12 Stroke (Cerebrovascular Accident) Nursing Care Plans

Risk for Ineffective Cerebral Tissue Perfusion

The goals for this nursing diagnosis include decreasing the risk of ineffective cerebral tissue perfusion. Ischemic stroke pathophysiology starts with inadequate blood supply to a focal area of brain tissue. The central core of tissue evolves toward death within minutes and is referred to as the area of infarction. More adenosine triphosphate (ATP) is consumed than produced in the area of reduced blood flow, leading to decreased energy stores, ionic imbalance, and electric disturbances. These ischemia-related changes can later lead to cell membrane destruction and cell death (Tadi & Lui, 2023).

May be related to

• Clot emboli
• Hemorrhage of cerebral vessel
• Occlusive disorder
• Cerebral vasospasms
• Cerebral edema

Possibly evidenced by

• Altered level of consciousness
• Memory loss
• Changes in motor and sensory responses
• Restlessness
• Sensory, language, intellectual, and emotional deficits
• Changes in vital signs

Desired Outcomes

• The client will maintain the usual/improved level of consciousness, cognition, and motor/sensory function.
• The client will demonstrate stable vital signs and the absence of signs of increased ICP.
• The client will display no further deterioration/recurrence of deficits.

Nursing Assessment and Rationales

1. Assess airway patency and respiratory pattern.
Neurologic deficits of a stroke may include loss of gag reflex or cough reflex; thus, airway patency and breathing pattern must be part of the initial assessment. Clients with a decreased level of consciousness should be assessed to ensure that they are able to protect their airways. Clients with stroke, especially hemorrhagic stroke, can suffer quick clinical deterioration; therefore, constant reassessment is critical (Jauch & Lutsep, 2022).

2. Assess factors related to decreased cerebral perfusion and the potential for increased intracranial pressure (ICP).
The extensive neurologic examination will help guide therapy and the choice of interventions. Contusions, lacerations, and deformities may suggest trauma as the etiology for the client’s symptoms. ICP elevation after a stroke compromises the perfusion of the ischemic penumbra by reducing cerebral perfusion pressure. Even an ICP elevation of 5 mm Hg above pre-stroke levels can dramatically reduce the blood flow through the collateral-supplied arterioles feeding the ischemic penumbra. This suggests that ICP elevation is probably a dominant cause of collateral failure and early neurological deterioration (McLeod et al., 2023).

3. Recognize the clinical manifestations of a transient ischemic attack (TIA).
Clients with TIA present with temporary neurologic symptoms such as sudden loss of motor, sensory, or visual function caused by transient ischemia to a specific region of the brain, with their brain imaging scan showing no evidence of ischemia. Recognizing symptoms of TIA may serve as a warning of an impending stroke as approximately 15% of all strokes are preceded by a TIA (Amarenco et al., 2018; Sacco, 2004). Evaluation and prompt treatment of the patient who experienced TIA can help prevent stroke and its irreversible complications.

4. Frequently assess and monitor neurological status.
This assesses trends in the level of consciousness (LOC), the potential for increased ICP, and helps determine the location, extent, and progression of damage. The prognosis depends on the neurologic condition of the client. It may also reveal the presence of TIA, which may warn of impending thrombotic CVA. Neurologic assessment includes a change in the level of consciousness or responsiveness, response to stimulation, orientation to time, place, and person, eye-opening, pupillary reactions to light, accommodation, and size of pupils.

5. Monitor changes in blood pressure, and compare BP readings in both arms.
Hypertension is a significant risk factor for stroke. Fluctuation in blood pressure may occur because of cerebral injury in the vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse), and increased ICP may occur because of tissue edema or clot formation. Subclavian artery blockage may be revealed by the difference in pressure readings between arms. Many clients with stroke are hypertensive at baseline, and their blood pressure may become more elevated after stroke. While hypertension at presentation is common, blood pressure decreases spontaneously over time in most clients (Jauch & Lutsep, 2022). Additionally, if the client is eligible for fibrinolytic therapy, blood pressure control is essential to decrease the risk of bleeding.

6. Monitor heart rate and rhythm, and assess for murmurs.
Changes in rate, especially bradycardia, can occur because of brain damage. Dysrhythmias and murmurs may reflect cardiac disease, precipitating CVA (stroke after MI or valve dysfunction). The presence of atrial fibrillation increases the risk of emboli formation. Strokes may occur concurrently with other acute cardiac conditions, such as acute myocardial infarction and acute heart failure; thus, auscultation for murmurs and gallops is recommended (Jauch & Lutsep, 2022).

7. Monitor respirations, noting patterns and rhythm, Cheyne-Stokes respiration.
Irregular respiration can suggest the location of cerebral insult or increasing ICP and the need for further intervention, including possible respiratory support. Ischemic strokes, unless large or involve the brainstem, do not tend to cause immediate problems with airway patency, breathing, or circulation compromise. On the other hand, clients with intracerebral or subarachnoid hemorrhage frequently require intervention for airway protection and ventilation (Jauch & Lutsep, 2022).

8. Monitor computed tomography scan.
A CT scan is the initial diagnostic test performed for clients with a stroke that is executed immediately once the client presents to the emergency department. CT scan is used to determine if the event is ischemic or hemorrhagic as the type of stroke will guide therapy. A computed tomography angiography (CTA) may also be performed to detect intracranial occlusions and the extent of occlusion in the arterial tree (Menon & Demchuk, 2011). The expedient acquisition is of utmost importance in acute stroke imaging because of the narrow window of time available for definitive ischemic stroke treatment with pharmacologic agents and mechanical devices (Jauch & Lutsep, 2022).

9. Evaluate pupils, noting size, shape, equality, and light reactivity.
Pupil reactions are regulated by the oculomotor (III) cranial nerve and help determine whether the brain stem is intact. Pupil size and equality are determined by the balance between parasympathetic and sympathetic innervation. Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves. Studies show the development of oculomotor cranial nerve palsy was associated with an increased risk of subsequent stroke, and the risk for stroke reduced with time only after third and fourth nerve palsies, but not with sixth nerve palsy (Park et al., 2018).

10. Document changes in vision: reports of blurred vision, alterations in the visual field, and depth perception.
Visual disturbances may occur if the aneurysm is adjacent to the oculomotor nerve. Specific visual alterations reflect an area of the brain involved. Many clients report vision difficulties, including poor visual memory, a decrease in balance, decreased depth perception, and reading problems. Spatial inattention can result in not paying attention to the side of the body affected by stroke (American Stroke Association, 2018).

11. Assess higher functions, including speech, if the client is alert.
Changes in cognition and speech content indicate location and degree of cerebral involvement and may indicate deterioration or increased ICP. input from family members, coworkers, and bystanders may be required to help establish the exact time of onset, especially in right hemispheric strokes accompanied by neglect or left hemispheric strokes with aphasia (Jauch & Lutsep, 2022).

12. Assess for nuchal rigidity, twitching, increased restlessness, irritability, and the onset of seizure activity.
Nuchal rigidity (pain and rigidity of the back of the neck) may indicate meningeal irritation. Seizures may reflect an increase in ICP or cerebral injury requiring further evaluation and intervention. A seizure occurs in 2 to 23% of clients within the first days after an ischemic stroke. Moreover, a fraction of clients who have experienced stroke develops chronic seizure disorders (Jauch & Lutsep, 2022).

13. Use the National Institutes of Health Stroke Scale (NIHSS)  for assessing neurologic impairment.
A useful tool in quantifying neurologic impairment is the NIHSS. The NIHSS enables the healthcare provider to rapidly determine the severity and possible location of the stroke. NIHSS scores are strongly associated with outcomes and can help to identify those clients who are likely to benefit from reperfusion therapies and those who are at higher risk of developing complications from stroke (Jauch & Lutsep, 2022).

14. Screen the client for stroke risk.
Risk factors for ischemic stroke include modifiable and nonmodifiable conditions. Identification of risk factors in each client can uncover clues to the cause of the stroke and the most appropriate treatment and secondary prevention plan. In a prospective study, it was found that migraine with aura was a strong risk factor for any type of stroke (Jauch & Lutsep, 2022).

15. Monitor blood glucose levels.
Hypoglycemia and hyperglycemia need to be identified and treated early in the evaluation. Not only can both produce symptoms that mimic ischemic stroke, but they can also aggravate ongoing neuronal ischemia (Jauch & Lutsep, 2022).

Nursing Interventions and Rationales

1. Position with head slightly elevated and in a neutral position.
This reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion. During the acute phase of stroke, maintain the head of the bed at less than 30 degrees. Because prolonged immobilization may lead to its own complications, the client should not be kept flat for longer than 24 hours. Additionally, lying flat can increase ICP (Jauch & Lutsep, 2022).

2. Maintain bedrest, provide a quiet and relaxing environment, and restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit the duration of procedures.
Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may be needed to prevent rebleeding. Client position, hyperventilation, and hyperosmolar therapy may be used for clients with increased ICP secondary to closed head injury. The maximum severity of cerebral edema is typically reached 72 to 96 hours after the onset of stroke (Jauch & Lutsep, 2022).

3. Prevent straining at stool, holding breath, and physical exertion.
Valsalva maneuver increases ICP and potentiates the risk of rebleeding. Significant cerebral edema after ischemic stroke is thought to be somewhat rare (10 to 20%). Early indicators of ischemia on presentation and on non-contrast CT are independent indicators of potential swelling and deterioration (Jauch & Lutsep, 2022).

4. Stress smoking cessation.
Cigarette smoking is a well-established risk factor for all forms of stroke. Smoking increases the risk of stroke by three to fourfold (Shah & Cole, 2010). Encouraging the client to quit, counseling, nicotine replacement, and oral smoking cessation medications are some approaches to aid in quitting. Nurses are the first line of treatment among hospital staff capable of planning and implementing interventions to quit smoking. Research suggests that smoking cessation counseling by nurses plays a crucial role in quitting smoking (Kazemzadeh, Manzari, & Pouresmail, 2017).

5. Administer supplemental oxygen as indicated.
This reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema formation. Supplemental oxygen is recommended when the client has a documented oxygen requirement (oxygen saturation <95%) (Jauch & Lutsep, 2022).

6. Administer medications as indicated: 

6.1. Thrombolytics: Tissue plasminogen activator (tPA), recombinant tPA (rt-PA)
These are given concurrently with an anticoagulant to treat ischemic stroke. tPA converts plasminogen to plasmin, dissolving the blood clot that is blocking blood flow to the brain. Fibrinolytic therapy is administered 3 to 4.5 hours after symptom onset was found to improve neurologic outcomes in the European Cooperative Acute Stroke Study III (ECASS III), suggesting a wider time window for fibrinolysis in carefully selected clients (Jauch & Lutsep, 2022). It is given intravenously (or intra-arterial delivery) as soon as ischemic stroke is confirmed. Monitor for signs of bleeding. Thrombolytics are contraindicated in clients with hemorrhagic stroke.

6.2. Anticoagulants: warfarin sodium, low-molecular-weight heparin
These are administered to prevent further extension of the clot and formation of new clots and improve cerebral blood flow. They do not dissolve an existing clot. Clients with embolic stroke who have another indication for anticoagulation may be placed on anticoagulation therapy nonemergently, with the goal of preventing further embolic disease. However, the potential benefits of that intervention must be weighed against the risk of hemorrhagic transformation (Jauch & Lutsep, 2022). Anticoagulants are never administered to clients with hemorrhagic stroke.

6.3. Antiplatelet agents: aspirin, dipyridamole, ticlopidine
Daily low-dose administration of aspirin interferes with platelet aggregation. It can help decrease the incidence of cerebral infarction in clients who have experienced TIAs from a stroke of embolic or thrombotic in origin. AHA/ASA guidelines recommend giving aspirin, 325 mg orally, within 24 to 48 hours of ischemic stroke onset (Jauch & Lutsep, 2022). These medications are contraindicated in hypertensive clients because of the increased risk of hemorrhage.

6.4. Antifibrinolytics: aminocaproic acid
This is used with caution in hemorrhagic disorder to prevent lysis of formed clots and subsequent rebleeding. Fibrinolytics restore cerebral blood flow in some clients with acute ischemic stroke and may lead to improvement or resolution of neurologic deficits. Unfortunately, fibrinolytics may also cause symptomatic intracranial hemorrhage (Jauch & Lutsep, 2022).

6.5. Antihypertensives: ACE inhibitors, diuretics
These are used for clients undergoing fibrinolytic therapy; blood pressure control is essential to decrease the risk of bleeding. Thresholds for antihypertensive treatment in acute ischemic stroke clients who are not fibrinolysis candidates, according to the 2013 ASA guidelines, are systolic blood pressure higher than 200 mm Hg or diastolic blood pressure above 120 mm Hg. A reasonable goal is to lower blood pressure by 15% during the first 24 hours after the onset of the stroke. (Jauch & Lutsep, 2022)  Antihypertensives are also used for secondary stroke prevention.

6.6. Peripheral vasodilators: nitroprusside sodium
Transient hypertension often occurs during an acute stroke and usually resolves without therapeutic intervention. It is used to improve collateral circulation or decrease vasospasm. Vasodilators lower blood pressure through direct vasodilation and relaxation of the vascular smooth muscle (Jauch & Lutsep, 2022).

6.7. Neuroprotective agents: excitatory amino acid inhibitors and gangliosides.
The rationale for the use of neuroprotective agents is that reducing the release of excitatory neurotransmitters by neurons in the ischemic penumbra may enhance the survival of these neurons. However, no single neuroprotective agent in ischemic stroke has as yet been supported by randomized, placebo-controlled human studies (Jauch & Lutsep, 2022).

6.8. Anticonvulsants: phenytoin and phenobarbital; benzodiazepines: diazepam, lorazepam
Generally, agents used for treating recurrent convulsive seizures are also used in clients with seizures after a stroke. Benzodiazepines, typically diazepam and lorazepam, are the first-line drugs for ongoing seizures. Diazepam is useful in controlling active seizures and should be augmented by longer-acting anticonvulsants such as phenytoin or phenobarbital (Jauch & Lutsep, 2022).

6.9. Stool softeners.
This prevents straining during bowel movement and the corresponding increase of ICP. Constipation frequently occurs after a stroke (Li et al., 2017). Clients who experienced a stroke typically reduce their physical mobility, fluid intake, and fiber intake because they may have difficulty swallowing. Furthermore, dependence on others to use the toilet may lead to constipation. Finally, the use of medications that can affect bowel function, dehydrating agents, for example, may prevent the gut from absorbing water (Li et al., 2017).

7. Monitor laboratory studies as indicated: prothrombin time (PT), activated partial thromboplastin time (aPTT), and Dilantin level.
This provides information about drug effectiveness and therapeutic level. Coagulation studies may reveal a coagulopathy and are useful when fibrinolytic or anticoagulants are to be used. In clients who are not taking anticoagulants or antithrombotics and in whom there is no suspicion of coagulation abnormality, administration of rt-PA should not be delayed while awaiting laboratory results (Jauch & Lutsep, 2022).

8. Prepare for surgery, as appropriate.
It may be necessary to resolve the situation and reduce neurological symptoms of recurrent stroke. Surgical management, compared to medical management alone, has been shown to decrease mortality for selected clients. Surgical options include minimally invasive hematoma evacuation with endoscopic or stereotactic aspiration, external ventricular drain insertion, and craniotomy (Tadi & Lui, 2023).

9. Administer insulin therapy as indicated.
Blood sugar control should be tightly maintained with insulin therapy, with the goal of establishing normoglycemia (90 to 140 mg/dL). Additionally, close monitoring of blood sugar levels should continue throughout hospitalization to avoid hypoglycemia (Jauch & Lutsep, 2022).