- 1 Definition
- 2 Description
- 3 Risk Factors
- 4 Pathophysiology
- 5 Statistics
- 6 Clinical Manifestations
- 7 Diagnostic Studies
- 8 Prevention
- 9 Medical Management
- 10 Management of Complications
- 11 Nursing Assessment
- 12 Nursing Diagnoses
- 13 Potential Complications
- 14 Planning and Goals
- 15 Nursing Priorities
- 16 Nursing Care Plans
- 17 Nursing Interventions
- 18 Evaluation
- 19 Discharge Goals
- 20 References
A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a sudden loss of brain function resulting from a disruption of the blood supply to a part of the brain.
- Stroke is the primary cerebrovascular disorder in the United States.
- Strokes are usually hemorrhagic (15%) or ischemic/nonhemorrhagic (85%).
- Ischemic strokes are categorized according to their cause: large artery thrombotic strokes (20%), small penetrating artery thrombotic strokes (25%), cardiogenic embolic strokes (20%), cryptogenic strokes (30%), and other (5%).
- Cryptogenic strokes have no known cause, and other strokes result from causes such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.
- The result is an interruption in the blood supply to the brain, causing temporary or permanent loss of movement, thought, memory, speech, or sensation.
- Advanced age (older than 55 years)
- Gender (Male)
- Race (African American)
- Atrial ﬁbrillation
- Asymptomatic carotid stenosis and valvular heart disease (eg, endocarditis, prosthetic heart valves)
- Periodontal disease
Cerebrovascular accident (CVA, “stroke” or “brain attack”) is injury or death to parts of the brain caused by an interruption in the blood supply to that area causing dis- ability, such as paralysis or speech impairment.
- Morbidity: In 2005, prevalence of stroke was estimated at 2.3 million males and 3.4 million females; many of the approximately 5.7 million U.S. stroke survivors have permanent stroke-related disabilities.
- Mortality: In 2004, stroke ranked ﬁfth as the cause of death for those aged 45 to 64 years and third for those aged 65 years or older (National Heart, Lung and Blood Institute [NHLBI], 2007), with 150,000 deaths (American Heart Association and American Stroke Association, 2008); hemorrhagic strokes are more severe, and mortality rates are higher than ischemic strokes, with a 30-day mortality rate of 40% to 80%.
- Cost: Estimated direct and indirect cost for 2008 was $65.5 billion (American Heart Association and American Stroke Association, 2008).
General signs and symptoms include numbness or weakness of face, arm, or leg (especially on one side of body); confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; loss of balance, dizziness, difﬁculty walking; or sudden severe headache.
- Hemiplegia, hemiparesis
- Flaccid paralysis and loss of or decrease in the deep tendon reﬂexes (initial clinical feature) followed by (after 48 hours) reappearance of deep reﬂexes and abnormally increased muscle tone (spasticity)
- Dysarthria (difﬁculty speaking)
- Dysphasia (impaired speech) or aphasia (loss of speech)
- Apraxia (inability to perform a previously learned action)
Perceptual Disturbances and Sensory Loss
- Visual-perceptual dysfunctions (homonymous hemianopia [loss of half of the visual ﬁeld])
- Disturbances in visual spatial relations (perceiving the relation of two or more objects in spatial areas), frequently seen in patients with right hemispheric damage
- Sensory losses: slight impairment of touch or more severe with loss of proprioception; difﬁculty in interrupting visual, tactile, and auditory stimuli
Impaired Cognitive and Psychological Effects
- Frontal lobe damage: Learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reﬂected in a limited attention span, difﬁculties in comprehension, forgetfulness, and lack of motivation.
- Depression, other psychological problems: emotional lability, hostility, frustration, resentment, and lack of cooperation.
- CT scan (with/without enhancement): Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions. Note: May not immediately reveal all changes, e.g., ischemic infarcts are not evident on CT for 8–12 hr; however, intracerebral hemorrhage is immediately apparent; therefore, emergency CT is always done before administering tissue plasminogen activator (t-PA). In addition, patients with TIA commonly have a normal CT scan.
- PET scan: Provides data on cerebral metabolism and blood flow changes, especially in ischemic stroke.
- MRI: Shows areas of infarction, hemorrhage, AV malformations; and areas of ischemia.
- Cerebral angiography: Helps determine specific cause of stroke, e.g., hemorrhage or obstructed artery, pinpoints site of occlusion or rupture. Digital subtraction angiography evaluates patency of cerebral vessels, identifies their position in head and neck, and detects/evaluates lesions and vascular abnormalities.
- Lumbar puncture (LP): Pressure is usually normal and CSF is clear in cerebral thrombosis, embolism, and TIA. Pressure elevation and grossly bloody fluid suggest subarachnoid and intracerebral hemorrhage. CSF total protein level may be elevated in cases of thrombosis because of inflammatory process. LP should be performed if septic embolism from bacterial endocarditis is suspected.
- Transcranial Doppler ultrasonography: Evaluates the velocity of blood flow through major intracranial vessels; identifies AV disease, e.g., problems with carotid system (blood flow/presence of atherosclerotic plaques).
- EEG: Identifies problems based on reduced electrical activity in specific areas of infarction; and can differentiate seizure activity from CVA damage.
- X-rays (skull): May show shift of pineal gland to the opposite side from an expanding mass; calcifications of the internal carotid may be visible in cerebral thrombosis; partial calcification of walls of an aneurysm may be noted in subarachnoid hemorrhage.
- Laboratory studies to rule out systemic causes: CBC, platelet and clotting studies, VDRL/RPR, erythrocyte sedimentation rate (ESR), chemistries (glucose, sodium).
- ECG, chest x-ray, and echocardiography: To rule out cardiac origin as source of embolus (20% of strokes are the result of blood or vegetative emboli associated with valvular disease, dysrhythmias, or endocarditis).
- Help patients alter risk factors for stroke; encourage patient to quit smoking, maintain a healthy weight, follow a healthy diet (including modest alcohol consumption), and exercise daily.
- Prepare and support patient through carotid endarterectomy.
- Administer anticoagulant agents as prescribed (eg, low dose aspirin therapy).
- Recombinant tissue plasminogen activator (tPA), unless contraindicated; monitor for bleeding
- Anticoagulation therapy
- Management of increased intracranial pressure (ICP): osmotic diuretics, maintain PaCO2 at 30 to 35 mm Hg, position to avoid hypoxia (elevate the head of bed to promote venous drainage and to lower increased ICP)
- Possible hemicraniectomy for increased ICP from brain edema in a very large stroke
- Intubation with an endotracheal tube to establish a patent airway, if necessary
- Continuous hemodynamic monitoring (the goals for blood pressure remain controversial for a patient who has not received thrombolytic therapy; antihypertensive treatment may be withheld unless the systolic blood pressure exceeds mm Hg or the diastolic blood pressure exceeds 120 mm Hg)
- Neurologic assessment to determine if the stroke is evolving and if other acute complications are developing
Management of Complications
- Decreased cerebral blood ﬂow: Pulmonary care, maintenance of a patent airway, and administration of supplemental oxygen as needed.
- Monitor for UTIs, cardiac dysrhythmias, and complications of immobility.
Acute phase starts during the first three days. Weigh patient (used to determine medication dosages), and maintain a neurologic ﬂow sheet to reﬂect the following nursing assessment parameters:
- Change in level of consciousness or responsiveness, ability to speak, and orientation
- Presence or absence of voluntary or involuntary movements of the extremities: muscle tone, body posture, and head position
- Stiffness or ﬂaccidity of the neck
- Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position
- Color of face and extremities; temperature and moisture of skin
- Quality and rates of pulse and respiration; ABGs, body temperature, and arterial pressure
- Volume of ﬂuids ingested or administered and volume of urine excreted per 24 hours
- Signs of bleeding
- Blood pressure maintained within normal limits
Assess the following functions:
- Mental status (memory, attention span, perception, orientation, affect, speech/language).
- Sensation and perception (usually the patient has decreased awareness of pain and temperature).
- Motor control (upper and lower extremity movement); swallowing ability, nutritional and hydration status, skin integrity, activity tolerance, and bowel and bladder function.
- Continue focusing nursing assessment on impairment of function in patient’s daily activities.
- Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
- Acute pain related to hemiplegia and disuse
- Deﬁcient self-care (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke sequelae
- Disturbed sensory perception (kinesthetic, tactile, or visual) related to altered sensory reception, transmission, and/or integration
- Impaired swallowing
- Impaired urinary elimination related to ﬂaccid bladder, detrusor instability, confusion, or difﬁculty in communicating
- Disturbed thought processes related to brain damage
- Impaired verbal communication related to brain damage
- Risk for impaired skin integrity related to hemiparesis or hemiplegia, decreased mobility
- Interrupted family processes related to catastrophic illness and caregiving burdens
- Sexual dysfunction related to neurologic deﬁcits or fear of failure
- Decreased cerebral blood ﬂow due to increased ICP
- Inadequate oxygen delivery to the brain
Planning and Goals
The major goals for the patient (and family) may include improved mobility, avoidance of shoulder pain, achievement of self-care, relief of sensory and perceptual deprivation, prevention of aspiration, incontinence of bowel and bladder, improved thought processes, achieving a form of communication, maintaining skin integrity, restored family functioning, improved sexual function, and absence of complications. Goals are affected by knowledge of what the patient was like before the stroke.
- Promote adequate cerebral perfusion and oxygenation.
- Prevent/minimize complications and permanent disabilities.
- Assist patient to gain independence in ADLs.
- Support coping process and integration of changes into self-concept.
- Provide information about disease process/prognosis and treatment/rehabilitation needs.
Nursing Care Plans
For nursing care plans, please see:
- 8 Cerebrovascular Accident (Stroke) Nursing Care Plans
- 14 Cerebrovascular Accident Nursing Care Plans
- Hemorrhagic Stroke Nursing Care Plans
Improving Mobility and Preventing Deformities
- Position to prevent contractures; use measures to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies.
- Apply a splint at night to prevent ﬂexion of affected extremity.
- Prevent adduction of the affected shoulder with a pillow placed in the axilla.
- Elevate affected arm to prevent edema and ﬁbrosis.
- Position ﬁngers so that they are barely ﬂexed; place hand in slight supination. If upper extremity spasticity is noted, do not use a hand roll; dorsal wrist splint may be used.
- Change position every 2 hours; place patient in a prone position for 15 to 30 minutes several times a day.
Establishing an Exercise Program
- Provide full range of motion four or ﬁve times a day to maintain joint mobility, regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. If tightness occurs in any area, perform range of motion exercises more frequently.
- Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.
- Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (eg, shortness of breath, chest pain, cyanosis, and increasing pulse rate).
- Supervise and support patient during exercises; plan frequent short periods of exercise, not longer periods; encourage patient to exercise unaffected side at intervals throughout the day.
Preparing for Ambulation
- Start an active rehabilitation program when consciousness returns (and all evidence of bleeding is gone, when indicated).
- Teach patient to maintain balance in a sitting position, then to balance while standing (use a tilt table if needed).
- Begin walking as soon as standing balance is achieved (use parallel bars and have wheelchair available in anticipation of possible dizziness).
- Keep training periods for ambulation short and frequent.
Preventing Shoulder Pain
- Never lift patient by the ﬂaccid shoulder or pull on the affected arm or shoulder.
- Use proper patient movement and positioning (eg, ﬂaccid arm on a table or pillows when patient is seated, use of sling when ambulating).
- Range of motion exercises are beneﬁcial, but avoid over strenuous arm movements.
- Elevate arm and hand to prevent dependent edema of the hand; administer analgesic agents as indicated.
Enhancing Self Care
- Encourage personal hygiene activities as soon as the patient can sit up; select suitable self care activities that can be carried out with one hand.
- Help patient to set realistic goals; add a new task daily.
- As a ﬁrst step, encourage patient to carry out all self care activities on the unaffected side.
- Make sure patient does not neglect affected side; provide assistive devices as indicated.
- Improve morale by making sure patient is fully dressed during ambulatory activities.
- Assist with dressing activities (eg, clothing with Velcro closures; put garment on the affected side ﬁrst); keep environment uncluttered and organized.
- Provide emotional support and encouragement to prevent fatigue and discouragement.
Managing Sensory-Perceptual Difﬁculties
- Approach patient with a decreased ﬁeld of vision on the side where visual perception is intact; place all visual stimuli on this side.
- Teach patient to turn and look in the direction of the defective visual ﬁeld to compensate for the loss; make eye contact with patient, and draw attention to affected side.
- Increase natural or artiﬁcial lighting in the room; provide eyeglasses to improve vision.
- Remind patient with hemianopsia of the other side of the body; place extremities so that patient can see them.
Assisting with Nutrition
- Observe patient for paroxysms of coughing, food dribbling out or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids.
- Consult with speech therapist to evaluate gag reﬂexes; assist in teaching alternate swallowing techniques, advise patient to take smaller boluses of food, and inform patient of foods that are easier to swallow; provide thicker liquids or pureed diet as indicated.
- Have patient sit upright, preferably on chair, when eating and drinking; advance diet as tolerated.
- Prepare for GI feedings through a tube if indicated; elevate the head of bed during feedings, check tube position before feeding, administer feeding slowly, and ensure that cuff of tracheostomy tube is inﬂated (if applicable); monitor and report excessive retained or residual feeding.
Attaining Bowel and Bladder Control
- Perform intermittent sterile catheterization during period of loss of sphincter control.
- Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
- Assist the male patient to an upright posture for voiding.
- Provide highﬁber diet and adequate ﬂuid intake (2 to 3 L/day), unless contraindicated.
- Establish a regular time (after breakfast) for toileting.
Improving Thought Processes
- Reinforce structured training program using cognitive perceptual retraining, visual imagery, reality orientation, and cueing procedures to compensate for losses.
- Support patient: Observe performance and progress, give positive feedback, convey an attitude of conﬁdence and hopefulness; provide other interventions as used for improving cognitive function after a head injury.
- Reinforce the individually tailored program.
- Jointly establish goals, with patient taking an active part.
- Make the atmosphere conducive to communication, remaining sensitive to patient’s reactions and needs and responding to them in an appropriate manner; treat patient as an adult.
- Provide strong emotional support and understanding to allay anxiety; avoid completing patient’s sentences.
- Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes may help with memory and concentration; a communication board may be used.
- Maintain patient’s attention when talking with patient, speak slowly, and give one instruction at a time; allow patient time to process.
- Talk to aphasic patients when providing care activities to provide social contact.
Maintaining Skin Integrity
- Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.
- Employ pressure relieving devices; continue regular turning and positioning (every 2 hours minimally); minimize shear and friction when positioning.
- Keep skin clean and dry, gently massage healthy dry skin, and maintain adequate nutrition.
Improving Family Coping
- Provide counseling and support to family.
- Involve others in patient’s care; teach stress management techniques and maintenance of personal health for family coping.
- Give family information about the expected outcome of the stroke, and counsel them to avoid doing things for patient that he or she can do.
- Develop attainable goals for patient at home by involving the total health care team, patient, and family.
- Encourage everyone to approach patient with a supportive and optimistic attitude, focusing on abilities that remain; explain to family that emotional lability usually improves with time.
Helping the Patient Cope with Sexual Dysfunction
- Perform indepth assessment to determine sexual history before and after the stroke.
- Interventions for patient and partner focus on providing relevant information, education, reassurance, adjustment
- of medications, counseling regarding coping skills, suggestions for alternative sexual positions, and a means of sexual expression and satisfaction.
Teach patient to resume as much selfcare as possible; provide assistive devices as indicated.
- Have occupational therapist make a home assessment and recommendations to help patient become more independent.
- Coordinate care provided by numerous health care professionals; help family plan aspects of care.
- Advise family that patient may tire easily, become irritable and upset by small events, and show less interest in daily events.
- Make referral for home speech therapy. Encourage family involvement. Provide family with practical instructions to help patient between speech therapy sessions.
- Discuss patient’s depression with physician for possible antidepressant therapy.
- Encourage patient to attend community based stroke clubs to give a feeling of belonging and fellowship with others.
- Encourage patient to continue with hobbies, recreational and leisure interests, and contact with friends to prevent social isolation.
- Encourage family to support patient and give positive reinforcement.
- Remind spouse and family to attend to personal health and wellbeing.
Expected Patient Outcomes
- Achieves improved mobility.
- Has no complaints of pain.
- Achieves self care; performs hygiene care; uses adaptive equipment.
- Demonstrates techniques to compensate for altered sensory reception, such as turning the head to see people or objects.
- Demonstrates safe swallowing.
- Achieves normal bowel and bladder elimination.
- Participates in cognitive improvement program.
- Demonstrates improved communication.
- Maintains intact skin without breakdown.
- Family members demonstrate a positive attitude and coping mechanisms.
- Develops alternative approaches to sexual expression.
- Cerebral function improved, neurological deficits resolving/stabilized.
- Complications prevented or minimized.
- ADL needs met by self or with assistance of other(s).
- Coping with situation in positive manner, planning for the future.
- Disease process/prognosis and therapeutic regimen understood.
- Plan in place to meet needs after discharge.
- American Heart Association. Heart Disease and Stroke Statistics — 2014 Update.