Nursing Care Plan For Stroke (Cerebrovascular Accident) or CVA

A Stroke is also known as Cerebrovascular Accident (CVA) / Cerebral Infarction or Brain Attack occurs when blood flow to the brain is disrupted, either by a blocked blood vessel or a ruptured blood vessel. Two major types of stroke Cerebrovascular Accident (CVA) are Ischemic and hemorrhagic.

Types of Stroke

Ischemic stroke is caused by thrombotic or embolic blockage of blood flow to the brain. Bleeding into the brain tissue or subarachnoid space causes a hemorrhagic stroke. Another type of classification is Large vessel stroke and small vessel stroke based on the blood vessels involved.

Causes of Stroke

• Thrombosis
• Hemorrhage
• Embolism
• Cerebral arterial spasm
• Hypercoagulable state
• Compression of cerebral vessels due to tumors, brain abscess, large blood clots

Risk Factors for Stroke

• Hypertension
• Cardiovascular diseases such as atrial fibrillation
• History of transient ischemic attack
• Hyperlipidemia
• Cigarette Smoking
• Heavy alcohol use,
• Cocaine use
• Obesity

Signs and Symptoms of Stroke

This can lead to a range of symptoms, including paralysis, difficulty speaking, and cognitive impairment. Here are some additional signs and symptoms of stroke:

1. Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.
2. Sudden confusion, trouble speaking, or difficulty understanding speech.
3. Sudden trouble seeing in one or both eyes.
4. Sudden dizziness, loss of balance, or difficulty walking.
5. Sudden severe headache with no known cause.
6. Difficulty swallowing or drooling.
7. Loss of coordination or balance.
8. Nausea or vomiting.
9. Fatigue or weakness.
10. Difficulty with memory, attention, or problem-solving.
11. Changes in behavior or mood, such as sudden aggression or depression.
12. Seizures or convulsions.

Diagnosis

• CT Scan
• Diffusion Weighted Imaging MRI Scan
• Cerebral Angiogram
• Carotid duplex scan (an ultrasound test that shows how well blood is flowing through the carotid arteries)

Medical Management

• Identify Stroke Early
• Maintain Cerebral Perfusion
• Restore Cerebral Blood flow
• Prevent Complication
• Rehabilitation after stroke

A stroke nursing care plan is critical for ensuring that patients receive the best possible care and support throughout their recovery. Nursing diagnosis, outcomes, therapies, and rationales for stroke patients will be discussed in this section.

Nursing Care Plan for Stroke

Assessment

All body systems must be evaluated on an ongoing basis. The use of standardized neurologic assessment tools, such as the GCS, aids nurses in documenting changes in the neurological condition of patients. The National Institute of Health Stroke Scale (NIH Stroke Scale) is also extensively used.
The client’s blood pressure, heart sounds, heart rate and rhythm, respiratory rate and rhythm, temperature, amount of nutrition, ability to swallow, bladder and bowel disposal, and communication must all be evaluated in addition to the neurologic assessment.

Nursing Diagnosis for Stroke

Impaired physical mobility, impaired verbal communication, risk of aspiration, risk of impaired skin integrity, risk of falls, disrupted sensory perception, impaired urine elimination, and disturbed sleep pattern are all nursing diagnoses for stroke patients.

Outcome:

The ultimate goal of a stroke nursing care plan is to assist the patient in achieving optimal recovery and avoiding complications. Improved physical mobility, increased verbal communication, aspiration avoidance, skin integrity maintenance, fall prevention, enhanced sensory perception, improved urine elimination, and improved sleep patterns are all desired outcomes for stroke patients.

1. Ineffective Tissue Perfusion related to interruption of blood flow to the brain secondary to a cerebrovascular accident (CVA) as evidenced by neurological deficits, altered level of consciousness, and/or abnormal diagnostic tests.

Outcome

The nursing goal for this diagnosis is to increase tissue perfusion and prevent further brain damage, which can be accomplished by actions such as maintaining a patent airway, delivering oxygen therapy, and monitoring vital signs.

Nursing Interventions and Rationales

Nursing Interventions	Rationales
Monitor vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation.	Vital signs provide valuable information about the patient’s hemodynamic status and oxygenation. Monitoring them regularly helps detect changes that may indicate worsening tissue perfusion.
Administer oxygen therapy as ordered.	Supplemental oxygen can help increase the oxygen supply to the brain and improve tissue perfusion.
Administer medications as ordered, such as antiplatelet agents, thrombolytics, or anticoagulants.	These medications can help improve blood flow to the brain, prevent clot formation, and dissolve existing clots, thereby improving tissue perfusion.
Elevate the head of the bed to promote cerebral blood flow.	Elevating the head of the bed can help improve blood flow to the brain, reducing the risk of further tissue damage.
Encourage mobility and ambulation as appropriate.	Mobilization and ambulation can help increase blood flow to the brain and promote overall cardiovascular health, improving tissue perfusion.

Evaluation

• Regularly monitor the patient’s vital signs to look for any improvements or changes.
• Examine the patient for any changes in neurological impairments or consciousness, such as increased alertness, attentiveness, or motor function.
• Keep an eye on the patient’s diagnostic tests results, such as CT scans or MRIs, for changes in the size or location of the stroke.
• Assess the patient’s response to drugs and oxygen therapy, including changes in blood pressure, oxygen saturation, and neurological condition.
• Assess the patient’s capacity to move and ambulate safely, as well as any improvements in general cardiovascular health.

2. Impaired Physical Mobility related to weakness or paralysis of one or more extremities, alterations in gait or balance, and/or decreased coordination secondary to a cerebrovascular accident (CVA)

Outcome:

For this condition, the nursing goal is to maximize the patient’s physical mobility and functional independence, which can be accomplished by interventions such as promoting safe movement, providing assistive devices, and supporting rehabilitation.

Interventions and Rationales

Interventions	Rationales
Assist the patient with a range of motion exercises.	Range of motion exercises helps maintain joint flexibility and prevent contractures.
Help the patient with activities of daily living (ADLs).	Assistance with ADLs ensures that the patient receives adequate hygiene and nutrition.
Encourage the patient to participate in physical therapy.	Physical therapy can help improve the patient’s strength and balance, leading to improved mobility.
Monitor the patient for signs of muscle weakness or spasticity.	Monitoring for muscle weakness or spasticity helps identify potential complications and allows for prompt intervention.

3. Impaired Verbal Communication related to neurological damage, cognitive impairment, and/or language deficits secondary to a cerebrovascular accident (CVA) as evidenced by difficulty speaking, slurred speech, aphasia, and/or altered level of consciousness

Outcome:

The nursing goal for this condition is to encourage effective communication and improve the patient’s ability to communicate, which can be accomplished by interventions such as nonverbal communication, visual aids, and speech therapy.

Nursing Interventions and Rationales

Nursing Interventions	Rationales
Use simple, clear language when communicating with the patient.	Using simple, clear language helps the patient understand instructions and participate in their care.
Encourage the patient to use nonverbal communication methods if necessary.	Nonverbal communication methods, such as pointing or using gestures, can help the patient express their needs.
Consult with a speech therapist if the patient has severe communication difficulties.	Speech therapy can help patient improve their communication skills and reduce frustration.

4. Risk of Aspiration related to impaired swallowing, decreased level of consciousness, and/or altered gag reflex secondary to a cerebrovascular accident (CVA) as evidenced by coughing, choking, and/or difficulty swallowing

Outcome:

The nursing goal for this diagnosis is to avoid aspiration and reduce the risk of related problems through interventions such as assessing swallowing ability, offering modified foods and thickened liquids, and positioning the patient appropriately during meals.

Nursing Interventions and Rationales

Nursing Interventions	Rationales
Assess the patient’s ability to swallow.	Assessing the patient’s ability to swallow helps identify any swallowing difficulties.
Provide thickened liquids or pureed foods if necessary.	Thickened liquids or pureed foods can reduce the risk of aspiration.
Elevate the head of the bed during meals.	Elevating the head of the bed during meals helps prevent food from entering the lungs.
Monitor the patient for signs of aspiration.	Monitoring for signs of aspiration allows for prompt intervention if necessary.

5. Risk of Impaired Skin Integrity related to decreased mobility, impaired sensation, and/or incontinence secondary to a cerebrovascular accident (CVA) as evidenced by pressure ulcers, skin tears, and/or skin breakdown

Outcome:

The nursing goal for this diagnosis is to prevent skin breakdown and promote skin integrity, which can be achieved through interventions such as frequent skin assessments, repositioning the patient regularly, providing appropriate pressure-relieving devices, and implementing incontinence care measures.

Nursing Interventions and Rationales

Interventions	Rationales
Turn the patient frequently to prevent pressure ulcers.	Turning the patient frequently helps distribute pressure and prevent pressure ulcers.
Assess the patient’s skin for signs of breakdown.	Assessing the patient’s skin for signs of breakdown allows for prompt intervention.
Use pressure-relieving devices as needed.	Pressure-relieving devices, such as foam pads or special mattresses, can reduce pressure on bony prominences.
Keep the patient clean and dry.	Keeping the patient clean and dry helps prevent skin breakdown.

6. Risk of Falls related to impaired balance, decreased mobility, and/or altered level of consciousness secondary to a cerebrovascular accident (CVA) as evidenced by unsteady gait, dizziness, and/or confusion

Outcome:

The nursing goal for this diagnosis is to prevent falls and reduce the risk of related problems by interventions such as assessing the patient’s fall risk, providing appropriate assistive devices, and adopting fall prevention methods such as bed rails or alarms.

Nursing Interventions and Rationales

Interventions	Rationales
Assess the patient’s risk for falls.	Assessing the patient’s risk for falls helps identify any factors that increase the risk of falls, such as weakness or unsteady gait.
Use bed rails or other safety devices as needed.	Bed rails or other safety devices can help prevent the patient from falling out of bed.
Encourage the patient to call for assistance when getting out of bed.	Encouraging the patient to call for assistance when getting out of bed reduces the risk of falls.
Keep the environment free of clutter.	Keeping the environment free of clutter reduces the risk of trips and falls.

7. Disturbed Sensory Perception related to altered sensory input secondary to a cerebrovascular accident (CVA) as evidenced by changes in vision, hearing, taste, smell, or touch

Outcome:

The nursing goal for this diagnosis is to improve patient safety and sensory perception through interventions such as providing suitable assistive devices, maintaining a safe and peaceful environment, and employing sensory stimulation strategies.

Nursing Interventions and Rationales

Nursing Interventions	Rationales
Provide a calm and quiet environment.	Providing a calm and quiet environment can reduce sensory overload.
Reduce environmental stimuli as needed.	Reducing environmental stimuli can help the patient focus on important sensory information.
Assess the patient’s vision and hearing.	Assessing the patient’s vision and hearing helps identify any deficits that may contribute to sensory perception problems.
Use assistive devices as needed.	Using assistive devices, such as glasses or hearing aids, can improve the patient’s sensory perception.

8. Impaired Urinary Elimination related to urinary retention or urinary incontinence secondary to a cerebrovascular accident (CVA) as evidenced by decreased urinary output, difficulty initiating or stopping the urinary flow, and/or involuntary loss of urine.

Outcome:

The nursing goal for this diagnosis is to promote optimal urinary elimination and prevent associated complications, which can be accomplished through interventions such as urinary output monitoring, bladder retraining programs, incontinence care measures, and the use of appropriate bladder management techniques such as intermittent catheterization or indwelling catheterization.

Nursing Interventions and Rationales

Nursing Interventions	Rationales
Assess the patient’s urinary output and frequency.	Assessing the patient’s urinary output and frequency helps identify any urinary problems.
Encourage the patient to drink plenty of fluids.	Encouraging the patient to drink plenty of fluids helps maintain urinary function.
Assist the patient with toileting as needed.	Assisting the patient with toileting reduces the risk of incontinence and urinary retention.
Consult with a urologist or other specialist as needed.	Consulting with a specialist can help manage more complex urinary problems.

9. Disturbed Sleep Patterns related to physiological and psychological changes secondary to a cerebrovascular accident (CVA) as evidenced by difficulty falling asleep, difficulty staying asleep, and/or excessive daytime sleepiness

Outcome:

The nursing goal for this diagnosis is to promote optimal sleep patterns and avoid associated complications. This can be accomplished through interventions such as assessing the patient’s sleep patterns and identifying factors that contribute to sleep disturbance, implementing sleep hygiene measures such as establishing a regular sleep schedule and promoting relaxation techniques, and adjusting medication schedules and doses as needed.

Nursing Interventions and Rationales

Nursing Interventions	Rationales
Encourage the patient to maintain a regular sleep schedule.	Maintaining a regular sleep schedule helps regulate the patient’s sleep pattern.
Provide a comfortable and quiet sleep environment.	Providing a comfortable and quiet sleep environment promotes restful sleep.
Use relaxation techniques as needed.	Relaxation techniques, such as deep breathing or guided imagery, can help the patient fall asleep.
Assess the patient’s medication regimen for potential sleep disturbances.	Assessing the patient’s medication regimen helps identify any medications that may contribute to sleep disturbances.

Conclusion

A stroke nursing care plan is critical for ensuring that patients receive comprehensive treatment and support during their rehabilitation. The nursing diagnoses, outcomes, actions, and rationales listed above may help nurses provide high-quality care while avoiding problems. Nurses can help stroke patients recover quickly and regain their independence by working closely with other members of the healthcare team

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