Cerebrovascular Accident (Stroke) Nursing Care and Management: A Study Guide

Time is brain. Every minute a stroke goes unrecognized, more tissue dies, so your job at the bedside starts with fast recognition and protecting the brain that is left.

What is Cerebrovascular Accident?

A cerebrovascular accident (CVA), also called an ischemic stroke or "brain attack," is a sudden loss of brain function from a disrupted blood supply to part of the brain. It is the primary cerebrovascular disorder in the United States and a functional abnormality of the central nervous system. The interruption in blood supply causes temporary or permanent loss of movement, thought, memory, speech, or sensation. Cryptogenic strokes have no known cause; others result from illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.

Classification

Strokes fall into two classes. Ischemic stroke is loss of brain function from a disrupted blood supply. Hemorrhagic stroke is bleeding into the brain tissue, the ventricles, or the subarachnoid space.

Risk Factors

Nonmodifiable risk factors are advanced age (older than 55 years), male gender, and African American race.

Modifiable risk factors are hypertension, atrial fibrillation, hyperlipidemia, obesity, smoking, diabetes, asymptomatic carotid stenosis, valvular heart disease (endocarditis, prosthetic heart valves), and periodontal disease.

Pathophysiology

The ischemic cascade begins when cerebral blood flow drops below 25 mL per 100g of blood per minute. Neurons can no longer maintain aerobic respiration, so mitochondria switch to anaerobic respiration. That generates large amounts of lactic acid, shifts pH, and leaves the neurons unable to make enough ATP. The membrane pumps that hold electrolyte balance fail, and the cells stop functioning.

Statistics and Epidemiology

Stroke is the third leading cause of death after heart disease and cancer, and the leading cause of serious, long-term disability in the United States.

In 2005, prevalence was estimated at 2.3 million males and 3.4 million females, and many of the roughly 5.7 million U.S. survivors carry permanent stroke-related disability. In 2004, stroke ranked fifth as a cause of death for ages 45 to 64 years and third for ages 65 years and older, with 150,000 deaths. Hemorrhagic strokes are more severe and carry a higher 30-day mortality rate of 40% to 80%. Estimated direct and indirect cost for 2008 was $65.5 billion.

About 780,000 people have a stroke each year in the United States: roughly 600,000 new and 180,000 recurrent. About 5.6 million noninstitutionalized survivors are alive today. Strokes are hemorrhagic (15%) or ischemic/nonhemorrhagic (85%). Ischemic strokes are categorized by cause: large artery thrombotic (20%), small penetrating artery thrombotic (25%), cardiogenic embolic (20%), cryptogenic (30%), and other (5%).

Causes

Large artery thrombosis comes from atherosclerotic plaques in the large vessels of the brain. Small penetrating artery thrombosis affects one or more vessels and is the most common type of ischemic stroke. Cardiogenic emboli are associated with cardiac dysrhythmias, usually atrial fibrillation.

Clinical Manifestations

Deficits depend on the location of the lesion, the size of the underperfused area, and the collateral blood flow. General signs include numbness or weakness of the face, arm, or leg (especially on one side); confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; loss of balance, dizziness, difficulty walking; or sudden severe headache.

Specific findings include:

• Homonymous hemianopsia. Loss of half of the visual field.
• Loss of peripheral vision. Difficulty seeing at night, unaware of objects or their borders.
• Hemiparesis. Weakness of face, arm, and leg on the same side from a lesion in the opposite hemisphere.
• Hemiplegia. Paralysis of face, arm, and leg on the same side from a lesion in the opposite hemisphere.
• Ataxia. Staggering, unsteady gait and inability to keep the feet together.
• Dysarthria. Difficulty forming words.
• Dysphagia. Difficulty swallowing.
• Paresthesia. Numbness and tingling of extremities and difficulty with proprioception.
• Expressive aphasia. Unable to form understandable words; can manage single-word responses.
• Receptive aphasia. Unable to comprehend the spoken word; can speak but may not make sense.
• Global aphasia. Combination of expressive and receptive aphasia.

Motor loss: hemiplegia, hemiparesis; flaccid paralysis with loss of or decreased deep tendon reflexes (initial feature), followed after 48 hours by reappearance of deep reflexes and 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 and sensory loss: visual-perceptual dysfunction (homonymous hemianopia); disturbed visual-spatial relations, common with right hemispheric damage; sensory loss ranging from slight impairment of touch to loss of proprioception and difficulty interpreting visual, tactile, and auditory stimuli.

Cognitive and psychological effects: frontal lobe damage impairs learning, memory, and higher cortical function, showing up as limited attention span, poor comprehension, forgetfulness, and lack of motivation. Depression and other problems include emotional lability, hostility, frustration, resentment, and lack of cooperation.

Prevention

Primary prevention is the best approach. A healthy lifestyle (no smoking, healthy weight, healthy diet, daily exercise) can cut stroke risk by about one half. The DASH (Dietary Approaches to Stop Hypertension) diet, high in fruits and vegetables, moderate in low-fat dairy, and low in animal protein, lowers risk. Stroke risk screenings identify high-risk people, and patient and community education targets recognition and prevention. Low-dose aspirin may lower risk in women who are at risk.

Complications

When cerebral oxygenation stays inadequate, tissue ischemia results. The heart compensates for the decreased cerebral blood flow, and the extra pumping can trigger cardiac dysrhythmias.

Assessment and Diagnostic Findings

Any patient with neurologic deficits needs a careful history and full physical and neurologic exam.

• CT scan. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions. Ischemic infarcts are not evident on CT for 8 to 12 hours, but intracerebral hemorrhage is immediately apparent, so emergency CT is always done before giving tissue plasminogen activator (t-PA). Patients with TIA commonly have a normal CT.
• PET scan. Provides data on cerebral metabolism and blood flow changes.
• MRI. Shows infarction, hemorrhage, AV malformations, and ischemia.
• Cerebral angiography. Determines specific cause, pinpoints site of occlusion or rupture. Digital subtraction angiography evaluates patency of cerebral vessels and detects lesions and vascular abnormalities.
• Lumbar puncture. Pressure is normal and CSF clear in cerebral thrombosis, embolism, and TIA. Elevated pressure and grossly bloody fluid suggest subarachnoid and intracerebral hemorrhage. CSF total protein may rise with thrombosis from inflammation. Perform if septic embolism from bacterial endocarditis is suspected.
• Transcranial Doppler ultrasonography. Evaluates blood flow velocity through major intracranial vessels and identifies carotid problems and atherosclerotic plaques.
• EEG. Identifies reduced electrical activity in areas of infarction and differentiates seizure activity from CVA damage.
• Skull x-ray. May show a shift of the pineal gland away from an expanding mass, calcifications of the internal carotid in thrombosis, or partial aneurysm wall calcification in subarachnoid hemorrhage.
• ECG and echocardiography. Rule out a cardiac source of embolus (20% of strokes result from emboli associated with valvular disease, dysrhythmias, or endocarditis).
• Laboratory studies. CBC, platelet and clotting studies, VDRL/RPR, erythrocyte sedimentation rate (ESR), and chemistries (glucose, sodium) to rule out systemic causes.

Medical Management

Patients who have had a TIA or stroke need medical management for secondary prevention. Give recombinant tissue plasminogen activator unless contraindicated, and monitor for bleeding. Manage increased ICP with osmotic diuretics, maintenance of PaCO2 at 30 to 35 mmHg, and head-of-bed elevation to avoid hypoxia. Intubate to establish a patent airway if necessary. Use continuous hemodynamic monitoring to avoid a rise in blood pressure, and reassess neuro status to catch an evolving stroke or other acute complications.

Surgical Management

Carotid endarterectomy removes atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive extracranial disease. Hemicraniectomy may be done for increased ICP from brain edema in severe cases.

Nursing Management

Once the stroke is complete, management shifts to prompt rehabilitation of any deficits.

Nursing Assessment

During the acute phase, keep a neurologic flow sheet tracking level of consciousness and responsiveness, voluntary or involuntary movement of extremities, neck stiffness or flaccidity, eye opening, pupil size and reaction to light, face and extremity color, skin temperature and moisture, ability to speak, presence of bleeding, and blood pressure.

During the postacute phase, assess mental status (memory, attention span, perception, orientation, affect, speech and language); sensation and perception (the patient usually has decreased awareness of pain and temperature); motor control of upper and lower extremities; swallowing ability; nutrition and hydration; skin integrity; activity tolerance; and bowel and bladder function. Keep focusing on how impaired function affects daily activities.

Nursing Diagnosis

• 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 related to stroke sequelae.
• Disturbed sensory perception related to altered sensory reception, transmission, or integration.
• Impaired urinary elimination related to flaccid bladder, detrusor instability, confusion, or difficulty 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 and decreased mobility.
• Interrupted family processes related to catastrophic illness and caregiving burdens.
• Sexual dysfunction related to neurologic deficits or fear of failure.

Nursing Care Planning & Goals

Goals for the patient and family include improved mobility, avoidance of shoulder pain, self-care, relief of sensory and perceptual deprivation, prevention of aspiration, bowel and bladder continence, improved thought processes, a workable form of communication, intact skin, restored family functioning, improved sexual function, and absence of complications.

Nursing Interventions

Improving mobility and preventing deformities. Position to prevent contractures, relieve pressure, maintain good alignment, and prevent compressive neuropathies. Apply a splint at night to prevent flexion of the affected extremity. Prevent adduction of the affected shoulder with a pillow in the axilla. Elevate the affected arm to prevent edema and fibrosis. Position the fingers barely flexed with the hand in slight supination; if upper extremity spasticity appears, do not use a hand roll, and consider a dorsal wrist splint. Change position every 2 hours and place the patient prone for 15 to 30 minutes several times a day.

Establishing an exercise program. Provide full range of motion four or five times a day to maintain joint mobility, regain motor control, prevent contractures, and enhance circulation; increase frequency if tightness appears. Exercise prevents venous stasis that predisposes to thrombosis and pulmonary embolus. Watch for pulmonary embolus or excessive cardiac workload during exercise (shortness of breath, chest pain, cyanosis, rising pulse). Supervise the patient, keep sessions short and frequent, and have the patient exercise the unaffected side throughout the day.

Preparing for ambulation. Start active rehabilitation when consciousness returns and bleeding has resolved. Teach the patient to balance while sitting, then standing (use a tilt table if needed). Begin walking once standing balance is achieved, using parallel bars with a wheelchair available for possible dizziness. Keep ambulation training short and frequent.

Preventing shoulder pain. Never lift the patient by the flaccid shoulder or pull on the affected arm. Support the flaccid arm on a table or pillows when seated and use a sling when ambulating. Range of motion helps, but avoid overstrenuous arm movement. Elevate the arm and hand to prevent dependent edema, and give analgesics as ordered.

Enhancing self-care. Encourage hygiene as soon as the patient can sit up, choosing one-handed tasks. Set realistic goals and add a new task daily. Have the patient start self-care on the unaffected side but never neglect the affected side; provide assistive devices. Improve morale by keeping the patient fully dressed during activity, using Velcro closures, and dressing the affected side first. Keep the environment uncluttered and give emotional support to prevent fatigue and discouragement.

Managing sensory-perceptual difficulties. Approach from the side where visual perception is intact and place all visual stimuli there. Teach the patient to turn toward the defective field to compensate, make eye contact, and draw attention to the affected side. Increase room lighting and provide eyeglasses. Remind the patient with hemianopsia about the neglected side and place the extremities where they can be seen.

Assisting with nutrition. Watch for coughing, food dribbling or pooling on one side of the mouth, food held in the mouth, or nasal regurgitation with liquids. Consult speech therapy to evaluate gag reflexes and teach swallowing techniques; offer smaller boluses and easier-to-swallow foods, and provide thicker liquids or a pureed diet as ordered. Have the patient sit upright when eating and drinking, and advance the diet as tolerated. For tube feedings, elevate the head of the bed, check tube position first, feed slowly, inflate the tracheostomy cuff if present, and report excessive residual.

Attaining bowel and bladder control. Use intermittent sterile catheterization during loss of sphincter control. Analyze the voiding pattern and offer the urinal or bedpan on schedule. Help the male patient to an upright posture for voiding. Provide a high-fiber diet and adequate fluids (2 to 3 L/day) unless contraindicated, and set a regular toileting time after breakfast.

Improving thought processes. Reinforce a structured program using cognitive and perceptual retraining, visual imagery, reality orientation, and cueing. Observe performance, give positive feedback, and convey confidence and hope.

Improving communication. Reinforce the individualized program and set goals jointly with the patient. Keep the atmosphere conducive to communication, treat the patient as an adult, and avoid finishing the patient's sentences. Stay consistent with schedule, routines, and repetition; written schedules, checklists, audiotapes, and a communication board may help. Hold the patient's attention, speak slowly, give one instruction at a time, allow processing time, and talk to aphasic patients during care to provide social contact.

Maintaining skin integrity. Assess frequently for breakdown over bony areas and dependent parts. Use pressure-relieving devices, turn and reposition at least every 2 hours, and minimize shear and friction. Keep skin clean and dry, gently massage healthy dry skin, and maintain nutrition.

Improving family coping. Counsel and support the family, involve them in care, and teach stress management and self-care. Share the expected outcome and counsel them not to do things the patient can do. Build attainable home goals with the whole team, patient, and family. Encourage a supportive, optimistic approach that focuses on remaining abilities, and explain that emotional lability usually improves with time.

Helping with sexual dysfunction. Assess sexual history before and after the stroke. Interventions for the patient and partner focus on relevant information, education, reassurance, medication adjustment, coping skills, alternative positions, and means of sexual expression and satisfaction.

Teaching points. Help the patient resume as much self-care as possible and provide assistive devices. Have occupational therapy do a home assessment. Coordinate the multidisciplinary team and help the family plan care. Warn the family that the patient may tire easily, become irritable, and show less interest in daily events. Refer for home speech therapy and give the family practical instructions for between sessions. Discuss depression with the physician for possible antidepressant therapy. Encourage community-based stroke clubs, continued hobbies and contact with friends to prevent isolation, and remind the family to attend to their own health.

Evaluation

Confirm the patient meets the planned goals: mobility improved, no shoulder pain, self-care achieved, sensory and perceptual deprivation relieved, aspiration prevented, bowel and bladder continence regained, thought processes improved, a workable form of communication established, skin intact, family functioning restored, sexual function improved, and no complications.

Discharge and Home Care Guidelines

Patient and family education is fundamental to rehabilitation. Occupational therapy assesses the home and recommends modifications for independence. A physical therapy program, at home or outpatient, may help. Depression is a common, serious problem after stroke and may need antidepressant therapy. Community-based stroke support groups let the patient and family learn from others with similar problems. Assess caregivers for depression too, since it is common among caregivers of stroke survivors.

Documentation Guidelines

Document individual findings including level of function and ability to participate in desired activities, needed resources and adaptive devices, results of labs and diagnostic studies, mental status or cognitive evaluation, family support and participation, the plan of care and who was involved, the teaching plan, response to interventions and teaching, progress toward outcomes, and any modifications to the plan.