Stroke Nursing Care Plan: CVA Assessment & Interventions

Understanding Stroke (CVA)

A cerebrovascular accident (CVA) occurs when blood flow to part of the brain is interrupted, causing brain cell death. Stroke is the fifth leading cause of death in the US and a leading cause of long-term disability.

Types of Stroke

• Ischemic stroke (87%): Blood clot blocks cerebral artery

- Thrombotic: clot forms in cerebral vessel

- Embolic: clot travels from elsewhere (often heart)

• Hemorrhagic stroke (13%): Blood vessel ruptures

- Intracerebral hemorrhage

- Subarachnoid hemorrhage

• Transient ischemic attack (TIA): Temporary blockage, symptoms resolve within 24 hours ("mini-stroke")

Rapid Assessment: FAST + BE-FAST

Traditional FAST

• Face drooping
• Arm weakness
• Speech difficulty
• Time to call 911

Extended BE-FAST

• Balance: Sudden loss of balance or coordination
• Eyes: Sudden vision changes in one or both eyes
• Face, Arm, Speech, Time (as above)

NIH Stroke Scale (NIHSS)

The NIHSS quantifies stroke severity (0-42 points):

• 0: No stroke symptoms
• 1-4: Minor stroke
• 5-15: Moderate stroke
• 16-20: Moderate to severe stroke
• 21-42: Severe stroke

Categories Assessed

1. Level of consciousness
2. Best gaze (horizontal eye movement)
3. Visual fields
4. Facial palsy
5. Motor arm
6. Motor leg
7. Limb ataxia
8. Sensory
9. Best language
10. Dysarthria
11. Extinction and inattention

Nursing Care Plan

Diagnosis 1: Ineffective Cerebral Tissue Perfusion

Related to: Interruption of cerebral blood flow secondary to ischemic/hemorrhagic event

Expected Outcomes:

• Patient will maintain cerebral perfusion pressure within normal limits
• Patient will demonstrate stable or improving neurological status

Interventions:

• Perform neurological assessments every 1-2 hours (NIHSS, pupil checks, GCS)
• Maintain head of bed at 30 degrees (promotes venous drainage)
• Monitor blood pressure closely per stroke protocol
• Administer tPA within 4.5-hour window for ischemic stroke (as prescribed)
• Monitor for signs of increased ICP (Cushing's triad: hypertension, bradycardia, irregular respirations)

Diagnosis 2: Impaired Physical Mobility

Related to: Neuromuscular impairment (hemiparesis/hemiplegia)

Expected Outcomes:

• Patient will participate in prescribed rehabilitation activities
• Patient will demonstrate techniques to prevent complications of immobility

Interventions:

• Reposition every 2 hours
• Apply sequential compression devices (DVT prevention)
• Begin passive and active range of motion exercises within 24-48 hours
• Collaborate with physical and occupational therapy
• Assess swallowing before oral intake (dysphagia screening)

Diagnosis 3: Impaired Verbal Communication

Related to: Cerebral injury affecting language centers (Broca's or Wernicke's area)

Expected Outcomes:

• Patient will demonstrate alternative communication methods
• Patient will participate in speech therapy

Interventions:

• Assess type of aphasia (expressive vs. receptive vs. global)
• Speak slowly, use simple sentences, allow time to respond
• Use communication aids (picture boards, writing, gestures)
• Collaborate with speech-language pathology
• Avoid speaking loudly (hearing is usually intact)

Diagnosis 4: Risk for Aspiration

Related to: Impaired swallowing secondary to cranial nerve dysfunction

Expected Outcomes:

• Patient will not aspirate
• Patient will demonstrate safe swallowing techniques

Interventions:

• NPO until formal swallowing assessment is completed
• Elevate HOB 90 degrees during and 30 minutes after meals
• Provide modified diet texture as recommended by SLP
• Monitor for signs of aspiration (coughing, wet voice, desaturation)
• Provide oral care every 2 hours

Stroke-Specific Nursing Considerations

Ischemic Stroke

• tPA administration: strict inclusion/exclusion criteria
• Blood pressure management (permissive hypertension initially)
• Antiplatelet therapy (aspirin within 24-48 hours)
• Monitor for hemorrhagic transformation

Hemorrhagic Stroke

• Strict blood pressure control (often SBP < 140)
• Possible surgical intervention (craniotomy, aneurysm clipping)
• Seizure precautions
• Reverse anticoagulants if applicable

Patient and Family Education

• Warning signs of stroke recurrence
• Medication adherence (antihypertensives, antiplatelets, statins)
• Lifestyle modifications (diet, exercise, smoking cessation)
• Rehabilitation expectations and timeline
• Community support resources (stroke support groups)

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