Nursing Care Plan for Stroke
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Nursing Care Plans for Stroke Cerebrovascular Accident. Stroke Also known as brain attack or a Cerebrovascular accident, Cerebrovascular accident (CVA), or “stroke,” is the interruption of normal blood flow in one or more of the blood vessels that supply the brain. Stroke interrupts or diminishes oxygen supply and commonly causes serious damage or necrosis in brain tissues.
The sooner circulation returns to normal after stroke, the better chances are for complete recovery. About half of those who survive stroke remain permanently disabled and experience a recurrence within weeks, months, or years. A CVA is an acute neurological injury that occurs because of changes in the blood vessels of the brain. The changes can be intrinsic to the vessel (atherosclerosis, inflammation, arterial dissection, dilation of the vessel, weakening of the vessel, obstruction of the vessel) or extrinsic, such as when an embolism travels from the heart. Although reduced blood flow interferes with brain function, the brain can remain viable with decreased blood flow for long periods of time. However, total cessation of blood flow produces irreversible brain infarction within 3 minutes. Once the blood flow stops, toxins released by damaged neurons, cerebral edema, and alterations in local blood flow contribute to neuron dysfunction and death.
Major causes of stroke include cerebral thrombosis, embolism, and hemorrhage.
- Thrombosis is the most common cause of stroke in middle-age and elderly people.
- Embolism, the second most common cause of stroke, can occur at any age, especially among patients with a history of rheumatic heart disease, endocarditis, posttraumatic valvular disease, or myocardial fibrillation and other cardiac arrhythmias.
- Hemorrhage, the third most common cause of stroke, may also occur suddenly at any age. Such hemorrhage results from chronic hypertension or aneurysms, which cause sudden, rupture of a cerebral artery.
Factors that increase the risk of stroke include:
• History of TIAs
• Heart disease
• Rheumatic heart disease
• Diabetes mellitus
• Postural hypotension
• Cardiac enlargement
• And a family history of cerebrovascular disease
Complications for Stroke Cerebrovascular Accident
Among the many possible complications of stroke are unstable blood pressure from loss of vasomotor control, fluid imbalances, malnutrition, infections such as pneumonia, and sensory impairment, including vision problems. Altered level of consciousness (LOC), aspiration, contractures, and pulmonary emboli also may occur.
Nursing Assessment Nursing Care Plans for Stroke Cerebrovascular Accident
Patient history. Determine if the patient has experienced an inability to recognize familiar objects or persons through sensory stimuli or any memory loss. Elicit a history of speech difficulties such as an inability to understand language or express language aphasia, poorly articulated speech dysarthria, or any other form of speech impairment (dysphasia), lost the ability to comprehend written words (alexia), read written words (dyslexia), or write (agraphia). History of visual difficulties such as diplopia, defective vision, or blindness in the right or left halves of the visual fields of both eyes , lack of depth perception, color blindness, blindness, blurring on the affected side, or drooping eyelids (ptosis).
Neurologic examination identifies most of the physical findings associated with stroke. These may include unconsciousness or changes in LOC, such as a decreased attention span, difficulties with comprehension, forgetfulness, and a lack of motivation. If conscious, the patient may exhibit anxiety along with communication and mobility difficulties.
Inspection may reveal related urinary incontinence.
Diagnostic tests for Stroke Cerebrovascular Accident
- Computed tomography scan.
- Magnetic resonance imaging.
- Carotid duplex may detect carotid artery stenosis.
- EEG helps to localize the damaged area.
Nursing Diagnosis Nursing care plan for Stroke Cerebrovascular Accident
Diagnosis of stroke is based on observation of clinical features, a history of risk factors, and the results of diagnostic tests, Nursing Diagnosis for Stroke Cerebrovascular Accident:
- Self-Care Deficit: bathing/hygiene, dressing/grooming, feeding, toileting
- Disturbed sensory perception: Tactile
- Impaired gas exchange
- Impaired physical mobility
- Impaired verbal communication
- Ineffective airway clearance
- Ineffective tissue perfusion: Cerebral
- Risk for aspiration
- Risk for disuse syndrome
- Risk for impaired skin integrity
- Risk for infection
- Risk for injury
- Situational low self-esteem
- Toileting self-care deficit
- Total urinary incontinence
Nursing Outcomes Nursing Care Plan For Stroke Cerebrovascular Accident
Nursing Outcomes Nursing Care Plan For Stroke Cerebrovascular Accident patient will:
- Identify strategies to reduce anxiety.
- Perform bathing and hygiene needs to the fullest extent possible.
- Report signs and symptoms of impaired sensation.
- Perform dressing and grooming needs to the fullest extent possible.
- Maintain adequate ventilation and oxygenation.
- Achieve the maximum mobility possible within the confines of the condition.
- Effectively communicate needs verbally or through an alternative means of communication.
- Maintain a patent airway.
- Exhibit signs of adequate cerebral perfusion.
- Express feelings of control over health and well-being.
- Free from signs of aspiration.
- Maintain joint mobility and range of motion (ROM).
- Maintain intact skin with no signs of breakdown.
- Remain free from signs or symptoms of infection.
- Free from injury.
- Verbalize feelings regarding self-esteem.
- Perform toileting needs to the fullest extent possible.
- Identify strategies to reduce incontinent episodes.
Nursing Interventions Nursing care plan for Stroke Cerebrovascular Accident
- Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
- Provision of a modified environment for the patient who is experiencing a confusional state
- Calming Technique: Reducing anxiety in patient experiencing acute distress
- Self-Care Assistance: Assisting another to perform activities of daily living
- Bathing: Cleaning of the body for the purpose of relaxation, cleanliness, and healing
- Hair/Nail Care: Promotion of neat, clean, attractive hair/nails and prevention of skin lesions related to improper care of nails
- Feeding: Providing nutritional intake for patient who is unable to feed self
- Bowel/Urinary Elimination Management: Establishment and maintenance of a regular pattern of bowel elimination/Maintenance of an optimum urinary elimination pattern
- Communication Enhancement: Hearing/Vision Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing/vision
- Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids
- Environmental Management: Manipulation of the patient’s surroundings for therapeutic benefit
- Peripheral Sensation Management: Prevention or minimization of injury or discomfort in the patient with altered sensation
- Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
- Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
- Airway Management: Facilitation of patency of air passages