Hemodynamic ValuesGrab the Free Cheatsheet"What's the Standard Cardiac Output level?" Want a Free Hemodynamics Values Cheatsheet?

Nursing Care Plan for Stroke

Pathophysiology

A stroke is essentially a neurological deficit caused by decreased blood flow to a portion of the brain. They will be classified as either hemorrhagic or ischemic.  An ischemic stroke is the result of an obstruction of blood flow within a blood vessel. A hemorrhagic stroke is when a weaken blood vessel ruptures and blood spills into the brain where it shouldn’t be.  Both of these can cause edema and cellular death. Lack of blood flow for greater than 10 minutes can cause irreversible damage.

Etiology

Various things can cause an ischemic stroke, which comprises approximately 85% of all strokes.  Some of those who are at highest risk are those on anticoagulation therapy. People are on anticoagulants therapy for various reasons (mechanical heart valves, atrial fibrillation, etc.) and if they become subtherapeutic and therefore their blood is too thick, a clot can easily form and end up in the brain, causing an ischemic stroke. Diabetes is also one of the major risk factors, in addition to atherosclerosis, hypertension, cardiac dysrhythmias, obesity, substances abuse, and oral contraceptives.  Hemorrhagic strokes (the remaining 15% of strokes) can be caused by an aneurysm rupture (which are very difficult to predict… frequently noted increased incidence in smokers, drug abuse, and people with family history of a first-degree relative with one), high blood pressure, or the rupture of an arteriovenous malformation (which is genetic).

Desired Outome

Restoring as much blood flow as possible as quickly as possible, and minimizing cellular death/damage is key. Clot-busting meds can be given to restore blood flow for ischemic strokes. Hemorrhagic strokes are managed by keeping the blood pressure controlled, controlling intracranial pressure, reversing any anticoagulants on board, and even very invasive procedures or surgery to relieve increased intracranial pressure. You want the patient to gain back as much function as possible.  This is done slowly over time by the brain creating collateral circulation around the infarcted area. Physical, occupational, and speech therapy are essential aspects of stroke recovery. Some patients may make a complete recovery, while others may have profound deficits.

Stroke Nursing Care Plan

Subjective Data:

  • Numbness
  • Tingling
  • Decreased sensation
  • Difficulty swallowing
  • Headache
  • Pain
  • Nausea
  • Dizziness

Objective Data:

  • Hemiparesis
  • Hemiplegia
  • Ataxia
  • Dysmetria
  • Facial droop
  • Paralysis
  • Aphasia
  • Dysphagia
  • Dysarthria
  • Vomiting
  • Increased secretions
  • Incontinence
  • LOC changes

Nursing Interventions and Rationales:

  1. Use assistive ambulatory devices
    • Facilitates ambulation/transfers safely
  2. Frequent neurological assessments (per orders)
    • Alerts nurse to neurological changes as early as possible, enables them to notify MD and intervene when needed
  3. HOB at 30 degrees unless otherwise indicated
    • Increases venous return, decreases ICP
  4. Initiate DVT prophylaxis (mechanical and/or chemical)
    • Decreases risk for subsequent stroke, as patient most likely will not be as mobile as they are at baseline
  5. Ensure PT/OT/ST is ordered
    • Rehab is essential in stroke recovery; all must complete a baseline assessment and provide recommendations
  6. Fall prevention measures (non-skid socks, bed in lowest locked position, call bell within reach, and so forth)
    • Injury prevention; patient will most likely not be able to ambulate as they could prior to stroke and will require assistance
  7. Prevent contractions
    • Extremities that are now paralyzed are at risk for becoming contracted; ensure pillow supports are in place as well as rolled towels and adaptive devices
  8. Prevent aspiration: follow ST recommendations, keep HOB at 45 degrees during oral intake and keep patient upright after a meal, have suction available, assess lung sounds and body temp
    • Stroke patients frequently have impaired swallowing, and are at high risk for aspiration from their own oral secretions and oral intake.
  9. Cluster care; promote rest
    • Maximizes time with the patient so they can rest when care is not being provided
  10. Monitor vital signs appropriately; know BP limits
    • Closely monitoring BP is essential in managing ICP
  11. Prevent edema: elevate limbs, utilize compression stockings, promote ambulation, promote complete bladder emptying
    • Patients who are in bed more will have a harder time clearing fluid out, especially if they have any underlying heart condition causing a decreased cardiac output (like atrial fibrillation)
  12. Promote self-care
    • Patients will have a decreased ability to care for self due to new deficits; promote confidence and participation in caring for themselves as much as possible
  13. Promote cerebral tissue perfusion (interventions per orders, as this can differ depending on kind of stroke, location, and other factors)
    • This prevents additional neurological damage
  14. Facilitate safe swallowing: ensure bedside swallow screening completed and/or speech therapy assessment prior to oral intake
    • Frequently, brain injury results in an impaired ability to swallow safely. This is not always apparent as patients don’t always cough when aspirating and have silent aspiration.
  15. Promote adequate nutrition
    • Once a patient is cleared to eat, do what you can to encourage appropriate intake… as patients cannot heal if they don’t eat
  16. Initiate discharge planning
    • Stroke patients typically require multiple needs at discharge (follow up appts, rehab/therapy, and may need to go to long-term care or inpatient rehab, depending on the situation) begin getting your mind around their discharge needs at the beginning even if it’s not clear yet what their needs will be
  17. Prevent skin breakdown: turn q2hrs, ensure adequate protein intake, off-loading, pillow support, keep linen clean and dry
    • There are many reasons why a stroke patient will be at risk for skin breakdown… from an inability to feel or move extremities, incontinence, inability to communicate needs/pain/discomfort, decreased nutritional status.
  18. Facilitate communication; promote family coping and communication
    • Having a stroke is a major life event. Roles within families and support systems may change, especially if the patient played a caregiving role within their family structure

References

Date Published - May 15, 2017
Date Modified - Nov 12, 2018