PRIORITY: Number 1 Nursing Diagnosis: Ineffective cerebral tissue perfusion May be related to: Interruption of blood flowocclusive disorder,

hemorrhage; cerebral vasospasm, cerebral edema Cause Analysis: Cerebrovascular disorders is an umbrella term that refers to a functional abnormality of the central nervous system (CNS) that occurs when the normal blood supply to the brain is disrupted. In ischemic stroke, significant hypoperfusion occur because of vascular occlusion. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1896) Cues Objective Cues Altered LOC; memory loss Changes in motor or sensory responses; restlessness Sensory, language, intellectual, and emotional deficits Changes in vital signs Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Demonstrate stable vital signs and absence of signs of increased ICP. Display no further deterioration or recurrence of deficits. Long-term Objective Within 3 days of providing nursing interventions, the patient will: Maintain usual or improved LOC, cognition, and motor and sensory function. Independent Determine factors related to individual situation, cause for coma, decreased cerebral perfusion, and potential for ICP. Influences choice of interventions. Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity, which requires that client be admitted to critical care area for monitoring of ICP and for specific therapies geared to maintaining ICP within a specified range. If the stroke is evolving, client can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is completed, the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence. Assesses trends in LOC and potential for increased ICP and is useful in determining location, extent, and progression or resolution of CNS damage. May also reveal TIA, which may resolve with no further symptoms or may precede thrombotic CVA. Nursing Interventions Rationale

Monitor and document neurological status frequently and compare with baseline. (Refer to CP: Craniocerebral TraumaAcute Rehabilitative Phase, ND: ineffective cerebral tissue Perfusion for complete neurological evaluation. Monitor vital signs noting: Hypertension or hypotension; compare blood pressure (BP) readings in both arms

Fluctuations in pressure may occur because of cerebral pressure or injury in vasomotor area of the brain. Hypertension or hypotension may have been a precipitating factor. Hypotension may follow stroke

because of circulatory collapse. Heart rate and rhythm; auscultate for murmurs Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA, for example, stroke after MI or from valve dysfunction. Irregularities can suggest location of cerebral insult or increased ICP and need for further intervention, including possible respiratory support. (Refer to CP: Craniocerebral TraumaAcute Rehabilitative Phase, ND: risk for ineffective Breathing Pattern.) Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brainstem is intact. Pupil size and equality is determined by balance between parasympathetic and sympathetic enervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves. Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions. Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate increased ICP. Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation and perfusion. Continual stimulation can increase ICP. Absolute rest and quiet may be needed to prevent recurrence of bleeding,

Respirations, noting patterns and rhythmperiods of apnea after hyperventilation, Cheyne-Stokes respiration

Evaluate pupils, noting size, shape, equality, and light reactivity.

Document changes in vision, such as reports of blurred vision and alterations in visual field or depth perception.

Assess higher functions, including speech, if client is alert. (Refer to ND: impaired verbal [and/or written] Communication.) Position with head slightly elevated and in neutral position.

Maintain bedrest, provide quiet environment, and restrict visitors or activities, as indicated. Provide rest periods between care activities, limiting duration of procedures.

in the case of hemorrhagic stroke.

Valsalvas maneuver increases ICP and potentiates risk of bleeding. Prevent straining at stool or holding breath. Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures may reflect increased ICP or reflect location and severity of cerebral injury, requiring further evaluation and intervention.

Assess for nuchal rigidity, twitching, increased restlessness, irritability, and onset of seizure activity.

Collaborative Administer supplemental oxygen, as indicated. Administer medications, as indicated, for example Intravenous thrombolytics, such as tissue plasminogen activator (tPA), alteplase (Activase), and recombinant prourokinase (Prourokinase)

Reduces hypoxemia.

As the only proven therapy for early acute ischemic stroke, tPA is useful in minimizing the size of the infarcted area by opening blocked vessels that are occluded with clot. Treatment must be started within 3 hours of initial symptoms to improve outcomes. Note: These agents are contraindicated in several instances intracranial hemorrhage as diagnosed by CT scan, recent intracranial surgery, serious head trauma, and uncontrolled hypertension. May be used to improve cerebral blood flow and prevent further clotting when embolus or thrombosis is the problem.

Anticoagulants, such as warfarin sodium (Coumadin); lowmolecular- weight heparin, for example, enoxaparin (Lovenox) and dalteparin (Fragmin); and direct thrombin inhibitor, such as ximelagatran (Exanta)

Antiplatelet agents are used following an ischemic stroke

or TIA. Antiplatelet agents, such as aspirin (ASA), aspirin with extended-release dipyridamole (Aggrenox), ticlopidine (Ticlid), and clopidogrel (Plavix)

Antihypertensives

Preexisting or chronic hypertension requires cautious treatment because aggressive management increases the risk of extension of tissue damage during an evolving stroke. Transient hypertension often occurs during acute stroke and usually resolves without therapeutic intervention. Used to improve collateral circulation or decrease vasospasm.

Peripheral vasodilators, such as cyclandelate (Cyclospasmol), papaverine (Pavabid), and isoxsuprine (Vasodilan) Neuroprotective agents, such as calcium channel blockers, excitatory amino acid inhibitors, and gangliosides

These agents are being researched as a means to protect the brain by interrupting the destructive cascade of biochemical eventsinflux of calcium into cells, release of excitatory neurotransmitters, buildup of lactic acid to limit ischemic injury. May be used to control seizures and for sedative action. Note: Phenobarbital enhances action of antiepileptics. May be necessary to resolve hemorrhagic situation and reduce neurological symptoms and risk of recurrent stroke. Provides information about effectiveness and therapeutic level of anticoagulants when used.

Phenytoin (Dilantin) and Phenobarbital.

Prepare for surgery, as appropriatecarotid endarterectomy, microvascular bypass, and cerebral angioplasty. Monitor laboratory studies as indicated, such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and Dilantin level.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p242-244 PRIORITY: Number 2 Nursing Diagnosis: Impaired physical Mobility May be related to: Neuromuscular involvement: weakness, paresthesia; flaccid, hypotonic paralysis (initially); spastic paralysis, Perceptual or cognitive impairment Cause Analysis: A stroke is an upper motor neuron lesion and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate (cross), a disturbance of voluntary motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1897) Cues Objective Cues

Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Maintain or increase strength and function of affected or compensatory body part. Maintain optimal position of function as evidenced by absence of contractures and footdrop. Long-term Objective Within 3 days of providing nursing interventions, the client will: Demonstrate techniques and behaviors that enable resumption of activities. Maintain skin integrity. Independent

Nursing Interventions

Rationale

Inability to purposefully move within the physical environment Impaired coordination Limited range of motion (ROM), Decreased muscle strength and control

Positioning Assess functional ability and extent of impairment initially and on a regular basis. Classify according to a 0 to 4 scale. (Refer to CP: Craniocerebral TraumaAcute Rehabilitative Phase, ND: impaired physical Mobility.) Change positions at least every 2 hours (supine, side lying) and possibly more often if placed on affected side. Position in prone position once or twice a day if client can tolerate. Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head. Use arm sling when client is in upright position, as indicated.

Identifies strengths and deficiencies and may provide information regarding recovery. Assists in choice of interventions because different techniques are used for flaccid and spastic types of paralysis. Reduces risk of tissue ischemia and injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown and pressure ulcers. Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe. Prevents contractures and footdrop and facilitates use when or if function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side. During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and shoulder-hand syndrome.

Evaluate use of and need for positional aids and splints during spastic paralysis: Place pillow under axilla to abduct arm. Elevate arm and hand. Place hard hand-rolls in the palm with fingers and thumb opposed. Place knee and hip in extended position. Maintain leg in neutral position with a trochanter roll. Discontinue use of footboard, when appropriate.

Flexion contractures occur because flexor muscles are stronger than extensors. Prevents adduction of shoulder and flexion of elbow. Promotes venous return and helps prevent edema formation. Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in a functional position. Maintains functional position. Prevents external hip rotation. Continued use after change from flaccid to spastic paralysis can cause excessive pressure on the ball of the foot, enhance spasticity, and actually increase plantar flexion. Edematous tissue is more easily traumatized and heals more slowly. Pressure points over bony prominences are most at risk for decreased perfusion and ischemia. Circulatory stimulation and padding help prevent skin breakdown and decubitus ulcer development.

Observe affected side for color, edema, or other signs of compromised circulation. Inspect skin prominences. regularly, particularly over bony

Gently massage any reddened areas and provide aids such as sheepskin pads, as necessary. Exercise Therapy: Muscle Control Begin active or passive ROM to all extremities (including splinted) on admission. Encourage exercises, such as quadriceps or gluteal exercise, squeezing rubber ball, and extension of fingers and legs and feet.

Minimizes muscle atrophy, promotes circulation, and helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. Note: Excessive and imprudent stimulation can predispose to recurrence of bleeding.

Assist client to develop sitting balance (such as raise head of bed; assist to sit on edge of bed, having client use the strong arm to support body weight and strong leg to move affected leg; increase sitting time) and standing balance put flat walking shoes on client, support clients lower back with hands while positioning own knees outside clients knees, and assist in using parallel bars and walker. Get client up in chair as soon as vital signs are stable except following cerebral hemorrhage.

Aids in retraining neuronal pathways, proprioception and motor response.

enhancing

Helps stabilize BP, restoring vasomotor tone, and promotes maintenance of extremities in a functional position and emptying of bladder and kidneys, reducing risk of urinary stones and infections from stasis. Note: If stroke is not completed, activity increases risk of additional bleeding and infarction. Reduces pressure on the coccyx and prevents skin breakdown. Promotes sense of expectation of progress and improvement, and provides some sense of control and independence. May respond as if affected side is no longer part of body and need encouragement and active training to reincorporate it as a part of own body.

Pad chair seat with foam or water-filled cushion, and assist client to shift weight at frequent intervals. Set goals with client/significant other (SO) for increasing participation in activities, exercise, and position changes. Encourage client to assist with movement and exercises using unaffected extremity to support and move weaker side. Collaborative Positioning Provide egg-crate mattress, water bed, flotation device, or specialized bed, such as kinetic, as indicated.

Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown and pressure ulcer formation. Specialized beds help with positioning, enhance circulation, and reduce venous

stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia. Exercise Therapy: Muscle Control Consult with physical therapist regarding active, resistive exercises and client ambulation. Assist with electrical stimulationtranscutaneous electrical nerve stimulator (TENS) unit, as indicated. Administer muscle relaxants and antispasmodics as indicated, such as baclofen (Lioresal) and dantrolene (Dantrium). Individualized program can be developed to meet particular needs and deal with deficits in balance, coordination, and strength. May assist with muscle strengthening and increase voluntary muscle control, as well as pain control. May be required to relieve spasticity in affected extremities.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p244-245

PRIORITY: Number 3 Nursing Diagnosis: Impaired verbal [and/or written] Communication May be related to: Impaired cerebral circulation; neuromuscular impairment, loss of facial or oral muscle tone and control; generalized weakness and fatigue Cause Analysis: The cortical area that is responsible for integrating the myriad pathways required for the comprehension and formulation of language is called Brocas area. It is located in a convolution adjoining the middle cerebral artery. This area is responsible for control of the combinations of muscular movements needed to speak each word. Brocas area is so close to the left motor area that a disturbance in the motor area often affects the speech area. This is why so many patients who are paralyzed on the right side (due to damage or injury to the left side of the brain) cannot speak, whereas those paralyzed on the left side are less likely to have speech disturbances. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1908) Cues Objective Cues

Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Be able Indicate understanding of the communication problems. Long-term Objective Within 3 days of providing nursing interventions, the client will: Establish method of communication in which needs can be expressed. Use resources appropriately. Independent

Nursing Interventions

Rationale

Impaired articulation; soft speech or does not or cannot speak Inability to modulate speech, find and name words, identify objects; inability to comprehend written or spoken language, global Aphasia Inability to produce written communication, expressive aphasia

Assess type and degree of dysfunction, such as receptive aphasiaclient does not seem to understand words, or expressive aphasiaclient has trouble speaking or making self understood:

Helps determine area and degree of brain involvement and difficulty client has with any or all steps of the communication process. Client may have trouble understanding spoken words (damage to Wernickes speech area), speaking words correctly (damage to Brocas speech areas), or may experience damage to both areas. Choice of interventions depends on type of impairment. Aphasia is a defect in using and interpreting symbols of language and may involve sensory and/or motor components, such as inability to comprehend written or spoken words or to write, make signs, and speak. A dysarthric person can understand, read, and write language, but has difficulty forming or pronouncing words because of weakness and paralysis of oral musculature, resulting in softly spoken speech. Client may lose ability to monitor verbal output and be

Differentiate aphasia from dysarthria.

Listen for errors in conversation and provide feedback.

unaware that communication is not sensible. Feedback helps client realize why caregivers are not understanding and responding appropriately and provides opportunity to clarify content and meaning. Ask client to follow simple commands, such as Shut your eyes, Point to the door; repeat simple words or sentences. Point to objects and ask client to name them. Have client produce simple sounds, such as sh, cat. Tests for receptive aphasia. Tests for expressive aphasiaclient may recognize item but not be able to name it. Identifies dysarthria because motor components of speech (tongue, lip movement, breath control) can affect articulation and may or may not be accompanied by expressive aphasia. Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia. Allays anxiety related to inability to communicate and fear that needs will not be met promptly. Call bell that is activated by minimal pressure is useful when client is unable to use regular call system. Provides for communication of needs or desires based on individual situation or underlying deficit. Helpful in decreasing frustration when dependent on others and unable to communicate desires. Reduces confusion and anxiety at having to process and respond to large amount of information at one time. As retraining progresses, advancing complexity of communication stimulates memory and further enhances

Ask client to write name and/or a short sentence. If unable to write, have client read a short sentence. Post notice at nurses station and clients room about speech impairment. Provide special call bell if necessary.

Provide alternative methods of communication, such as writing or felt board and pictures. Provide visual clues gestures, pictures, needs list, and demonstration. Anticipate and provide for clients needs. Talk directly to client, speaking slowly and distinctly. Use yes/no questions to start, progressing in complexity as client responds.

word and idea association. Speak with normal volume and avoid talking too fast. Give client ample time to respond. Talk without pressing for a response. Client is not necessarily hearing impaired and raising voice may irritate or anger client. Forcing responses can result in frustration and may cause client to resort to automatic speech, such as garbled speech and obscenities. It is important for family members to continue talking to client to reduce clients isolation, promote establishment of effective communication, and maintain sense of connectedness with family. Promotes meaningful conversation opportunity to practice skills. and provides

Encourage SO and visitors to persist in efforts to communicate with client, such as reading mail and discussing family happenings even if client is unable to respond appropriately. Discuss familiar topicsjob, family, hobbies, and current events. Respect clients preinjury capabilities; avoid speaking down to client or making patronizing remarks. Collaborative Consult with or refer to speech therapist.

Enables client to feel esteemed because intellectual abilities often remain intact.

Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits and therapy needs.

References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p246-247