Cerebrovascular Accident (CVA)

  1. General information
    1. Destruction (infarction) of brain cells caused by a reduction in cerebral blood flow and oxygen
    2. Affects men more than women; incidence increases with age
    3. Caused by thrombosis, embolism, hemorrhage
    4. Risk factors
      1. Hypertension, diabetes mellitus, arteriosclerosis/atherosclerosis, cardiac disease (valvular disease/replacement, chronic atrial fibrillation, myocardial infarction)
      2. Life-style: obesity, smoking, inactivity, stress, use of oral contraceptives
    5. Pathophysiology
      1. Interruption of cerebral blood flow for 5 minutes or more causes death of neurons in affected area with irreversible loss of function
      2. Modifying factors
        1. cerebral edema: develops around affected area causing further impairment
        2. vasospasm: constriction of cerebral blood vessel may occur, causing further decrease in blood flow
        3. collateral circulation: may help to maintain cerebral blood flow when there is compromise of main blood supply
    6. Stages of development
      1. Transient ischemic attack (TIA)
        1. warning sign of impending CVA
        2. brief period of neurologic deficit: visual loss, hemiparesis, slurred speech, aphasia, vertigo
        3. may last less than 30 seconds, but no more than 24 hours with complete resolution of symptoms
      2. Stroke in evolution: progressive development of stroke symptoms over a period of hours to days
      3. Completed stroke: neurologic deficit remains unchanged for a 2- to 3-day period.
  2. Assessment findings
    1. Headache
    2. Generalized signs: vomiting, seizures, confusion, disorientation, decreased LOC, nuchal rigidity, fever, hypertension, slow bounding pulse, Cheyne-Stokes respirations
    3. Focal signs (related to site of infarction): hemiplegia, sensory loss, aphasia, homonymous hemianopsia
    4. Diagnostic tests
      1. CT and brain scan: reveal lesion
      2. EEG: abnormal changes
      3. Cerebral arteriography: may show occlusion or malformation of blood vessels
  3. Nursing interventions: acute stage
    1. Maintain patent airway and adequate ventilation.
    2. Monitor vital signs and neuro checks and observe for signs of increased ICP, shock, hyperthermia, and seizures.
    3. Provide complete bed rest as ordered.
    4. Maintain fluid and electrolyte balance and ensure adequate nutrition.
      1. IV therapy for the first few days
      2. Nasogastric tube feedings if client unable to swallow
      3. Fluid restriction as ordered to decrease cerebral edema
    5. Maintain proper positioning and body alignment.
      1. Head of bed may be elevated 30°-45° to decrease ICP
      2. Turn and reposition every 2 hours (only 20 minutes on the affected side)
      3. Passive ROM exercises every 4 hours.
    6. Promote optimum skin integrity: turn client and apply lotion every 2 hours
    7. Maintain adequate elimination.
      1. Offer bedpan or urinal every 2 hours, catheterize only if absolutely necessary.
      2. Administer stool softeners and suppositories as ordered to prevent constipation and fecal impaction.
    8. Provide a quiet, restful environment.
    9. Establish a means of communicating with the client.
    10. Administer medications as ordered.
      1. Hyperosmotic agents, corticosteroids to decrease cerebral edema
      2. Anticonvulsants to prevent or treat seizures
      3. Thrombolytics given to dissolve clot (hemorrhage must be ruled out)
        1. tissue plasminogen activator (tPA, Alteplase)
        2. streptokinase, urokinase
        3. must be given within 2 hours of episode
      4. Anticoagulants for stroke in evolution or embolic stroke (hemorrhage must be ruled out)
        1. heparin
        2. warfarin (Coumadin) for long-term therapy
        3. aspirin and dipyridamole (Persantine) to inhibit platelet aggregation in treating TIAs
      5. Antihypertensives if indicated for elevated blood pressure
  4. Nursing interventions: rehabilitation
    1. Hemiplegia: results from injury to cells in the cerebral motor cortex or to corticospinal tracts (causes contralateral hemiplegia since tracts cross in medulla)
      1. Turn every 2 hours (20 minutes only on affected side).
      2. Use proper positioning and repositioning to prevent deformities (foot drop, external rotation of hip, flexion of fingers, wrist drop, abduction of shoulder and arm).
      3. Support paralyzed arm on pillow or use sling while out of bed to prevent subluxation of shoulder.
      4. Elevate extremities to prevent dependent edema.
      5. Provide active and passive ROM exercises every 4 hours.
    2. Susceptibility to hazards
      1. Keep side rails up at all times.
      2. Institute safety measures.
      3. Inspect body parts frequently for signs of injury.
    3. Dysphagia (difficulty swallowing)
      1. Check gag reflex before feeding client.
      2. Maintain a calm, unhurried approach.
      3. Place client in upright position.
      4. Place food in unaffected side of mouth.
      5. Offer soft foods.
      6. Give mouth care before and after meals.
    4. Homonymous hemianopsia: loss of half of each visual field
      1. Approach client on unaffected side.
      2. Place personal belongings, food, etc., on unaffected side.
      3. Gradually teach client to compensate by scanning, i.e., turning the head to see things on affected side.
    5. Emotional lability: mood swings, frustration
      1. Create a quiet, restful environment with a reduction in excessive sensory stimuli.
      2. Maintain a calm, nonthreatening manner.
      3. Explain to family that the client's behavior is not purposeful.
    6. Aphasia: most common in right hemiplegics; may be receptive/expressive
      1. Receptive aphasia
        1. give simple, slow directions.
        2. give one command at a time; gradually shift topics.
        3. use nonverbal techniques of communication (e.g., pantomime, demonstration).
      2. Expressive aphasia
        1. listen and watch very carefully when the client attempts to speak.
        2. anticipate client's needs to decrease frustration and feelings of helplessness.
        3. allow sufficient time for client to answer.
    7. Sensory/perceptual deficits: more common in left hemiplegics; characterized by impulsiveness, unawareness of disabilities, visual neglect (neglect of affected side and visual space on affected side)
      1. Assist with self-care.
      2. Provide safety measures.
      3. Initially arrange objects in environment on unaffected side.
      4. Gradually teach client to take care of the affected side and to turn frequently and look at affected side.
    8. Apraxia: loss of ability to perform purposeful, skilled acts
      1. Guide client through intended movement (e.g., take object such as washcloth and guide client through movement of washing).
      2. Keep repeating the movement.
    9. Generalizations about clients with left hemiplegia versus right hemiplegia and nursing care
      1. Left hemiplegia
        1. Perceptual, sensory deficits; quick and impulsive behavior
        2. Use safety measures, verbal cues, simplicity in all areas of care
      2. Right hemiplegia
        1. Speech-language deficits; slow and cautious behavior
        2. Use pantomime and demonstration