A cerebrovascular accident (CVA) more commonly known as a stroke, occurs when blood flow to the brain is blocked. There are two main types of strokes: ischemic and hemorrhagic. Show
Ischemic strokes are caused by a blockage, usually, a clot that blocks blood flow to the brain. Hemorrhagic strokes are sudden bleeding in the brain such as when an artery bursts. This can be caused by an aneurysm, high blood pressure, or trauma. Transient ischemic attacks (TIA) which may be referred to as “mini-strokes” are blockages in the brain that resolve before lasting damage occurs. A history of TIAs can increase the risk of a stroke in the future. The Nursing ProcessStroke patients often require monitoring by nurses who are NIHSS certified and in higher care settings such as the ICU or step-down units. This is because stroke symptoms can change rapidly and subtly and require critical thinking and prompt intervention to prevent deterioration. Depending on the severity, strokes can leave the patient disabled requiring total care in feeding, bathing, and turning. Long-term deficits can be debilitating and cause depression for the client and their family. The nurse utilizes compassionate care and alternative communication techniques to keep the patient safe while managing their physical and psychosocial needs. Ineffective Cerebral Tissue Perfusion Care PlanWhen blood is blocked from the brain it does not receive necessary oxygen. If blood flow is not restored promptly this will result in tissue death. Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion
As evidenced by:
Expected Outcomes:
Ineffective Cerebral Tissue Perfusion Assessment1. Determine baseline presentation. 2. Perform neurological assessments. 3. Obtain a CT scan or MRI of the brain. Ineffective Cerebral Tissue Perfusion Interventions1. Maintain blood pressure. 2. Administer thrombolytics. 3.
Educate on risk factors of strokes. 4. Instruct on symptoms of a stroke using FAST. Impaired Verbal Communication Care PlanCerebrovascular accidents often result in deficits in communication. Patients may struggle with comprehending or expressing speech as well as a physical inability to produce meaningful speech. Nursing Diagnosis: Impaired Verbal Communication
As evidenced by:
Expected Outcomes:
Impaired Verbal Communication Assessment1. Note type of aphasia. 2. Observe how the patient communicates. Impaired Verbal Communication Interventions1. Speak in short, direct sentences. 2. Utilize alternative communication methods. 3. Encourage speech therapy. 4. Encourage family participation. Risk For Injury Care PlanDepending on the area of the brain affected by the stroke, the patient may have spatial-perceptual issues and impaired judgment. Along with deficits in swallowing, motor coordination, and generalized weakness, safety is a priority. Nursing Diagnosis: Risk For Injury
Note: A risk for diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and nursing interventions are directed at prevention. Expected Outcomes:
Risk For Injury AssessmentDetermine deficits related to the area of brain injury. Assess sensory awareness. Note neglect or visual disturbances. Risk For Injury Interventions1. Use bed and chair alarms. 2. Assist with
eating. 3. Teach to scan the environment. 4. Turn and assess skin frequently. References and Sources
How soon do you need to start treating a patient with an ischemic stroke?The main treatment for ischemic stroke is intravenous tissue plasminogen activator (tPA), which breaks up clots. 2018 guidelines from the American Heart Association (AHA) and the American Stroke Association (ASA) state that tPA is most effective when it's given within four and a half hours from the start of a stroke.
What is the first priority of nursing care for the stroke patient?The initial nursing assessment of the patient with stroke after admission to the hospital should include evaluating the patient's vital signs, particularly oxygen saturation, BP, and temperature, in addition to measuring blood glucose and performing a bedside dysphagia screen/assessment.
What is the rehabilitation stage of stroke?This pattern is detailed in Brunnstrom's seven stages of stroke recovery. The stages include flaccidity, spasticity appears, spasticity increases, spasticity decreases, complex movement combinations, spasticity disappears, and normal function returns.
Which is the critical period of stroke rehabilitation?1–3 Months Post-Stroke
“The first three months after a stroke are the most important for recovery and when patients will see the most improvement,” says Pruski. During this time, most patients will enter and complete an inpatient rehabilitation program, or make progress in their outpatient therapy sessions.
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