A cerebrovascular accident (CVA), commonly known as a stroke, is a critical medical condition that occurs when blood supply to the brain is disrupted. Hemorrhagic stroke, a particularly dangerous type, involves bleeding within the brain tissue or the surrounding spaces. This article will focus on nursing diagnoses crucial for managing patients experiencing hemorrhagic stroke, providing an in-depth guide for healthcare professionals.
Understanding Hemorrhagic Stroke
Hemorrhagic strokes arise from the rupture of a blood vessel in the brain, leading to bleeding into brain tissue. This bleeding causes increased pressure within the skull, damaging brain cells and disrupting normal brain function. Hemorrhagic strokes are less common than ischemic strokes but often result in higher mortality and morbidity rates.
There are two main types of hemorrhagic stroke:
- Intracerebral Hemorrhage (ICH): Bleeding directly into the brain tissue itself. This is often caused by hypertension, cerebral amyloid angiopathy, arteriovenous malformations (AVMs), or aneurysms.
- Subarachnoid Hemorrhage (SAH): Bleeding into the space between the brain and the surrounding membrane (subarachnoid space). SAH is frequently caused by ruptured aneurysms or head trauma.
Both types of hemorrhagic stroke require prompt recognition and intensive medical and nursing management to minimize brain damage and improve patient outcomes.
The Nursing Process for Hemorrhagic Stroke
Nursing care for patients with hemorrhagic stroke is complex and demands a systematic approach using the nursing process. This involves assessment, diagnosis, planning, implementation, and evaluation, all tailored to the unique needs of each patient. Nurses play a pivotal role in the early detection of changes in patient condition, implementing critical interventions, and providing supportive care throughout the recovery phase.
Patients experiencing hemorrhagic stroke often present with significant neurological deficits and require intensive care, frequently in settings such as the Intensive Care Unit (ICU) or specialized stroke units. Nurses caring for these patients often hold certifications like the NIH Stroke Scale (NIHSS) certification, reflecting their expertise in monitoring and responding to the rapidly changing neurological status of stroke patients.
Severe hemorrhagic strokes can lead to profound disabilities, necessitating comprehensive care addressing physical, psychological, and emotional needs. Compassionate nursing care is essential to maintain patient safety, dignity, and optimize recovery.
Nursing Assessment for Hemorrhagic Stroke
The cornerstone of effective nursing care begins with a thorough and ongoing nursing assessment. This involves gathering both subjective and objective data to understand the patient’s condition comprehensively. For hemorrhagic stroke, the assessment is crucial for identifying specific nursing diagnoses and guiding interventions.
Review of Health History
1. Elicit Presenting Symptoms: Sudden onset of specific symptoms is a hallmark of stroke. Inquire about the following, which may indicate a hemorrhagic stroke:
- Severe Headache: Often described as the “worst headache of my life,” particularly in subarachnoid hemorrhage.
- Neurological Deficits:
- Hemiparesis or hemiplegia (weakness or paralysis on one side of the body)
- Sensory deficits (numbness, tingling)
- Dysphagia (difficulty swallowing)
- Visual disturbances (vision loss, double vision)
- Speech difficulties (aphasia, dysarthria)
- Ataxia (uncoordinated movements)
- Balance and coordination problems
- Altered mental status, including confusion or decreased level of consciousness
- Seizures
2. Determine Symptom Onset: The timing of symptom onset is critical. Establish when symptoms first appeared and the last time the patient was known to be at their baseline neurological function. This information is vital for determining treatment options and assessing prognosis.
3. Identify Risk Factors for Hemorrhagic Stroke: Certain factors increase the likelihood of hemorrhagic stroke:
- Hypertension: Uncontrolled high blood pressure is the most significant risk factor for intracerebral hemorrhage.
- Age: Risk increases with age.
- Cigarette Smoking: Damages blood vessels and increases blood pressure.
- Excessive Alcohol Consumption: Can contribute to hypertension and bleeding disorders.
- Use of Anticoagulants or Antiplatelet Medications: Increases bleeding risk.
- Pre-existing Conditions:
- Brain aneurysms or arteriovenous malformations (AVMs)
- Cerebral amyloid angiopathy (protein deposits weakening blood vessels)
- Bleeding disorders
- Liver disease
4. Review Medical History: Explore the patient’s medical history for conditions that predispose to hemorrhagic stroke:
- History of hypertension and medication adherence.
- Known aneurysms or AVMs.
- History of head trauma.
- Bleeding disorders or anticoagulant use.
- Liver disease or other conditions affecting coagulation.
- History of prior stroke or TIA.
5. Medication Review: Obtain a complete medication list, noting:
- Anticoagulants (warfarin, heparin, direct oral anticoagulants) and antiplatelet agents (aspirin, clopidogrel).
- Blood pressure medications and adherence.
- Estrogen-containing medications (birth control pills, hormone replacement therapy), which can slightly increase stroke risk.
6. Substance Use History: Inquire about the use of illicit drugs, particularly cocaine and amphetamines, which can acutely elevate blood pressure and trigger hemorrhagic stroke.
7. Lifestyle Factors: Assess lifestyle habits that contribute to stroke risk:
- Diet high in sodium, saturated fats, and cholesterol.
- Physical inactivity.
- Smoking history.
- Alcohol consumption patterns.
Physical Assessment
1. Rapid Neurological Assessment: Perform a focused neurological exam, prioritizing:
- Level of Consciousness (LOC): Glasgow Coma Scale (GCS) to assess alertness and responsiveness.
- Pupillary Response: Size, equality, and reactivity to light. Unequal or sluggish pupils can indicate increased intracranial pressure (ICP).
- Motor Function: Assess strength and movement in all extremities. Note any hemiparesis or hemiplegia.
- Sensory Function: Test sensation to light touch and pain in all extremities.
- Cranial Nerve Function:
- Facial Nerve (VII): Check for facial droop, smile symmetry (F.A.S.T. – Face).
- Oculomotor Nerves (III, IV, VI): Assess eye movements, gaze preference, and nystagmus.
- Glossopharyngeal and Vagus Nerves (IX, X): Evaluate gag reflex and swallowing ability.
- Hypoglossal Nerve (XII): Observe tongue movement and symmetry.
- Speech: Assess for dysarthria, aphasia (expressive or receptive).
- Cerebellar Function: Assess balance and coordination (ataxia).
2. Vital Signs Monitoring: Closely monitor vital signs, paying particular attention to blood pressure. Hypertension is common in hemorrhagic stroke, but excessively high blood pressure can worsen bleeding, while overly rapid reduction can compromise cerebral perfusion.
- Blood Pressure: Note systolic and diastolic readings.
- Heart Rate and Rhythm: Assess for bradycardia or arrhythmias.
- Respiratory Rate and Pattern: Monitor for changes in breathing, including Cheyne-Stokes respirations, which can indicate increased ICP.
- Temperature: Fever can increase metabolic demand and worsen neurological injury.
3. Signs of Increased Intracranial Pressure (ICP): Hemorrhagic stroke frequently leads to elevated ICP. Assess for:
- Decreased level of consciousness
- Headache
- Vomiting (often projectile)
- Pupillary changes (unequal, dilated, or non-reactive)
- Bradycardia with hypertension (Cushing’s triad – a late sign)
- Papilledema (swelling of the optic disc, visualized during fundoscopic exam)
Diagnostic Procedures
Prompt diagnostic testing is essential to confirm hemorrhagic stroke, determine its type and location, and guide treatment.
1. Blood Glucose Level: Rule out hypoglycemia as a cause of neurological symptoms with a fingerstick glucose test. Hypoglycemia can mimic stroke symptoms.
2. Brain Imaging: Neuroimaging is crucial.
- Non-contrast Head CT Scan: The initial imaging modality of choice for suspected stroke. It rapidly differentiates between ischemic and hemorrhagic stroke, identifies the location and size of hemorrhage, and can detect hydrocephalus or mass effect.
- CT Angiography (CTA): May be performed to visualize cerebral vasculature, identify aneurysms, AVMs, or other vascular abnormalities contributing to hemorrhage.
- MRI (Magnetic Resonance Imaging): Provides more detailed images of brain tissue and can be useful in later stages to assess tissue damage and identify underlying causes, but CT is faster and more readily available acutely.
3. Lumbar Puncture: In suspected subarachnoid hemorrhage with a negative CT scan, a lumbar puncture may be performed to analyze cerebrospinal fluid (CSF) for blood. However, this is contraindicated if there is evidence of increased ICP or mass effect on CT.
4. Laboratory Tests: Blood tests help identify underlying causes and guide management.
- Complete Blood Count (CBC): Evaluates for thrombocytopenia (low platelets), which can increase bleeding risk, or polycythemia.
- Coagulation Studies (PT/INR, PTT): Essential, especially in patients on anticoagulants or with suspected bleeding disorders.
- Electrolytes, Renal Function, Liver Function Tests: Assess overall metabolic status and identify potential contributing factors.
- Cardiac Biomarkers (Troponin): May be ordered to evaluate for cardiac ischemia, although less directly relevant to hemorrhagic stroke itself unless considering underlying cardiac conditions contributing to risk factors.
- Toxicology Screen: If substance abuse is suspected.
5. Electrocardiogram (ECG): While less directly diagnostic of hemorrhagic stroke, ECG can identify cardiac arrhythmias like atrial fibrillation, which are risk factors for stroke in general and may need to be considered in overall patient management.
Nursing Diagnoses for Hemorrhagic Stroke
Based on the assessment findings, several nursing diagnoses are commonly relevant for patients with hemorrhagic stroke. These diagnoses guide the development of individualized care plans. Key nursing diagnoses include:
1. Ineffective Tissue Perfusion (Cerebral)
This is a primary Nursing Diagnosis For Hemorrhagic Stroke, reflecting the compromised blood supply and oxygen delivery to brain tissue due to bleeding and increased ICP.
- Related to:
- Interruption of arterial blood flow due to hemorrhage
- Increased intracranial pressure (ICP)
- Cerebral edema
- Vasospasm (especially in SAH)
- Compression of brain tissue
- As evidenced by:
- Altered level of consciousness (confusion, lethargy, coma)
- Neurological deficits (weakness, paralysis, sensory loss, speech impairment, visual disturbances)
- Changes in vital signs (hypertension, bradycardia, irregular respirations – Cushing’s triad in late stages of increased ICP)
- Pupillary changes (unequal, sluggish, dilated)
- Headache
- Vomiting
- Seizures
Nursing Interventions:
- Monitor Neurological Status Closely: Frequent neurological assessments (NIHSS, GCS, vital signs, pupillary checks) to detect changes promptly.
- Manage Blood Pressure: Maintain blood pressure within ordered parameters. In acute hemorrhagic stroke, guidelines often recommend cautious blood pressure reduction to prevent re-bleeding, but avoiding hypotension to ensure cerebral perfusion. Strict adherence to prescribed antihypertensive medications is crucial.
- Manage Intracranial Pressure (ICP):
- Positioning: Elevate head of bed 30-45 degrees to promote venous drainage and reduce ICP (if not contraindicated). Maintain neutral head and neck alignment.
- Limit Stimulation: Minimize environmental stimuli, cluster nursing activities to allow for rest periods.
- Avoid Valsalva Maneuver: Prevent straining during bowel movements (administer stool softeners as ordered).
- Fluid Management: Maintain fluid balance, avoiding both dehydration and fluid overload. Isotonic IV fluids are usually preferred.
- Administer Medications as Ordered:
- Osmotic diuretics (mannitol, hypertonic saline): To reduce cerebral edema.
- Antihypertensives: To control blood pressure.
- Anticonvulsants: For seizure prophylaxis or treatment.
- Pain management: Manage headache cautiously, as over-sedation can mask neurological changes.
- Ensure Adequate Oxygenation: Monitor oxygen saturation and provide supplemental oxygen as needed to maintain SpO2 > 94%.
- Prepare for Potential Interventions: Be prepared for interventions to manage increased ICP, such as external ventricular drain (EVD) placement or surgical hematoma evacuation, if indicated.
2. Risk for Increased Intracranial Pressure (ICP)
Even if ICP is not currently elevated, the potential for it to increase rapidly is high in hemorrhagic stroke. This diagnosis focuses on preventative measures.
- Related to:
- Intracranial bleeding
- Cerebral edema formation
- Mass effect from hematoma
- As evidenced by: (Risk diagnosis, so no “as evidenced by” – focus is on risk factors)
- Presence of hemorrhagic stroke
- Potential for hematoma expansion
- Underlying conditions predisposing to increased ICP
Nursing Interventions:
- Implement ICP Precautions: Same as interventions for managing elevated ICP (positioning, limit stimulation, avoid Valsalva, fluid management).
- Frequent Neurological Monitoring: Early detection of ICP increase is critical.
- Monitor for Signs of ICP Increase: Vigilantly assess for headache, vomiting, decreased LOC, pupillary changes, and vital sign changes.
- Educate Patient and Family: Explain the importance of ICP management and report any new symptoms promptly.
3. Impaired Physical Mobility
Neurological deficits from hemorrhagic stroke commonly lead to impaired motor function.
- Related to:
- Neuromuscular impairment (hemiparesis, hemiplegia)
- Decreased muscle strength and control
- Impaired balance and coordination
- As evidenced by:
- Weakness or paralysis of extremities
- Difficulty with voluntary movement
- Impaired balance and gait
- Decreased range of motion
- Need for assistance with mobility
Nursing Interventions:
- Assess Motor Function: Evaluate muscle strength, tone, range of motion, and functional mobility.
- Positioning and Repositioning: Regularly reposition the patient (at least every 2 hours) to prevent pressure ulcers and promote comfort. Use pillows and supports to maintain proper body alignment and prevent contractures.
- Range of Motion (ROM) Exercises: Perform passive or active ROM exercises to maintain joint mobility and prevent stiffness and contractures.
- Assist with Transfers and Ambulation: Provide safe assistance with transfers (bed to chair, chair to commode) and ambulation as tolerated. Use assistive devices (walkers, canes) as needed and prescribed by physical therapy.
- Fall Prevention: Implement fall precautions (bed alarm, side rails, clear environment, non-slip footwear).
- Consult Physical Therapy (PT): Early PT consultation is essential for developing a rehabilitation plan to improve mobility, strength, balance, and coordination.
4. Impaired Verbal Communication
Stroke can affect language centers in the brain, leading to communication deficits.
- Related to:
- Neurological damage affecting speech centers
- Dysarthria (muscle weakness affecting speech)
- Aphasia (language impairment – expressive, receptive, global)
- As evidenced by:
- Difficulty expressing thoughts verbally (expressive aphasia)
- Difficulty understanding spoken language (receptive aphasia)
- Slurred speech (dysarthria)
- Inability to find words
- Frustration with communication attempts
- Use of gestures or nonverbal cues instead of speech
Nursing Interventions:
- Assess Communication Abilities: Determine the type and extent of communication impairment.
- Create a Supportive Communication Environment:
- Speak slowly and clearly, facing the patient.
- Use short, simple sentences.
- Allow ample time for the patient to respond.
- Minimize distractions.
- Utilize Alternative Communication Methods:
- Encourage use of gestures, pointing, writing, drawing, communication boards, or electronic devices.
- Work with family to understand patient’s usual communication methods.
- Speech Therapy Consultation: Refer to speech-language pathology for comprehensive assessment and therapy to improve communication skills.
- Involve Family: Educate family members on effective communication strategies and encourage their participation in therapy sessions.
5. Self-Care Deficit
Motor and cognitive impairments from hemorrhagic stroke can significantly impact the ability to perform self-care activities.
- Related to:
- Neuromuscular impairment (weakness, paralysis)
- Cognitive deficits
- Perceptual deficits
- Fatigue
- As evidenced by:
- Inability to perform activities of daily living (ADLs) such as bathing, dressing, feeding, toileting, and grooming independently.
- Need for assistance with self-care tasks.
- Decreased motivation to perform self-care.
Nursing Interventions:
- Assess Self-Care Abilities: Evaluate the patient’s ability to perform ADLs and identify specific deficits.
- Provide Assistance with ADLs: Assist with bathing, dressing, feeding, toileting, and grooming as needed, while promoting as much independence as possible.
- Adaptive Equipment: Introduce and train the patient in the use of adaptive equipment (long-handled reachers, dressing sticks, plate guards, specialized utensils) to enhance independence.
- Establish Routines: Establish a structured daily routine for self-care activities.
- Occupational Therapy Consultation: Refer to occupational therapy for assessment and interventions to improve self-care skills and recommend adaptive equipment.
- Maintain Skin Integrity: Pay meticulous attention to skin care, especially in areas prone to pressure ulcers due to immobility or sensory deficits.
6. Risk for Aspiration
Dysphagia (difficulty swallowing) is common after stroke, increasing the risk of aspiration.
- Related to:
- Impaired swallowing reflex
- Decreased level of consciousness
- Weakness or paralysis of facial and oral muscles
- As evidenced by: (Risk diagnosis, focus on risk factors)
- Presence of dysphagia
- Weak cough or gag reflex
- History of aspiration
- Decreased level of consciousness
Nursing Interventions:
- Assess Swallowing Function: Perform a swallow screening or bedside swallow evaluation prior to oral intake.
- Maintain NPO Status Initially: Keep the patient NPO (nothing by mouth) until swallowing ability is assessed.
- Positioning for Feeding: Position the patient upright (90 degrees) during and for at least 30-60 minutes after meals.
- Diet Modifications: Implement prescribed diet modifications (thickened liquids, pureed foods) as recommended by speech therapy.
- Feeding Techniques: Provide small, frequent meals. Encourage slow eating and swallowing. Ensure patient is focused and not distracted during meals.
- Suction Equipment at Bedside: Have suction equipment readily available in case of aspiration.
- Monitor for Signs of Aspiration: Assess for coughing, choking, wet voice, or respiratory distress during or after meals.
- Speech Therapy Consultation: Essential for dysphagia evaluation and management, including swallow therapy and diet recommendations.
7. Unilateral Neglect
Unilateral neglect, often associated with right-hemisphere stroke, involves inattention to one side of the body and environment.
- Related to:
- Neurological deficits affecting spatial awareness and attention
- Perceptual deficits
- As evidenced by:
- Ignoring stimuli on the affected side
- Not attending to one side of the body (e.g., not grooming one side, bumping into objects on one side)
- Visual field deficits (hemianopsia)
- Spatial disorientation
Nursing Interventions:
- Assess for Unilateral Neglect: Observe for signs of neglect during self-care, mobility, and interactions with the environment.
- Approach Patient from Unaffected Side Initially: To maximize awareness and communication.
- Encourage Patient to Attend to Neglected Side:
- Place objects (call light, water, personal items) on the affected side to encourage attention.
- Teach scanning techniques (consciously turning head to the neglected side).
- Provide tactile and auditory stimulation to the neglected side.
- Safety Precautions: Protect the neglected side from injury (e.g., position limbs to prevent injury, pad side rails if needed).
- Rehabilitation Strategies: Work with occupational therapy and physical therapy to implement strategies to address neglect, such as visual scanning exercises and environmental adaptation.
Stroke Recovery and Prevention
Nursing care extends beyond the acute phase of hemorrhagic stroke. Rehabilitation and secondary stroke prevention are crucial.
1. Stroke Rehabilitation: Referral to comprehensive stroke rehabilitation programs is essential. This interdisciplinary approach includes:
- Physical Therapy: To improve motor function, strength, balance, and mobility.
- Occupational Therapy: To enhance self-care skills, fine motor skills, and address perceptual and cognitive deficits.
- Speech Therapy: To address communication and swallowing difficulties.
- Cognitive Therapy: To manage cognitive impairments.
- Psychological Support: To address emotional and psychological impact of stroke.
2. Patient and Family Education: Provide comprehensive education on:
- Medications: Purpose, dosage, side effects, and importance of adherence (especially antihypertensives, anticoagulants if prescribed for secondary prevention).
- Lifestyle Modifications:
- Blood Pressure Control: Dietary sodium restriction, regular exercise, medication adherence.
- Smoking Cessation: Strongly encourage quitting smoking.
- Moderate Alcohol Consumption: If alcohol is consumed, limit intake.
- Healthy Diet: Low in saturated and trans fats, cholesterol, and sodium; rich in fruits, vegetables, and whole grains.
- Regular Exercise: Aim for at least 30 minutes of moderate-intensity exercise most days of the week.
- Weight Management: Achieve and maintain a healthy weight.
- Stroke Warning Signs (F.A.S.T.): Reinforce recognition of stroke symptoms and the importance of immediate medical attention.
- Follow-up Care: Emphasize the importance of regular medical check-ups and adherence to treatment plans.
- Support Groups: Connect patients and families with stroke support groups for emotional support and peer learning.
Conclusion
Nursing diagnoses are fundamental to providing individualized and effective care for patients experiencing hemorrhagic stroke. By conducting thorough assessments, identifying relevant nursing diagnoses such as Ineffective Cerebral Tissue Perfusion, Risk for Increased Intracranial Pressure, and Impaired Physical Mobility, nurses can develop targeted care plans. These plans guide interventions aimed at minimizing brain damage, managing complications, facilitating recovery, and preventing future strokes. A collaborative, interdisciplinary approach, with nurses at the forefront of patient care and education, is vital to improving outcomes and quality of life for individuals affected by hemorrhagic stroke.
References
(To be populated with relevant references – example below)
- American Heart Association/American Stroke Association. (2019). Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke, 50(3), e344-e418.
- Hickey, J. V. (2019). The clinical practice of neurological and neurosurgical nursing. Wolters Kluwer.
- National Institute of Neurological Disorders and Stroke. (n.d.). Stroke. Retrieved from https://www.ninds.nih.gov/Disorders/All-Disorders/Stroke-Information-Page
