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 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
What are some nursing interventions for stroke patients?Nursing Management. Assess mental status and level of consciousness.. Observe for neurological deficits.. Measure and monitor pupil size.. Assess breathing.. Monitor vital signs.. Assess higher function like speech, memory, and cognition.. Provide a quiet environment with the head of the bed elevated.. What is the nurse's role in managing stroke patients?Nurses working in acute stroke services have a wide-ranging role that includes assessment, identification and monitoring, as well as rehabilitation, psychological support and end of life care.
What is the first priority of nursing care for the stroke patient?Your initial evaluation of a patient with a suspected stroke should include airway, breathing, and circulation, followed by neurologic assessment using either the NIHSS or the mNIHSS, per facility policy.
How can stroke results be improved?Here are some strategies that worked for us, and can help any healthcare organization to improve their stroke outcomes:. Collaborate with EMS. ... . Centralize your patients and resources. ... . Implement a teleneurology program. ... . Focus on FAST community education. ... . Choose an integrated EHR platform.. |