Care Plan - Stroke

 

Introduction: Stroke

Stroke is still the most common cause of disability and death in the Philippines. Evaluating the current state of stroke care, needed resources, and gaps in health policies and programs is critical for effectively reducing stroke-related mortality and morbidity. The purpose of this paper is to characterize the stroke system of care and network in the Philippines using the World Health Organization's health system building blocks framework. The Philippine Department of Health (DOH) institutionalized a national policy framework for preventing and managing stroke to integrate existing national laws and policies governing stroke and its risk factors dispersed across many general policies. Despite policy changes, government financing remains limited. From 2009 to 2019, stroke remains the second leading cause of death and one of the top five leading causes of disability in the Philippines (3). The true stroke prevalence is uncertain, but reported estimates vary between 0.9% (2005) (4) to 2.6% (2017) of the population (5). Based on types of stroke, seven out of 10 cases are diagnosed as ischaemic while the other three are considered hemorrhagic (4). Thirty-six percent (36%) of the total stroke deaths are not attended by any medical personnel (6).

Nursing Care Plan

The main nursing care plan goals for stroke patients vary depending on the stage of CVA the client is in. Efforts should be focused on survival needs and preventing further complications during the acute phase of CVA. Care focuses on efficient continuing neurologic assessment, respiration support, continuous vital sign monitoring, careful positioning to avoid aspiration and contractures, management of GI problems, and electrolyte and nutritional status monitoring. Nursing care should also include preventative measures.

1. Risk for Ineffective Tissue Perfusion

Assess airway patency and respiratory pattern.

Neurologic deficits of a stroke may include loss of gag reflex or cough reflex; thus, airway patency and breathing pattern must be part of the initial assessment.

Assess factors related to decreased cerebral perfusion and the potential for increased intracranial pressure (ICP).

The extensive neurologic examination will help guide therapy and the choice of interventions.

Recognize the clinical manifestations of a transient ischemic attack (TIA).

Patients with TIA present with temporary neurologic symptoms such as sudden loss of motor, sensory, or visual function caused by transient ischemia to a specific region of the brain, with their brain imaging scan showing no evidence of ischemia. Recognizing symptoms of TIA may serve as a warning of an impending stroke as approximately 15% of all strokes are preceded by a TIA (Amarenco et al., 2018; Sacco, 2004). Evaluation and prompt treatment of the patient who experienced TIA can help prevent stroke and its irreversible complications.

Assess and monitor neurological status on a regular basis

Assesses trends in the level of consciousness (LOC), the possibility of increased ICP, and aids in determining the location, extent, and progression of damage. The prognosis is determined by the patient's neurologic condition. It may also reveal the presence of TIA, which may indicate the presence of an impending thrombotic CVA. The following items are included in the neurologic evaluation:

• Alteration in consciousness or responsiveness
• Reaction to stimulation
• Time, place, and person orientation
• pupillary responses to light and accommodation, pupillary size

Monitor blood pressure changes and compare BP readings in both arms.

Hypertension is a major risk factor for stroke. Blood pressure fluctuations can occur as a result of cerebral injury in the vasomotor area of the brain. A precipitating factor could have been hypertension or postural hypotension. Hypotension can result from shock (circulatory collapse), and increased ICP can result from tissue edema or clot formation. The difference in pressure readings between arms may indicate subclavian artery blockage. Furthermore, if the patient is a candidate for fibrinolytic therapy, blood pressure control is critical to lowering the risk of bleeding.

Keep an eye on your heart rate and rhythm, and listen for murmurs.

Changes in rate, particularly bradycardia, can occur as a result of brain damage. Dysrhythmias and murmurs may indicate cardiac disease, which can lead to CVA (stroke after MI or valve dysfunction). The presence of atrial fibrillation raises the possibility of emboli formation.

Keep track of your breathing patterns and rhythms, as well as your Cheyne-Stokes respiration.

Irregular respiration can indicate the location of a cerebral insult or an increase in ICP, as well as the need for additional intervention, such as respiratory support.

Monitor computed tomography scan.

A CT scan is the first diagnostic test performed on patients who have had a stroke and is performed as soon as the patient arrives at the emergency department. A CT scan is used to determine whether the stroke is ischemic or hemorrhagic, as the type of stroke will influence treatment. A computed tomography angiography (CTA) may be performed as well to detect intracranial occlusions and the extent of occlusion in the arterial tree (Menon & Demchuk, 2011).

Examine the pupils, taking note of their size, shape, equality, and light reactivity.

The oculomotor (III) cranial nerve regulates pupil reactions, which aid in determining whether the brain stem is intact. The balance of parasympathetic and sympathetic innervation determines pupil size and equality. The combined function of the optic (II) and oculomotor (III) cranial nerves is reflected in the response to light.

Changes in vision should be documented, including reports of blurred vision, changes in the visual field, and depth perception.

If the aneurysm is close to the oculomotor nerve, visual disturbances may occur. Specific visual changes reflect the involvement of a specific brain area. Initiate safety-promoting measures.

If the patient is awake, assess higher functions, including speech.

Changes in cognition and speech content indicate the location and degree of cerebral involvement, as well as deterioration or increased ICP.

Examine the patient for nuchal rigidity, twitching, increased restlessness, irritability, and the onset of seizure activity.

Meningeal irritation can cause nuchal rigidity (pain and stiffness in the back of the neck). Seizures may indicate an increase in ICP or a cerebral injury that necessitates further evaluation and treatment.

References: 

• https://nurseslabs.com/cerebrovascular-accident-stroke-nursing-care-plans/
• https://www.frontiersin.org/articles/10.3389/fneur.2021.665086/full