17. Ischemic stroke (CVA, brain attack): brain lesion resulting from damage to blood vessels supplying brain (middle cerebral artery most common).
1. Pathophysiology: reduced or interrupted blood flow-interruption of nerve impulses down corticospinal tract-decreased or absent voluntary movement on one side of the body (fine movements are more affected than coarse movements); later, autonomous reflex activity-spasticity and rigidity of muscles.
2. Risk factors:
1. Cerebral thrombosis (most common), embolism, hemorrhage.
2. Prior ischemic episodes (TIAs).
3. Hypertension.
4. Oral contraceptives.
5. Emotional stress.
6. Family history.
7. Age.
8. Diabetes mellitus.
3. Assessment:
1. Subjective data:
1. Weakness: sudden or gradual loss of movement of extremities on one side.
2. Difficulty forming words.
3. Difficulty swallowing (dysphagia).
4. Nausea, vomiting.
5. History of TIAs.
2. Objective data:
1. Vital signs:
1. BP-elevated; widened pulse pressure.
2. Temperature-elevated.
3. Pulse-normal, slow.
4. Respirations-tachypnea, altered pattern; deep; sonorous.
2. Neurological:
1. Altered level of consciousness.
2. Pupils-unequal; vision-homonymous hemianopia.
3. Ptosis of eyelid, drooping mouth.
4. Paresis or paralysis (hemiplegia).
5. Loss of sensation and reflexes.
6. Incontinence of urine or feces.
7. Aphasia
4. Analysis/nursing diagnosis:
1. Impaired physical mobility related to hemiplegia.
2. Impaired swallowing related to paralysis.
3. Impaired verbal communication related to aphasia.
4. Risk for aspiration related to unconsciousness.
5. Sensory/perceptual alterations related to altered cerebral blood flow, visual field blindness.
6. Altered thought processes related to cerebral edema.
7. Self-care deficit related to paresis or paralysis.
8. Body image disturbance related to hemiplegia.
9. Total incontinence related to interruption of normal nerve transmission.
10. Impaired social interaction related to aphasia or neurological deficit.
11. Risk for impaired skin integrity related to immobility.
12. Unilateral neglect related to cerebral damage
5. Nursing care plan/implementation:
1. Goal: reduce cerebral anoxia.
1. Patent airway:
1. Oxygen therapy as ordered; suctioning to prevent aspiration.
2. Turn, cough, deep breathe q2h due to high incidence of aspiration pneumonia.
2. Activity: bed rest, progressing to out of bed as tolerated.
3. Position:
1. Maximize ventilation.
2. Support with pillows when on side; use hand rolls and arm slings as ordered.
2. Goal: promote cardiovascular function and maintain cerebral perfusion.
1. Vital signs; neurological checks.
2. Medications as ordered:
1. Antiplatelet aggregation inhibitors (ASA, ticlopidine, dipyridamole [Persantine]).
2. Antihypertensives to prevent rupture.
3. Anticoagulants to prevent thrombus.
3. Fluids: IVs to prevent hemoconcentration; I&O; weigh daily.
4. ROM exercises to prevent contractures, muscle atrophy, phlebitis.
5. Skin care and position changes to prevent decubiti.
3. Goal: provide for emotional relaxation.
1. Identify grief reaction to changes in body image.
2. Encourage expression of feelings, concerns.
4. Goal: patient safety.
1. Identify existence of homonymous hemianopia (visual field blindness) and agnosia (disturbance in sensory information).
2. Use side rails and assist as needed.
3. Remind to walk slowly, take adequate rest periods, ensure good lighting, look where patient is going.
5. Goal: health teaching.
1. Exercise routines.
2. Diet: self-feeding, but assist as needed.
3. Resumption of self-care activities.
4. Use of supportive devices; transfer techniques.
6. Evaluation/outcome criteria:
1. No complications (pneumonia).
2. Regains functional independence-resumes self-care activities.
3. Return of control over body functions (bowel, bladder, speech).