Nursing Care Plan (NCP) for Stroke (CVA)

Pathophysiology

A stroke is essentially a neurological deficit caused by decreased blood flow to a portion of the brain. They will be classified as either hemorrhagic or ischemic.  An ischemic stroke is the result of an obstruction of blood flow within a blood vessel. A hemorrhagic stroke is when a weakened blood vessel ruptures and blood spills into the brain where it shouldn’t be.  Both of these can cause edema and cellular death. Lack of blood flow for greater than 10 minutes can cause irreversible damage.

Etiology

Various things can cause an ischemic stroke, which comprises approximately 85% of all strokes.  Some of those who are at the highest risk are those on anticoagulation therapy. People are on anticoagulant therapy for various reasons (mechanical heart valves, atrial fibrillation, etc.) and if they become subtherapeutic and therefore their blood is too thick, a clot can easily form and end up in the brain, causing an ischemic stroke. Diabetes is also one of the major risk factors, in addition to atherosclerosis, hypertension, cardiac dysrhythmias, obesity, substance abuse, and oral contraceptives.  Hemorrhagic strokes (the remaining 15% of strokes) can be caused by an aneurysm rupture (which are very difficult to predict… frequently noted increased incidence in smokers, drug abuse, and people with a family history of a first-degree relative with one), high blood pressure, or the rupture of an arteriovenous malformation (which is genetic).

Desired Outcome

Restoring as much blood flow as possible as quickly as possible, and minimizing cellular death/damage is key. Clot-busting meds can be given to restore blood flow for ischemic strokes. Hemorrhagic strokes are managed by keeping the blood pressure controlled, controlling intracranial pressure, reversing any anticoagulants on board, and even very invasive procedures or surgery to relieve increased intracranial pressure. You want the patient to gain back as much function as possible.  This is done slowly over time by the brain creating collateral circulation around the infarcted area. Physical, occupational, and speech therapy are essential aspects of stroke recovery. Some patients may make a complete recovery, while others may have profound deficits.

Stroke Nursing Care Plan

Nursing Interventions and Rationales

• Use assistive ambulatory devices if limb weakness present

• Frequent neurological assessments (per orders)

• HOB at 30 degrees unless otherwise indicated

• Initiate DVT prophylaxis (mechanical and/or chemical)

• Ensure PT/OT is ordered

• Consult Speech Therapy for swallow evaluation before oral intake

• Prevent aspiration: follow ST recommendations, keep HOB at 45 degrees during oral intake and keep patient upright after a meal, have suction available, assess lung sounds and body temp

• Promote adequate nutrition

• Fall prevention measures (non-skid socks, bed in the lowest locked position, call bell within reach, and so forth)

• Prevent contractions

• Cluster care; promote rest

• Monitor vital signs appropriately; know BP limits

• Promote cerebral tissue perfusion (interventions differ depending on kind of stroke, location, and other factors)

• Prevent edema:
  • Elevate limbs
  • Utilize compression stockings
  • Promote ambulation
  • Promote complete bladder emptying

• Promote self-care

• Initiate discharge planning

• Prevent skin breakdown:
  • Turn q2hrs
  • Ensure adequate protein intake
  • Off-load pressure areas
  • Pillow support
  • Keep linen clean and dry

• Facilitate communication; promote family coping and communication

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References