CVA Nursing Care Plans: Nursing Diagnoses and Interventions

A cerebrovascular accident (CVA), commonly known as a stroke, is a critical medical condition characterized by the disruption of blood flow to the brain. This interruption deprives brain tissue of oxygen and vital nutrients, leading to potential brain damage within minutes. Effective nursing care is paramount in managing stroke patients, focusing on rapid assessment, timely interventions, and comprehensive rehabilitation strategies. This article provides an in-depth guide to CVA nursing care plans, emphasizing nursing diagnoses and interventions essential for optimal patient outcomes.

Understanding Stroke: Types and Impact

Strokes are broadly classified into two primary categories: ischemic and hemorrhagic strokes.

Ischemic Strokes: These are the most prevalent type, resulting from a blockage or reduction in blood flow to a brain region. The obstruction is often caused by blood clots, fatty deposits (plaque), or other emboli traveling to the cerebral arteries. The lack of oxygen and glucose quickly leads to brain cell death in the affected area.

Hemorrhagic Strokes: These occur when a blood vessel in the brain ruptures, causing bleeding into the surrounding brain tissue. This hemorrhage increases intracranial pressure and damages brain cells. Common causes include aneurysms (weakened blood vessel walls), uncontrolled hypertension, head injuries, anticoagulant overuse, cerebral amyloid angiopathy, or the conversion of an ischemic stroke to hemorrhagic.

Transient Ischemic Attacks (TIAs): Often referred to as “mini-strokes,” TIAs are temporary episodes of reduced blood flow to the brain. Symptoms are similar to a stroke but resolve within 24 hours, usually within an hour, leaving no permanent damage. However, TIAs are significant warning signs of a potential future stroke, necessitating risk factor modification and medical evaluation.

Image alt text: Diagram illustrating the two main types of stroke, ischemic caused by blockage and hemorrhagic caused by bleeding.

The Nursing Process in CVA Care

Nursing care for CVA patients requires a systematic approach, following the nursing process: assessment, diagnosis, planning, implementation, and evaluation. The severity of stroke-related disabilities varies widely, influenced by the stroke’s extent, the time to treatment initiation, and pre-existing health conditions. Initial care often takes place in intensive care units (ICU) or step-down units, where specialized nurses with NIH Stroke Scale (NIHSS) certification closely monitor patients. The dynamic nature of stroke symptoms necessitates vigilant observation, critical thinking, and prompt nursing interventions to prevent neurological deterioration.

For severe strokes, patients may experience significant disabilities, requiring comprehensive assistance with daily activities such as feeding, bathing, and mobility. Long-term effects can lead to physical and emotional challenges for both the patient and their families, including depression. Nurses play a vital role in providing compassionate care, ensuring patient safety and dignity while addressing their diverse physical and psychosocial needs.

Comprehensive Nursing Assessment for CVA Patients

The initial step in CVA nursing care is a thorough nursing assessment, encompassing physical, psychosocial, emotional, and diagnostic data collection. This assessment guides the subsequent nursing diagnoses and interventions.

Review of Health History: Subjective Data Collection

1. Elicit General Stroke Symptoms: Promptly inquire about sudden onset symptoms indicative of a potential stroke:

• Hemiparesis or hemiplegia (weakness or paralysis on one side of the body, affecting face, arm, and leg)
• Sensory deficits (numbness, tingling, or paresthesia in extremities)
• Dysphagia (difficulty swallowing)
• Visual disturbances (hemianopsia – loss of half of the visual field, or peripheral vision loss)
• Speech difficulties:
  • Expressive aphasia (difficulty expressing or forming words)
  • Receptive aphasia (difficulty understanding spoken language)
  • Dysarthria (difficulty articulating words)
• Ataxia (unsteady gait or loss of coordination)
• Balance and coordination alterations
• Changes in mental status and cognition

2. Determine Symptom Onset Time: Stroke symptoms manifest abruptly. Accurately determine the time of symptom onset and the last time the patient was known to be at their baseline functional level. This information is crucial for determining eligibility for thrombolytic therapy and other time-sensitive interventions.

3. Identify Stroke Risk Factors: Assess for predisposing factors that increase stroke risk:

• Advanced age (55 years or older)
• Ethnicity (African American and Hispanic populations have higher risk)
• Male sex
• History of prior stroke or TIA

4. Review Medical History for Contributing Conditions: Ischemic strokes are frequently linked to underlying medical conditions that promote blood clot formation or arterial blockages:

• Hypertension
• Obesity
• Hypercholesterolemia
• Diabetes mellitus
• Obstructive sleep apnea
• Heart disease
• Atrial fibrillation
• Recent COVID-19 infection

5. Explore Family History of Stroke: A positive family history of stroke, particularly in immediate relatives before age 65, increases an individual’s risk. Genetic conditions like CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) can also predispose to stroke.

6. Medication History Review: Obtain a detailed medication list, including prescription, over-the-counter medications, and supplements. Note the indication for each medication and adherence to prescribed regimens.

• Estrogen-containing birth control pills or hormone replacement therapy can elevate stroke risk.
• Inconsistent use of antihypertensive medications can lead to uncontrolled hypertension and increased stroke vulnerability.
• Aspirin or other anticoagulants (enoxaparin, heparin, warfarin) may indicate pre-existing conditions that increase stroke risk, such as clotting disorders or cardiac conditions.

7. Inquire About Substance Use: Illicit substance use, particularly stimulants like amphetamines, cocaine, and heroin, has been associated with increased stroke risk.

8. Lifestyle Factor Assessment: Evaluate lifestyle habits that can contribute to stroke risk:

• Diet high in cholesterol, saturated fats, and trans fats
• Physical inactivity
• Excessive alcohol intake
• Smoking

Image alt text: Infographic listing various stroke risk factors including age, ethnicity, medical conditions and lifestyle choices.

Physical Assessment: Objective Data Collection

1. Rapid Stroke Recognition: F.A.S.T. Assessment: Utilize the F.A.S.T. acronym for rapid stroke symptom identification:

• Face: Assess for facial drooping or asymmetry when smiling or showing teeth.
• Arms: Evaluate for arm weakness by asking the patient to raise both arms and observe for downward drift.
• Speech: Check for speech difficulties, slurring, or inability to speak clearly.
• Time: Note the time of symptom onset and emphasize the urgency of immediate medical attention.

2. ABCs Assessment: Immediately evaluate Airway, Breathing, and Circulation. Stroke patients are at risk for aspiration and respiratory compromise due to neurological deficits and increased intracranial pressure.

3. Neurological Examination and NIHSS: Perform a comprehensive neurological exam, including the National Institutes of Health Stroke Scale (NIHSS), to quantify stroke severity and neurological deficits. The NIHSS assesses:

• Level of consciousness (LOC)
• Eye gaze
• Visual fields
• Facial movement
• Motor function in arms and legs
• Limb ataxia
• Sensory function
• Language comprehension and expression
• Speech articulation (dysarthria)
• Neglect or inattention

4. Vital Signs Monitoring: Hypertension is commonly observed in stroke patients. Monitor blood pressure closely and avoid rapid or aggressive blood pressure reduction, especially in the acute phase.

Diagnostic Procedures for CVA

1. Blood Glucose Measurement: Perform a fingerstick glucose test immediately to rule out hypoglycemia, as its symptoms can mimic stroke-like neurological deficits.

2. Brain Imaging: Prepare the patient for emergent brain imaging, typically a non-contrast head CT scan, to differentiate between ischemic and hemorrhagic stroke and rule out other conditions. Additional imaging modalities may include:

• CT angiography (CTA) and CT perfusion (CTP) scanning
• Magnetic resonance imaging (MRI)
• Carotid duplex ultrasound
• Digital subtraction angiography (DSA)

3. Laboratory Blood Tests: Obtain blood samples for laboratory analysis to identify underlying causes and contributing factors:

• Complete blood count (CBC) to assess for polycythemia or thrombocytopenia
• Cardiac biomarkers to evaluate for underlying cardiac disease or coronary artery disease
• Toxicology screen to rule out substance intoxication as the cause of symptoms
• Fasting lipid profile to assess cholesterol levels
• Coagulation studies prior to anticoagulant or antiplatelet administration

4. Pregnancy Test (for women of childbearing age): Perform a urine pregnancy test for women of reproductive age before fibrinolytic therapy, as safety in pregnancy has not been established.

5. Electrocardiogram (ECG): Obtain an ECG to assess for cardiac arrhythmias, particularly atrial fibrillation, a common source of embolic stroke.

Essential Nursing Interventions for CVA

Nursing interventions are crucial for stroke patients, aimed at restoring brain perfusion, managing complications, and facilitating recovery.

Restoring Brain Perfusion: Time-Sensitive Interventions

1. Rapid Evaluation and Diagnostic Imaging: Within one hour of arrival in the emergency department, patients with suspected stroke should undergo brain imaging (STAT non-contrast head CT) to confirm stroke diagnosis and type (ischemic or hemorrhagic).

2. Thrombolytic Therapy (for Ischemic Stroke): Initiate alteplase (tissue plasminogen activator – tPA) administration as rapidly as possible for confirmed ischemic stroke patients meeting eligibility criteria. Alteplase dissolves blood clots and is contraindicated in hemorrhagic stroke due to bleeding risk. Administer IV alteplase within 3 hours of symptom onset (or up to 4.5 hours in select patients per AHA/ASA guidelines).

3. Continuous Neurological Monitoring: Perform frequent neurological assessments post-stroke to detect changes in neurological status and enable timely interventions.

• Monitor and document pupil size, equality, and reactivity to light.
• Assess level of consciousness, orientation, speech, memory, and cognition.
• Observe for mood changes and emotional lability.
• Evaluate bilateral strength and coordination in extremities.

4. Medication Administration: Administer medications as prescribed to manage secondary complications and optimize recovery:

• Antihypertensive medications to maintain blood pressure within target parameters.
• Antiseizure medications for seizure prophylaxis, especially in hemorrhagic stroke or cortical strokes. Short-term antiseizure medication may be indicated for seizures within two weeks of stroke onset.
• Stool softeners or laxatives to prevent constipation and straining, which can increase intracranial pressure (ICP).

5. Blood Pressure Management: Maintain blood pressure within recommended ranges. For the first 24 hours post-alteplase, target BP is <180/105 mm Hg. For non-thrombolytic ischemic stroke, moderate hypertension may be permitted initially. Avoid aggressive or rapid blood pressure lowering.

• In ischemic stroke, slightly elevated BP may be maintained for the first 2-3 days to support cerebral perfusion. Gradual reduction to manage underlying hypertension follows.
• Hemorrhagic stroke management requires tighter BP control, with an initial goal of systolic BP ≤140 mmHg.

6. Mechanical Thrombectomy Consideration: For patients with large vessel occlusions, prepare for potential mechanical thrombectomy. This procedure involves catheter-based clot retrieval or disruption from major cerebral arteries. Ensure informed consent is obtained prior to the procedure.

7. Endovascular Techniques: Prepare patients for potential endovascular procedures such as carotid endarterectomy (surgical removal of plaque from the carotid artery) or carotid artery stenting to improve cerebral blood flow and reduce future stroke risk.

Image alt text: Illustration depicting stroke nursing interventions including thrombolysis to dissolve clots and thrombectomy to remove clots.

Stroke Recovery and Secondary Prevention

1. Stroke Rehabilitation Referral: Facilitate referrals to comprehensive stroke rehabilitation programs, involving:

• Speech therapy (for communication and swallowing deficits)
• Physical therapy (for motor deficits, mobility, and balance)
• Occupational therapy (for activities of daily living and functional skills)
• Cognitive therapy (for cognitive impairments)

2. Speech Deficit Management Education: Provide education on communication strategies for patients with aphasia, reinforcing speech therapy recommendations:

• Encourage consistent use of communication partner training strategies for family and caregivers.
• Promote speech practice using flashcards, books, computer programs, and visual aids.
• Introduce assistive communication devices such as communication boards, pen and paper, and communication apps.

3. Medication Education: Educate patients and families about prescribed medications for secondary stroke prevention:

• Anticoagulants (apixaban, dabigatran, rivaroxaban) for atrial fibrillation-related stroke. Low-dose heparin or enoxaparin for DVT prophylaxis. Aspirin for secondary stroke prevention.
• Antihypertensive medications (diuretics, beta-blockers, calcium channel blockers, ACE inhibitors) to manage hypertension.

4. Safety Strategies Implementation: Due to motor and coordination deficits, implement safety measures to prevent falls and injuries:

• Ensure bed rails are up, bed alarms are activated, and call light is within reach.
• Provide assistive devices for ambulation and ADLs as needed.

5. Support Group Encouragement: Refer patients and caregivers to stroke support groups for peer support, encouragement, and shared experiences.

6. Lifestyle Modification Promotion: Educate on lifestyle modifications to minimize secondary stroke risk:

• Dietary changes: limit processed foods, saturated and trans fats.
• Regular physical exercise.
• Smoking cessation.
• Moderate alcohol consumption.
• Weight management.

7. Adherence to Treatment Regimens: Emphasize the importance of adherence to medication regimens and follow-up care for managing comorbidities like hypertension, diabetes, and hypercholesterolemia to prevent future strokes.

CVA Nursing Care Plans: Example Diagnoses and Interventions

Nursing care plans for CVA patients are individualized based on identified nursing diagnoses, prioritizing short-term and long-term care goals. Examples of common nursing diagnoses and associated care plans include:

1. Impaired Verbal Communication

CVA frequently leads to communication deficits, affecting speech comprehension and expression due to neurological damage.

Nursing Diagnosis: Impaired Verbal Communication

Related to:

• Cerebral occlusion and neurological damage
• Dysarthria (muscle weakness affecting speech articulation)
• Aphasia (language comprehension or production impairment)

As evidenced by:

• Slurred speech or dysarthria
• Nonverbal communication or minimal verbal output
• Difficulty forming words or expressive aphasia
• Difficulty understanding spoken language or receptive aphasia
• Slow or delayed responses due to comprehension deficits
• Extremity weakness or paralysis affecting writing or typing ability

Expected Outcomes:

• Patient will establish effective communication methods to express needs and thoughts.
• Patient will actively participate in speech therapy to improve communication skills.
• Patient will utilize assistive communication resources and devices as needed.

Nursing Assessments:

1. Identify Type of Aphasia: Differentiate between global, Wernicke’s, and Broca’s aphasia to tailor communication strategies.
2. Observe Communication Methods: Identify patient’s preferred communication methods (gestures, signals, sounds) and involve family to understand these cues.

Nursing Interventions:

1. Simple and Direct Communication: Speak in short, direct sentences, facing the patient, using clear lip movements and facial expressions. Ask simple “yes” or “no” questions.
2. Alternative Communication Methods: Utilize writing, drawing, flashcards, communication boards, or assistive technology as appropriate.
3. Speech Therapy Referral and Support: Encourage and facilitate speech-language therapy.
4. Family Involvement in Communication Strategies: Educate and involve family members in communication techniques to support patient interaction and therapy goals.

2. Ineffective Cerebral Tissue Perfusion

Reduced or interrupted blood flow in CVA results in inadequate oxygen supply to brain tissue, leading to potential irreversible damage.

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion

Related to:

• Interruption of cerebral blood flow
• Thrombus or embolus formation
• Cerebral artery occlusion
• Cerebral edema
• Hemorrhage

As evidenced by:

• Altered mental status and decreased level of consciousness
• Blurred vision or visual disturbances
• Slurred speech or dysarthria
• Extremity weakness or paralysis

Expected Outcomes:

• Patient will recognize stroke symptoms and seek prompt medical attention in the future.
• Patient will demonstrate improved cerebral perfusion, evidenced by stable vital signs within prescribed parameters.
• Patient will show improvement in stroke-related deficits (speech, weakness, swallowing) by discharge.

Nursing Assessments:

1. Establish Baseline Neurological Status: Determine the patient’s pre-stroke baseline function and time of symptom onset to guide interventions and assess progress.
2. Frequent Neurological Assessments: Perform regular neurological assessments using stroke scales (NIHSS) to monitor LOC, motor, sensory, speech, and cognitive changes.
3. Review Brain Imaging Results: Analyze CT scan or MRI findings to confirm stroke type (ischemic vs. hemorrhagic) and guide treatment decisions.

Nursing Interventions:

1. Maintain Blood Pressure Parameters: Adhere to prescribed blood pressure ranges to optimize cerebral perfusion, allowing for permissive hypertension in ischemic stroke (unless thrombolysis is indicated) and tighter control in hemorrhagic stroke.
2. Administer Thrombolytic Therapy: Administer thrombolytics (alteplase) for eligible ischemic stroke patients within the therapeutic time window.
3. Stroke Risk Factor Education: Educate patients and families about modifiable stroke risk factors (hypertension, heart disease, diabetes, smoking, stress) and preventive strategies.
4. FAST Stroke Symptom Education: Instruct patients and families on recognizing stroke symptoms using the FAST acronym and the importance of immediate emergency response.

3. Risk for Injury

Neurological deficits from CVA, such as impaired judgment, spatial-perceptual issues, weakness, and dysphagia, increase the risk of falls and injuries.

Nursing Diagnosis: Risk for Injury

Related to:

• Impaired judgment and cognitive deficits
• Spatial-perceptual deficits and neglect
• Muscle weakness and impaired motor coordination
• Balance deficits
• Poor time perception
• Impaired sensory awareness
• Dysphagia and swallowing difficulties
• Communication impairments
• Hemiplegia or hemiparesis
• Shortened attention span and impulsivity

Expected Outcomes:

• Patient will remain free from falls and other injuries during hospitalization.
• Patient will maintain intact skin integrity and prevent skin breakdown.
• Caregivers will create a safe environment and implement strategies to prevent patient injury.

Nursing Assessments:

1. Identify Stroke-Related Deficits: Assess specific neurological deficits based on the affected brain region (e.g., right-brain stroke – spatial deficits, left-brain stroke – speech and swallowing issues).
2. Sensory Awareness Assessment: Evaluate sensory function to identify loss of pain, temperature, or pressure sensation, increasing skin breakdown risk.
3. Assess Neglect and Visual Disturbances: Identify unilateral neglect (lack of awareness of one side of the body) and visual field deficits (hemianopsia), which increase injury risk.

Nursing Interventions:

1. Implement Fall Precautions: Utilize bed and chair alarms, especially for impulsive patients or those with right-brain strokes.
2. Assist with Feeding and Swallowing Precautions: Provide mealtime assistance, thickened liquids, and dysphagia precautions to prevent aspiration.
3. Environmental Scanning Training: Teach patients with neglect or visual deficits to scan their environment from left to right to improve awareness.
4. Skin Integrity Maintenance: Implement frequent turning schedules (every 2 hours), pressure relief measures, and proper body alignment to prevent skin breakdown, especially on paralyzed limbs.

4. Self-Care Deficit

Hemiparesis and other stroke-related impairments can significantly hinder a patient’s ability to perform self-care activities and activities of daily living (ADLs).

Nursing Diagnosis: Self-Care Deficit

Related to:

• Neurobehavioral impairments
• Muscle weakness and motor deficits
• Musculoskeletal impairment
• Cognitive dysfunction
• Decreased motivation
• Impaired physical mobility
• Unilateral neglect

As evidenced by:

• Inability to perform personal hygiene and cleansing activities independently.
• Difficulty dressing and undressing.
• Impaired ability to use eating utensils, prepare food, or self-feed.
• Inability to access the bathroom or manage toileting independently.

Expected Outcomes:

• Patient will maintain skin integrity and be free from body odor.
• Patient will verbalize successful use of assistive devices for bathing.
• Patient will express dignity and satisfaction with caregiver assistance for bathing.
• Patient will achieve optimal independence in dressing and ADLs.
• Patient will demonstrate competence in using assistive devices for self-care.
• Patient will safely and effectively self-feed.
• Patient will maintain continence and skin integrity in perineal area.

Nursing Assessments:

1. Functional Ability and Limitations Assessment: Evaluate physical mobility, sensation, cognition, and emotional status to determine self-care capabilities and limitations.
2. Patient Preferences Assessment: Inquire about patient preferences for hygiene, food, and self-care practices to promote comfort and autonomy.
3. Routine Risk Assessments: Perform regular risk assessments for falls (Morse Fall Scale), skin breakdown (Braden Scale), and swallowing difficulties (bedside swallow study).

Nursing Interventions:

1. Establish Toileting Schedule: Implement a regular toileting schedule and administer stool softeners to prevent constipation.
2. Promote Independence in ADLs: Encourage patient participation in self-care activities to maximize autonomy and self-esteem.
3. Allow Adequate Mealtime: Provide sufficient time for meals and assist with feeding as needed, considering swallowing difficulties.
4. Assistive Equipment Provision and Training: Introduce and train patients on adaptive equipment (button hooks, zipper pulls, shower benches, electric toothbrushes, modified utensils, mobility aids).
5. Physical and Occupational Therapy Consultation: Collaborate with physical and occupational therapists for rehabilitation and ADL training.

5. Unilateral Neglect

Unilateral neglect, a common consequence of stroke, involves a lack of awareness of one side of the body and the surrounding environment.

Nursing Diagnosis: Unilateral Neglect

Related to:

• Underlying disease process (CVA)
• Brain trauma or damage
• Ischemia of cerebral tissue

As evidenced by:

• Altered safety behavior on the neglected side (e.g., bumping into objects)
• Failure to move eyes or attend to stimuli in the neglected visual field
• Inability to move limbs on the neglected side
• Difficulty with grooming or dressing the neglected side
• Unawareness of the position of the neglected limb

Expected Outcomes:

• Patient will demonstrate techniques to minimize unilateral neglect.
• Patient will effectively care for both sides of the body and protect the affected side from harm.
• Patient will achieve the highest possible level of functional independence based on individual abilities and goals.

Nursing Assessments:

1. Assess for Unilateral Neglect Signs: Observe for behaviors indicative of neglect, such as neglecting self-care on one side, leaning on the affected side, eating from only one side of the plate, or ignoring stimuli from the affected side.
2. Assess Awareness of Neglect: Determine the patient’s insight into their neglect and readiness to learn compensatory strategies.
3. Skin Assessment (Neglected Side): Carefully assess skin integrity on the neglected side due to increased risk of injury and pressure ulcers from lack of awareness and repositioning.

Nursing Interventions:

1. Fall Prevention Measures: Implement fall precautions, including bed alarms and call light accessibility.
2. Assistive Device Utilization: Encourage the use of assistive devices to compensate for neglect and enhance safety.
3. Neutral Body Positioning: Instruct and assist the patient in maintaining neutral body alignment and regular position changes to prevent pain, joint complications, and contractures.
4. Environmental Modification: Position personal belongings and approach the patient from the unaffected side to promote awareness of the neglected side.
5. Rehabilitation Program Referral: Coordinate transfer to appropriate rehabilitation programs (physical, occupational, and speech therapy) to address neglect and maximize functional recovery.