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Cerebrovascular Accident or commonly known as Stroke or Brain Attack is the leading cause of disability and the second leading cause of death in the Philippines according to the Stroke Society in the Philippines.

stroke-nursing-care-plan illustration

Stroke happens when an artery supplying the brain is blocked causing neurological deficits like paralysis and weakness.

Stroke versus Heart Attack

Brain attack and Heart Attack are commonly interchanged by most people. Some people call heart attack as stroke. Heart attack is somewhat like stroke, the only difference is the location. Heart attack is known as Myocardial Infarction, wherein there is a blockage of one or more arteries supplying the heart.

The common risk factor of these both deadly disease is arteriosclerosis or thickening and hardening of the arteries. Include to the risk factor list are: Hypertension, Diabetes Mellitus, Stress, and Obesity. As you can see, the risk factors for these diseases are highly modifiable. Nurses should emphasize and raise the awareness of their clients that these disease are very preventable.

How can we easily diagnose CVA/Stroke/Brain Attack?

The usual clinical manifestations of stroke are sudden numbness or weakness, sudden confusion or trouble speaking, sudden trouble seeing with one eye, sudden trouble walking or loss of balance, sudden severe dizziness, and sudden severe headache with unknown cause. You will notice that these signs and symptoms are all SUDDEN. So whenever you think of Stroke, always remember the word FAST. We should think and act FAST because time is brain cells. I created a simple illustration below so that you could easily memorize and store this acronym in a nutshell:

stroke-fast-abbreviation easy to rememberWhat are the common assessment tools for Stroke Patients?

  1. National Instituted of Health Stroke Scale (NIHSS).

In the hospitals, they usually use this type of scaling for stroke patients. According to http://www.nihstrokescale.org/ “…it is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. The NIHSS was originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Now, the scale is also widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome.”

Please check the link for the complete NIHSS monitoring assessment tool and the details of how to use it. You can also take the test and get your own certification for this scale: http://www.nihstrokescale.org/

Example of the areas assessed in NIHSS. (This is not a complete version)

Level of Consciousness0-alert can be aroused by minor stimulation
2-requires repeated simulation
3-unresponsive
Best gaze 0-normal
1-partial gaze palsy
2-forced deviation
Visual0-no visual loss
1-partial hemianopia
2-complete hemianopia
3-bilateral hemianopia
Facial palsy0-normal
1-minor palsy
2-partial paralysis
3-complete paralysis
Sensory0-normal
1-mild to moderate sensory loss
2-severe to total sensory loss
Dysarthria0-normal
1-mild to moderate dysarthria
2-severe dysarthria
3-mute/global dysarthria
  1. Modified Rankin Score (functional scale)

Modified Ranking Score is used to measure the disability of the person who suffered from brain attack. The scoring is from 0-6. The nurse asks the patient if he/she is able to carry out activities of daily living (e.g. bathing, eating, going to work, and banking) without the help of other persons. If the patient has no symptoms of stroke at all, his/her score is 0. If the patient is severely disable, he/she is scored 5. The score of 6 means the patient is dead.

Name of the Patient:Age:                   Gender:
Date of Stroke:Date of Examination:
0No symptoms at all.
1No significant disability despite symptoms, able to do ADLs
2Slightly disabled, unable to carry out usual ADLs, but able to look after
3Moderately disabled, need some help but able to ambulate with assistance
4Moderately serve disabled, unable to walk without assistance, can sit up in bed without any help
5Severely disabled, cannot sit up in bed (bedridden), requiring constant care
6Dead

Nursing consideration for thrombolytic administration

Intravenous thrombolytics; tissue plasminogen activator (tPA), alteplase (Activase)

This wonder drug is a proven therapy for acute stroke. t-PA is useful in minimizing the size of the infarcted area by opening blocked vessels that are occluded with the clot. Treatment must be started within 3 hours of initial symptoms to improve outcomes.

These are the usual criteria for t-PA administration:

  1. The stroke should be an acute ischemic attack with onset at least less than 3 hours.
  2. A significant neurologic deficit expected to result in major long term disability.
  3. No hemorrhage shown on Non-contrast CT scan
  4. No brain tumor or abscess
  5. No bacterial endocarditis
  6. No known bleeding tendencies or active internal bleeding
  7. No severe uncontrolled hypertension
  8. No recent CNS trauma or surgery

Usual dose:

IV (adults): 0.9 mg/kg (not to exceed 90 mg) given as an infusion over 1 hour with 10% of the dose given as bolus over the first minute.

What are the usual work-up before this drug is given?

  1. blood exam: CBC, platelets, PT, (INR), PTT, ESR, fibrinogen to check the risk for bleeding
  2. Blood type and cross match in case massive bleeding or hemorrhage occurs
  3. ECG
  4. Non-contrast CT scan for baseline of results
  5. Neurologic status as baseline criteria for the effective of the medication

What are the important nursing considerations before and after this drug is administered?

  1. Clarify orders especially abbreviated words. Have other practitioner check the original order, dosage, and infusion pump setting. Always use the read back method in carrying out orders.
  2. Make sure all blood and diagnostic procedures are done, before the administration.
  3. Assess patient carefully for bleeding every 15 minutes during the 1st hour of therapy, every 15-30 minutes during the next 8 hours, and at least every 4 hours for the duration of the therapy. Frank bleeding may occur from sites of invasive procedures of from body orifices. Internal bleeding may also occur (decreased neurologic status, abdominal pain with coffee ground emesis, or black tarry stools, hematuria, joint pain)
  4. Assess neurologic status throughout therapy. Altered sensorium may indicate intracranial bleeding. If intracranial bleeding is suspected, notify physician immediately and prepare for stat CT scan.
  5. If local bleeding occurs, apply pressure to site. If severe bleeding occurs, check CBC, PT, PTT, platelets, fibrinogen and D-dimer. Prepare for infusion of fresh frozen plasma, cryoprecipitate, and platelets. Administer Aminocaproic Acid as an antidote.

How to prevent Stroke?

Why take all the risk of thrombolytic administration if we can prevent stroke? So, what should we do to prevent stroke?

The best way to prevent stroke or brain attack is to eliminate the risk factors. And we all know that Arteriosclerosis Hypertension, Diabetes Mellitus, Obesity can be highly prevented through a lifestyle and diet change.

What are the foods that you should encourage?

  • Eating complex carbohydrate such as whole grains, wheat bread, oats, cereals, and unpolished rice
  • Fiber rich food like fruits and vegetable
  • Foods rich in potassium such as raisins, beans, and radish
  • Plant-based food has zero trans-fat and zero cholesterol

So, what will be the foods that you should discourage or should be taken moderately?

  • Processed food or canned foods because it contains trans-fat
  • Animal meat because it is high in cholesterol
  • Cheese, pork, beef because it is rich in saturated fat
  • Foods high with simple sugars like cake, ice creams, sodas

Following this healthy diet, together with physical exercise, getting enough rest, and drinking lots of water will keep you away from circulatory diseases such as stroke or brain attack.

Cerebrovascular Accident (CVA) Nursing Care Plan

References

  • Deglin, J. & Vallerand, A. (2007). Davis’s Drug guide for nurses. F.A Davis Company. Philadelphia. 10th edition.
  • Doenges, M., Moorhouse, M. & Murr, A. (2006). Nursing Care Plans. Guidelines for Individualizing Client Care Across the Lifespan. F. A. Davis Company. Philadelphia. 7th edition.
  • NIH Stroke Scale at http://www.nihstrokescale.org/
  • Silvestri, L. (200). Saunders Comprehensive Review for the NCLEX-RN Examination. Saunders Elsevier. 4th edition.
  • Stroke Society of the Philippines. (2010). Guidelines for the Prevention, Treatment, and Rehabilitation of Stroke. 5th edition.
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Rina Malones is currently working as a critical care/acute stroke nurse. Besides from blogging, she's also studying International Health at University of the Philippines Open University.