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 essential nutrients, leading to potential brain cell damage within minutes. Effective nursing care, guided by accurate nursing diagnoses, is paramount in managing stroke patients and optimizing their recovery.
Understanding Stroke Types and Their Impact
Strokes are broadly classified into two primary categories: ischemic and hemorrhagic. Understanding these types is crucial for formulating appropriate nursing diagnoses and interventions.
Ischemic Strokes: These are the most prevalent, accounting for approximately 87% of all strokes. Ischemic strokes occur due to an obstruction in blood vessels supplying the brain, significantly reducing or completely blocking blood flow. Common causes include:
- Thrombosis: Formation of a blood clot within a cerebral artery.
- Embolism: Migration of a blood clot or plaque from another part of the body (often the heart or carotid arteries) to a cerebral artery.
- Systemic hypoperfusion: Reduced blood flow to the brain due to conditions like shock or severe hypotension.
Alt text: Illustration depicting an ischemic stroke with blocked blood flow in a brain artery.
Hemorrhagic Strokes: These strokes result from the rupture of a blood vessel in the brain, causing bleeding into brain tissue or the surrounding spaces. The increased pressure from the leaked blood damages brain cells. Hemorrhagic strokes are further divided into:
- Intracerebral hemorrhage: Bleeding within the brain tissue itself.
- Subarachnoid hemorrhage: Bleeding in the space between the brain and the surrounding membrane (subarachnoid space), often due to a ruptured aneurysm.
Common causes of hemorrhagic stroke include:
- Hypertension: Chronic high blood pressure weakens blood vessels, making them prone to rupture.
- Aneurysm: A weakened, bulging area in a blood vessel wall that can burst.
- Arteriovenous malformation (AVM): An abnormal tangle of blood vessels that can rupture.
- Head trauma: Injury to the head can damage blood vessels and lead to bleeding.
- Anticoagulant overuse: Excessive use of blood thinners can increase the risk of bleeding.
Transient Ischemic Attacks (TIAs): Often referred to as “mini-strokes,” TIAs are temporary episodes of neurological dysfunction caused by brief interruptions in blood flow to the brain. Symptoms are similar to a stroke but resolve within minutes to hours, typically within 24 hours, without causing permanent brain damage. TIAs are significant warning signs, indicating an increased risk of a future, more severe stroke.
The Nursing Process for Stroke Patients
The nursing process is a systematic approach to patient care, essential for stroke patients who often present with complex and rapidly changing conditions. It involves assessment, diagnosis, planning, implementation, and evaluation.
Nursing Assessment: A comprehensive assessment is the cornerstone of stroke care. It includes gathering subjective and objective data to understand the patient’s condition and needs.
Subjective Data: Health History Review
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Symptom Onset and Nature: Elicit a detailed history of the onset, duration, and characteristics of symptoms. Sudden onset of neurological deficits is a hallmark of stroke. Key symptoms include:
- Motor weakness or paralysis (hemiparesis/hemiplegia): Weakness or paralysis affecting one side of the body (face, arm, leg).
- Sensory deficits: Numbness, tingling, or loss of sensation on one side of the body.
- Dysphagia: Difficulty swallowing.
- Visual disturbances: Sudden vision loss, double vision, or visual field deficits.
- Speech difficulties:
- Aphasia (expressive, receptive, or global): Difficulty producing or understanding speech.
- Dysarthria: Difficulty articulating words due to muscle weakness.
- Ataxia: Lack of coordination and balance.
- Cognitive and mental status changes: Confusion, disorientation, memory problems, or altered level of consciousness.
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Risk Factors: Identify predisposing factors for stroke:
- Non-modifiable risk factors: Age (over 55), race (African American, Hispanic), gender (male), family history of stroke, prior stroke or TIA.
- Modifiable risk factors: Hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking, excessive alcohol consumption, sedentary lifestyle, atrial fibrillation, heart disease, sleep apnea, COVID-19 infection.
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Medical and Medication History: Review past medical conditions, especially cardiovascular diseases, and current medications, including:
- Antihypertensives: Assess adherence and blood pressure control.
- Anticoagulants/Antiplatelets: Note use and indication (e.g., atrial fibrillation, history of clots).
- Hormone replacement therapy/Oral contraceptives: Estrogen-containing medications increase stroke risk.
- Substance use: History of illicit drug use (cocaine, amphetamines) is a significant risk factor.
Objective Data: Physical Assessment
- Initial Rapid Assessment (ABCs & FAST):
- Airway, Breathing, Circulation (ABCs): Ensure patent airway, adequate breathing, and stable circulation. Stroke patients may be at risk for aspiration and respiratory compromise.
- F.A.S.T. Assessment: Quickly assess for key stroke signs:
- Face: Facial drooping or asymmetry.
- Arms: Arm weakness or drift when raised.
- Speech: Slurred or incomprehensible speech.
- Time: Note time of symptom onset – critical for treatment decisions.
Alt text: Diagram illustrating the FAST acronym for stroke assessment: Face, Arms, Speech, Time.
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Neurological Examination (NIHSS): Utilize the National Institutes of Health Stroke Scale (NIHSS) to quantify neurological deficits and stroke severity. This standardized tool assesses:
- Level of Consciousness (LOC): Alertness, orientation, responsiveness.
- Visual Function: Visual fields, gaze, and eye movements.
- Facial Nerve Function: Facial symmetry and movement.
- Motor Function: Arm and leg strength in both extremities.
- Sensory Function: Sensation to touch and pain.
- Cerebellar Function: Coordination and ataxia.
- Language and Speech: Aphasia, dysarthria, and comprehension.
- Neglect: Inattention to one side of the body or space.
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Vital Signs: Monitor blood pressure, heart rate, respiratory rate, and oxygen saturation. Hypertension is common in acute stroke, but rapid blood pressure reduction can be detrimental.
Diagnostic Procedures
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Blood Glucose: Rule out hypoglycemia, which can mimic stroke symptoms.
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Brain Imaging:
- Non-contrast CT scan: Essential to differentiate between ischemic and hemorrhagic stroke.
- CT angiography (CTA) and CT perfusion: Visualize blood vessels and assess cerebral blood flow.
- MRI: Provides detailed brain tissue imaging, useful for detecting subtle lesions and assessing stroke age.
- Carotid Doppler Ultrasound: Evaluate carotid artery stenosis (narrowing), a risk factor for ischemic stroke.
- Transcranial Doppler (TCD): Assess blood flow velocity in cerebral arteries.
- Digital Subtraction Angiography (DSA): Invasive angiography for detailed visualization of cerebral vasculature.
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Laboratory Tests:
- Complete Blood Count (CBC): Assess for polycythemia, thrombocytopenia, or infection.
- Coagulation Studies (PT/INR, PTT): Baseline before thrombolytic therapy or anticoagulation.
- Cardiac Biomarkers (Troponin, CK-MB): Evaluate for cardiac ischemia or damage.
- Lipid Profile: Assess cholesterol and triglyceride levels, risk factors for atherosclerosis.
- Electrolytes and Renal Function: Baseline assessment of metabolic status.
- Toxicology Screen: Rule out drug intoxication.
- Pregnancy Test (for women of childbearing age): Contraindication for thrombolytics in pregnancy.
- Electrocardiogram (ECG): Detect cardiac arrhythmias, especially atrial fibrillation, a common cause of embolic stroke.
Common Nursing Diagnoses for CVA Patients
Based on the assessment data, several nursing diagnoses are commonly identified in stroke patients. These diagnoses guide the development of individualized care plans.
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Impaired Verbal Communication: Related to neurological deficits (aphasia, dysarthria), evidenced by difficulty expressing thoughts, understanding speech, or forming words.
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Ineffective Cerebral Tissue Perfusion: Related to interruption of blood flow (ischemia, hemorrhage), evidenced by altered mental status, neurological deficits, and changes in vital signs.
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Risk for Injury: Related to impaired mobility, sensory deficits, cognitive impairment, and perceptual deficits, evidenced by weakness, balance problems, and altered safety awareness.
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Self-Care Deficit: Related to motor deficits, cognitive impairment, and perceptual deficits, evidenced by inability to perform activities of daily living (ADLs) such as bathing, dressing, feeding, and toileting.
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Unilateral Neglect: Related to neurological impairment, evidenced by inattention to one side of the body or environment, and altered safety behavior on the neglected side.
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Impaired Physical Mobility: Related to hemiparesis/hemiplegia, balance and coordination deficits, evidenced by weakness, paralysis, and difficulty with movement.
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Dysphagia: Related to neuromuscular impairment, evidenced by coughing, choking, or pocketing food while eating, and difficulty swallowing.
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Risk for Aspiration: Related to dysphagia, decreased level of consciousness, and impaired gag reflex, evidenced by weak cough, hoarse voice, and history of aspiration.
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Disturbed Sensory Perception: Related to neurological deficits, evidenced by visual disturbances, sensory loss, and spatial-perceptual alterations.
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Risk for Impaired Skin Integrity: Related to immobility, sensory deficits, and incontinence, evidenced by pressure points, redness, and potential skin breakdown.
Nursing Interventions and Expected Outcomes
Nursing interventions are tailored to address the identified nursing diagnoses and achieve specific patient outcomes.
Restoring Brain Perfusion
Nursing Interventions:
- Rapid Assessment and Diagnostic Imaging: Prioritize immediate neurological assessment and STAT non-contrast head CT scan to confirm stroke type (ischemic or hemorrhagic) within one hour of arrival.
- Thrombolytic Therapy (for Ischemic Stroke): Administer IV alteplase (tPA) within 3-4.5 hours of symptom onset for eligible ischemic stroke patients to dissolve clots and restore blood flow. Monitor for bleeding complications.
- Neurological Monitoring: Frequent neurological assessments (including NIHSS) to detect changes in neurological status promptly and guide interventions. Monitor LOC, pupils, speech, motor strength, and sensory function.
- Medication Administration: Manage blood pressure, prevent seizures, and manage secondary complications.
- Antihypertensives: Maintain blood pressure within ordered parameters.
- Anticonvulsants: Seizure prophylaxis, especially for hemorrhagic stroke or cortical involvement.
- Stool softeners: Prevent constipation and straining, which can increase intracranial pressure (ICP).
- Blood Pressure Management: Maintain optimal blood pressure to support cerebral perfusion.
- Ischemic stroke: Permissive hypertension may be allowed initially, avoiding aggressive lowering unless extremely high (e.g., >220/120 mmHg).
- Hemorrhagic stroke: More stringent blood pressure control to limit bleeding expansion (target systolic BP around 140 mmHg).
- Mechanical Thrombectomy: Prepare for and assist with mechanical thrombectomy for large vessel occlusions in ischemic stroke, if indicated and within the therapeutic window.
- Endovascular Procedures: Prepare for carotid endarterectomy or angioplasty with stent placement for carotid artery stenosis to improve cerebral blood flow and prevent future stroke.
Expected Outcomes:
- Timely restoration of cerebral blood flow.
- Minimized neurological deficits.
- Prevention of stroke recurrence.
Stroke Recovery and Rehabilitation
Nursing Interventions:
- Rehabilitation Referrals: Initiate early referrals to speech therapy, physical therapy, occupational therapy, and cognitive therapy to address specific deficits.
- Speech Therapy Strategies: Implement communication strategies for patients with aphasia:
- Communication partner training for family and caregivers.
- Speech practice using flashcards, visual aids, and technology.
- Alternative communication methods (communication boards, writing, gestures).
- Medication Education: Educate patients and families about prescribed medications:
- Anticoagulants (e.g., apixaban, rivaroxaban, warfarin) for atrial fibrillation.
- Antiplatelets (e.g., aspirin, clopidogrel) for secondary stroke prevention.
- Antihypertensives for blood pressure control.
- Safety Measures: Implement fall precautions and injury prevention strategies:
- Bed and chair alarms.
- Bed rails up, call light within reach.
- Assistive devices for mobility (walkers, canes).
- Environmental modifications to reduce fall risks.
- Support Groups: Encourage participation in stroke support groups for patients and caregivers to provide emotional support, education, and peer interaction.
- Lifestyle Modification Education: Educate on risk factor modification to prevent secondary stroke:
- Healthy diet (low in saturated fats and processed foods).
- Regular physical exercise.
- Smoking cessation.
- Moderate alcohol consumption.
- Weight management.
- Adherence to Treatment Regimens: Emphasize the importance of medication adherence, follow-up appointments, and management of comorbidities (hypertension, diabetes, hyperlipidemia).
Expected Outcomes:
- Improved communication abilities.
- Enhanced physical function and mobility.
- Safe performance of ADLs.
- Adaptation to residual deficits.
- Reduced risk of secondary stroke.
- Improved quality of life.
Nursing Care Plan Examples
Specific nursing care plans are developed based on the identified nursing diagnoses. Here are examples for some common diagnoses:
Nursing Care Plan: Impaired Verbal Communication
Nursing Diagnosis: Impaired Verbal Communication related to prolonged cerebral occlusion, dysarthria, and aphasia.
Expected Outcomes:
- Patient will establish effective communication methods to express needs and thoughts.
- Patient will actively participate in speech therapy.
- Patient will utilize assistive communication devices as needed.
Nursing Interventions:
- Assess Type of Aphasia: Determine specific language deficits (expressive, receptive, global) to tailor communication strategies.
- Observe Communication Methods: Identify patient’s preferred and effective communication methods (gestures, sounds, writing).
- Use Simple Language: Speak slowly, clearly, and in short, direct sentences. Use visual cues and gestures.
- Utilize Alternative Communication: Implement communication boards, writing, drawing, or electronic devices.
- Speech Therapy Referral: Ensure timely referral and active participation in speech therapy.
- Family Involvement: Encourage family participation in therapy and communication strategies.
Nursing Care Plan: Ineffective Cerebral Tissue Perfusion
Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow to the brain (thrombus, hemorrhage).
Expected Outcomes:
- Patient will demonstrate improved cerebral perfusion evidenced by stable vital signs and neurological status.
- Patient will recognize stroke symptoms and seek prompt medical attention.
- Patient will exhibit improvement in neurological deficits (speech, weakness, swallowing).
Nursing Interventions:
- Baseline Assessment: Establish baseline neurological status upon admission to monitor for changes.
- Neurological Assessments: Frequent neurological assessments using NIHSS or facility-specific stroke scales.
- Brain Imaging: Ensure timely CT scan or MRI to confirm stroke type and guide treatment.
- Blood Pressure Management: Maintain blood pressure within ordered parameters to optimize cerebral perfusion.
- Thrombolytic Administration: Administer thrombolytics as indicated for ischemic stroke within the time window.
- Risk Factor Education: Educate patient and family on stroke risk factors and prevention strategies (FAST).
Nursing Care Plan: Risk for Injury
Nursing Diagnosis: Risk for Injury related to impaired judgment, spatial-perceptual deficits, weakness, and poor motor coordination.
Expected Outcomes:
- Patient will remain free from falls and injuries.
- Patient will maintain intact skin integrity.
- Caregivers will create a safe environment to prevent injury.
Nursing Interventions:
- Assess Deficits: Identify specific deficits related to brain injury (right-brain vs. left-brain stroke) to anticipate potential safety risks.
- Sensory Assessment: Assess sensory awareness (pain, temperature) to prevent skin injury.
- Neglect and Visual Field Assessment: Note unilateral neglect or visual field deficits (hemianopia) to implement appropriate safety measures.
- Bed/Chair Alarms: Utilize alarms to alert staff of patient attempts to get out of bed or chair unassisted.
- Assist with Eating: Supervise meals for patients with dysphagia to prevent aspiration.
- Environmental Scanning Education: Teach scanning techniques to compensate for neglect or visual field deficits.
- Skin Care: Frequent turning and skin assessment, especially for paralyzed or immobile patients.
Nursing Care Plan: Self-Care Deficit
Nursing Diagnosis: Self-Care Deficit related to neurobehavioral manifestations, weakness, and impaired mobility.
Expected Outcomes:
- Patient will maintain hygiene and skin integrity.
- Patient will utilize assistive devices effectively for self-care.
- Patient will perform ADLs to their maximum potential.
- Patient will maintain bowel and bladder continence.
Nursing Interventions:
- Functional Ability Assessment: Assess patient’s functional abilities and limitations to tailor self-care assistance.
- Preference Assessment: Respect patient preferences and cultural considerations in self-care activities.
- Risk Assessments: Routine fall risk, skin assessment, and swallowing assessment.
- Toileting Schedule: Establish a regular toileting schedule and manage bowel function.
- Encourage Independence: Promote independence in ADLs as much as possible.
- Adequate Meal Time: Allow sufficient time for meals, especially for patients with dysphagia.
- Assistive Devices: Provide and train patient on the use of adaptive equipment (dressing aids, bathing aids, eating utensils).
- Rehabilitation Consultation: Consult with physical and occupational therapy for comprehensive rehabilitation planning.
Nursing Care Plan: Unilateral Neglect
Nursing Diagnosis: Unilateral Neglect related to brain damage from stroke.
Expected Outcomes:
- Patient will demonstrate techniques to minimize unilateral neglect.
- Patient will care for both sides of the body effectively.
- Patient will achieve the highest possible functional level.
Nursing Interventions:
- Assess for Neglect: Observe for signs of unilateral neglect (ignoring one side of body, environment, food on one side of plate).
- Awareness Assessment: Assess patient’s awareness of their neglect and ability to learn compensatory strategies.
- Skin Assessment: Frequent skin checks, especially on the neglected side, for injury.
- Fall Precautions: Implement fall precautions due to increased risk of falls with unilateral neglect.
- Assistive Devices: Encourage the use of assistive devices to promote awareness of the neglected side.
- Neutral Positioning: Maintain neutral body alignment and encourage regular position changes.
- Environmental Placement: Position belongings and approach patient from the unaffected side initially.
- Rehabilitation Program: Coordinate transfer to rehabilitation for comprehensive therapy.
By utilizing these nursing diagnoses and implementing targeted interventions, nurses play a critical role in the comprehensive care of CVA patients, maximizing their recovery potential and improving their long-term outcomes.
