CVA can be ischemic or hemorrhagic. Hemorrhagic strokes results from a weakened vessel that ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue. The two types of hemorrhagic strokes are intracerebral hemorrhage or subarachnoid hemorrhage. Hemorrhagic strokes have the slowest recovery of all types of stroke.
The nursing goal for patients with stroke can be towards maintaining effective tissue perfusion, preventing further complications, and enhancing coping.
Check out the updated version: 8 Stroke Nursing Care Plans
Nursing Care Plans
Ineffective Cerebral Tissue Perfusion
The presence of partial blockage of the blood vessel can be multifactorial. These can be due to vasoconstriction, platelet adherence on rough surface, fat accumulation and therefore decreases elasticity of vessel wall leading to alteration of blood perfusion with the initiation of the clotting sequence. This may later lead to the development of thrombus which can be loosened and dislodged in some areas of the brain such as mid cerebral carotid artery that may lead to alteration of blood perfusion and further develop to cerebral infarct.
Impaired Physical Mobility
Stroke in w/c nerve cells in the brain die for lack of oxygen can result in permanent disability for the patient because the pathways that transmit information in the brain are interrupted. The symptoms often primarily affect only one side of the body because blood flow is cut off to only part of the brain.
Motor deficits are the most obvious effect of stroke. Symptoms are caused by the destruction of motor neurons in the pyramidal pathways (nerve fibers in the brain and passing through the spinal cord to motor tract.)
Motor deficit are the most obvious effect of stroke. Symptoms are caused by destruction of motor neurons in the pyramidal pathways (nerve fibers in the brain and passing through the spinal cord to the motor tract.) When this happens, activities of daily living can be impaired and even self-care.
Risk for Injury
CVA pt is a t risk for injury since it may affect the anterior or middle cerebral artery leading to an infarction in the motor strip of the frontal cortex and this may cause hemiparesis or hemiplegia with the manifestations it may predispose an individual for any injury since part of their body is not functioning well.
Risk for Unilateral Neglect
An ischemic stroke, cerebrovascular accident (CVA), or “brain attack” is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. In an ischemic brain attack, there is disruption of the cerebral blood flow due to obstruction of a blood vessel. This can cause a wide variety of neurologic deficits depending on the location of the lesion with which vessels are obstructed. A stroke is an upper motor neuron lesion and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate (cross), a disturbance of voluntary motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. The most common motor dysfunction is hemiplegia (paralysis on one side of the body).
Other Nursing Care Plans
- Risk for Aspiration. This is due to depressed or absent cough reflex due to infarction of a brain area.
- Risk for Hyperthermia. This may be due to bleeding or edema of the hypothalamus which can lead to ischemia and thus changes in the thermoregulatory center of the brain.
- Risk for Impaired Skin Integrity. This is due to the loss of protective sensation and decreased ability to move away from injury.
- Imbalanced Nutrition: Less Than Body Requirements. If the client has inability to swallow secondary to stroke.
- Impaired Verbal Communication. Loss of verbal communication may be due to ischemia and may be frustrating to the patient.
- Ineffective Coping. Management of stroke requires a strong need for healthy lifestyle or change, this may be difficult for the patient.
- Disturbed Thought Process.
- Disturbed Sensory Perception: Visual