A Cerebrovascular accident is an acute neurological injury that occurs because of changes in the blood vessels of the brain. The changes can be intrinsic to the vessel (atherosclerosis, inflammation, arterial dissection, dilation of the vessel, weakening of the vessel, obstruction of the vessel) or extrinsic, such as when an embolism travels from the heart. Although reduced blood flow interferes with brain function, the brain can remain viable with decreased blood flow for long periods of time. However, total cessation of blood flow produces irreversible brain infarction within 3 minutes. Once the blood flow stops, toxins released by damaged neurons, cerebral edema, and alterations in local blood flow contribute to neuron dysfunction and death. Complications of cerebrovascular accident include unstable blood pressure, sensory and motor impairment, infection (encephalitis), pneumonia, contractures, and pulmonary emboli.
Thrombosis, embolism, and hemorrhage are the primary causes of CVA. In cerebral thrombosis, the most common cause of cerebrovascular accident, a blood clot obstructs a cerebral vessel. The most common vessels involved are the carotid arteries of the neck and the arteries in the vertebrobasilar system at the base of the brain near the circle of Willis. Cerebral thrombosis also contributes to transient ischemic attacks (TIAs), which are temporary episodes (10 to 30 minutes) of poor cerebral perfusion caused by partial occlusion of the arterial lumen. A thrombotic cerebrovascular accident that causes a slow evolution of symptoms over several hours is called a stroke in evolution. When the condition stabilizes, it is called a completed stroke.
In an embolic cerebrovascular accident, a clot is carried into the cerebral circulation, usually by the carotid arteries. Blockage of an intracerebral artery results in a localized cerebral infarction. Hemorrhagic cerebrovascular accident results from hypertension, rupture of an aneurysm, arteriovenous malformations, or bleeding disorder. Risk factors thought to cause blood vessel changes that cause vessel walls to be more susceptible to rupture and hemorrhage include elevated low-density lipoprotein (LDL) and lowered high-density lipoprotein (HDL) levels, cigarette smoking, and a sedentary lifestyle.
Nursing care plan assessment and examination
Determine if the patient is on any medications or abuses intravenous drugs. Elicit a history of neurological deficits. Determine if the patient has experienced an inability to recognize familiar objects or persons through sensory stimuli (agnosia) or any memory loss (amnesia). Elicit a history of speech difficulties such as an inability to understand language or express language (aphasia), poorly articulated speech (dysarthria), or any other form of speech impairment (dysphasia). Determine if the patient has lost the ability to comprehend written words (alexia), read written words (dyslexia), or write (agraphia). Establish a history of visual difficulties such as double vision (diplopia), defective vision, or blindness in the right or left halves of the visual fields of both eyes (homonymous hemianopia), lack of depth perception, color blindness, blindness, blurring on the affected side, or drooping eyelids (ptosis).
Elicit a history of motor difficulties such as the inability to move the muscles (akinesia), inability to perform purposeful acts or manipulate objects (apraxia), poor coordination, impairment of voluntary movement (dyskinesia), muscular weakness or partial paralysis affecting one side of the body (hemiparesis), or paralysis of one side of the body (hemiplegia). Ask if the patient has experienced numbness and ascertain the specific location. Determine if the patient has experienced headaches. Establish a history of personality changes such as flat affect or distractibility.
If the patient appears unconscious, quickly determine his or her airway status and level of consciousness. If the patient is conscious, he or she may be experiencing a TIA or a stroke in evolution. Determine the level of orientation; ability to respond to questions of intellectual functioning; and speech, hearing, and vision ability. Lightly touch the patient’s skin on various parts of the body and ask the patient to identify the location. Apply firm pressure to various parts of the body and observe the patient’s responses. Be sure to test skin sensations sensed in both hemispheres of the body and compare the responses. Begin your assessment by determining the patient’s understanding of your commands and the appropriateness of her or his verbal and nonverbal responses. In left-hemisphere cerebrovascular accident, there is likely to be loss of language ability, although memory may be intact. In right-hemisphere cerebrovascular accident, patients are often confused and disoriented, but the ability to speak remains. Determine the presence of hemiplegia or hemiparesis and the patient’s muscle strength, gait, and balance. Assess the patient’s cranial nerves (V, VII, IX, X, and XII) to determine the patient’s tongue movement and ability to chew and swallow, as well as the presence of a gag reflex. Assess the patient for the presence of hemianopia by observing whether he or she sees objects on either side of the midvisual field. If the patient is disoriented or has lost the ability to understand language (receptive aphasia), assessing hemianopia is difficult. Try handing the patient a fork on the affected side, and ask the patient to tell you what it is you are holding or ask the patient to pick up the fork.
During the early stages of their condition, many patients with cerebrovascular accident experience great despair and frustration trying to communicate their needs. The inability to communicate causes profound depression. Although patients may laugh or cry or display outbursts of anger and frustration at unusual times, it is impossible to know with any certainty if these responses are inappropriate for the patient.
Nursing care plan primary nursing diagnosis: Sensory-perceptual alterations: Visual, auditory, kinesthetic, and tactile, as related to tissue injury.
Nursing care plan intervention and treatment
The treatment needs to be initiated rapidly, within 6 hours of the onset of symptoms. Medical management for patients with cerebrovascular accident typically includes support of vital functions and ongoing surveillance to identify early neurological changes as the patient’s condition evolves. Although the hallmark of stroke is the abrupt onset of neurological symptoms and deficits due to the interruption of the vascular supply to a specific brain region, therapeutic intervention may save tissue that is at risk for infarction. Recombinant tissue-plasminogen activator (rt-PA) can improve outcome for some patients with acute nonhemorrhagic ischemic stroke if it is given within 3 hours of the onset of symptoms.
When a cerebrovascular accident has occurred, the treatment consists of maintaining life, reducing intracranial pressure (ICP), limiting the extension of the cerebrovascular accident, and preventing complications. For patients who cannot maintain airway, breathing, and circulation independently, assist with endotracheal intubation, ventilation, and oxygenation as prescribed. In hemorrhagic cerebrovascular accident, surgery may be required to evacuate a hematoma or to stop bleeding. A ventricular shunt may be placed to drain cerebrospinal fluid. Physical therapy is begun as soon as the patient’s condition stabilizes. Flaccid muscles soon become spastic and subject to contractures. Use passive range-of-motion exercises on the affected side. Strengthening the unaffected side assists the patient in compensating for the losses of the opposite hemisphere. The physical therapist teaches the patient to transfer with the use of assistive devices, and the physical or occupational therapist teaches the patient how to perform self-care activity.
Position the patient to maintain a patent airway by elevating the head of the bed 30 degrees to promote pulmonary drainage and limit upper airway obstruction. Suction the patient’s mouth and, if needed, the nasopharynx and trachea. Before suctioning, oxygenate the patient well; to minimize ICP increases, limit suctioning to 20 to 30 seconds at a time.
The patient with a cerebrovascular accident is at extremely high risk for complications caused by immobility. If appropriate, use compression boots to promote venous return and help prevent phlebitis. To reduce the risk of pulmonary infection, promote skin integrity, and prevent contractures, turn and reposition the patient every 2 hours. Keep the patient’s joints in a functional position, and keep the affected hand elevated slightly on a pillow. Use a trochanter roll to prevent external rotation of the hip. Keep the patient safe by putting the bed in a low position and keeping the side rails up.
Prevent aspiration pneumonia by first determining the patient’s ability to handle solids and liquids. Keep a suction machine nearby while feeding the patient. Some patients have difficulty with liquids, so thicken fluids with soft foods like cooked cereal, applesauce, soup, or mashed potatoes.
Make sure the patient has a bowel movement each morning after breakfast to stimulate normal peristalsis and prevent constipation. A catheter may be in place immediately after the cerebrovascular accident, but the goal is to have the patient gain control through a bladder training program. If the patient has expressive aphasia (inability to transform sounds into speech), give the patient ample time to respond to questions and be supportive if the patient becomes frustrated during speech. Be sure to accept any method of self-expression the patient uses, such as pointing, gesturing, or writing. Some patients find it easier to point to a picture that describes a word rather than trying to say the word.
Nursing care plan discharge and home health care guidelines
Teach the family to check for skin breakdown and the development of contractures and to take appropriate preventative measures. Be sure the family performs frequent range-of-motion activities, as taught in the rehabilitation unit. Advise the family whom to call in an emergency. Be sure that the patient and family understand the importance of maintaining the mobility and selfcare routine developed in the rehabilitation unit. Be sure that the social worker or rehabilitation personnel have provided the family with a list of resources for in-home care. Determine whether a home care agency will be providing in-home supervision and ongoing physical therapy support. Advise the family how to seek ongoing support for home maintenance.