trauma.
Transient ischemic attacks (TIA) which may be referred to as “mini-strokes” are blockages in the brain that resolve before lasting damage occurs. A history of TIAs can increase the risk of a stroke in the future.
The Nursing Process
Stroke patients often require monitoring by nurses who are NIHSS certified and in higher care settings such as the ICU or step-down units. This is because stroke symptoms can change rapidly and subtly and require critical thinking and prompt intervention to prevent deterioration.
Depending on the severity, strokes can leave the patient disabled requiring total care in feeding, bathing, and turning. Long-term deficits can be debilitating and cause depression for the client and their family. The nurse utilizes compassionate care and alternative communication techniques to keep the patient safe while managing their physical and psychosocial needs.
Nursing Care Plans Related to Cerebrovascular Accident (CVA) or Stroke
Ineffective Cerebral Tissue Perfusion Care Plan
When blood is blocked from the brain it does not receive necessary oxygen. If blood flow is not restored promptly this will result in tissue death.
Nursing Diagnosis: Ineffective Tissue Perfusion
- Interruption of blood flow to the brain
- Thrombus formation
- Artery occlusion
- Cerebral edema
As evidenced by:
- Altered mental status
- Blurred vision
- Slurred speech
- Extremity weakness
- Patient will recognize symptoms of a stroke and seek immediate medical attention
- Patient will display improved cerebral perfusion as evidenced by vital signs within ordered parameters
- Patient will display improvement in stroke deficits such as slurred speech, weakness, and swallowing ability by discharge
Ineffective Cerebral Tissue Perfusion Assessment
1. Determine baseline presentation.
When assessing for a possible stroke it is vital to know the last time the client was “well” or at their baseline level of functioning before exhibiting symptoms. Certain interventions (thrombolytics) can only be administered within a 4-hour timeframe of when symptoms started. The nurse can also use this information when performing follow-up assessments to determine improvement or deterioration.
2. Perform neurological assessments.
The nurse will perform stroke scale assessments as directed by their facility. These frequent assessments monitor LOC, visual changes, facial movement, motor coordination, sensory changes, and speech or language deficits.
3. Obtain a CT scan or MRI of the brain.
These are the most important diagnostic tests to confirm or rule out a stroke. They also show whether a stroke is hemorrhagic or ischemic which will further determine treatment.
Ineffective Cerebral Tissue Perfusion Interventions
1. Maintain blood pressure.
To maintain cerebral perfusion, blood pressure is kept elevated. For ischemic strokes, the blood pressure may be allowed as high as 220 systolic (unless receiving thrombolytic therapy) and no lower than 140 systolic for a hemorrhagic stroke. Specific parameters will be ordered by the provider.
2. Administer thrombolytics.
Thrombolytics are administered to dissolve clots in an ischemic stroke. They should never be administered for a hemorrhagic stroke as this will cause fatal bleeding. Also, thrombolytics must be administered within 4 hours of the development of stroke symptoms to be effective.
3. Educate on risk factors of strokes.
If the patient only experiences a TIA or does not suffer long-term deficits from a stroke, prevention of a future stroke should be communicated. Risk factors include hypertension, heart disease, diabetes, smoking, and stress. These are modifiable risk factors that the patient can work towards changing through diet, exercise, and lifestyle behaviors.
4. Instruct on symptoms of a stroke using FAST.
“Time is tissue” in the instance of a stroke. The sooner symptoms are recognized, the quicker the treatment, and less sustained damage to brain tissue. Patients and family members should be instructed on the acronym F.A.S.T which stands for Facial drooping, Arm weakness, Speech difficulty, and Time (call 911).
Impaired Verbal Communication Care Plan
Cerebrovascular accidents often result in deficits in communication. Patients may struggle with comprehending or expressing speech as well as a physical inability to produce meaningful speech.
Nursing Diagnosis: Impaired Verbal Communication
- Prolonged cerebral occlusion
- Dysarthria (weakened muscles used for speech)
- Aphasia (impaired ability to comprehend or produce language)
As evidenced by:
- Slurred speech
- Difficulty forming words
- Difficulty expressing thoughts
- Slow to respond due to delayed comprehension
- Extremity weakness or paralysis resulting in an inability to write or type
- Patient will establish a form of communication to express their thoughts and needs
- Patient will participate in speech therapy to improve communication
- Patient will utilize resources and devices to support communication
Impaired Verbal Communication Assessment
1. Note type of aphasia.
Global aphasia is severe and affects the patient’s ability to produce and understand language. Wernicke’s aphasia may cause the patient to speak in nonsensical sentences. Broca’s aphasia means the patient may understand what is said to them and know what they want to say but have difficulty getting the words out.
2. Observe how the patient communicates.
Patients may have their own unique way of communicating such as in gestures, signals, or sounds. Family members can aid in teaching the nurse how the patient requests something.
Impaired Verbal Communication Interventions
1. Speak in short, direct sentences.
Always speak clearly, facing the patient so they can see your lips and expressions. Use direct sentences as they may not be able to comprehend abstract thoughts. Short “yes” or “no” questions may be easiest for the patient to comprehend.
2. Utilize alternative communication methods.
Use writing, drawing, and flashcards if these work for the patient. The nurse and patient may be able to work out a system to communicate needs such as a thumbs up or down, eye blinking, or smiling if they are nonverbal.
3. Encourage speech therapy.
Speech-language therapy is vital in improving communication. Aphasia can improve over time and speech therapy can help the patient restore language abilities as well as instruct on devices and technology to aid in communicating.
4. Encourage family participation.
Family involvement is crucial as both the patient and family learn to maneuver communication changes. Family members should also participate in therapy sessions and learn specific techniques that support clear communication.
Risk For Injury Care Plan
Depending on the area of the brain affected by the stroke, the patient may have spatial-perceptual issues and impaired judgment. Along with deficits in swallowing, motor coordination, and generalized weakness, safety is a priority.
Nursing Diagnosis: Risk For Injury
- Impaired judgment
- Spatial-perceptual deficit
- Poor motor coordination
- Poor balance
- Poor concept of time
- Impaired sensory awareness
- Inability to communicate
- Short attention span
Note: A risk for diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and nursing interventions are directed at prevention.
- Patient will remain free from falls
- Patient will maintain intact skin integrity
- Caregivers will support the patient and create a modified environment to keep the patient safe and free from injury
Risk For Injury Assessment
Determine deficits related to the area of brain injury.
Depending on the area of the brain that is damaged by the stroke the patient may display specific deficits. Right-brain strokes may result in difficulty in gauging the distance of an object making driving and walking dangerous. Left-brain strokes are more likely to have impaired swallowing and speech.
Assess sensory awareness.
An inability to recognize pain, heat, or sharp sensations places the patient at an increased risk of skin breakdown and injury.
Note neglect or visual disturbances.
A stroke on one side of the brain may cause a lack of awareness in the opposite side of the body. This can also affect the visual field. Hemianopia is a loss of half of the visual field which can be dangerous in certain situations.
Risk For Injury Interventions
1. Use bed and chair alarms.
When patients suffer a right-brain stroke specifically, they may be more impulsive and deny or minimize their deficits. This puts them at high risk for injury and falls. Keeping a bed alarm on at all times and a chair alarm if they are sitting up will increase safety.
2. Assist with eating.
Patients with dysphagia will require special meals and thickened liquids. Ensure they are chewing and swallowing adequately and are not displaying signs of possible aspiration such as pocketing food, drooling, or coughing.
3. Teach to scan the environment.
If the patient has left or right-sided neglect or visual disturbances teach them to scan from left to right. This can help them when moving in their environment but also assist with activities such as reading.
4. Turn and assess skin frequently.
If the patient is paralyzed on one side and lacks sensation it is the nurse’s responsibility to maintain their skin integrity. Turn every 2 hours, keep boney areas supported, maintain proper alignment of extremities and ensure lines and tubes are not digging into the patient’s skin.
References and Sources
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- NIH Stroke Scale. (n.d.). Know Stroke. Retrieved February 17, 2022, from https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf
- Pressman, P. (2021, February 23). How Blood Pressure Is Managed After an Ischemic Stroke. Verywell Health. Retrieved February 17, 2022, from https://www.verywellhealth.com/blood-pressure-ischemic-stroke-2488837
- Saver, J. L., & Lutsep, H. L. (2021, May 5). Thrombolytic Therapy in Stroke: Ischemic Stroke and Neurologic Deficits, Clinical Trials, Thrombolysis Guidelines. Medscape Reference. Retrieved February 17, 2022, from https://emedicine.medscape.com/article/1160840-overview
- Stroke | NHLBI, NIH. (2020, October 28). National Heart, Lung, and Blood Institute. Retrieved February 17, 2022, from https://www.nhlbi.nih.gov/health-topics/stroke
- Stroke-related eye conditions. (n.d.). RNIB. Retrieved February 17, 2022, from https://www.rnib.org.uk/eye-health/eye-conditions/stroke-related-eye-conditions