Criical Nursing Care Plan For Cerebrovascular Accident (CVA)


A cerebrovascular accident, or stroke, occurs when a sudden decrease in cerebral blood circulation as a result of thrombosis, embolus, or hemorrhage leads to hypoxia of brain tissues, causing swelling and death. When circulation is impaired or interrupted the small area of the brain becomes infarcted and this changes membrane permeability resulting in increased edema and intracranial pressure (ICP). The clinical symptoms may vary depending on the area and extent of the injury.


Thrombosis of small arteries in the white matter of the brain account for the most common cause of strokes. A history of hypertension, diabetes mellitus, cardiac disease, vascular disease, or atherosclerosis may lead to thrombosis, which causes ischemia to the brain supplied by the vessel involved.
Embolism is the second most common cause of CVA, and happens when a blood vessel is suddenly occluded with blood, air, tumor, fat, or septic particulate. The embolus migrates to the cerebral arteries and obstructs circulation causing edema and necrosis.
When hemorrhage occurs, it is usually the sudden result of ruptured aneurysms, tumors, or AV malformations, or involves problems with hypertension or bleeding dyscrasias. The cerebral bleeding decreases the blood supply and compresses neuronal tissue.
Patients who have strokes frequently have had prior events, such as TIAs (transient ischemic attacks) with reversible focal neurological deficits lasting less than 24 hours or RINDS (reversible ischemic neurological deficits) lasting greater than 24 hours but leaving little, if any, residual neuro- logical impairment.
In addition to the disease processes discussed earlier, cardiac dysrhythmias, alcohol use, cocaine or other recreational drug use, smoking, and the use of oral contraceptives may predispose patients to strokes.
Strokes may cause temporary or permanent losses of motor function, thought processes, memory, speech, or sensory function. Difficulty with swallowing and speaking, hemiplegia, and visual field defects are stations of this disease. Treatment is aimed at supporting vital functions and ensuring adequate cerebral perfusion, and prevention of major complications or permanent disability.
MEDICAL CARE
CT scans: used to identify thrombosis or hemorrhagic stroke, tumors, or hydrocephalus; may not reveal changes immediately
Skull x-rays: may show calcifications of the carotids in the presence of cerebral thrombosis, or partial calcification of an aneurysm in subarachnoid hemorrhage; pineal gland may shift to the opposite side if mass is expanding
Brain scans: used to identify ischemic areas due to CVA but usually are not discernible until up to 2 weeks after injury Angiography used to identify site and degree of occlusion or rupture of vessel, assess collateral blood circulation and presence of AV malformations
MRI: used to identify areas of infarction, hemorrhage, and AV malformations
Ultrasound: may be used to gather information regarding flow velocity in the major circulation
Lumbar puncture: performed to evaluate ICP and to identify infection; bloody CSF may indicate a hemorrhagic stroke, and clear fluid with normal pressure may be noted in cerebral thrombosis, embolism, and with TIAs; protein may be elevated if thrombosis results from inflammation
EEG: may be used to help localize area of injury based on brain waves
Laboratory: CBC used to identify blood loss or infection; serum osmolality used to evaluate oncotic pressures and permeability; electrolytes, glucose levels, and urinalysis performed to identify problems and imbalances that may be responsible
Surgery: endarterectomy may be required to remove the occlusion, or microvascular bypass may be performed to bypass the occluded area, such as the carotid artery, aneurysm, or AV malformation Corticosteroids: used to decrease cerebral edema
Anticonvulsants: used in the treatment and prophylaxis of seizure activity
Analgesics: used for discomfort and pain; aspirin and aspirin-containing products are contraindicated with hemorrhage
TPA: use is controversial because of risks of uncontrolled bleeding
NURSING CARE PLANS
Alteration in tissue perfusion: cerebral
Related to: occlusion, hemorrhage, interruption of cerebral blood flow, vasospasm, edema
Defining characteristics: changes in level of consciousness, mental changes, personality changes, memory loss, restlessness, combativeness, vital sign changes, motor function impairment, sensory impairment
Outcome Criteria
Patient will have improved or normal cerebral per- fusion with no mental status changes or complications. 

INTERVENTIONS
RATIONALES
Measure blood pressure in both arms.

Cerebral injury may cause variations in blood pressure readings. Hypotension may result from circulatory collapse, and increased ICP may result from edema or clot formation. Differences in readings between arms may indicate a subclavian artery blockage.
Maintain head of bed in elevated position with head in a neutral position.
Helps to improve venous drainage, reduces arterial pressure, and may improve cerebral perfusion.
Provide calm, quiet environment with adequate rest periods between activities.
Bedrest may be required to prevent rebleeding after initial hemorrhage. Activity may increase ICI?
Administer anticoagulants as ordered.
May be warranted to improve blood flow to cerebral tissues and to prevent further clotting and embolus formation. These are contraindicated in hypertension due to the potential for hemorrhage.
Administer antihypertensive as ordered.
Hypertension may be transient when occurring during the CVA, but chronic hypertension will require judicious treatment to prevent further tissue ischemia and damage.
Administer vasodilators as ordered.
Helps to improve collateral circulation and to reduce the incidence of vasospasm.
Information, Instruction, Demonstration
INTERVENTIONS
RATIONALES
Instruct on use of stool softeners and avoidance of straining at stool.
Valsalva maneuvers increase ICP and may result in rebleeding. Stool softeners help to prevent straining.
Prepare patient for surgery as warranted.
May be required to treat problem and prevent further complications.

Impaired verbal communication
Related to: weakness, loss of muscle control, cerebral circulation impairment, neuromuscular impairment
Defining characteristics: inability to speak, inability to identify objects, inability to comprehend language, inability to write, inability to choose and use appropriate words, dysarthria
Outcome Criteria
Patient will be able to communicate normally or will be able to make needs known by some form of communication.
INTERVENTIONS
RATIONALES
Evaluate patient’s ability to speak or understand language.
Provides a baseline from which to begin planning intervention. Determination of specific areas of brain injury involvement will- preclude what type of assistance will be required.
Assess whether patient suffers from aphasia or dysarthria.
Aphasic patients have difficulty using and interpreting language, comprehending words, and inability to speak or make signs. Dysarthria patients can under- stand language, but have problems forming or pronouncing words as a result of weakness of paralysis of the oral muscles.
Evaluate patient‘s response to simple commands.
Inability to follow simple commands may indicate receptive aphasia.
Evaluate patient‘s ability to name objects.
Inability to do so indicates expressive aphasia.
Evaluate patient’s ability to write simple sentences or his name.
May indicate patient’s disability with receptive and expressive aphasia.
Avoid talking down to patient or making patronizing comments.
Intellect frequently remains unimpaired after injury.
When asking questions, use yes or no type questions initially, and progress as patient is able.
Provides for method of communication without necessity of response to large volumes of information. As patient progresses, the intricacy of questions may increase.
Provide a method of communication for patient, such as a writing board, or communication board to which patient may point.
Allows for communication of needs and allays anxiety.

Information, Instruction, Demonstration
INTERVENTIONS
RATIONALES
Consult with speech therapy.
May be required to identify cognition, function, and plan interventions for recovery.
Assist patient/family to identify and use methods for communication.
Provides method for patient to communicate his needs.
Discharge or Maintenance Evaluation
·       Patient will be able to communicate effectively.
·       Patient will be able to understand communication problem and access resources to meet needs. 
Impaired physical mobility
[See Head Injuries]
Related to: weakness, paralysis, paresthesia’s, impaired cognition
Defining characteristics: inability to move at will, muscle incoordination, decreased range of motion, decreased muscle strength
Sensory-perceptual alterations: visual, kinesthetic, gustatory, tactile, olfactory
Related to: neurological trauma/deficit, stress, altered reception of stimuli
Defining characteristics: behavior changes, disorientation to time, place, self, and situation, diminished concentration, inability to focus, alteration in thought processes, decreased sensation, paresthesias, paralysis, altered ability to taste and smell, inability to recognize objects, muscle incoordination, muscle weakness, inappropriate communication
Outcome Criteria
Patient will achieve and maintain alertness and orientation with acceptable behavior and motor/sensory function.
INTERVENTIONS
RATIONALES
Assess patient’s perceptions and reorient as necessary.
May help decrease distortions of thought and identify reality.
Assess for visual field defects, visual disturbances, or problems with depth perception.
Visual distortion may prevent patient from having realistic perception of his environment.
Assist patient by placing objects in his field of vision.
Allows for recognition of people and objects, and decreases confusion.
Limit amount of stimuli. Avoid excess noise or equipment.
May create sensory overload and confusion.
Observe patient for non-use of extremities. Test for sensation awareness and ability to discern position of body.
May create self-care deficiencies. Loss of sensation or inability to recognize objects may impair return to function level. Sensory impairment affects balance and positioning.
Evaluate environment for safety hazards, such as temperature extremes.
Promotes safety and decreases potential for injury.
Information, Instruction, Demonstration
INTERVENTIONS
RATIONALES
Instruct patient to observe feet when standing or ambulating, and to make a conscious effort to reposition body parts. Assist with sensory stimulation to non-use side.
Visual and tactile stimulation helps to retrain movement and to experience sensations.
Discharge or Maintenance Evaluation
·       Patient will be alert and oriented to all phases.
·       Patient will be able to understand changes in functional ability and residual neurological deficits.
·       Patient will be able to compensate for dysfunctional abilities.
Risk for impaired swallowing
Related to: neuromuscular impairment
Defining characteristics: inability to swallow effectively, choking, aspiration
Outcome Criteria
Patient will be able to swallow effectively with no incidence of aspiration.
INTERVENTIONS
RATIONALES
Evaluate patient’s ability to swallow, extent of any paralysis, ability to maintain airway.
Provides baseline information from which to plan interventions for care.
Maintain head position and sup- port, head of bed elevated at least 30 degrees or more during and after feeding.
Helps to prevent aspiration and facilitates ability to swallow.
Place food in the unaffected side of mouth.
Allows for sensory stimulation and taste, and may assist to trigger swallowing reflexes. These types of foods are easier to control and decrease potential for choking or aspiration.
Provide foods that are soft and require little, if any, chewing, or provide thickened liquids. Assist with stimulation of tongue, cheeks, or lips as warranted.
May help to retrain oral muscles and facilitate adequate tongue movement and swallowing.

Monitor intake and output, and caloric intake.
Insufficient nutrient intake orally may result in the need for alternate types of nutritional support.
Administer tube feedings/TPN as warranted/ordered.
May be required if oral intake is insufficient.
Information, Instruction, Demonstration
INTERVENTIONS
RATIONALES
Instruct to use straw for drinking liquids. Maintain swallowing precautions identified by speech therapists.
Helps to strengthen facial and oral muscles to decrease potential for choking.
Encourage family to bring patient’s favorite foods. intake.
Familiar foods may increase oral
Discharge or Maintenance Evaluation
·       Patient will be able to eat and swallow normally.
·       Patient will be able to ingest an adequate amount of nutrients without danger of aspiration.
·       Patient will be able to follow instructions and strengthen muscles used for eating/swallowing.
Self-care deficit: bathing, dressing, feeding, toileting
Related to: weakness, decreased muscle strength, muscle incoordination, paralysis, paresthesia, pain, functional impairment
Defining characteristics: inability to perform ADLs, inability to feed self, inability to maintain personal hygiene, inability to dress/undress self, inability to take care of toileting needs
Outcome Criteria
Patient will be able to meet self-care needs within own ability level.
INTERVENTIONS
RATIONALES
Evaluate level of neurological impairment and patient’s abilities to perform ADLs.
Provides baseline from which to plan care for patient needs.
Assist patient with ADLs as needed and encourage patient to perform tasks he may be capable of doing.
Assistance may reduce levels of frustration but patient will have more self-esteem with tasks he may complete.
Alter plans of care keeping in mind patient’s visual, motor, or sensory deficits
Assists patient with safety concerns and allows for some degree of independence.
Utilize self-help devices and instruct patient in their use.
Allows patient to perform task and improves his self-esteem.
Establish a bowel regime, using stool softeners, suppositories, etc. Offer bedpan or bedside commode or regular intervals.
Medications may be helpful when establishing a bowel regime and to regulate function. Retraining will allow the patient to gain independence and fosters self-esteem.
Information, Instruction, Demonstration
INTERVENTIONS
RATIONALES
Consult physical/occupational therapist.
May be required to assist with development of therapy plan and to identify methods for patient to compensate for neurological deficits.
Discharge or Maintenance Evaluation
·       Patient will be able to perform self-care activities by himself or with the assistance of a caregiver.
·       Patient will be able to understand and identify methods to facilitate meeting self-care needs.
·       Patient will be able to access community resources to meet continuing needs.


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