Nursing Guide to Stroke: Nursing Diagnosis, Interventions, & Care Plans

A stroke, also known as a cerebrovascular accident (CVA), occurs when the blood supply to part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients. Within minutes, brain cells begin to die, leading to potential permanent neurological damage or death.  

Strokes can be ischemic, caused by a blockage in an artery, or hemorrhagic, caused by bleeding in the brain. Immediate treatment is crucial to minimize brain damage, with early recognition of stroke symptoms being a critical factor in improving patient outcomes. 

Etiology and epidemiology 

Strokes are broadly classified into two main types: ischemic and hemorrhagic. 

• Ischemic stroke: Accounts for 62% of strokes and occurs when a blood clot or atherosclerotic plaque blocks an artery supplying blood to the brain. Common causes include atherosclerosis, heart disease (especially atrial fibrillation), and clot formation elsewhere in the body (embolism).
• Hemorrhagic stroke: Results from the rupture of a blood vessel in the brain, causing bleeding into the surrounding tissue. Risk factors include hypertension, aneurysms, and arteriovenous malformations (AVMs). Hemorrhagic strokes can be further divided into intracerebral and subarachnoid hemorrhages. 

Risk factors: 

• Modifiable risk factors: Hypertension, smoking, diabetes, high cholesterol, obesity, atrial fibrillation, and physical inactivity.
• Non-modifiable risk factors: Age (older than 55), gender (higher incidence in males), race (higher in African Americans), and family history of stroke or heart disease. 

Epidemiology: 

Stroke is the second leading cause of death worldwide and a leading cause of long-term disability. In the U.S., about 795,000 people experience a stroke each year, with one occurring approximately every 40 seconds. Ischemic strokes are more common, but hemorrhagic strokes have a higher fatality rate. 

Stroke ICD-10 code 

The ICD-10 code for ischemic stroke is I63.9 – Cerebral infarction, unspecified, and for hemorrhagic stroke, I61.9 – Nontraumatic intracerebral hemorrhage, unspecified. 

Diagnosis 

The diagnosis of stroke is based on clinical evaluation, imaging studies, and laboratory tests. 

1. Clinical assessment: Sudden onset of neurological deficits, such as weakness or numbness (typically on one side), speech difficulties (aphasia or slurred speech), vision problems, dizziness, and loss of coordination. Use of the FAST (Face drooping or weakness, Arm weakness or numbness, Speech difficulty, Time to call emergency services) mnemonic is encouraged to quickly identify strokes.
2. CT scan: The primary imaging modality to differentiate between ischemic and hemorrhagic stroke, as it quickly detects intracerebral bleeding.
3. MRI: More sensitive for identifying ischemic stroke, particularly in the early stages, and can help visualize small areas of brain tissue damage.
4. CT angiography (CTA) or MR angiography (MRA): These imaging techniques are used to identify blocked or narrowed arteries in the brain.
5. Carotid ultrasound: Helps assess blood flow in the carotid arteries and detect stenosis or blockages.
6. Blood tests: May include clotting profiles, blood glucose levels, and cholesterol levels to rule out other causes or assess risk factors. 

Management 

The management of stroke varies depending on the type and severity, but rapid intervention is critical in minimizing brain damage. 

Ischemic stroke management: 

1. Thrombolytic therapy: The administration of tissue plasminogen activator (tPA) is the standard treatment for acute ischemic stroke within 3 to 4.5 hours of symptom onset. tPA dissolves clots and restores blood flow to the brain.
2. Mechanical thrombectomy: For large artery blockages, endovascular treatment using a stent retriever may be performed to remove the clot up to 6 to 24 hours after symptom onset.
3. Antiplatelet therapy: Aspirin is typically started within 24-48 hours of stroke onset to reduce the risk of recurrent stroke. Long-term antiplatelet therapy with aspirin or clopidogrel may be prescribed.
4. Anticoagulation: In cases of atrial fibrillation or other high-risk conditions, anticoagulants like warfarin or newer agents (DOACs) may be used to prevent further embolic events. 

Hemorrhagic stroke management: 

1. Blood pressure control: Hypertension is aggressively managed to reduce further bleeding. Medications like labetalol or nicardipine are commonly used.
2. Surgical intervention: In cases of large hemorrhages, surgical evacuation of the hematoma may be necessary to relieve pressure on the brain.
3. Aneurysm repair: If an aneurysm is the cause, interventions like clipping or coiling may be performed to prevent rebleeding.
4. Rehabilitation: After initial stabilization, patients may require extensive rehabilitation, including physical, occupational, and speech therapy, to regain lost function. 

Stroke nursing care plan 

Nursing considerations 

Stroke patients often require intensive nursing care, focusing on acute treatment, prevention of complications, and promoting rehabilitation. 

Assessment 

• Neurological status: Regularly assess using standardized tools like the National Institutes of Health Stroke Scale (NIHSS) to monitor changes in the patient's condition.
• Vital signs: Monitor blood pressure closely, especially in hemorrhagic stroke patients, to prevent further bleeding. Keep blood glucose levels within normal ranges, as hyperglycemia can worsen outcomes.
• Cardiac monitoring: Many stroke patients, especially those with atrial fibrillation or other heart conditions, may have concurrent cardiac issues that require continuous monitoring.
• Swallowing assessment: Perform a bedside swallowing test before administering oral medications or food to prevent aspiration pneumonia, a common complication post-stroke. 

Nursing diagnosis/risk for 

• Impaired physical mobility related to hemiparesis or hemiplegia.
• Risk for aspiration related to impaired swallowing function post-stroke.
• Impaired verbal communication related to aphasia.
• Risk for impaired skin integrity due to immobility. 

Interventions 

• Positioning: Turn the patient every two hours to prevent pressure ulcers and promote venous return. Ensure the head of the bed is elevated to reduce intracranial pressure in hemorrhagic stroke cases.
• Dysphagia management: Collaborate with speech therapy to assess swallowing ability. If dysphagia is present, consider alternative nutrition routes such as a nasogastric tube.
• Early mobilization: Engage physical therapy early to prevent complications like deep vein thrombosis (DVT) and promote recovery of motor skills. Use splints to prevent contractures in paralyzed limbs.
• Communication aids: For patients with aphasia, use visual aids or non-verbal communication techniques to support communication. Involve family members in strategies to facilitate communication.
• Bladder and bowel management: Implement a toileting schedule and assess for incontinence. Use catheters only when necessary to reduce infection risk. 

Expected outcomes 

• The patient will demonstrate improved neurological function or stabilization without further deterioration.
• The patient will maintain clear airways and prevent aspiration, as evidenced by normal breath sounds and absence of respiratory complications.
• The patient will exhibit safe mobility practices with assistance and will not experience falls or pressure injuries.
• The patient will show progress in rehabilitation efforts, regaining some degree of independence in activities of daily living (ADLs). 

Individual/caregiver education 

• Signs of stroke: Teach the patient and family the FAST acronym to recognize signs of stroke and the importance of seeking emergency care immediately.
• Medication management: Ensure the patient and caregiver understand the importance of taking antiplatelets, anticoagulants, and antihypertensive medications as prescribed to reduce the risk of recurrent stroke.
• Diet and lifestyle changes: Educate on the importance of a heart-healthy diet, regular exercise, smoking cessation, and controlling comorbidities like hypertension, diabetes, and hyperlipidemia.
• Rehabilitation participation: Encourage participation in rehabilitation programs to maximize recovery and restore function. 

References 

1. Mayo Clinic: Stroke Overview
2. American Stroke Association: Stroke Management
3. National Institutes of Health: Stroke Research and Information
4. Centers for Disease Control and Prevention: Stroke Statistics
5. ICD-10 Data: I63.9 Cerebral infarction, unspecified Acute Stroke - StatPearls - NCBI Bookshelf 

Resources 

• American Stroke Association: Provides comprehensive information on stroke prevention, treatment, and recovery.
• National Stroke Association: Offers support and resources for stroke survivors and their caregivers, including educational materials and recovery tools.
• Centers for Disease Control and Prevention (CDC): Supplies up-to-date information on stroke statistics and prevention guidelines.
• Stroke Rehabilitation Centers: Local rehabilitation centers can help patients regain physical and cognitive functions following a stroke.