What is the first priority of nursing care for the stroke patient?

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What is Cerebrovascular Accident (CVA) or Stroke?
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Last Updated: 14-06-2017

Dysphagia (inability to swallow properly) is a common and significant complication that occurs in about 40-60% of stroke victims.

Patients with dysphagia have trouble swallowing solids or liquids without aspirating the contents into the bronchopulmonary tract. They may also find it hard to chew or move their tongues adequately to prepare food for the swallowing action. Proper assessment and early management is essential, as dysphagia is associated with high rates of morbidity and mortality.

Ideally, the nurse looking after a stroke victim should strive to observe for dysphagia, monitor for and report any complications such as infection, and monitor for signs of dehydration and malnutrition.

Dysphagia can lead to:

Malnutrition
Weight loss
Starvation
Dehydration
Aspiration pneumonia
Lower respiratory tract infections
Longer time needed to recover from stroke
Emotional distress – embarrassment or anger at requiring assistance with eating, especially as dining is often done in a social setting

Assessment findings indicative of increased risk of dysphagia, aspiration, and pneumonia:

Comorbid diseases with pulmonary compromise (such as chronic obstructive airways disease)
Smoking history
A hoarse, wet voice or weak cough
Dental decay
Requiring assistance with eating
Medications that list dysphagia as a potential adverse effect (such as potassium supplements)
Poor posture control (cannot remain upright)
Low level of consciousness/Glasgow Coma Scale (GCS)

Identification of dysphagia in stroke victims: A patient is more likely to be suffering from dysphagia if some of the following factors are present: palatal asymmetry, impaired pharyngeal response, being male, being more than 70 years old, and not being able to clear the oral cavity completely. A nurse should also observe the patient’s ability to move the mouth spontaneously, e.g. licking lips, smiling, speaking well (i.e. is it intelligible?). There are various screening methods for identifying dysphagia, such as a swallow test. Patients can be tested to see how well they swallow food of different consistencies and textures, e.g. water, then thickened fluids, then mashed foods, then more solid foods. Afterwards, patients should be assessed for any delayed coughing. Vital signs should also be monitored, as a patient’s temperature will rise when aspirating food, whilst oxygen saturation levels may fall. Additionally, the incidence rate of identifying dysphagia was found in one study to be higher when a clinician trained in swallowing was involved, and highest when instruments such as videofluroscopy were involved. Dysphagia assessments are important – one multicentre study found that when a standardised screening protocol for dysphagia was used on stroke victims, the risk of aspiration pneumonia decreased. The patient should also be referred to a speech pathologist for a thorough clinical assessment. Speech pathologists can formally assess for dysphagia, and recommend strategies for eating and swallowing. They can also teach patients how to exercise the muscles involved in swallowing.

Important practice points for managing patients with dysphagia:

As with all patients, check vital signs regularly.

Weigh the patient on admission to obtain a baseline weight. Regular weights throughout admission can then aid in monitoring for malnutrition and weight loss.

Keep patients nil by mouth immediately following a stroke, until an assessment of their swallowing ability and risk of aspiration can be made.

Don’t allow patients to eat/drink until there is a definite plan regarding what type of solids/texture they can safely eat.

Refer to speech pathologists for a formal swallowing assessment, and assistance on helping patients improve their swallowing abilities.

Refer to a dietitian, to assess for nutritional intake in the diet and any weight gain/loss. For malnourished patients, a high-protein, high-energy diet may be best. Nutritional supplements may be recommended. On discharge, they can also educate patients on planning snacks and meals so they can continue to get adequate nutritional intake.

Patients may need foods of certain textures e.g. thickened fluids or pureed meals. Additionally, chilled foods may be beneficial as they stimulate the swallow reflex.

Try placing a spoonful of food in the unaffected side of the mouth (if the stroke has affected one side of the face), whilst trying to avoid the teeth or pushing to food too far into the mouth.

Make sure they remain upright whilst you are feeding them.

Help maintain patients’ personal hygiene and dignity standards: keep napkins available, and assist them in washing their hands or cleaning their teeth if they wish to do so.

Good non-verbal signs may assist the nurse helping to feed the patient, e.g. sitting in front of the patient, leaning forward and keeping good eye contact.

If a patient aspirates: encourage them to cough to help clear their airway, keep them in an upright position, and if necessary, assist them to clear the oral cavity with use of suction.

If patients are at risk of becoming dehydrated, it is likely that they will require intravenous fluids.

If aspiration is suspected, the patient’s doctor will need to be informed and the patient will generally need a chest x-ray and possibly antibiotics.

Sources

• http://www.sign.ac.uk/pdf/sign119.pdf

• http://www.uptodate.com/contents/medical-complications-of-stroke
• https://www.stroke.org/sites/default/files/resources/NSAFactSheet_Eating_2014.pdf
• http://www.nursingtimes.net/clinical-archive/nutrition/nutrition-and-hydration-tips-for-stroke-patients-with-dysphagia/203500.fullarticle

*This article passed Copyscape Premium on 2 June 2016 at 2:58 GMT.

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What is Cerebrovascular Accident (CVA) or Stroke?

Cerebrovascular accident (CVA), also known as stroke, cerebral infarction, brain attack, is any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels of the entire cerebrovascular system. It is the sudden impairment of cerebral circulation in one or more blood vessels supplying the brain. This pathology either causes hemorrhage from a tear in the vessel wall or impairs the cerebral circulation by partial or complete occlusion of the vessel lumen with transient or permanent effects. The sooner the circulation returns to normal after a stroke, the better the chances are for a full recovery. However, about half of those who survived a stroke remain disabled permanently and experience the recurrence within weeks, months, or years.

Thrombosis, embolism, and hemorrhage are the primary causes of stroke, with thrombosis being the leading cause of both CVAs and transient ischemic attacks (TIAs). The most common vessels involved are the carotid arteries and those of the vertebrobasilar system at the base of the brain.

A thrombotic CVA causes a slow evolution of symptoms, usually over several hours, and is “completed” when the condition stabilizes. An embolic CVA occurs when a clot is carried into cerebral circulation and causes a localized cerebral infarct. Hemorrhagic CVA is caused by other conditions such as a ruptured aneurysm, hypertension, arteriovenous (AV) malformations, or other bleeding disorders.

Nursing Care Plans

The primary nursing care plan goals for patients with stroke depend on the phase of CVA the client is in. During the acute phase of CVA, efforts should focus on survival needs and prevent further complications. Care revolves around efficient continuing neurologic assessment, support of respiration, continuous monitoring of vital signs, careful positioning to avoid aspiration and contractures, management of GI problems, and monitoring of electrolyte and nutritional status. Nursing care should also include measures to prevent complications.

Listed below are 12 nursing diagnoses for stroke (cerebrovascular accident) nursing care plans:

NOTE: This nursing care plan is recently updated with new content and a change in formatting. Nursing assessment and nursing interventions are listed in bold and followed by their specific rationale in the following line. Still, when writing nursing care plans, follow the format here.

The goals for this nursing diagnosis include decreasing the risk of ineffective cerebral tissue perfusion.

Nursing Diagnosis

Risk for Ineffective Tissue Perfusion

Risk factors may include

Common risk factors for this nursing diagnosis:

Clot emboli
Hemorrhage of cerebral vessel
Occlusive disorder
Cerebral vasospasms
Cerebral edema

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

Interventions for this diagnosis include ways to decrease the risk of cerebral perfusion related to stroke or transient ischemic attack. Also, note that some treatment modalities are different for ischemic and hemorrhagic stroke. As always, please individualize your nursing care plans and choose interventions appropriate to your client.

Nursing Assessment and Rationales

The following is a nursing assessment guide for this cerebrovascular accident (stroke) nursing care plan.

1. Assess airway patency and respiratory pattern.
Neurologic deficits of a stroke may include loss of gag reflex or cough reflex; thus, airway patency and breathing pattern must be part of the initial assessment.

2. Assess factors related to decreased cerebral perfusion and the potential for increased intracranial pressure (ICP).
The extensive neurologic examination will help guide therapy and the choice of interventions.

3. Recognize the clinical manifestations of a transient ischemic attack (TIA).
Patients with TIA present with temporary neurologic symptoms such as sudden loss of motor, sensory, or visual function caused by transient ischemia to a specific region of the brain, with their brain imaging scan showing no evidence of ischemia. Recognizing symptoms of TIA may serve as a warning of an impending stroke as approximately 15% of all strokes are preceded by a TIA (Amarenco et al., 2018; Sacco, 2004). Evaluation and prompt treatment of the patient who experienced TIA can help prevent stroke and its irreversible complications.

4. Frequently assess and monitor neurological status.
Assess trends in the level of consciousness (LOC), the potential for increased ICP, and helps determine location, extent, and progression of damage. Prognosis depends on the neurologic condition of the patient. It may also reveal the presence of TIA, which may warn of impending thrombotic CVA. Neurologic assessment includes:

Change in the level of consciousness or responsiveness
Response to stimulation
Orientation to time, place, and person
Eye opening, pupillary reactions to light and accomodation, size of pupils

Alternatively, you can use the National Institutes of Health Stroke Scale to help guide you through assessment.

5. Monitor changes in blood pressure, compare BP readings in both arms.
Hypertension is a significant risk factor for stroke. Fluctuation in blood pressure may occur because of cerebral injury in the vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse), and increased ICP may occur because of tissue edema or clot formation. Subclavian artery blockage may be revealed by the difference in pressure readings between arms. Additionally, if the patient is eligible for fibrinolytic therapy, blood pressure control is essential to decrease the risk of bleeding.

6. Monitor heart rate and rhythm, assess for murmurs.
Changes in rate, especially bradycardia, can occur because of brain damage. Dysrhythmias and murmurs may reflect cardiac disease, precipitating CVA (stroke after MI or valve dysfunction). The presence of atrial fibrillation increases the risk of emboli formation.

7. Monitor respirations, noting patterns and rhythm, Cheyne-Stokes respiration.
Irregular respiration can suggest the location of cerebral insult or increasing ICP and the need for further intervention, including possible respiratory support.

8. Monitor computed tomography scan.
A CT scan is the initial diagnostic test performed for patients with stroke that is executed immediately once the patient presents to the emergency department. CT scan is used to determine if the event is ischemic or hemorrhagic as the type of stroke will guide therapy. A computed tomography angiography (CTA) may also be performed to detect intracranial occlusions and the extent of occlusion in the arterial tree (Menon & Demchuk, 2011).

9. Evaluate pupils, noting size, shape, equality, light reactivity.
Pupil reactions are regulated by the oculomotor (III) cranial nerve and help determine whether the brain stem is intact. Pupil size and equality are determined by the balance between parasympathetic and sympathetic innervation. Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves.

10. Document changes in vision: reports of blurred vision, alterations in the visual field, depth perception.
Visual disturbances may occur if the aneurysm is adjacent to the oculomotor nerve. Specific visual alterations reflect an area of the brain involved. Initiate measures to promote safety.

11. Assess higher functions, including speech, if the patient is alert.
Changes in cognition and speech content indicate location and degree of cerebral involvement and may indicate deterioration or increased ICP.

12. Assess for nuchal rigidity, twitching, increased restlessness, irritability, the onset of seizure activity.
Nuchal rigidity (pain and rigidity of the back of the neck) may indicate meningeal irritation. Seizures may reflect an increase in ICP or cerebral injury requiring further evaluation and intervention.

Nursing Interventions and Rationales

Here are the nursing interventions for this stroke nursing care plan.

1. Screen the patient for stroke risk.
Prevention of stroke is still the best approach. A healthy lifestyle, exercising, maintaining a healthy weight, and following a healthy diet can reduce the risk of having a stroke (Gorelick et al., 2015).

2. Position with head slightly elevated and in a neutral position.
Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion. During the acute phase of stroke, maintain the head of the bed less than 30 degrees.

3. Maintain bedrest, provide a quiet and relaxing environment, restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit duration of procedures.
Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may be needed to prevent rebleeding.

4. Prevent straining at stool, holding breath, physical exertion.
Valsalva maneuver increases ICP and potentiates the risk of rebleeding.

5. Stress smoking cessation.
Cigarette smoking is a well-established risk factor for all forms of stroke. Smoking increases the risk of stroke by three to fourfold (Shah & Cole, 2010). Encouraging the patient to quit, counseling, nicotine replacement, and oral smoking cessation medications (e.g., Zyban) are some approaches to aid in quitting. Nurses are the first line of treatment among hospital staff capable of planning and implementing interventions to quit smoking. Research suggests that smoking cessation counseling by nurses plays a crucial role in quitting smoking (Kazemzadeh, Manzari, & Pouresmail, 2017).

6. Administer supplemental oxygen as indicated.
Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema formation.

7. Administer medications as indicated:

7.1. Thrombolytics: Tissue plasminogen activator (tPA), recombinant tPA (rt-PA) (Alteplase)
Given concurrently with an anticoagulant to treat ischemic stroke. tPA converts plasminogen to plasmin, dissolving the blood clot that is blocking blood flow to the brain. Rapid diagnosis of stroke and immediate treatment of rt-PA (0-90 minutes) from stroke onset increases the odds of improvement at 24 hours and favorable 3-month outcome (Marler et al., 2000). It is given intravenously (or intra-arterial delivery) as soon as ischemic stroke is confirmed. Monitor for signs of bleeding. Thrombolytics are contraindicated in patients with hemorrhagic stroke.

7.2. Anticoagulants: warfarin sodium (Coumadin), low-molecular-weight heparin (Lovenox)
Administered to prevent further extension of the clot and formation of new clots and improve cerebral blood flow. They do not dissolve an existing clot. Anticoagulants are never administered for patients with hemorrhagic stroke.

7.3. Antiplatelet agents: aspirin (ASA), dipyridamole (Persantine), ticlopidine (Ticlid)
Daily low-dose administration of aspirin interferes with platelet aggregation. It can help decrease the incidence of cerebral infarction in patients who have experienced TIAs from a stroke of embolic or thrombotic in origin. These medications are contraindicated in hypertensive patients because of the increased risk of hemorrhage.

7.4. Antifibrinolytics: aminocaproic acid (Amicar)
Used with caution in hemorrhagic disorder to prevent lysis of formed clots and subsequent rebleeding.

7.5. Antihypertensives: ACE-Inhibitors, Diuretics
Used for patients undergoing fibrinolytic therapy, blood pressure control is essential to decrease the risk of bleeding. Blood pressure should be maintained with the systolic pressure less than 180 mmHg and diastolic at 105 mmHg (Cumbler & Glasheen, 2007). Antihypertensive are also used for secondary stroke prevention.

7.6. Peripheral vasodilators: cyclandelate (Cyclospasmol), papaverine (Pavabid), isoxsuprine (Vasodilan).
Transient hypertension often occurs during an acute stroke and usually resolves without therapeutic intervention. It is used to improve collateral circulation or decrease vasospasm.

7.7. Neuroprotective agents: calcium channel blockers, excitatory amino acid inhibitors, gangliosides.
These agents are being researched (Ovbiagele et al., 2003) 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.

7.8. Phenytoin (Dilantin), phenobarbital.
Used if there is an increase in ICP and occurrence of seizures. Phenobarbital enhances the action of antiepileptics.

7.9. Stool softeners.
Prevents straining during bowel movement and the corresponding increase of ICP. Constipation frequently occurs after a stroke (Li et al., 2017).

8. Monitor laboratory studies as indicated: prothrombin time (PT), activated partial thromboplastin time (aPTT), and Dilantin level.
Provides information about drug effectiveness and therapeutic level.

9. Prepare for surgery, as appropriate: endarterectomy, microvascular bypass, cerebral angioplasty.
It may be necessary to resolve the situation, reduce neurological symptoms of recurrent stroke.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

References and Sources

The following are the references and recommended sources for stroke nursing care plans and nursing diagnosis, including interesting resources to further your reading about the topic:

Acharya, A. B., & Wroten, M. (2017). Wernicke Aphasia.
Amarenco, P., Lavallée, P. C., Monteiro Tavares, L., Labreuche, J., Albers, G. W., Abboud, H., … & Wong, L. K. (2018). Five-year risk of stroke after TIA or minor ischemic stroke. New England Journal of Medicine, 378(23), 2182-2190.
Crawford, A., & Harris, H. (2016). Caring for adults with impaired physical mobility. Nursing2020, 46(12), 36-41.
Cumbler, E., & Glasheen, J. (2007). Management of blood pressure after acute ischemic stroke: An evidence‐based guide for the hospitalist. Journal of Hospital Medicine: An Official Publication of the Society of Hospital Medicine, 2(4), 261-267.
Dowswell, G., Dowswell, T., & Young, J. (2000). Adjusting stroke patients’ poor position: an observational study. Journal of Advanced Nursing, 32(2), 286-291.
Gorelick, P. B., Farooq, M. U., & Min, J. (2015). Population-based approaches for reducing stroke risk. Expert review of cardiovascular therapy, 13(1), 49-56.
Hansen, A. P., Marcussen, N. S., Klit, H., Andersen, G., Finnerup, N. B., & Jensen, T. S. (2012). Pain following stroke: a prospective study. European journal of pain, 16(8), 1128-1136.
Kazemzadeh, Z., Manzari, Z. S., & Pouresmail, Z. (2017). Nursing interventions for smoking cessation in hospitalized patients: a systematic review. International nursing review, 64(2), 263-275.
Kumar, R., Metter, E. J., Mehta, A. J., & Chew, T. (1990). Shoulder pain in hemiplegia. The role of exercise. American journal of physical medicine & rehabilitation, 69(4), 205-208.
Lankhorst, G. J., & Bouter, L. M. (2002). Risk factors for hemiplegic shoulder pain: A systematic review. Critical Reviews’ in Physical and Rehabilitation. Medicine, 14(3&4), 223-233.
Li, J., Yuan, M., Liu, Y., Zhao, Y., Wang, J., & Guo, W. (2017). Incidence of constipation in stroke patients: a systematic review and meta-analysis. Medicine, 96(25).
Li, Z., & Alexander, S. A. (2015). Current evidence in the management of poststroke hemiplegic shoulder pain: a review. Journal Of Neuroscience Nursing, 47(1), 10-19.
Marler, J. R., Tilley, B. C., Lu, M., Brott, T. G., Lyden, P. C., Grotta, J. C., … & NINDS rt-PA Stroke Study Group. (2000). Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology, 55(11), 1649-1655.
Menon, B. K., & Demchuk, A. M. (2011). Computed tomography angiography in the assessment of patients with stroke/TIA. The Neurohospitalist, 1(4), 187-199.
Ovbiagele, B., Kidwell, C. S., Starkman, S., & Saver, J. L. (2003). Neuroprotective agents for the treatment of acute ischemic stroke. Current neurology and neuroscience reports, 3(1), 9-20.
Purnawinadi, I. G. (2019). The Characteristics Of Impaired Physical Mobility Among Patients With Stroke. Klabat Journal of Nursing, 1(1), 1-8.
Sacco, R. L. (2004). Risk factors for TIA and TIA as a risk factor for stroke. Neurology, 62(8 suppl 6), S7-S11.
Shah, R. S., & Cole, J. W. (2010). Smoking and stroke: the more you smoke the more you stroke. Expert review of cardiovascular
Tyson, S. F., & Chissim, C. (2002). The immediate effect of handling technique on range of movement in the hemiplegic shoulder. Clinical rehabilitation, 16(2), 137-140.
Xie, H. M., Guo, T. T., Sun, X., Ge, H. X., Chen, X. D., Zhao, K. J., & Zhang, L. N. (2021). Effectiveness of Botulinum Toxin A in Treatment of Hemiplegic Shoulder Pain: A Systematic Review and Meta-Analysis. Archives of Physical Medicine and Rehabilitation.