- A cerebrovascular accident (CVA), an ischemic stroke or“brain attack,” is a sudden loss of brain function resulting fromCerebral Vascular Accident (Ischemic Stroke)a disruption of the blood supply to a part of the brain.
- Stroke isthe primary cerebrovascular disorder in the United States.
- Strokesare usually hemorrhagic (15%) orischemic/nonhemorrhagic(85%).
- Ischemic strokes are categorized according to their cause:large artery thrombotic strokes (20%), small penetrating arterythrombotic strokes (25%), cardiogenic embolic strokes (20%),cryptogenic strokes (30%), and other (5%).
- Cryptogenic strokeshave no known cause, and other strokes result from causes suchas illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.
- The result is an interruption in the blood supply to the brain, causing temporary or permanent loss of movement, thought, memory, speech, or sensation.
- Advanced age (older than 55 years)
- Gender (Male)
- Race (African American)
- Atrial ﬁbrillation
- Asymptomatic carotid stenosis and valvular heart disease(eg, endocarditis, prosthetic heart valves)
- Periodontal disease
General signs and symptoms include numbness or weakness offace, arm, or leg (especially on one side of body); confusionor change in mental status; trouble speaking or understandingspeech; visual disturbances; loss of balance, dizziness, difﬁcultywalking; or sudden severe headache.
- Hemiplegia, hemiparesis
- Flaccid paralysis and loss of or decrease in the deep tendonreﬂexes (initial clinical feature) followed by (after 48 hours)reappearance of deep reﬂexes and abnormally increased muscle tone (spasticity)
- Dysarthria (difﬁculty speaking)
- Dysphasia (impaired speech) or aphasia (loss of speech)
- Apraxia (inability to perform a previously learned action)
Perceptual Disturbances and Sensory Loss
- Visualperceptual dysfunctions (homonymous hemianopia[loss of half of the visual ﬁeld])
- Disturbances in visualspatial relations (perceiving the relation of two or more objects in spatial areas), frequently seenin patients with right hemispheric damage
- Sensory losses: slight impairment of touch or more severewith loss of proprioception; difﬁculty in interrupting visual,tactile, and auditory stimuli
Impaired Cognitive and Psychological Effects
- Frontal lobe damage: Learning capacity, memory, or otherhigher cortical intellectual functions may be impaired. Suchdysfunction may be reﬂected in a limited attention span, difﬁculties in comprehension, forgetfulness, and lack of motivation.
- Depression, other psychological problems: emotional lability,hostility, frustration, resentment, and lack of cooperation.
Assessment and Diagnostic Methods
- History and complete physical and neurologic examination
- Noncontrast CT scan
- 12lead ECG and carotid ultrasound
- CT angiography or MRI and angiography
- Transcranial Doppler ﬂow studies
- Transthoracic or transesophageal echocardiography
- Xenonenhanced CT scan
- Single photon emission CT (SPECT) scan
- Help patients alter risk factors for stroke; encourage patientto quit smoking, maintain a healthy weight, follow a healthydiet (including modest alcohol consumption), and exercisedaily.
- Prepare and support patient through carotid endarterectomy.
- Administer anticoagulant agents as prescribed (eg, lowdoseaspirin therapy).
- Recombinant tissue plasminogen activator (tPA), unlesscontraindicated; monitor for bleeding
- Anticoagulation therapy
- Management of increased intracranial pressure (ICP):osmotic diuretics, maintain PaCO2 at 30 to 35 mm Hg, position to avoid hypoxia (elevate the head of bed to promotevenous drainage and to lower increased ICP)
- Possible hemicraniectomy for increased ICP from brainedema in a very large stroke
- Intubation with an endotracheal tube to establish a patentairway, if necessary
- Continuous hemodynamic monitoring (the goals for bloodpressure remain controversial for a patient who has notreceived thrombolytic therapy; antihypertensive treatmentmay be withheld unless the systolic blood pressure exceedsmm Hg or the diastolic blood pressure exceeds 120 mm Hg)
- Neurologic assessment to determine if the stroke is evolvingand if other acute complications are developing
Management of Complications
- Decreased cerebral blood ﬂow: Pulmonary care, maintenance of a patent airway, and administration of supplemental oxygen as needed.
- Monitor for UTIs, cardiac dysrhythmias, and complicationsof immobility.
During Acute Phase (1 to 3 days)
Weigh patient (used to determine medication dosages),and maintain a neurologic ﬂow sheet to reﬂect the followingnursing assessment parameters:
- Change in level of consciousness or responsiveness, abilityto speak, and orientation
- Presence or absence of voluntary or involuntarymovements of the extremities: muscle tone, body posture,and head position
- Stiffness or ﬂaccidity of the neck
- Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position
- Color of face and extremities; temperature and moisture ofskin
- Quality and rates of pulse and respiration; ABGs, bodytemperature, and arterial pressure
- Volume of ﬂuids ingested or administered and volume ofurine excreted per 24 hours
- Signs of bleeding
- Blood pressure maintained within normal limits
Assess the following functions:
- Mental status (memory, attention span, perception, orientation, affect, speech/language).
- Sensation and perception (usually the patient hasdecreased awareness of pain and temperature).
- Motor control (upper and lower extremity movement);swallowing ability, nutritional and hydration status, skinintegrity, activity tolerance, and bowel and bladder function.
- Continue focusing nursing assessment on impairment offunction in patient’s daily activities.
- Impaired physical mobility related to hemiparesis, loss ofbalance and coordination, spasticity, and brain injury
- Acute pain related to hemiplegia and disuse
- Deﬁcient selfcare (bathing, hygiene, toileting, dressing,grooming, and feeding) related to stroke sequelae
- Disturbed sensory perception (kinesthetic, tactile, orvisual) related to altered sensory reception, transmission,and/or integration
- Impaired swallowing
- Impaired urinary elimination related to ﬂaccid bladder,detrusor instability, confusion, or difﬁculty in communicating
- Disturbed thought processes related to brain damage
- Impaired verbal communication related to brain damage
- Risk for impaired skin integrity related to hemiparesis orhemiplegia, decreased mobility
- Interrupted family processes related to catastrophic illnessand caregiving burdens
- Sexual dysfunction related to neurologic deﬁcits or fear offailure
Collaborative Problems/Potential Complications
- Decreased cerebral blood ﬂow due to increased ICP; inadequate oxygen delivery to the brain; pneumonia.
Planning and Goals
The major goals for the patient (and family) may includeimproved mobility, avoidance of shoulder pain, achievementof selfcare, relief of sensory and perceptual deprivation, prevention of aspiration, continence of bowel and bladder,improved thought processes, achieving a form of communication, maintaining skin integrity, restored family functioning,improved sexual function, and absence of complications.Goals are affected by knowledge of what the patient was likebefore the stroke.
Improving Mobility and Preventing Deformities
- Position to prevent contractures; use measures to relievepressure, assist in maintaining good body alignment, andprevent compressive neuropathies.
- Apply a splint at night to prevent ﬂexion of affectedextremity.
- Prevent adduction of the affected shoulder with a pillowplaced in the axilla.
- Elevate affected arm to prevent edema and ﬁbrosis.
- Position ﬁngers so that they are barely ﬂexed; placehand in slight supination. If upper extremity spasticity isnoted, do not use a hand roll; dorsal wrist splint may beused.
- Change position every 2 hours; place patient in a proneposition for 15 to 30 minutes several times a day.
Establishing an Exercise Program
- Provide full range of motion four or ﬁve times a day tomaintain joint mobility, regain motor control, preventcontractures in the paralyzed extremity, prevent furtherdeterioration of the neuromuscular system, and enhancecirculation. If tightness occurs in any area, perform rangeofmotion exercises more frequently.
- Exercise is helpful in preventing venous stasis, which maypredispose the patient to thrombosis and pulmonaryembolus.
- Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (eg, shortness ofbreath, chest pain, cyanosis, and increasing pulse rate).
- Supervise and support patient during exercises; planfrequent short periods of exercise, not longer periods;encourage patient to exercise unaffected side at intervalsthroughout the day.
Preparing for Ambulation
- Start an active rehabilitation program when consciousnessreturns (and all evidence of bleeding is gone, when indicated).
- Teach patient to maintain balance in a sitting position,then to balance while standing (use a tilt table if needed).
- Begin walking as soon as standing balance is achieved(use parallel bars and have wheelchair available in anticipation of possible dizziness).
- Keep training periods for ambulation short and frequent.
NURSING ALERT:Initiate a full rehabilitation program even for elderlypatients.
Preventing Shoulder Pain
- Never lift patient by the ﬂaccid shoulder or pull on theaffected arm or shoulder.
- Use proper patient movement and positioning (eg, ﬂaccidarm on a table or pillows when patient is seated, use ofsling when ambulating).
- Rangeofmotion exercises are beneﬁcial, but avoid overstrenuous arm movements.
- Elevate arm and hand to prevent dependent edema of thehand; administer analgesic agents as indicated.
Enhancing Self Care
- Encourage personal hygiene activities as soon as thepatient can sit up; select suitable selfcare activities thatcan be carried out with one hand.
- Help patient to set realistic goals; add a new task daily.
- As a ﬁrst step, encourage patient to carry out all selfcareactivities on the unaffected side.
- Make sure patient does not neglect affected side; provideassistive devices as indicated.
- Improve morale by making sure patient is fully dressedduring ambulatory activities.
- Assist with dressing activities (eg, clothing with Velcroclosures; put garment on the affected side ﬁrst); keepenvironment uncluttered and organized.
- Provide emotional support and encouragement to preventfatigue and discouragement.
Managing Sensory Perceptual Difﬁculties
- Approach patient with a decreased ﬁeld of vision on theside where visual perception is intact; place all visualstimuli on this side.
- Teach patient to turn and look in the direction of thedefective visual ﬁeld to compensate for the loss; make eyecontact with patient, and draw attention to affected side.
- Increase natural or artiﬁcial lighting in the room; provideeyeglasses to improve vision.
- Remind patient with hemianopsia of the other side of thebody; place extremities so that patient can see them.
Assisting with Nutrition
- Observe patient for paroxysms of coughing, food dribblingout or pooling in one side of the mouth, food retained forlong periods in the mouth, or nasal regurgitation whenswallowing liquids.
- Consult with speech therapist to evaluate gag reﬂexes;assist in teaching alternate swallowing techniques, advisepatient to take smaller boluses of food, and inform patientof foods that are easier to swallow; provide thicker liquidsor pureed diet as indicated.
- Have patient sit upright, preferably on chair, when eatingand drinking; advance diet as tolerated.
- Prepare for GI feedings through a tube if indicated;elevate the head of bed during feedings, check tube position before feeding, administer feeding slowly, and ensurethat cuff of tracheostomy tube is inﬂated (if applicable);monitor and report excessive retained or residual feeding.
Attaining Bowel and Bladder Control
- Perform intermittent sterile catheterization during periodof loss of sphincter control.
- Analyze voiding pattern and offer urinal or bedpan onpatient’s voiding schedule.
- Assist the male patient to an upright posture for voiding.
- Provide highﬁber diet and adequate ﬂuid intake (2 to3 L/day), unless contraindicated.
- Establish a regular time (after breakfast) for toileting.
Improving Thought Processes
- Reinforce structured training program using cognitiveperceptual retraining, visual imagery, reality orientation,and cueing procedures to compensate for losses.
- Support patient: Observe performance and progress, givepositive feedback, convey an attitude of conﬁdence andhopefulness; provide other interventions as used forimproving cognitive function after a head injury.
- Reinforce the individually tailored program.
- Jointly establish goals, with patient taking an active part.
- Make the atmosphere conducive to communication,remaining sensitive to patient’s reactions and needs andresponding to them in an appropriate manner; treatpatient as an adult.
- Provide strong emotional support and understanding toallay anxiety; avoid completing patient’s sentences.
- Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes may help with memory and concentration; a communication board may be used.
- Maintain patient’s attention when talking with patient,speak slowly, and give one instruction at a time; allowpatient time to process.
- Talk to aphasic patients when providing care activities toprovide social contact.
Maintaining Skin Integrity
- Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.
- Employ pressurerelieving devices; continue regular turning and positioning (every 2 hours minimally); minimizeshear and friction when positioning.
- Keep skin clean and dry, gently massage healthy dry skin,and maintain adequate nutrition.
Improving Family Coping
- Provide counseling and support to family.
- Involve others in patient’s care; teach stress managementtechniques and maintenance of personal health for familycoping.
- Give family information about the expected outcome ofthe stroke, and counsel them to avoid doing things forpatient that he or she can do.
- Develop attainable goals for patient at home by involvingthe total health care team, patient, and family.
- Encourage everyone to approach patient with a supportiveand optimistic attitude, focusing on abilities that remain;explain to family that emotional lability usually improveswith time.
Helping the Patient Cope with Sexual Dysfunction
- Perform indepth assessment to determine sexual historybefore and after the stroke.
- Interventions for patient and partner focus on providingrelevant information, education, reassurance, adjustment
- of medications, counseling regarding coping skills, suggestions for alternative sexual positions, and a means of sexual expression and satisfaction.
- Teach patients about the “act FAST” Campaign
- Teach patient to resume as much selfcare as possible; provide assistive devices as indicated.
- Have occupational therapist make a home assessment andrecommendations to help patient become more independent.
- Coordinate care provided by numerous health care professionals; help family plan aspects of care.
- Advise family that patient may tire easily, become irritable and upset by small events, and show less interest indaily events.
- Make referral for home speech therapy. Encourage familyinvolvement. Provide family with practical instructions tohelp patient between speech therapy sessions.
- Discuss patient’s depression with physician for possibleantidepressant therapy.
- Encourage patient to attend communitybased stroke clubsto give a feeling of belonging and fellowship with others.
- Encourage patient to continue with hobbies, recreationaland leisure interests, and contact with friends to preventsocial isolation.
- Encourage family to support patient and give positivereinforcement.
- Remind spouse and family to attend to personal healthand wellbeing.
Expected Patient Outcomes
- Achieves improved mobility.
- Has no complaints of pain.
- Achieves selfcare; performs hygiene care; uses adaptiveequipment.
- Demonstrates techniques to compensate for alteredsensory reception, such as turning the head to see peopleor objects.
- Demonstrates safe swallowing.
- Achieves normal bowel and bladder elimination.
- Participates in cognitive improvement program.
- Demonstrates improved communication.
- Maintains intact skin without breakdown.
- Family members demonstrate a positive attitude and coping mechanisms.
- Develops alternative approaches to sexual expression.
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Nursing Care Plan
- Ineffective Cerebral Tissue Perfusion
May be related to
- Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vasospasm, cerebral edema
Possibly evidenced by
- Altered level of consciousness; memory loss
- Changes in motor/sensory responses; restlessness
- Sensory, language, intellectual, and emotional deficits
- Changes in vital signs
- Maintain usual/improved level of consciousness, cognition, and motor/sensory function.
- Demonstrate stable vital signs and absence of signs of increased ICP.
- Display no further deterioration/recurrence of deficits
- Assess factors related to individual situation for decreased cerebral perfusion and potential for increased ICP.
- Rationale:Assessment will determine and influence the choice of interventions. Deterioration in neurological signs or failure to improve after initial insult may reflect decreased intracranial adaptive capacity requiring patient to be transferred to critical area for monitoring of ICP, other therapies.If the stroke is evolving, patient can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence.
- Closely assess and monitor neurological status frequently and compare with baseline.
- Rationale:Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression of damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA.
Monitor vital signs:
- changes in blood pressure, compare BP readings in both arms.
- Rationale:Fluctuations in pressure may occur because of cerebral injury in vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse). Increased ICPmay occur because of tissue edema or clot formation. Subclavian artery blockage may be revealed by difference in pressure readings between arms.
- Heart rate and rhythm, assess for murmurs.
- Rationale:Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (stroke after MI or from valve dysfunction).
- Respirations, noting patterns and rhythm(periods of apnea after hyperventilation), Cheyne-Stokes respiration.
- Rationale:Irregularities can suggest location of cerebral insultorincreasing ICP and need for further intervention, including possible respiratory support.
- Evaluate pupils, noting size, shape, equality, light reactivity.
- Rationale:Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined by balance between parasympathetic and sympathetic innervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves.
- Document changes in vision: reports of blurred vision, alterations in visual field, depth perception.
- Rationale:Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions.
- Assess higher functions, including speech, if patient is alert.
- Rationale:Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate deterioration or increased ICP.
- Position with head slightly elevated and in neutral position.
- Rationale:Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion.
- Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit duration of procedures.
- Rationale:Continuous stimulation or activity can increase intracranial pressure (ICP).Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage.
- Prevent straining at stool, holding breath.
- Rationale:Valsalva maneuver increases ICP and potentiates risk of rebleeding.
- Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity.
- Rationale:Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may reflect increased ICP or cerebral injury, requiring further evaluation and intervention.
- Administer supplemental oxygen as indicated.
- Rationale:Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema formation.
Administer medications as indicated:
- Alteplase (Activase), t-PA;
- Rationale:Thrombolytic agents are useful in dissolving clot when started within 3 hr of initial symptoms. Thirty percent are likely to recover with little or no disability. Treatment is based on trying to limit the size of the infarct, and use requires close monitoring for signs of intracranial hemorrhage.Note: These agents are contraindicated in cranial hemorrhage as diagnosed by CT scan.
- Anticoagulants: warfarin sodium (Coumadin), low-molecular-weight heparin (Lovenox);
- Rationale:May be used to improve cerebral blood flow and prevent further clotting when embolism and/or thrombosis is the problem.
- Antiplateletagents: aspirin (ASA), dipyridamole (Persantine), ticlopidine (Ticlid);
- Rationale:Contraindicated in hypertensive patients because of increased risk of hemorrhage.
- Antifibrinolytics: aminocaproic acid (Amicar);
- Rationale:Used with caution in hemorrhagic disorder to prevent lysis of formed clots and subsequent rebleeding.
- Rationale:Chronic hypertension requires cautious treatment because aggressive management increases the risk of extension of tissue damage.
- Peripheral vasodilators: cyclandelate (Cyclospasmol), papaverine (Pavabid), isoxsuprine (Vasodilan).
- Rationale:Transient hypertension often occurs during acute stroke and resolves often without therapeutic intervention.Used to improve collateral circulation or decrease vasospasm.
- Steroids: dexamethasone (Decadron).
- Rationale:Use is controversial in control of cerebral edema.
- Neuroprotective agents:calcium channel blockers, excitatory amino acid inhibitors, gangliosides.
- Rationale:These agents are being researched as a means to protect the brain by interrupting the destructive cascade of biochemical events (influx of calcium into cells, release of excitatory neurotransmitters, buildup of lactic acid) to limit ischemic injury.
- Phenytoin (Dilantin), phenobarbital.
- Rationale:May be used to control seizures and/or for sedative action.Note: Phenobarbital enhances action of antiepileptics.
- Stool softeners.
- Rationale:Prevents straining during bowel movement and corresponding increase of ICP.
- Prepare for surgery, as appropriate: endarterectomy, microvascular bypass, cerebral angioplasty.
- Rationale:May be necessary to resolve situation, reduce neurological symptoms of recurrent stroke.
- Monitor laboratory studies as indicated: prothrombin time (PT) and/or activated partial thromboplastin time (aPTT) time, Dilantin level.
- Rationale:Provides information about drug effectiveness and/or therapeutic level.
- Impaired Physical Mobility
May be related to
- Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic paralysis
- Perceptual/cognitive impairment
Possibly evidenced by
- Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength/control
- Maintain/increase strength and function of affected or compensatory body part.
- Maintain optimal position of function as evidenced by absence of contractures, foot drop.
- Demonstrate techniques/behaviors that enable resumption of activities.
- Maintain skin integrity.
- Assess extent of impairment initially and on a regular basis. Classify according to 0–4 scale.
- Rationale:Identifies strengths and deficiencies thatmay provide information regarding recovery. Assists in choice of interventions, because different techniques are used for flaccid and spastic paralysis.
- Change positions at least every 2 hr (supine, side lying) and possibly more often if placed on affected side.
- Rationale:Reduces risk of tissue injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown.
- Position in prone position once or twice a day if patient can tolerate.
- Rationale:Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe.
- Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head.
- Rationale:Prevents contractures and footdrop and facilitates use when function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side.
- Use arm sling when patient is in upright position, as indicated.
- Rationale:During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and shoulder-hand syndrome.
- Evaluate need for positional aids and/or splints during spastic paralysis:
- Rationale:Flexion contractures occur because flexor muscles are stronger than extensors.
- Place pillow under axilla to abduct arm
- Rationale:Prevents adduction of shoulder and flexion of elbow.
- Elevate arm and hand
- Rationale:Promotes venous return and helps prevent edema formation.
- Place hard hand-rolls in the palm with fingers and thumb opposed.
- Rationale:Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in a functional position.
- Place knee and hop in extended position;
- Rationale:Maintains functional position.
- Maintain leg in neutral position with a trochanter roll;
- Rationale:Prevents external hip rotation.
- Discontinue use of footboard, when appropriate.
- Rationale:Continued use (after change from flaccid to spastic paralysis) can cause excessive pressure on the ball of the foot, enhance spasticity, and actually increase plantar flexion.
- Observe affected side for color, edema, or other signs of compromised circulation.
- Rationale:Edematous tissue is more easily traumatized and heals more slowly.
- Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary.
- Rationale:Pressure points over bony prominences are most at risk for decreased perfusion. Circulatory stimulation and padding help prevent skin breakdown and decubitus development.
- Begin active or passive ROM to all extremities (including splinted) on admission. Encourage exercises such as quadriceps/gluteal exercise, squeezing rubber ball, extension of fingers and legs/feet.
- Rationale:Minimizes muscle atrophy, promotes circulation, helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage.Note: Excessive stimulation can predispose to rebleeding.
- Assist patient with exercise and perform ROM exercises for both the affected and unaffected sides. Teach and encourage patient to use his unaffected side to exercise his affected side.
- Assist patient to develop sitting balance by raising head of bed, assist to sit on edge of bed, having patient to use the strong arm to support body weight and move using the strong leg. Assist to develop standing balance by putting flat walking shoes, support patient’s lower back with hands while positioning own knees outside patient’s knees, assist in using parallel bars.
- Rationale:Aids in retraining neuronal pathways, enhancing proprioception and motor response.
- Get patient up in chair as soon as vital signs are stable, except following cerebral hemorrhage.
- Rationale:Helps stabilize BP (by restoring vasomotor tone), promotes maintenance of extremities in a functional position and emptying of bladder, reducing risk of urinary stones and infections from stasis.Note:If stroke is not completed, activity increases risk of additional bleed.
- Pad chair seat with foam or water-filled cushion, and assist patient to shift weight at frequent intervals.
- Rationale:To prevent pressure on the coccyx and skin breakdown.
- Set goals with patient and SO for participation in activities and position changes.
- Rationale:Promotes sense of expectation of improvement, and provides some sense of control and independence.
- Encourage patient to assist with movement and exercises using unaffected extremity to support and move weaker side.
- Rationale:May respond as if affected side is no longer part of body and needs encouragement and active training to “reincorporate” it as a part of own body.
- Provide egg-crate mattress, water bed, flotation device, or specialized beds, as indicated.
- Rationale:Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown and decubitus formation. Specialized beds help with positioning, enhance circulation, and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia.
- Position the patient and align his extremities correctly. Use high-top sneakers to prevent footdrop and contracture and convoluted foam, flotation, or pulsating mattresses or sheepskin.
- Rationale:These are measures to prevent pressure ulcers.
- Communication, impaired verbal [and/or written]
May be related to
- Impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle tone/control; generalized weakness/fatigue
Possibly evidenced by
- Impaired articulation; does not/cannot speak (dysarthria)
- Inability to modulate speech, find and name words, identify objects; inability to comprehend written/spoken language
- Inability to produce written communication
- Indicate an understanding of the communication problems.
- Establish method of communication in which needs can be expressed.
- Use resources appropriately.
- Assess extentof dysfunction: patient cannot understand words or has trouble speaking or making self understood. Differentiate aphasia from dysarthria.
- Rationale:Helps determine area and degree of brain involvement and difficulty patient has with any or all steps of the communication process. Patient may have receptive aphasia or damage to the Wernicke’s speech area which is characterized by difficulty of understanding spoken words. He may also have expressive aphasiaor damage to the Broca’s speech areas, which is difficulty in speaking words correctly, or may experience both. Choice of interventions depends on type of impairment. Aphasia is a defect in using and interpreting symbols of language and may involve sensory and/or motor components (inability to comprehend written and/or spoken words or to write, make signs, speak). A dysarthric person can understand, read, and write language but has difficulty forming and pronouncing words because of weakness and paralysis of oral musculature. Patient may lose ability to monitor verbal output and be unaware that communication is not sensible.
- Listen for errors in conversation and provide feedback.
- Rationale:Feedback helps patient realize why caregivers are not understanding or responding appropriately and provides opportunity to clarify meaning.
- Ask patient to follow simple commands (“Close and open your eyes,” “Raise your hand”); repeat simple words or sentences;
- Rationale:Tests for receptive aphasia.
- Point to objects and ask patient to name them.
- Rationale:Tests for expressive aphasia. Patient may recognize item but not be able to name it.
- Have patient produce simple sounds (“Dog,” “meow,” “Shh”).
- Rationale:Identifies dysarthria, because motor components of speech (tongue, lip movement, breath control) can affect articulation and mayormay not be accompanied by expressive aphasia.
- Ask patient to write his name anda short sentence. If unable to write, have patient read a short sentence.
- Rationale:Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia.
- Write a notice at the nurses’ station and patient’s room about speech impairment. Provide a special call bell that can be activated by minimal pressure if necessary.
- Rationale:Allays anxiety related to inability to communicate and fear that needs will not be met promptly.
- Provide alternative methods of communication: writing, pictures.
- Rationale:Provides communication needs of patient based on individual situation and underlying deficit.
- Anticipate and provide for patient’s needs.
- Rationale:Helpful in decreasing frustration when dependent on others and unable to communication desires.
- Talk directly to patient, speaking slowly and distinctly. Phrase questions to be answered simply by yes or no. Progress in complexity as patient responds.
- Rationale:Reduces confusion and allays anxiety at having to process and respond to large amount of information at one time. As retraining progresses, advancing complexity of communication stimulates memory and further enhances word and idea association.
- Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Avoidpressing for a response.
- Rationale:Patient is not necessarily hearing impaired, and raising voice may irritate or anger patient. Forcing responses can result in frustration and may cause patient to resort to “automatic” speech (garbled speech, obscenities).
- Encourage SO/visitors to persist in efforts to communicate with patient: reading mail, discussing family happenings even if patient is unable to respond appropriately.
- Rationale:It is important for family members to continue talking to patient to reduce patient’s isolation, promote establishment of effective communication, and maintain sense of connectedness with family.
- Discuss familiar topics, e.g., weather, family, hobbies, jobs.
- Rationale:Promotes meaningful conversation and provides opportunity to practice skills.
- Respect patient’s preinjury capabilities; avoid “speaking down” to patient or making patronizing remarks.
- Rationale:Enables patient to feel esteemed, because intellectual abilities often remain intact.
- Consult and refer patientto speech therapist.
- Rationale:Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits/therapy needs.
- Disturbed Sensory Perception
May be related to
- Altered sensory reception, transmission, integration (neurological trauma or deficit)
- Psychological stress (narrowed perceptual fields caused by anxiety)
Possibly evidenced by
- Disorientation to time, place, person
- Change in behavior pattern/usual response to stimuli; exaggerated emotional responses
- Poor concentration, altered thought processes/bizarre thinking
- Reported/measured change in sensory acuity: hypoparesthesia; altered sense of taste/smell
- Inability to tell position of body parts (proprioception)
- Inability to recognize/attach meaning to objects (visual agnosia)
- Altered communication patterns
- Motor incoordination
- Regain/maintain usual level of consciousness and perceptual functioning.
- Acknowledge changes in ability and presence of residual involvement.
- Demonstrate behaviors to compensate for/overcome deficits.
- Review pathology of individual condition.
- Rationale:Awareness on the type and areas of involvement aid in assessing specific deficit and planning of care.
- Observe behavioral responses:crying, inappropriate affect, agitation, hostility, agitation, hallucination.
- Rationale:Individual responses are variable, but commonalities such as emotional lability, lowered frustration threshold, apathy, and impulsiveness may complicate care.
- Establish and maintain communication with the patient. Set up a simple method of communicating basic needs. Remember to phrase your questions so he’ll be able to answer using this system. Repeat yourself quietly and calmly and use gestures when necessary to help in understanding.
- Rationale:Note: even an unresponsive patient may be able to hear, so don’t say anything in his presence you wouldn’t want him to hear and remember.
- Eliminate extraneous noise and stimuli as necessary.
- Rationale:Reduces anxiety and exaggerated emotional responses and confusion associated with sensory overload.
- Speak in calm, comforting, quiet voice, using short sentences. Maintain eye contact.
- Rationale:Patient may have limited attention span or problems with comprehension. These measures can help patient attend to communication.
- Ascertain patient’s perceptions. Reorient patient frequently to environment, staff, procedures.
- Rationale:Assists patient to identify inconsistencies in reception and integration of stimuli and may reduce perceptual distortion of reality.
- Evaluate for visual deficits. Note loss of visual field, changes in depth perception (horizontal and/or vertical planes), presence of diplopia (double vision).
- Rationale:Presence of visual disorders can negatively affect patient’s ability to perceive environment and relearn motor skills and increases risk of accident and injury.
- Approach patient from visually intact side. Leave light on; position objects to take advantage of intact visual fields. Patch affected eye if indicated.
- Rationale:Helps the patient to recognize the presence of persons or objects and may help with depth perception problems. This also prevents patient from being startled. Patching the eye may decrease sensory confusion of double vision.
- Assess sensory awareness: dull from sharp, hot from cold, position of body parts, joint sense.
- Rationale:Diminished sensory awareness and impairment of kinesthetic sense negatively affects balanceandpositioning and appropriateness of movement, which interferes with ambulation, increasing risk of trauma.
- Stimulate sense of touch.Give patient objects to touch, and hold. Have patient practice touching walls boundaries.
- Rationale:Aids in retraining sensory pathways to integrate reception and interpretation of stimuli. Helps patient orient self spatially and strengthens use of affected side.
- Protect from temperature extremes; assess environment for hazards. Recommend testing warm water with unaffected hand.
- Rationale:Promotes patient safety, reducing risk of injury.
- Note inattention to body parts, segments of environment, lack of recognition of familiar objects/persons.
- Rationale:Agnosia, the loss of comprehension of auditory, visual, or other sensations, may lead result to unilateral neglect, inability to recognize environmental cues, considerable self-care deficits, and disorientation or bizarre behavior.
- Encourage patient to watch feet when appropriate and consciously position body parts. Make patient aware of all neglected body parts: sensory stimulation to affected side, exercises that bring affected side across midline, reminding person to dress/care for affected (“blind”) side.
- Rationale:Use of visual and tactile stimuli assists in reintegration of affected side and allows patient to experience forgotten sensations of normal movement patterns.
- Ineffective Coping
May be related to
- Situational crises, vulnerability, cognitive perceptual changes
Possibly evidenced by
- Inappropriate use of defense mechanisms
- Inability to cope/difficulty asking for help
- Change in usual communication patterns
- Inability to meet basic needs/role expectations
- Difficulty problem solving
- Verbalize acceptance of self in situation.
- Talk/communicate with SO about situation and changes that have occurred.
- Verbalize awareness of own coping abilities.
- Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.
- Assess extent of altered perception and related degree of disability. Determine Functional Independence Measure score.
- Rationale:Determination of individual factors aids in developing plan of care/choice of interventions and discharge expectations.
- Identify meaning of the dysfunction and change to patient.Note ability to understand events, provide realistic appraisalof the situation.
- Rationale:Independence is highly valued in American culture but is not as significant in some cultures. Some patients accept and manage altered function effectively with little adjustment, whereas others may have considerable difficulty recognizing and adjust to deficits.In order to provide meaningful support and appropriate problem-solving, healthcare providers need to understand the meaning of the stroke/limitations to patient.
- Determine outside stressors: family, work, future healthcare needs.
- Rationale:Helps identify specific needs, provides opportunity to offer information and begin problem-solving. Consideration of social factors, in addition to functional status, is important in determining appropriate discharge destination.
- Provide psychological support and set realistic short-term goals. Involve the patient’s SO in plan of care when possible and explain his deficits and strengths.
- Rationale:To increase the patient’s sense of confidence and can help in compliance to therapeutic regimen.
- Encourage patient to express feelings, including hostility or anger, denial, depression, sense of disconnectedness.
- Rationale:Demonstrates acceptance ofpatient in recognizing and beginning to deal with these feelings.
- Note whether patient refers to affected side as “it” or denies affected side and says it is “dead.”
- Rationale:Suggests rejection of body part and negative feelings about body image and abilities, indicating need for intervention and emotional support.
- Acknowledge statement of feelings about betrayal of body; remain matter-of-fact about reality that patient can still use unaffected side and learn to control affected side. Use words (weak, affected, right-left) that incorporate that side as part of the whole body.
- Rationale:Helps patient see that the nurse accepts both sides as part of the whole individual. Allows patient to feel hopeful and begin to accept current situation.
- Identify previous methods of dealing with life problems. Determine presenceof support systems.
- Rationale:Provides opportunity to use behaviors previously effective, build on past successes, and mobilize resources.
- Emphasize small gains either in recovery of function or independence.
- Rationale:Consolidates gains, helps reduce feelings of anger and helplessness, and conveys sense of progress.
- Support behaviors and efforts such as increased interest/participation in rehabilitation activities.
- Rationale:Suggest possible adaptation to changes and understanding about own role in future lifestyle.
- Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope, lethargy, withdrawal.
- Rationale:May indicate onset of depression (common after effect of stroke), which may require further evaluation and intervention.
- Refer for neuropsychological evaluation and/or counseling if indicated.
- Rationale:May facilitate adaptation to role changes that are necessary for a sense of feeling/being a productive person.Note: Depression is common in stroke survivors and may be a direct result of the brain damage and/or an emotional reaction to sudden-onset disability.
- Self-Care Deficit
May be related to
- Neuromuscular impairment, decreased strength and endurance, loss of muscle control/coordination
- Perceptual/cognitive impairment
Possibly evidenced by
- Impaired ability to perform ADLs, e.g., inability to bring food from receptacle to mouth; inability to wash body part(s), regulate temperature of water; impaired ability to put on/take off clothing; difficulty completing toileting tasks
- Demonstrate techniques/lifestyle changes to meet self-care needs.
- Perform self-care activities within level of own ability.
- Identify personal/community resources that can provide assistance as needed.
- Assess abilities and level of deficit (0–4 scale) for performing ADLs.
- Rationale:Aids in planning for meeting individual needs.
- Avoid doing things for patient that patient can do for self, but provide assistance as necessary.
- Rationale:To maintain self-esteem and promote recovery, it is important for the patient to do as much as possible for self. These patients may become fearful and independent, although assistance is helpful in preventing frustration.
- Be aware of impulsive actions suggestive of impaired judgment.
- Rationale:May indicate need for additional interventions and supervision to promote patient safety.
- Maintain a supportive, firm attitude. Allow patient sufficient time to accomplish tasks. Don’t rush the patient.
- Rationale:Patients need empathy and to know caregivers will be consistent in their assistance.
- Provide positive feedback for efforts and accomplishments.
- Rationale:Enhances sense of self-worth, promotes independence, and encourages patient to continue endeavors.
- Create plan for visual deficits that are present: Place food and utensils on the tray related to patient’s unaffected side; Situate the bed so that patient’s unaffected side is facing the room with the affected side to the wall; Position furniture against wall/out of travel path.
- Rationale:Patient will be able to see to eat the food. Will be able to see when getting in/out of bed and observe anyone who comes into the room. Provides for safety when patient is able to move around the room, reducing risk of tripping/falling over furniture.
- Provide self-help devices: extensions with hooks for picking things up from the floor, toilet risers, long-handled brushes,drinking straw, leg bag for catheter, shower chair. Encourage good grooming and makeup habits.
- Rationale:To enable the patient to manage for self, enhancing independence and self-esteem, reduce reliance on others for meeting own needs, and enables the patient to be more socially active.
- Encourage SO to allow patient to do as much as possible for self.
- Rationale:Reestablishes sense of independence and fosters self-worth and enhances rehabilitation process.Note: This may be very difficult and frustrating for the caregiver, depending on degree of disability and time required for patient to complete activity.
- Assess patient’s ability to communicate the need to void and/or ability to use urinal, bedpan. Take patient to the bathroom at periodicintervals for voiding if appropriate.
- Rationale:Patient may have neurogenic bladder, be inattentive, or be unable to communicate needs in acute recovery phase, but usually is able to regain independent control of this function as recovery progresses.
- Identify previous bowel habits and reestablish normal regimen. Increase bulk in diet, encourage fluid intake, increased activity.
- Rationale:Assists in development of retraining program (independence) and aids in preventing constipation and impaction (long-term effects).
- Teach the patient to comb hair, dress, and wash.
- Rationale:To promote sense o f independence and self-esteem.
- Refer patient to physical and occupational therapist.
- Rationale:Rehabilitation helps to relearn skills that are lost when part of the brain is damaged. It also teaches new ways of performing tasks to circumvent or compensate for any residual disabilities.
What is the nursing goal for cerebrovascular accident? ›
Common goals and expected outcomes: Patient will maintain usual/improved level of consciousness, cognition, and motor/sensory function. Patient will demonstrate stable vital signs and absence of signs of increased ICP. Patient will display no further deterioration/recurrence of deficits.What is the management of cerebrovascular accident? ›
The main treatment for an ischemic stroke is a medicine called tissue plasminogen activator (tPA). It breaks up the blood clots that block blood flow to your brain. A doctor will inject tPA into a vein in your arm. This type of medicine must be given within 3 hours after your symptoms start.What are the 5 care priorities for a patient experiencing possible stroke? ›
Nurses are expected to perform comprehensive and systematic physical assessments for all patients with stroke, including monitoring the main 5 vital signs: body temperature, blood pressure (BP), breathing effort (rate, patterns, and chest expansion), oxygen saturation, and mental status/level of consciousness.What are the top 5 nursing interventions that need to be considered with a patient with a heart failure? ›
- Relieving fluid overload symptoms.
- Relieving symptoms of anxiety and fatigue.
- Promoting physical activity.
- Increasing medication compliance.
- Decreasing adverse effects of treatment.
- Teaching patients about dietary restrictions.
- Teaching patient about self-monitoring of symptoms.
An IV injection of recombinant tissue plasminogen activator (TPA) — also called alteplase (Activase) or tenecteplase (TNKase) — is the gold standard treatment for ischemic stroke. An injection of TPA is usually given through a vein in the arm within the first three hours.What are nursing goals in a care plan? ›
Goals can be short-term (e.g., resolve acute pain after surgery) or long-term (e.g., lower the patient's A1C with better diabetes management). Then the nurse prioritizes goals based on urgency, importance, and patient feedback. Nurses can also use Maslow's hierarchy of needs to help prioritize patient goals.What is the first priority of nursing care for the stroke patient? ›
Your initial evaluation of a patient with a suspected stroke should include airway, breathing, and circulation, followed by neurologic assessment using either the NIHSS or the mNIHSS, per facility policy.What are nursing goals interventions? ›
Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. As for risk nursing diagnoses, interventions should focus on reducing the client's risk factors.What is the role of the nurse in the management of a stroke? ›
The role of the nurse in stroke care
Physiological monitoring and maintenance of homeostasis. Reduce morbidity and prevent mortality. Prevent and detect lesion extension and cerebral oedema. Prevent complications.
Immediate goals include minimizing brain injury, treating medical complications, and moving toward uncovering the pathophysiologic basis of the patient's symptoms. Patient assessment and management during the acute phase (first few hours) of an ischemic stroke will be reviewed here.
What are the goals of treatment for stroke patients? ›
Treatment for Ischemic Stroke
With this type of stroke, the goal is to restore blood flow to the brain as quickly as possible. In most cases, medication is given at the hospital to help break up the clot and prevent the formation of new clots.
Common Rehabilitation Goals for Stroke Patients
Maximize each person's functional abilities and level of independence. Provide extensive training and education for the person and their family. Rebuild the person's quality of life.
- Activity. Bed rest should be maintained until acute symptoms and gross hematuria disappear.
- Prevent infection. The child must be protected from chilling and contact with people with infections.
- Monitor intake and output. ...
- Monitor BP. ...
- Monitor urine characteristics.
These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.What is nursing management of cardiac patients? ›
Promoting activity and reducing fatigue, Relieving fluid overload symptoms and improve respiration, Decreasing anxiety or increasing the patient's ability to manage anxiety, Teaching the patient about the self-care program.What is a quick intervention for stroke? ›
If you get to the hospital within 3 hours of the first symptoms of an ischemic stroke, you may get a type of medicine called a thrombolytic (a “clot-busting” drug) to break up blood clots. Tissue plasminogen activator (tPA) is a thrombolytic. tPA improves the chances of recovering from a stroke.What is the most important intervention to prevent stroke? ›
Choose healthy foods and drinks
Eating foods low in saturated fats, trans fat, and cholesterol and high in fiber can help prevent high cholesterol. Limiting salt (sodium) in your diet can also lower your blood pressure. High cholesterol and high blood pressure increase your chances of having a stroke.
Simple goal: I want to show more compassion and empathy to my patients. SMART nursing goal: I will spend an extra five minutes with each new patient and ask questions about their lives to learn at least three interests we can discuss to distract them from stress about their condition.How do you write nursing goals examples? ›
- Manage advanced technologies.
- Get nursing certifications.
- Find a mentor.
- Advance your nursing degree.
- Start volunteering.
- Specialize in a particular nursing field.
- Take care of yourself.
- Improve efficiency.
The focus is on these four major nursing areas: nursing practice, administration, education, and research.
What are three nursing goals? ›
- Acquiring skills in advancing technology.
- Fulfilling continuing education unit requirements (CEUs)
- Refining interpersonal skills.
- Honing a specific skill set to an expert level.
- Taking a management/leadership position.
- Obtaining professional certifications.
The primary goals of stroke rehabilitation are to regain independence and improve quality of life by minimizing the limitations of activities of daily living (ADL).What is the most important aspect of stroke treatment? ›
The most important part of stroke treatment is getting it fast. acronym “FAST” is an easy way to remember the main symptoms to be aware of in order to help someone who may be having a stroke: face drooping, arm weakness or speech difficulty. If any of these symptoms are present, the “t” stands for time to call 911.What are the goals of cerebral hemorrhage treatment? ›
Treatment focusses on stopping the bleeding, removing the clot and relieving pressure on the brain. If left alone, the brain will eventually re-absorb the clot. The damage done by increased brain pressure over a long period may be irreversible.What are the goals of nursing care during the acute phase of a stroke? ›
Introduction: Generally, nursing interventions during the acute stages following a stroke aim at preventing secondary brain injury (intracranial hypertension), maintaining the airways (due to paralysis of the pharynx muscles), providing general body support (vital signs, fluid and electrolyte balance), and anticipating ...What is the most important intervention for hemorrhagic stroke? ›
Blood pressure management
Because high blood pressure is the most common cause of hemorrhagic strokes, a top priority for treating these strokes is lowering your blood pressure and keeping it at a safe level. Doing this can reduce the amount of bleeding in your brain.
The goal of hemorrhagic stroke treatment is to reduce pressure in the brain and control any brain bleeding. Emergency care will likely include surgical blood vessel repair.What is the blood pressure management protocol for a stroke patient? ›
The current American Heart Association/American Stroke Association and ESO guidelines recommend maintaining BP <180/105 mm Hg for 24 hours post-intravenous thrombolytic administration. In patients treated with intravenous thrombolysis, hypertension usually resolves after recanalization.What is the long term goal for a stroke patient? ›
After a stroke, one of the most important ways to encourage recovery is to begin a rehabilitation program right away. The overarching goal of stroke rehabilitation is to stabilize your condition, help you gain optimal function, and promote the best quality of life.What are the four main areas that stroke recovery focuses on? ›
They are: physical therapy (PT), occupational therapy (OT), speech and cognitive therapy – usually provided by a Speech-Language Pathologist (SLP) – and mental health counseling. Read on for a description of each.