cerebrovascular accident

A cerebrovascular accident (CVA), an ischemic stroke or

“brain attack,” is a sudden loss of brain function resulting from

Cerebral Vascular Accident (Ischemic Stroke) 215

a disruption of the blood supply to a part of the brain. Stroke is

the primary cerebrovascular disorder in the United States. Strokes

are usually hemorrhagic (15%) or ischemic/nonhemorrhagic

(85%). Ischemic strokes are categorized according to their cause:

large artery thrombotic strokes (20%), small penetrating artery

thrombotic strokes (25%), cardiogenic embolic strokes (20%),

cryptogenic strokes (30%), and other (5%). Cryptogenic strokes

have no known cause, and other strokes result from causes such

as 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.

Risk Factors

Nonmodifiable

• Advanced age (older than 55 years)

• Gender (Male)

• Race (African American)

Modifiable

• Hypertension

• Atrial fibrillation

•Hyperlipidemia

• Obesity

• Smoking

• Diabetes

• Asymptomatic carotid stenosis and valvular heart disease

(eg, endocarditis, prosthetic heart valves)

• Periodontal disease

Clinical Manifestations

General signs and symptoms include numbness or weakness of

face, arm, or leg (especially on one side of body); confusion

or change in mental status; trouble speaking or understanding

speech; visual disturbances; loss of balance, dizziness, difficulty

walking; or sudden severe headache.

Motor Loss

• Hemiplegia, hemiparesis

• Flaccid paralysis and loss of or decrease in the deep tendon

reflexes (initial clinical feature) followed by (after 48 hours)

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reappearance of deep reflexes and abnormally increased muscle

tone (spasticity)

Communication Loss

• Dysarthria (difficulty speaking)

•Dysphasia (impaired speech) or aphasia (loss of speech)

• Apraxia (inability to perform a previously learned action)

Perceptual Disturbances and Sensory Loss

•Visual-perceptual dysfunctions (homonymous hemianopia

[loss of half of the visual field])

•Disturbances in visual-spatial relations (perceiving the relation

of two or more objects in spatial areas), frequently seen

in patients with right hemispheric damage

• Sensory losses: slight impairment of touch or more severe

with loss of proprioception; difficulty in interrupting visual,

tactile, and auditory stimuli

Impaired Cognitive and Psychological Effects

• Frontal lobe damage: Learning capacity, memory, or other

higher cortical intellectual functions may be impaired. Such

dysfunction 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

• 12-lead ECG and carotid ultrasound

• CT angiography or MRI and angiography

• Transcranial Doppler flow studies

• Transthoracic or transesophageal echocardiography

• Xenon-enhanced CT scan

• Single photon emission CT (SPECT) scan

Prevention

•Help patients alter risk factors for stroke; encourage patient

to quit smoking, maintain a healthy weight, follow a healthy

diet (including modest alcohol consumption), and exercise

daily.

• Prepare and support patient through carotid endarterectomy.

216 Cerebral Vascular Accident (Ischemic Stroke)

•Administer anticoagulant agents as prescribed (eg, low-dose

aspirin therapy).

Medical Management

• Recombinant tissue plasminogen activator (t-PA), unless

contraindicated; 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 promote

venous drainage and to lower increased ICP)

• Possible hemicraniectomy for increased ICP from brain

edema in a very large stroke

• Intubation with an endotracheal tube to establish a patent

airway, if necessary

• Continuous hemodynamic monitoring (the goals for blood

pressure remain controversial for a patient who has not

received thrombolytic therapy; antihypertensive treatment

may be withheld unless the systolic blood pressure exceeds 220

mm Hg or the diastolic blood pressure exceeds 120 mm Hg)

• Neurologic assessment to determine if the stroke is evolving

and 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 complications

of immobility.

NURSING PROCESS

THE PATIENT RECOVERING FROM AN

ISCHEMIC STROKE

Assessment

During Acute Phase (1 to 3 days)

Weigh patient (used to determine medication dosages),

and maintain a neurologic flow sheet to reflect the following

nursing assessment parameters:

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• Change in level of consciousness or responsiveness, ability

to speak, and orientation

• Presence or absence of voluntary or involuntary

movements 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 of

skin

• Quality and rates of pulse and respiration; ABGs, body

temperature, and arterial pressure

• Volume of fluids ingested or administered and volume of

urine excreted per 24 hours

• Signs of bleeding

• Blood pressure maintained within normal limits

Postacute Phase

Assess the following functions:

• Mental status (memory, attention span, perception, orientation,

affect, speech/language).

• Sensation and perception (usually the patient has

decreased awareness of pain and temperature).

• Motor control (upper and lower extremity movement);

swallowing ability, nutritional and hydration status, skin

integrity, activity tolerance, and bowel and bladder function.

• Continue focusing nursing assessment on impairment of

function in patient’s daily activities.

Diagnosis

Nursing Diagnoses

• Impaired physical mobility related to hemiparesis, loss of

balance and coordination, spasticity, and brain injury

• Acute pain related to hemiplegia and disuse

• Deficient self-care (bathing, hygiene, toileting, dressing,

grooming, and feeding) related to stroke sequelae

• Disturbed sensory perception (kinesthetic, tactile, or

visual) related to altered sensory reception, transmission,

and/or integration

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Cerebral Vascular Accident (Ischemic Stroke) 219

• 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 or

hemiplegia, decreased mobility

• Interrupted family processes related to catastrophic illness

and caregiving burdens

• Sexual dysfunction related to neurologic deficits or fear of

failure

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 include

improved mobility, avoidance of shoulder pain, achievement

of self-care, 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 like

before the stroke.

Nursing Interventions

Improving Mobility and Preventing Deformities

• Position to prevent contractures; use measures to relieve

pressure, assist in maintaining good body alignment, and

prevent compressive neuropathies.

• Apply a splint at night to prevent flexion of affected

extremity.

• Prevent adduction of the affected shoulder with a pillow

placed in the axilla.

• Elevate affected arm to prevent edema and fibrosis.

• Position fingers so that they are barely flexed; place

hand in slight supination. If upper extremity spasticity is

noted, do not use a hand roll; dorsal wrist splint may be

used.

• Use proper patient movement and positioning (eg, flaccid

arm on a table or pillows when patient is seated, use of

sling when ambulating).

• Range-of-motion exercises are beneficial, but avoid overstrenuous

arm movements.

• Elevate arm and hand to prevent dependent edema of the

hand; administer analgesic agents as indicated.

Enhancing Self-Care

• Encourage personal hygiene activities as soon as the

patient can sit up; select suitable self-care activities that

can 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 self-care

activities on the unaffected side.

• Make sure patient does not neglect affected side; provide

assistive devices as indicated.

• Improve morale by making sure patient is fully dressed

during ambulatory activities.

• Assist with dressing activities (eg, clothing with Velcro

closures; put garment on the affected side first); keep

environment uncluttered and organized.

• Provide emotional support and encouragement to prevent

fatigue and discouragement.

Managing Sensory-Perceptual Difficulties

• Approach patient with a decreased field of vision on the

side where visual perception is intact; place all visual

stimuli on this side.

• Teach patient to turn and look in the direction of the

defective visual field to compensate for the loss; make eye

contact with patient, and draw attention to affected side.

• Increase natural or artificial lighting in the room; provide

eyeglasses to improve vision.

• Remind patient with hemianopsia of the other side of the

body; place extremities so that patient can see them.

Assisting with Nutrition

• Observe patient for paroxysms of coughing, food dribbling

out or pooling in one side of the mouth, food retained for

long periods in the mouth, or nasal regurgitation when

swallowing liquids.

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• Consult with speech therapist to evaluate gag reflexes;

assist in teaching alternate swallowing techniques, advise

patient to take smaller boluses of food, and inform patient

of foods that are easier to swallow; provide thicker liquids

or pureed diet as indicated.

• Have patient sit upright, preferably on chair, when eating

and 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 ensure

that 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 period

of loss of sphincter control.

• Analyze voiding pattern and offer urinal or bedpan on

patient’s voiding schedule.

• Assist the male patient to an upright posture for voiding.

• Provide high-fiber diet and adequate fluid intake (2 to

3 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, give

positive feedback, convey an attitude of confidence and

hopefulness; provide other interventions as used for

improving cognitive function after a head injury.

Improving Communication

• 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 and

responding to them in an appropriate manner; treat

patient as an adult.

• Provide strong emotional support and understanding to

allay anxiety; avoid completing patient’s sentences.

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Cerebral Vascular Accident (Ischemic Stroke) 223

• 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; allow

patient time to process.

• Talk to aphasic patients when providing care activities to

provide social contact.

Maintaining Skin Integrity

• Frequently assess skin for signs of breakdown, with emphasis

on bony areas and dependent body parts.

• Employ pressure-relieving devices; continue regular turning

and positioning (every 2 hours minimally); minimize

shear 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 management

techniques and maintenance of personal health for family

coping.

• Give family information about the expected outcome of

the stroke, and counsel them to avoid doing things for

patient that he or she can do.

• Develop attainable goals for patient at home by involving

the total health care team, patient, and family.

• Encourage everyone to approach patient with a supportive

and optimistic attitude, focusing on abilities that remain;

explain to family that emotional lability usually improves

with time.

Helping the Patient Cope with Sexual Dysfunction

• Perform in-depth assessment to determine sexual history

before and after the stroke.

• Interventions for patient and partner focus on providing

relevant information, education, reassurance, adjustment

of medications, counseling regarding coping skills, suggestions

for alternative sexual positions, and a means of sexual

expression and satisfaction.

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Promoting Home- and Community-Based Care

• Teach patient to resume as much self-care as possible; provide

assistive devices as indicated.

• Have occupational therapist make a home assessment and

recommendations 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 in

daily events.

• Make referral for home speech therapy. Encourage family

involvement. Provide family with practical instructions to

help patient between speech therapy sessions.

• Discuss patient’s depression with physician for possible

antidepressant therapy.

• Encourage patient to attend community-based stroke clubs

to give a feeling of belonging and fellowship with others.

• Encourage patient to continue with hobbies, recreational

and leisure interests, and contact with friends to prevent

social isolation.

• Encourage family to support patient and give positive

reinforcement.

• Remind spouse and family to attend to personal health

and well-being.

Evaluation

Expected Patient Outcomes

• Achieves improved mobility.

• Has no complaints of pain.

• Achieves self-care; performs hygiene care; uses adaptive

equipment.

• Demonstrates techniques to compensate for altered

sensory reception, such as turning the head to see people

or objects.

• Demonstrates safe swallowing.

• Achieves normal bowel and bladder elimination.

• Participates in cognitive improvement program.

• Demonstrates improved communication.

• Maintains intact skin without breakdown.

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Cholelithiasis (and Cholecystitis) 225

• Family members demonstrate a positive attitude and coping

mechanisms.

• Develops alternative approaches to sexual expression.

For more information, see Chapter 62 in Smeltzer, S. C., Bare,

B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddarth’s

textbook of medical-surgical nursing (12th ed.).

Philadelphia: Lippincott Williams & Wilkins.