Nursing Care Plan for Stroke (CVA)

Pathophysiology

A stroke is essentially a neurological deficit caused by decreased blood flow to a portion of the brain. They will be classified as either hemorrhagic or ischemic.  An ischemic stroke is the result of an obstruction of blood flow within a blood vessel. A hemorrhagic stroke is when a weaken blood vessel ruptures and blood spills into the brain where it shouldn’t be.  Both of these can cause edema and cellular death. Lack of blood flow for greater than 10 minutes can cause irreversible damage.

Etiology

Various things can cause an ischemic stroke, which comprises approximately 85% of all strokes.  Some of those who are at highest risk are those on anticoagulation therapy. People are on anticoagulants therapy for various reasons (mechanical heart valves, atrial fibrillation, etc.) and if they become subtherapeutic and therefore their blood is too thick, a clot can easily form and end up in the brain, causing an ischemic stroke. Diabetes is also one of the major risk factors, in addition to atherosclerosis, hypertension, cardiac dysrhythmias, obesity, substances abuse, and oral contraceptives.  Hemorrhagic strokes (the remaining 15% of strokes) can be caused by an aneurysm rupture (which are very difficult to predict… frequently noted increased incidence in smokers, drug abuse, and people with family history of a first-degree relative with one), high blood pressure, or the rupture of an arteriovenous malformation (which is genetic).

Desired Outcome

Restoring as much blood flow as possible as quickly as possible, and minimizing cellular death/damage is key. Clot-busting meds can be given to restore blood flow for ischemic strokes. Hemorrhagic strokes are managed by keeping the blood pressure controlled, controlling intracranial pressure, reversing any anticoagulants on board, and even very invasive procedures or surgery to relieve increased intracranial pressure. You want the patient to gain back as much function as possible.  This is done slowly over time by the brain creating collateral circulation around the infarcted area. Physical, occupational, and speech therapy are essential aspects of stroke recovery. Some patients may make a complete recovery, while others may have profound deficits.

Stroke Nursing Care Plan

Subjective Data:

  • Numbness
  • Tingling
  • Decreased sensation
  • Difficulty swallowing
  • Headache
  • Pain
  • Nausea
  • Dizziness

Objective Data:

  • Hemiparesis
  • Hemiplegia
  • Ataxia
  • Dysmetria
  • Facial droop
  • Paralysis
  • Aphasia
  • Dysphagia
  • Dysarthria
  • Vomiting
  • Increased secretions
  • Incontinence
  • LOC changes

Nursing Interventions and Rationales

  1. Use assistive ambulatory devices if limb weakness present

  2. Facilitates ambulation/transfers safely

  3. Frequent neurological assessments (per orders)

  4. Alerts nurse to neurological changes as early as possible, enables them to notify MD and intervene when needed

  5. HOB at 30 degrees unless otherwise indicated

  6. Decreases ICP by:

    • Improving venous return
    • Minimizing intrathoracic pressure

  7. Initiate DVT prophylaxis (mechanical and/or chemical)

  8. Decreases risk for subsequent stroke, as patient most likely will not be as mobile as they are at baseline.

  9. Ensure PT/OT is ordered

  10. Rehab is essential in stroke recovery; all must complete a baseline assessment and provide recommendations

  11. Consult Speech Therapy for swallow evaluation PRIOR to oral intake

  12. All stroke patients are NPO until cleared by Speech Therapy due to high risk of dysphagia and aspiration.  Frequently, brain injury results in an impaired ability to swallow safely. This is not always apparent as patients don’t always cough when aspirating and have silent aspiration.  A bedside swallow evaluation can be done by the nurse, but will only clear the patient for PO meds, not for PO intake of food/fluids

  13. Prevent aspiration: follow ST recommendations, keep HOB at 45 degrees during oral intake and keep patient upright after a meal, have suction available, assess lung sounds and body temp

  14. Stroke patients frequently have impaired swallowing, and are at high risk for aspiration from their own oral secretions and oral intake.

  15. Promote adequate nutrition

  16. Once a patient is cleared to eat, do what you can to encourage appropriate intake. Patients cannot heal if they don’t eat.

  17. Fall prevention measures (non-skid socks, bed in lowest locked position, call bell within reach, and so forth)

  18. Injury prevention; patient will most likely not be able to ambulate as well as they could prior to stroke and will require assistance

  19. Prevent contractions

  20. Extremities that are now paralyzed are at risk for becoming contracted; ensure pillow supports are in place, as well as rolled towels in hands and adaptive devices

  21. Cluster care; promote rest

  22. Maximizes time with the patient so they can rest when care is not being provided

  23. Monitor vital signs appropriately; know BP limits

  24. Closely monitoring BP is essential in managing ICP so that we can ensure an appropriate CPP.

  25. Promote cerebral tissue perfusion (interventions differ depending on kind of stroke, location, and other factors)

  26. This prevents additional neurological damage.  (MAP – ICP = CPP)

  27. Prevent edema:

    • Elevate limbs
    • Utilize compression stockings
    • Promote ambulation
    • Promote complete bladder emptying
  28. Patients who are in bed more will have a harder time clearing fluid out, especially if they have any underlying heart condition causing a decreased cardiac output (like atrial fibrillation).

  29. Promote self-care

  30. Patients will have a decreased ability to care for self due to new deficits. Promote confidence and participation in caring for themselves as much as possible. Provide adaptive devices and alternate strategies for ADL’s

  31. Initiate discharge planning

  32. Stroke patients typically have multiple needs at discharge

    • Follow up appts
    • Rehab/therapy
    • Long-term care or inpatient rehab, depending on the situation

    Begin getting your mind around their discharge needs at the beginning, even if it’s not clear yet what their needs will be.

  33. Prevent skin breakdown:

    • Turn q2hrs
    • Ensure adequate protein intake
    • Off-load pressure areas
    • Pillow support
    • Keep linen clean and dry
  34. There are many reasons why a stroke patient will be at risk for skin breakdown…

    • Inability to feel or move extremities
    • Incontinence
    • Inability to communicate needs/pain/discomfort
    • Decreased nutritional status.

  35. Facilitate communication; promote family coping and communication

  36. Having a stroke is a major life event. Roles within families and support systems may change, especially if the patient played a caregiving role within their family structure.


References

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    Video Transcript

    All right guys, let’s work through an example Nursing Care Plan for a patient who’s had a stroke. Now specifically I’m going to work through a hypothetical patient who has a previous stroke. So we’re not talking about an active emergency, we’re just talking about a patient who has had a stroke before. So again, hypothetical patient with just a previous stroke as their only problem. So when we start to gather all the data, we want to look at what information we might find on this patient. 

    Now let’s go through relevant data first. So what are we going to see? Well, maybe they’ve got some numbness or maybe even like a Hemiplegia. I remember sometimes your stroke patients can be left with weakness on one side of their body, right? Maybe they’ve got decreased sensation, maybe they’ve got dysphagia. I remember dysphagia with the g means difficulty swallowing. So this is something that they could tell us or we could possibly even observe if we can see them coughing or choking after they eat. They might also have dysphasia or aphasia with an s with which with the s stands for speech. Right? So difficulty speaking, we’re going to be able to recognize that they may also have difficulty understanding communication. That’s another type of dysphasia. We might see a facial droop. So again, all of this kind of depends on what type of stroke they had and how severe it was. We may also recognize some Ataxia, which is uncoordination.

    So here’s this patient. They’re weak on one side, they’re struggling to swallow. They can’t really feel anything. They can’t really speak. They may have a facial droop and they’re pretty uncoordinated. Does that make sense? So again, when you’re taking all this information, you may also get, you know, a blood pressure. You’re going to get bowel sounds, you’re going to get urine output. When you’re gathering all your data, you’re going to see everything. You’re going to see their medical history, right? So everything comes together in this assess phase and this collection phase. And then when you get to the analysis phase, you actually kind of can get rid of that irrelevant, unnecessary information and focus just on the things that tell you there’s a problem. So what’s a big problem with this patient? Well, one of the big things I see with stroke patients is they have trouble moving around.

    There’s moving around, getting around, being able to do things. This might include trouble with ADLs, trouble performing ADLs. But see if they’re having trouble moving around, they’re definitely at risk for complications of immobility, right? If they’re not moving around enough. Let’s see, what can be improved? Maybe their communication because they have speech issues, right? That definitely something that could be improved is making sure that they can speak. Making sure they can understand communication. Let’s see. Other risks. If we have dysphagia with the g and the facial droop, we might have some risk for aspiration. They’re going to have trouble swallowing, trouble managing the fluids if that’s in their mouth. So they definitely are at risk for aspiration and swallowing issues there. Okay, what is the biggest priority for this patient?

    We literally said, didn’t we say there’s a risk for complications of immobility? There’s a risk for aspiration. There’s a risk for trouble moving around. I mean, what are they at risk for? If they have trouble moving around, right? They’re at risk for falls, especially if they have one side weaker. So honestly I see all these risk factors and I’m going to say my number one priority is going to become safety. Now I talked in how to write a care plan that typically actual problems are higher priority than potential problems except in one instance. And that is a safety related issue. And so when you have a safety related issue, that significant safety tends to take a little bit of priority. You know, if you have an active airway problem, then maybe that takes a little bit of priority over risk for falls, right? But if you had a patient that was on fire and had no airway, you have to put the fire out first, right? Because it’s a safety issue. So there’s definitely times when safety is going to Trump your actual issues. 

    So again, this is where we start to link our data. How do we know it was a problem? And when we kind of talked through that and we’ll just talk through it again in a second. But this is just our time to connect our data together and link it together. Kind of connect those dots. So we see that we have this problem with moving around. Problem with ADLs. This risk for injury from falls, immobility, aspiration. So what kinds of things are we going to do? Well, let’s see. We don’t want them to fall so we can use assistive devices, right? Walkers, canes, things like that.

    We know they’re at risk, you know, they’ve got decreased sensation, they’re at risk for skin issues. So we want to make sure that we’re assessing their skin, right? We can institute fall precautions, right? We can institute aspiration precautions. So that means, you know, making sure the patient is upright when they eat, making sure that they have the right consistency of liquids. We might even get speech therapy involved both for the aspiration aspect, but also for the actual speech aspects. Speech therapy is great at kind of rehabbing those muscles. So speech therapy is a great idea. Let’s see. They’re immobile. So what else are they at risk for? I’m going to want to assess their skin. I’m also going to want to do maybe like DVT prophylaxis, make sure they’re not getting blood clots in their legs from not being moving around. I’m assessing their skin, but I can also turn Q2 to help keep them from developing pressure ulcers.

    And then, let’s see, we talked about communication. What if I use like a writing board or a picture board or something along those lines? Is communication tools that help them to communicate their needs, right? So there’s a lot of things I can do. I’m literally just linking this information together. What was my problem and how would I address it? So how would I know if it gets better? Well, I had this problem with speech, right? With communication. So I know it gets better if my patient can actually communicate their needs. Right? I’m not necessarily worried about them communicating perfectly, but I am worried about them being able to tell us what they need. Right. So what about all of these things we said we were at risk for that we were afraid of, right? What if we just say a patient has no injury or patient doesn’t fall?

    Something along those lines, right? So we’re just connecting the dots and putting this all together. So step four is translate. This is where we put it in the terms that we need to use so that we can concisely communicate what the problem is. So let’s see, what was our major nursing priority for this patient? We said safety, right? We have this risk for falls, risk for aspiration, risk for skin breakdown. Risk for DVT is all of these risks that they have, right? So safety is going to be our number one concern. And let’s see, we talked about them possibly not being able to do their ADLsand so I really would like to look at something along the lines of mobility, possibly even functional ability. Cause what we’re worried about is are they as independent as possible. Are they able to take care of themselves? Right? 

    And then the last one, I think we’ll look at that communication issue, especially if you have a patient with Aphasia or dysphasia. Them being able to communicate their needs is so, so, so important. So last step transcribe, let’s get it on paper. Again, this is our chance to link the problem to the data that we found to what we’re going to do and why and how we’re going to know if it worked. So again, we set our top three priorities are safety, mobility and functional ability and communication. So what’s our data that tells you that there is a potential safety issue here. We already said they have weakness on one side, right? So that puts them at risk for falls. They have dysphasia, which can put them at risk for aspiration. They may have a facial droop that could also put them at risk for aspiration. And we know that they have this mobility issue, which puts them at risk for any complications of immobility, right? 

    So we’re going to institute fall precautions. We’re going to institute DVT prophylaxis, aspiration precautions. We’re going to turn to Q2 probably also gonna assess their skin, right? So our goal here is to prevent falls, prevent DVT, prevent skin issues, and prevent aspiration. Again, we’re trying to prevent these complications of immobility, right? So then what am I expected outcomes? This is one that gets a little, a little easy, right? What are my expected outcomes? My patient doesn’t fall. My patient has no complications of immobility and my patient doesn’t aspirate, right? So all those things I said was the reason why I was concerned about safety, my expected outcome from my interventions is that the patient remains safe, right? I have a safe patient. Okay, so let’s look at mobility.

    So again, we said this patient might have paralysis or weakness. They’re going to have Ataxia, which is like uncoordination. So it’s really important that we help them with their functional ability and their mobility. They’re not necessarily gonna be able to get around by themselves. They’re not necessarily going to be able to do things for themselves that they used to be able to do. So we’re gonna use those assistive devices and we’re probably going to consult PT or OT to help them, you know, rehab their muscles, help them figure out how to, to compensate for the things that they’re struggling with. So again, compensating for weakness, that’s what these assistive devices are for and the PT is going to help them improve their functional ability. So what are my expected outcomes? I’m trying to improve their functional ability, right? So my patient’s going to ambulate with the device appropriately and then any other goalies set really is probably going to be more of a long term goal.

    I’m not going to see much improvement from shift to shift. So longterm I want to see improvement in their abilities and I want to see them probably get independent as possible. And that’s specifically referring to them being able to perform their ADLs, right? I want to give them as much independence as I can. So let’s talk communication, again, dysphasia or aphasia, might even have decreased LOC, especially if it was a severe stroke. And they’re probably gonna have a facial droop potentially. And so being able to communicate is going to be difficult. So interventions, communication tools. So again, this is things like the writing board, or a photo board, a picture board where they can point to. And then we want to get that speech therapy consult in because they’re great at helping patients rehab these muscles. So again, compensating for that difficulty and improving their speech is why we’re doing those things.

    And the goal here, again, not for the patient to communicate perfectly, but to be able to communicate their specific needs to their provider or their family. So that’s it. We’ve put it on paper. This is a picture of if you have a patient with a history of a stroke, who has, you know, a lot of residual defects. This is the kind of thing we’re going to look at when it comes to prioritizing care for the patient.  

    So just a quick reminder of your five steps for writing a care plan. You’re going to collect your information, that’s your assessment data. You’re going to analyze that information, pick out what’s relevant, determine what the problem and priorities are. Then you’re gonna ask your how questions. How did I know it was a problem? How can I make it better? And how would I know if it worked? So that’s your plan, implement and evaluate phase. Translate it into whatever terms you need to use. Use the form or the template that you need it to. Just get it on paper. 

    All right, guys, I hope that was helpful. Again, usually your patients can have more than one problem. It’s not just going to be the stroke, there’s going to be stroke, there’s going to be other things going on as well. So make sure you’re looking holistically and big picture at your patient. Check out the rest of the course for some more examples, as well as our nursing care plan library for 130 plus examples of nursing care plans. All right guys, go out and be your best self today. And as always, happy nursing.

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