Cerebrovascular accident (CVA) or stroke is the leading cause of adult disability worldwide. Stroke is the fifth leading cause of death in the US. The incidence of stroke is around 800,000 people annually. The incidence of stroke has declined, but the morbidity has increased. Due to longer life expectancy, the lifetime risk of stroke is higher in women.
Stroke is an acute compromise of the cerebral perfusion or vasculature. Approximately 85% of strokes are ischemic and the rest are hemorrhagic. Stroke is defined as the sudden occurrence of a focal, non-convulsive neurologic deficit. Interruption of blood flow results in cell death. The presentation is variable, ranging from subtle to very severe, depending on the area of the brain involved and the nature of the attack.
Stroke is broadly classified into two types:
- Ischemic. Ischemic stroke commonly results from the occlusion of the lumina of the cerebral vessels by a thrombus or embolus. Systemic hemodynamic failure can also result in ischemic stroke as a consequence of a decreased volume of blood flowing through the cerebral vessels.
- Hemorrhagic. Hemorrhagic stroke, seen in 15-20% of cases, typically results from the rupture of a cerebral vessel. It is further classified into two subtypes:
- Intracerebral. Intracerebral hemorrhage (ICH), a subtype of stroke, is a condition wherein a hematoma is formed within the brain parenchyma with or without blood extension into the ventricles. Non-traumatic ICH comprises 10-15% of all strokes and is associated with high morbidity and mortality.
- Subarachnoid. Subarachnoid hemorrhages are life-threatening and result from the accumulation of blood between the arachnoid and the pia mater. Most subarachnoid hemorrhages are traumatic in nature. The characteristic presenting symptom is the thunderclap headache, which clients may describe as the “worst headache of my life”.
There are many causes of stroke. Ischemic etiologies can be further divided into embolic, thrombotic, and lacunar.
- Embolic. Cardiogenic emboli are a common source of recurrent stroke. They may account for up to 20% of acute strokes and have been reported to have the highest 1-month mortality.
- Thrombotic. Large-artery infarctions often involve thrombotic in situ occlusions on atherosclerotic lesions in the carotid, vertebrobasilar, and cerebral arteries, typically proximal to major branches; however, large-artery infarctions may also be cardioembolic.
- Lacunar. Small vessel or lacunar strokes are associated with small focal areas of ischemia due to obstruction of single small vessels, typically in deep penetrating arteries, that generate a specific vascular pathology.
Risk factors for stroke include modifiable and non-modifiable conditions. Non-modifiable risk factors include the following:
- Age. In the US in 2005, the average age of the incidence of stroke was 69.2 years. Recent research has indicated that people aged 20–54 years are at an increased risk of stroke, probably due to pre-existing secondary factors.
- Race. US research shows that black and Hispanic populations are at higher risk of stroke than white populations; notably, the incidence of hemorrhagic stroke is significantly higher in black people than in age-matched white populations.
- Sex. Women are at equal or greater risk of stroke than men, irrespective of age.
- Family history of stroke. Genetics contributes to both modifiable and non-modifiable risk factors for stroke. Genetic risk is proportional to the age, sex, and race of the individual, but a multitude of genetic mechanisms can increase the risk of stroke. A parental or family history of stroke increases the chance of an individual developing this disorder.
Modifiable risk factors include the following:
- Hypertension. It is one of the predominant risk factors for stroke. In one study, a blood pressure of at least 160/90 mm Hg and a history of hypertension were considered equally important predispositions for stroke, with 54% of the stroke-affected population having these characteristics.
- Diabetes mellitus. It doubles the risk of ischemic stroke and covers an approximately 20% higher mortality rate. Moreover, the prognosis for diabetic individuals after a stroke is worse than for non-diabetic clients, including higher rates of severe disability and slower recovery.
- Cardiac diseases. Atrial fibrillation (AF) is an important risk factor, increasing the risk two- to five-fold depending upon the age of the individual concerned. Research has shown that in AF, decreased blood flow in the left atrium causes thrombolysis and embolism in the brain.
- Hypercholesterolemia. It is a major contributor to coronary heart disease, but its relationship to stroke is complicated. Total cholesterol is associated with the risk of stroke, whereas high-density lipoprotein (HDL) decreases stroke incidence.
- Transient ischemic attacks (TIA). TIA is classified as a mini-stroke; the underlying mechanism is the same as for a full-blown stroke. In TIA, the blood supply to part of the brain is blocked temporarily.
- Excessive alcohol intake, tobacco use, illicit drug use. The relationship between stroke risk and alcohol intake follows a curvilinear pattern, with the risk related to the amount of alcohol consumed daily. Low to moderate consumption of alcohol reduces stroke risk, whereas high intake increases it. Illicit drug use is a common predisposing factor for stroke among individuals aged below 35 years. Tobacco smoking is directly linked to an increased risk of stroke. An average smoker has twice the chance of suffering from a stroke than a non-smoker.
- Obesity, insufficient physical activity, and poor diet. Lack of exercise increases the chances of a stroke attack in an individual. Insufficient physical activity is also linked to other health issues like hypertension, obesity, and diabetes, all conditions related to high stroke incidence. Poor diet influences the risk of stroke; excessive salt intake is linked to high hypertension and stroke.
Stroke is defined as an abrupt neurological outburst caused by impaired perfusion through the blood vessels to the brain. Ischemic stroke is caused by deficient blood and oxygen supply to the brain; hemorrhagic stroke is caused by bleeding or leaky blood vessels. Ischemic occlusion generates thrombotic and embolic conditions in the brain. In thrombosis, blood flow is affected by the narrowing of vessels due to atherosclerosis. In an embolic stroke, decreased blood flow to the brain region causes an embolism; the blood flow to the brain reduces, causing severe stress and untimely cell death.
Nursing care for clients diagnosed with cerebrovascular accidents must incorporate thorough yet quick assessments and timely interventions to increase the chances of recovery. The most important part of the history is the time of the onset of the symptoms, which the nurse initially assesses. Time is critical, as only clients who get all the required studies within 4.5 hours qualify for potentially lifesaving thrombolysis. Rapid evaluation and treatment are paramount for the best outcomes. The following are nursing diagnoses associated with cerebrovascular accidents.
- Ineffective Cerebral Tissue Perfusion
- Impaired Physical Mobility
- Disturbed Sensory Perception
Cerebrovascular Accident Nursing Care Plan
Below are sample nursing care plans for the problems identified above.
Ineffective Cerebral Tissue Perfusion
Cerebrovascular accident (CVA) or stroke is injury or death to parts of the brain caused by an interruption in the blood supply to that area, causing disability. The build-up of plaque eventually constricts the vascular chamber and forms clots, causing thrombotic stroke, while decreased blood flow to the brain causes an embolism that leads to an embolic stroke. This is followed by necrosis and plasma membrane disruption, organelle swelling, cellular contents leaking into extracellular space, and neuronal function loss.
- Ineffective Cerebral Tissue Perfusion
- Interruption of blood flow
- Occlusive disorder
- Cerebral vasospasm
- Cerebral edema
- Altered level of consciousness
- Changes in motor or sensory responses
- Sensory, language, intellectual, and emotional deficits
- Vital signs change
After implementation of nursing interventions, the client is expected to:
- Maintain usual or improve the level of consciousness, cognition, and motor and sensory function.
- Demonstrate stable vital signs and the absence of signs of increased ICP.
- Display no further deterioration or recurrence of deficits.
|Monitor vital signs and note for hypertension/hypotension; heart rate and rhythm; and respirations.||Fluctuation in pressure may occur because of cerebral pressure or injury in the vasomotor area of the brain. Changes in rate, especially bradycardia, can occur because of brain damage. Irregularities in respirations can suggest the location of cerebral insult or increased ICP.|
|Evaluate pupil size, noting size, shape, equality, and light reactivity.||Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brainstem is intact. Pupil size and equality are determined by the balance between parasympathetic and sympathetic enervation. Response to light reflects the combined function of the optic (III) and oculomotor (III) cranial nerves.|
|Monitor and document neurological status frequently and compare with baseline.||This assesses the trends in LOC and the potential for increased ICP and is useful in determining the location, extent, and progression or resolution of CNS damage.|
|Assess factors related to the individual situation, cause for coma, decreased cerebral perfusion, and potential for increased ICP.||These factors may influence the choice of interventions. Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity. If the stroke progresses, the client can deteriorate rapidly and require repeated assessment and progressive treatment.|
|Assess for nuchal rigidity, twitching, increased restlessness, irritability, and the onset of seizure activity.||These symptoms are indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures may reflect increased ICP or reflect the location and severity of cerebral injury.|
|Assess the client’s speech if the client is alert.||Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate increased ICP.|
|Position the client’s head in a slightly elevated and neutral position.||This position reduces arterial pressure by promoting venous drainage and may improve cerebral circulation and perfusion.|
|Instruct the client to maintain bed rest. Providing a quiet environment and restricting visitors to allow for uninterrupted rest periods.||Continual stimulation can increase ICP. Absolute rest and quiet may be needed to prevent the recurrence of bleeding, in the case of hemorrhagic stroke.|
|Educate the client to avoid Valsalva maneuver or straining at stool or holding their breath.||Valsalva maneuver increases ICP and potentiates the risk of bleeding.|
|Encourage the client on lifestyle changes such as smoking cessation, a healthy diet, and adherence to maintenance medications.||Educate the client to discontinue smoking, eat a healthy diet, exercise regularly, and maintain a healthy body weight. Clients should be provided with supporting literature and educated about stroke and its complications.|
|Monitor laboratory results such as prothrombin time (PT), activated partial thromboplastin (aPTT), and Dilantin level.||Various laboratory studies are done to rule out systemic causes of stroke. It also provides information about effectiveness and therapeutic level of anticoagulants used.|
|Administer supplemental oxygen, as indicated.||Supplemental oxygen reduces hypoxemia, especially in the brain.|
|Administer intravenous thrombolytics, as indicated.||Intravenous thrombolytics, such as tissue plasminogen activator (tPA), alteplase, and recombinant prourokinase are the only proven therapy for early acute ischemic stroke. tPA is useful in minimizing the size of the infarcted area by opening blocked vessels that are occluded with clot. Treatment must start within 3 hours of initial symptoms to improve outcomes.|
|Administer anticoagulants, as prescribed.||Anticoagulants such as warfarin sodium and heparin may be used to improve cerebral blood flow and prevent further clotting when embolus or thrombosis is the problem.|
|Administer antihypertensives as prescribed.||Correct treatment of hypertension during stroke is uncertain due to contradictory outcomes of clinical studies. Some research shows positive correlations between high BP and stroke-related mortality, hematoma expansion, or intracerebral damage.|
|Prepare for surgery, as appropriate.||Carotid endarterectomy, microvascular bypass, and cerebral angioplasty may be necessary to resolve the hemorrhagic situation and reduce neurological symptoms and the risk of recurrent stroke.|
Impaired Physical Mobility
After a stroke, it is common to experience changes in how the body is perceived. Altered perceptions of body awareness or ownership, pain, limb heaviness, weakness, or a lack of body response, affect how the body is mobilized or controlled. Stroke survivors frequently describe their bodies as uncontrollable, unresponsive, and untrustworthy. Many felt disembodied as they attempted to assert control over their ‘object’ body. They often relied on consciously talking to the body to encourage its cooperation. The static body felt unremarkable, yet awareness was brought to altered perceptions such as limb heaviness, absence, pain, or unresponsiveness when clients attempt to mobilize.
- Impaired Physical Mobility
- Neuromuscular involvement
- Perceptual or cognitive impairment
- Inability to purposefully move within the physical environment
- Impaired coordination
- Limited range of motion
- Decreased muscle strength and control
- Hypotonic/spastic paralysis
After implementation of nursing interventions, the client is expected to:
- Maintain or increase strength and function of the affected or compensatory body part.
- Maintain an optimal position of function as evidenced by the absence of contractures and foot drop.
- Maintain skin integrity and prevent pressure ulcers.
- Demonstrate techniques and behaviors that enable the resumption of activities.
|Assess functional ability and extent of impairment initially and on a regular basis.||This identifies strengths and deficiencies and may provide information regarding recovery. It also assists in the choice of interventions because different techniques are used for flaccid and spastic types of paralysis.|
|Observe the affected side for color, edema, or other signs of compromised circulation.||Edematous tissue is more easily traumatized and heals more slowly. Prolonged swelling has an impact on joint range of motion, soft tissue mobility, quality of scar tissue formation, function, strength, and aesthetics of the extremity. These factors may delay a client’s recovery, return to work, and resumption of activities of daily living.|
|Inspect skin regularly, particularly over bony prominences.||Pressure points over bony prominences are most at risk for decreased perfusion and ischemia. Pressure ulcers are associated with increased mortality rates, longer lengths of hospital stay, and direct costs for client care.|
|Change the client’s position at least every 2 hours and possibly more often if placed on affected side.||The affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown and pressure ulcers. Changing the client’s position reduces the risk of tissue ischemia and injury.|
|Use a footboard during the period of flaccid paralysis. Maintain a neutral position of the head.||The use of a footboard prevents contractures and foot drop and facilitates use when or if the function returns. Flaccid paralysis may interfere with the ability to support the head, whereas spastic paralysis may lead to deviation of the head to one side .|
|Provide positional aids and splints during spastic paralysis. Place a pillow under the axilla and elevate the arm and hand.||Flexion contractures occur because flexor muscles are stronger than extensors. A pillow under the axilla prevents adduction of the shoulder and flexion of the elbow. eleavting the arm and hand promotes venous return and helps prevent edema formation.|
|Place hard hand-rolls in the palm with fingers and thumb opposed.||Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in a functional position.|
|Begin active or passive ROM to all extremities. Encourage exercises, such as quadriceps or gluteal exercise, squeezing rubber ball, and extension of fingers and legs and feet.||Active or passive ROM minimizes muscle atrophy, promotes circulation, and helps prevent contractures. They also reduce the risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage.|
|Assist the client to develop sitting balance and standing balance.||Assist the client in raising the head of the bed, assisting to sit on edge of the bed, and having the client use a strong arm to support body weight and a strong leg to move the affected leg. These aid in retraining neuronal pathways, enhancing proprioception and motor response.|
|Pad chair seat with foam or water-filled cushion, and assist the client to shift weight at frequent intervals.||These positional aids help reduce the pressure on the coccyx and prevent skin breakdown.|
|Encourage the client to assist with movement and exercises using the unaffected extremity to support and move the weaker side.||The client may respond as if the affected side is no longer part of the body and needs encouragement and active training to “reincorporate” it as a part of their own body.|
|Provide egg-crate mattress, water bed, flotation device, or specialized bed, such as kinetic, as indicated.||This equipment promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown and pressure ulcer formation. Specialized beds help with positioning, enhance circulation, and reduce venous stasis to decrease the risk of tissue injury and complications such as orthostatic pneumonia.|
|Arrange a consultation with a physical therapist regarding active, resistive exercises and client ambulation.||An individualized program can be developed to meet particular needs and deal with deficits in balance, coordination, and strength.|
|Administer muscle relaxants and antispasmodics as prescribed.||Muscle relaxants may be required to relieve spasticity in the affected extremities.|
Disturbed Sensory Perception
There are many different sensory modalities affected by stroke. The loss of detection of touch sensation has been noted in up to 65% to 94% of all stroke survivors. When impairment in the ability to detect and process sensory data occurs, the client will have difficulty exploring and relating to their environment. The spontaneous use of the affected limb has been noted to significantly decrease when cutaneous sensory processing is impaired. This continued disuse of the affected extremity leads to a further decrease in skilled movement, particularly for functional skills that require constant sustained muscle contraction.
- Disturbed Sensory Perception
- Altered sensory perception, transmission, integration
- Neurological trauma or deficit
- Narrow perceptual fields
- Disorientation to time, place, person
- Changes in behavior pattern and usual response to stimuli
- Poor concentration, bizarre thinking
- Altered sense of taste or smell
- Inability to tell the position of body parts
- Inability to recognize or attach meaning to objects
- Motor incoordination
- Altered communication patterns
After implementation of nursing interventions, the client is expected to:
- Acknowledge changes in ability and presence of residual involvement.
- Regain and maintain usual LOC and perceptual functioning.
- Demonstrate behaviors to compensate for or overcome deficits.
|Assess sensory awareness, such as differentiation of hot and cold, dull or sharp, the position of body parts, and muscle and joint sense.||Diminished sensory awareness and impairment of kinesthetic sense negatively affect balance and positioning (proprioception) and appropriateness of movement, which interferes with ambulation, increasing the risk of trauma.|
|Observe behavioral responses such as inappropriate affect, agitation, and hallucination.||Awareness of type and area of involvement aids in assessing for and anticipating specific deficits and planning care.|
|Evaluate the client for visual deficits. Note loss of visual field, changes in in-depth perception, and presence of diplopia.||The presence of visual disorders can negatively affect the client’s ability to perceive the environment and relearn motor skills and increases the risk of accident and injury.|
|Assess for inattention to body parts and segments of environment and lack of recognition of familiar objects or persons.||The presence of agnosia (loss of comprehension of auditory, visual, or other sensations, although sensory sphere is intact) may lead to unilateral neglect, inability to recognize environmental cues or meaning of commonplace objects, considerable self-care deficits, and disorientation or bizarre behavior.|
|Prevent extraneous noise and stimuli as necessary.||This reduces anxiety and exaggerated emotional responses and confusion associated with sensory overload.|
|Speak in a calm, quiet voice, using short sentences. Maintain eye contact.||The client may have a limited attention span or problems with comprehension. these measures can help the client attend to communication.|
|Reorient the client frequently to the environment, staff, and procedures.||Ascertain and validate the client’s perceptions and assist the client to identify inconsistencies in reception and integration of stimuli. It may also reduce perceptual distortion of reality.|
|Approach the client from the visually intact side. Leave the light on; position objects within the client’s good visual field.||This provides for recognition of the presence of persons or objects; this may also help with depth perception problems and prevents the client from being startled.|
|Encourage the client to patch the affected eye or wear prism glasses if indicated.||Patching may decrease the sensory confusion of double vision and prism glasses may enhance vision across the midline, decreasing neglect of the affected side.|
|Stimulate the client’s sense of touch by giving objects to touch and grasp. Let the client practice touching the walls or other boundaries.||This aids in retraining sensory pathways to integrate reception and interpretation of stimuli. This may also help the client orient themselves spatially and strengthens the use of the affected side.|
|Protect the client from temperature extremes by assessing environmental hazards. Test warm water with an unaffected hand before bathing the client.||Deficits in somatic sensations after stroke are common with prevalence rates variously reported to be 11% to 85%. This intervention promotes client safety and reduces the risk of injury.|
|Encourage the client to watch their feet when appropriate and consciously position body parts.||Make the client aware of all neglected body parts using sensory stimulation to the affected side and exercises that bring the affected aide across the midline, reminding the client to dress or care for the affected side. The use of visual and tactile stimuli assists the reintegration of the affected side and allows the client to experience forgotten sensations of normal movement patterns.|
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