Cerebrovascular Accident CVA Stroke NCLEX Review Care Plans
Nursing Study Guide on Stroke
Stroke is a medical emergency that occurs when a part of the brain’s blood supply is cut off causing oxygen deprivation and death to brain tissues. It is also known as cerebrovascular accident (CVA) or cerebrovascular disease (CVD).
Stroke can affect the brain’s functions and the effect depends on which part of the brain is affected.
Nursing Stat Facts
Stroke can be categorized as hemorrhagic or ischemic depending on its cause.
Signs and Symptoms of Stroke
The clinical manifestations of stroke may occur suddenly. It is critical to seek immediate medical help as soon as possible to achieve a better outcome from treatment.
- Difficulty speaking and understanding what others are saying – people having stroke may become confused and have slurred speech and have difficulty understanding other people’s words.
- Sudden paralysis of the face, arm, or leg – sudden onset of weakness, typically on one side of the body, is often noted in people having stroke.
- Problems with vision in one or both eyes – vision changes may occur when having stroke. The person may complain of sudden double vision or loss of vision.
- Headache – a person having stroke may complain of a sudden severe headache mostly accompanied by vomiting, dizziness, or confusion.
- Unsteady gait – weakness may affect the person’s coordination and alter the ability to walk.
Organizations and health institutions are recommending the use of the acronym “FAST” which refers to the following:
F – Face – a drop in one side of the face when the person smiles.
A – Arms – one arm will drop when both arms are raised at the same time.
S – Speech – slurred speech when asked to repeat a simple phrase.
T – Time – call for help when the above signs are observed.
Causes of Stroke
Like the other organs in the body, brain cells need oxygen to survive. Anything that can cause disruption to the blood supply in the brain can cause stroke.
The causes of stroke can be categorized as hemorrhagic or ischemic.
Hemorrhagic stroke – occurs when a blood vessel in the brain bursts allowing blood to seep through the brain which causes the surrounding brain cells to die. The following are the common causes of blood vessel rupture:
- High blood pressure
- Overuse of blood thinners or anticoagulants
- Trauma such as in a car accident
- Having protein deposits in the blood vessel wall such as in cases of cerebral amyloid angiopathy
- Ischemic stroke leading to hemorrhage
Ischemic stroke – occurs when a blood vessel is severely narrowed or occluded causing a significant reduction or total loss of blood supply in the brain.
This is the most common cause of stroke accounting to about 85% of cases reported.
The most common cause is a blood clot from elsewhere in the body that gets dislodged in one of the blood vessels in the brain.
One of the risks of having Atrial Fibrillation is that the condition can cause a stroke.
Another condition that may occur is transient ischemic attack (TIA) or “mini” stroke. It is a condition where the blood supply is cut off temporarily.
It only lasts for a few minutes to about 24 hours. It is often a warning sign to a full-blown stroke in the future hence prompt treatment is also necessary.
Complications of Stroke
- Paralysis. Paralysis on one side of the body is quite a common complication following stroke.
- Problem talking and swallowing. Stroke can affect the muscles responsible for talking and swallowing. Slurring of speech is often seen in people who had stroke.
- Memory loss and problems with logical thinking
- Emotional issues. Stroke can be challenging to some people and coping with it can affect their emotional state.
- Pain. Some people with stroke can develop pain from the loss of sensation on one side of the body.
- Difficulty to carry out activities of daily living. Stroke can have lasting side effects that reduce the ability to carry out simple tasks.
Diagnosis of Stroke
- Blood tests – to measure the clotting ability, blood sugar level, and possible presence of infection.
- CT scan of the brain –helpful in the diagnosis of stroke. It will give detailed images of the brain that can show the presence of bleeding, ischemia, or tumor.
- MRI scan – another form of brain imaging that can be done if the CT scan is inconclusive or if a more detailed image of the brain is needed.
- Carotid scan – an ultrasound study of the carotid artery may be performed to observe for plaques in the arterial wall and assess the blood flow towards the brain.
- Echocardiogram – to look for possible blood clots in the heart that could cause ischemia to blood vessels in the brain.
Treatment of Stroke
Immediate medical attention is critical to prevent permanent disability.
For Ischemic Stroke:
- Administration of drugs to break up clots through intravenous injection – drugs that can dissolve clots will restore blood supply to the brain and prevent further damage. Giving the drugs intravenously allows for quicker delivery of drugs where it is needed.
- Emergency endovascular procedures
- Administration of medications to break clots directly into the brain – medications can be administered directly into the brain through endovascular procedures. A catheter is inserted into the groin through an artery which will then thread to the brain.
- Removal of the blood clot through a stent retriever – a procedure to retrieve the clot can also be performed via stent insertion. A catheter is inserted to thread into the brain and then a stent is inserted in the tube to reach the part of the brain where the clot is.
- Carotid endarterectomy – this procedure involves the removal of plaque build-up in the carotid artery. This procedure carries risks especially in people with heart problems.
- Angioplasty and stents – the use of angioplasty balloons and stents can open a narrowed blood vessel.
For Hemorrhagic Stroke:
Controlling the bleeding is the focus of treatment in hemorrhagic stroke.
- Emergency procedures includes the following:
- Use of drugs to counteract the effects of blood thinning medications
- Blood transfusion – to thicken blood by improving blood volume
- Anti-hypertensives – drugs to lower blood pressure
- Surgical intervention – in cases of severe bleeding, surgical procedures to evacuate the blood and repair blood vessels may be required.
- Surgical clipping – this procedure involves the clipping of an aneurysm to prevent it from bursting or to control the bleeding if it has already ruptured.
- Endovascular embolization – a procedure that involves the use of coils to block the ruptured blood vessel.
- Surgical AVM removal – this procedure is only performed if the AVM is easily accessible in the brain.
- Stereotactic radiosurgery – this procedure involves the use of highly focused radiation to correct blood vessel malformations.
Nursing Care Plans for Stroke
Nursing Care Plan 1
Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral) related to cerebral edema and increased intracranial pressure (ICP) secondary to stroke as evidenced by drowsiness, confusion, headache, irritability, and memory problems
Desired Outcome: The patient will re-establish effective cerebral tissue perfusion as evidenced by increased level of consciousness (i.e. awake and alert) and will show orientation with persons, places, and things.
|Assess the patient’s vital signs and neurological status at least every 4 hours, or more frequently if there is a change in them.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment for stroke.|
|Observe and monitor the patient for any signs and symptoms of further increase in ICP, such as sudden headache, vomiting, and decreased alertness.||To facilitate early detection and management of increased ICP.|
Increased ICP can be life-threatening as it may lead to further brain damage or coma.
|Administer osmotic diuretics as prescribed.||To promote blood flow to the brain and to reduce cerebral edema.|
|Elevate the head of the bed at 30 degrees.||To promote venous drainage from the patient’s head to the rest of the body in order to decrease ICP and reduce cerebral edema.|
|Advise the patient to avoid straining when passing stool. Monitor bowel movements and administer appropriate laxatives (e.g. stool softeners) as needed.||Valsalva maneuver or straining during elimination may increase the ICP even further, worsening the condition.|
|Prepare the patient for surgery as indicated.||Surgical intervention such as cerebral angioplasty, endarterectomy, or microvascular bypass may be indicated to resolve ineffective tissue perfusion in the cerebrum.|
Nursing Care Plan 2
Nursing Diagnosis: Impaired physical mobility related to paralysis of one side of the body secondary to stroke as difficulty of movement, unsteady gait, generalized weakness, inability to do activities of daily living (ADLs) as normal, and verbalization of overwhelming tiredness/ fatigue
Desired Outcome: The patient will be able to perform activities of daily living within the limits of the present condition.
|Assess the patient’s level of functional mobility and ability to perform ADLs.||To assist in creating an accurate diagnosis and monitor effectiveness of treatment and therapy.|
|Assist the patient during exercises and when performing activities of daily living.||To encourage the patient to perform muscle-strengthening exercises and promote dignity by allowing the patient to perform their ADLs while maintaining safety.|
|Ensure the safety of the environment. Check that the call bell is within reach, the bed rails are up when the patient is on the bed, the bed is in the lowest level, the room is well-lit, the floor is not slippery, and that important things like phone and eyeglasses are easy to reach.||To maintain patient safety and reduce the risk of falls.|
|Encourage the patient to perform range of motion (ROM) exercises in all extremities.||To improve venous return, muscle strength, and stamina while preventing stiffness and contracture deformation.|
|Refer to the physiotherapy and occupational therapy team.||To provide a specialized care for the patient to gain physical and mental support in performing ADLs and mobilizing.|
Nursing Care Plan 3
Nursing Diagnosis: Self-Care Deficit related to physical limitations secondary to stroke as evidenced by inability to bathe, get dressed, and perform toileting activities as normal, and decreased level of strength and endurance
Desired Outcome: The patient will be able to demonstrate optimal performance of ADLs or activities of daily living.
|Observe the patient’s functional ability to perform self-care activities, especially toileting. Use functioning assessment (from 0 to 4) scale.||To determine the functional capability of the patient.|
|Assess the patient’s limitation and barriers to self-care by asking open-ended questions.||To explore the patient’s self-care limitations and needs while allowing him/her to express his/her personal thoughts and feelings related to ADLs.|
|Offer appropriate pain medication as prescribed at least 30 minutes before the patient performs self-care activities.||Pain might discourage the patient to mobilize and carry out self-care activities.|
|Ensure that the patient takes medications on time and as prescribed.||To ensure adherence to medical regimen.|
|Allow the patient to have sufficient time to complete activities of daily living. Advise the client to be patient with one’s self when performing self-care.||To build patient’s confidence and allow him/her to have a greater sense of self-worth.|
|Refer the patient to occupational therapist.||Occupational therapists are skilled professionals in helping clients achieve optimal performance in their daily activities like bathing, dressing, and personal hygiene tasks.|
|Encourage the patient to use assistive devices and grooming aids as needed.||To promote autonomy when performing self-care activities.|
Other possible nursing diagnoses:
- Impaired Verbal Communication
- Disturbed Sensory Perception
- Risk for Impaired Swallowing
- Risk for Injury/ Fall
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.