Causes
Strokes are caused by the following:
Cerebrovascular Accident (Stroke)
Description
A cerebrovascular accident (CVA), an ischemic stroke or
“brain attack,” is a sudden loss of brain function resulting
from a disruption of the blood supply to a part of the brain.
• Cerebrovascular accident or stroke is the primary
cerebrovascular disorder in the United States.
• A cerebrovascular accident is a sudden loss of brain
functioning resulting from a disruption of the blood
supply to a part of the brain.
• It is a functional abnormality of the central nervous
system.
• Cryptogenic strokes have no known cause, and other
strokes result from causes such as illicit drug use,
coagulopathies, migraine, and spontaneous
dissection of the carotid or vertebral arteries.
• The result is an interruption in the blood supply to the
brain, causing temporary or permanent loss of
movement, thought, memory, speech, or sensation.
Classification
Strokes can be divided into two classifications.
• Ischemic stroke. This is the loss of function in the brain
as a result of a disrupted blood supply.
• Hemorrhagic stroke. Hemorrhagic strokes are caused by
bleeding into the brain tissue, the ventricles, or the
subarachnoid space.
Risk Factors
Nonmodifiable
• Advanced age (older than 55 years)
• Gender (Male)
• Race (African American)
Modifiable
• Hypertension
• Atrial fibrillation
• Hyperlipidemia
• Obesity
• Smoking
• Diabetes
• Asymptomatic carotid stenosis and valvular heart
disease (eg, endocarditis, prosthetic heart valves)
• Periodontal disease
Pathophysiology
The disruption in the blood flow initiates a complex series of
cellular metabolic events.
• Decreased cerebral blood flow. The ischemic cascade
begins when cerebral blood flow decreases to less
than 25 mL per 100g of blood per minute.
• Aerobic respiration. At this point, neurons are unable to
maintain aerobic respiration.
• Anaerobic respiration. The mitochondria would need to
switch to anaerobic respiration, which generates
large amounts of lactic acid, causing a change in pH
and rendering the neurons incapable of producing
sufficient quantities of ATP.
• Loss of function. The membrane pumps that maintain
electrolyte balances fail and the cells cease to
function.
• Large artery thrombosis. Large artery thromboses are
caused by atherosclerotic plaques in the large
blood vessels of the brain.
• Small penetrating artery thrombosis. Small penetrating
artery thrombosis affects one or more vessels and is
the most common type of ischemic stroke.
• Cardiogenic emboli. Cardiogenic emboli are associated
with cardiac dysrhythmias, usually atrial fibrillation.
Clinical Manifestations
Stroke can cause a wide variety of neurologic deficits,
depending on the location of the lesion, the size of the area of
inadequate perfusion, and the amount of the collateral blood
flow. General signs and symptoms include numbness or
weakness of face, arm, or leg (especially on one side of
the body); confusion or change in mental status; trouble
speaking or understanding speech; visual disturbances; loss
of balance, dizziness, difficulty walking; or sudden severe
headache.
General signs and symptoms include numbness or weakness
of face, arm, or leg (especially on one side of the body);
confusion or change in mental status; trouble speaking or
understanding speech; visual disturbances; loss of balance,
dizziness, difficulty walking; or sudden severe headache.
• Numbness or weakness of the face. Without adequate
perfusion, oxygen is also low, and facial tissues could
not function properly without them.
• Change in mental status. Due to decreased oxygen, the
patient experiences confusion.
• Trouble speaking or understanding speech. Cells
cease to function as a result of inadequate perfusion.
• Visual disturbances. The eyes also need enough oxygen
for optimal functioning.
• Homonymous hemianopsia. There is loss of half of the
visual field.
• Loss of peripheral vision. The patient experiences
difficulty seeing at night and is unaware of objects or
the borders of objects.
• Hemiparesis. There is a weakness of the face, arm, and
leg on the same side due to a lesion in the opposite
hemisphere.
• Hemiplegia. Paralysis of the face, arm, and leg on the
same side due to a lesion in the opposite
hemisphere.
• Ataxia. Staggering, unsteady gait and inability to keep
feet together.
• Dysarthria. This is the difficulty in forming words.
• Dysphagia. There is difficulty in swallowing.
• Paresthesia. There is numbness and tingling of
extremities and difficulty with proprioception.
• Expressive aphasia. The patient is unable to form words
that is understandable yet can speak in single-word
responses.
• Receptive aphasia. The patient is unable to comprehend
the spoken word and can speak but may not make
any sense.
• Global aphasia. This is a combination of both expressive
and receptive aphasia.

Motor Loss
• Hemiplegia, hemiparesis
• Flaccid paralysis and loss of or decrease in the deep
tendon reflexes (initial clinical feature) followed by
(after 48 hours) reappearance of deep reflexes
and abnormally increased muscle tone (spasticity)

Communication Loss
• Dysarthria (difficulty speaking)
• Dysphasia (impaired speech) or aphasia (loss of
speech)
• Apraxia (inability to perform a previously learned
action)
Perceptual Disturbances and Sensory Loss
• Visual-perceptual dysfunctions (homonymous
hemianopia [loss of half of the visual field])
• Disturbances in visual-spatial relations (perceiving
the relation of two or more objects in spatial
areas), frequently seen in patients with right
hemispheric damage
• Sensory losses: slight impairment of touch or more
severe with loss of proprioception; difficulty in
interrupting visual, tactile, and auditory stimuli
Impaired Cognitive and Psychological Effects
• Frontal lobe damage: Learning capacity, memory,
or other higher cortical intellectual functions may
be impaired. Such dysfunction may be reflected in
a limited attention span, difficulties in
comprehension, forgetfulness, and lack of
motivation.
• Depression, other psychological problems: emotional
lability, hostility, frustration, resentment, and lack
of cooperation.
Prevention

Primary prevention of stroke remains the best approach.

• Healthy lifestyle. Leading a healthy lifestyle which
includes not smoking, maintaining a healthy weight,
following a healthy diet, and daily exercise can
reduce the risk of having a stroke by about one half.
• DASH diet. The DASH (Dietary Approaches to Stop
Hypertension) diet is high in fruits and vegetables,
moderate in low-fat dairy products, and low in
animal protein and can lower the risk of stroke.
• Stroke risk screenings. Stroke risk screenings are an
ideal opportunity to lower stroke risk by identifying
people or groups of people who are at high risk for
stroke.
• Education. Patients and the community must be educated
about recognition and prevention of stroke.
• Low-dose aspirin. Research findings suggest that low-
dose aspirin may lower the risk of stroke in women
who are at risk.
Complications
If cerebral oxygenation is still inadequate; complications may
occur.
• Tissue ischemia. If cerebral blood flow is inadequate, the
amount of oxygen supplied to the brain is decreased,
and tissue ischemia will result.
• Cardiac dysrhythmias. The heart compensates for the
decreased cerebral blood flow, and with too much
pumping, dysrhythmias may occur.
Assessment and Diagnostic Findings
Any patient with neurologic deficits need a careful history and
complete physical and neurologic examination.
• CT scan. Demonstrates structural abnormalities, edema,
hematomas, ischemia, and infarctions. Demonstrates
structural abnormalities, edema, hematomas,
ischemia, and infarctions. Note: May not immediately
reveal all changes, e.g., ischemic infarcts are not
evident on CT for 8–12 hr; however, intracerebral
hemorrhage is immediately apparent; therefore,
emergency CT is always done before administering
tissue plasminogen activator (t-PA). In addition,
patients with TIA commonly have a normal CT scan
• PET scan. Provides data on cerebral metabolism and blood
flow changes.
• MRI. Shows areas of infarction, hemorrhage, AV
malformations, and areas of ischemia.
• Cerebral angiography. Helps determine specific cause of
stroke, e.g., hemorrhage or obstructed artery,
pinpoints site of occlusion or rupture. Digital
subtraction angiography evaluates patency of
cerebral vessels, identifies their position in head and
neck, and detects/evaluates lesions and vascular
abnormalities.
• Lumbar puncture. Pressure is usually normal and CSF is
clear in cerebral thrombosis, embolism, and TIA.
Pressure elevation and grossly bloody fluid suggest
subarachnoid and intracerebral hemorrhage. CSF
total protein level may be elevated in cases of
thrombosis because of inflammatory process. LP
should be performed if septic embolism from
bacterial endocarditis is suspected.
• Transcranial Doppler ultrasonography. Evaluates the
velocity of blood flow through major intracranial
vessels; identifies AV disease, e.g., problems with
carotid system (blood flow/presence of
atherosclerotic plaques).
• EEG. Identifies problems based on reduced electrical
activity in specific areas of infarction; and can
differentiate seizure activity from CVA damage.
• Skull x-ray. May show a shift of pineal gland to the
opposite side from an expanding mass; calcifications
of the internal carotid may be visible in cerebral
thrombosis; partial calcification of walls of an
aneurysm may be noted in subarachnoid
hemorrhage.
• ECG and echocardiography. To rule out cardiac origin as
source of embolus (20% of strokes are the result of
blood or vegetative emboli associated with valvular
disease, dysrhythmias, or endocarditis).
• Laboratory studies to rule out systemic causes: CBC,
platelet and clotting studies, VDRL/RPR, erythrocyte
sedimentation rate (ESR), chemistries (glucose,
sodium).
Medical Management
Patients who have experienced TIA or stroke should have
medical management for secondary prevention.
• Recombinant tissue plasminogen activator would be
prescribed unless contraindicated, and there should
be monitoring for bleeding.
• Increased ICP. Management of increased ICP includes
osmotic diuretics, maintenance of PaCO2 at 30-35
mmHg, and positioning to avoid hypoxia through
elevation of the head of the bed.
• Endotracheal Tube. There is a possibility of intubation to
establish patent airway if necessary.
• Hemodynamic monitoring. Continuous hemodynamic
monitoring should be implemented to avoid an
increase in blood pressure.
• Neurologic assessment to determine if the stroke is
evolving and if other acute complications are
developing
Surgical Management
Surgical management may include prevention and relief from
increased ICP.
• Carotid endarterectomy. This is the removal of
atherosclerotic plaque or thrombus from the carotid
artery to prevent stroke in patients with occlusive
disease of the extracranial cerebral arteries.
• Hemicraniectomy. Hemicraniectomy may be performed
for increased ICP from brain edema in severe cases
of stroke.
Nursing Management
After the stroke is complete, management focuses on the
prompt initiation of rehabilitation for any deficits.
Nursing Assessment
During the acute phase, a neurologic flow sheet is
maintained to provide data about the following important
measures of the patient’s clinical status:
• Change in level of consciousness or responsiveness.
• Presence or absence of voluntary or involuntary
movements of extremities.
• Stiffness or flaccidity of the neck.
• Eye opening, comparative size of pupils, and pupillary
reaction to light.
• Color of the face and extremities; temperature and
moisture of the skin.
• Ability to speak.
• Presence of bleeding.
• Maintenance of blood pressure.
During the postacute phase, assess the following functions:
• Mental status (memory, attention span, perception,
orientation, affect, speech/language).
• Sensation and perception (usually the patient
has decreased awareness of pain and temperature).
• Motor control (upper and lower extremity
movement); swallowing ability, nutritional and
hydration status, skin integrity, activity tolerance,
and bowel and bladder function.
• Continue focusing nursing assessment on impairment
of function in patient’s daily activities.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses
for a patient with stroke may include the following:
• Impaired physical mobility related to hemiparesis, loss
of balance and coordination, spasticity, and brain
injury.
• Acute pain related to hemiplegia and disuse.
• Deficient self-care related to stroke sequelae.
• Disturbed sensory perception related to altered sensory
reception, transmission, and/or integration.
• Impaired urinary elimination related to flaccid bladder,
detrusor instability, confusion, or difficulty in
communicating.
• Disturbed thought processes related to brain damage.
• Impaired verbal communication related to brain
damage.
• Risk for impaired skin integrity related to hemiparesis
or hemiplegia and decreased mobility.
• Interrupted family processes related to catastrophic
illness and caregiving burdens.
• Sexual dysfunction related to neurologic deficits or fear
of failure.
Planning & Goals
Main article: 8+ Cerebrovascular Accident (Stroke)
Nursing Care Plans
The major goals for the patient and family may include:
• Improve mobility.
• Avoidance of shoulder pain.
• Achievement of self-care.
• Relief of sensory and perceptual deprivation.
• Prevention of aspiration.
• Continence of bowel and bladder.
• Improved thought processes.
• Achieving a form of communication.
• Maintaining skin integrity.
• Restore family functioning.
• Improve sexual function.
• Absence of complications.
Nursing Interventions
Nursing care has a significant impact on the patient’s
recovery. In summary, here are some nursing interventions
for patients with stroke:
• Positioning. Position to prevent contractures, relieve
pressure, attain good body alignment, and prevent
compressive neuropathies.
• Prevent flexion. Apply splint at night to prevent flexion of
the affected extremity.
• Prevent adduction. Prevent adduction of the affected
shoulder with a pillow placed in the axilla.
• Prevent edema. Elevate affected arm to prevent edema
and fibrosis.
• Full range of motion. Provide full range of motion four or
five times a day to maintain joint mobility.
• Prevent venous stasis. Exercise is helpful in preventing
venous stasis, which may predispose the patient to
thrombosis and pulmonary embolus.
• Regain balance. Teach patient to maintain balance in a
sitting position, then to balance while standing and
begin walking as soon as standing balance is
achieved.
• Personal hygiene. Encourage personal hygiene activities
as soon as the patient can sit up.
• Manage sensory difficulties. Approach patient with a
decreased field of vision on the side where visual
perception is intact.
• Visit a speech therapist. Consult with a speech therapist
to evaluate gag reflexes and assist in teaching
alternate swallowing techniques.
• Voiding pattern. Analyze voiding pattern and offer urinal
or bedpan on patient’s voiding schedule.
• Be consistent in patient’s activities. Be consistent in
the schedule, routines, and repetitions; a written
schedule, checklists, and audiotapes may help with
memory and concentration, and a communication
board may be used.
• Assess skin. Frequently assess skin for signs of
breakdown, with emphasis on bony areas and
dependent body parts.
Improving Mobility and Preventing Deformities
• Position to prevent contractures; use measures to
relieve pressure, assist in maintaining good body
alignment, and prevent compressive neuropathies.
• Apply a splint at night to prevent flexion of
affected extremity.
• Prevent adduction of the affected shoulder with a
pillow placed in the axilla.
• Elevate affected arm to prevent edema and fibrosis.
• Position fingers so that they are barely flexed; place hand
in slight supination. If upper extremity spasticity
is noted, do not use a hand roll; dorsal wrist splint
may be used.
• Change position every 2 hours; place patient in a
prone position for 15 to 30 minutes several times a
day.
Establishing an Exercise Program
• Provide full range of motion four or five times a day
to maintain joint mobility, regain motor control,
prevent contractures in the paralyzed extremity,
prevent further deterioration of the neuromuscular
system, and enhance circulation. If tightness occurs
in any area, perform a range of motion exercises
more frequently.
• Exercise is helpful in preventing venous stasis, which
may predispose the patient to thrombosis and
pulmonary embolus.
• Observe for signs of pulmonary embolus or excessive
cardiac workload during exercise period (e.g.,
shortness of breath, chest pain, cyanosis, and
increasing pulse rate).
• Supervise and support the patient during exercises;
plan frequent short periods of exercise, not longer
periods; encourage the patient to exercise unaffected
side at intervals throughout the day.
Preparing for Ambulation
• Start an active rehabilitation program when
consciousness returns (and all evidence of bleeding
is gone, when indicated).
• Teach patient to maintain balance in a sitting position, then
to balance while standing (use a tilt table if needed).
• Begin walking as soon as standing balance is achieved (use
parallel bars and have a wheelchair available in
anticipation of possible dizziness).
• Keep training periods for ambulation short and frequent.
Preventing Shoulder Pain
• Never lift patient by the flaccid shoulder or pull on
the affected arm or shoulder.
• Use proper patient movement and positioning (e.g.,
flaccid arm on a table or pillows when patient is
seated, use of sling when ambulating).
• Range of motion exercises are beneficial, but avoid over
strenuous arm movements.
• Elevate arm and hand to prevent dependent edema of
the hand; administer analgesic agents as indicated.
Enhancing Self Care
• Encourage personal hygiene activities as soon as
the patient can sit up; select suitable self-care
activities that can be carried out with one hand.
• Help patient to set realistic goals; add a new task daily.
• As a first step, encourage patient to carry out all self-
care activities on the unaffected side.
• Make sure patient does not neglect affected side;
provide assistive devices as indicated.
• Improve morale by making sure patient is fully
dressed during ambulatory activities.
• Assist with dressing activities (e.g., clothing with
Velcro closures; put garment on the affected side
first); keep environment uncluttered and organized.
• Provide emotional support and encouragement to
prevent fatigue and discouragement.
Managing Sensory-Perceptual Difficulties
• Approach patient with a decreased field of vision on
the side where visual perception is intact; place all
visual stimuli on this side.
• Teach patient to turn and look in the direction of
 the defective visual field to compensate for the loss;
make eye contact with patient, and draw attention to
affected side.
• Increase natural or artificial lighting in the room;
provide eyeglasses to improve vision.
• Remind patient with hemianopsia of the other side of
the body; place extremities so that patient can see
them.
Assisting with Nutrition
• Observe patient for paroxysms of coughing, food
dribbling out or pooling in one side of the mouth,
food retained for long periods in the mouth, or nasal
regurgitation when swallowing liquids.
• Consult with speech therapist to evaluate gag
reflexes; assist in teaching alternate swallowing
techniques, advise patient to take smaller boluses of
food, and inform patient of foods that are easier to
swallow; provide thicker liquids or pureed diet as
indicated.
• Have patient sit upright, preferably on chair, when
eating and drinking; advance diet as tolerated.
• Prepare for GI feedings through a tube if indicated; elevate
the head of bed during feedings, check tube position
before feeding, administer feeding slowly, and
ensure that cuff of tracheostomy tube is inflated (if
applicable); monitor and report excessive retained or
residual feeding.
Attaining Bowel and Bladder Control
• Perform intermittent sterile catheterization during the
period of loss of sphincter control.
• Analyze voiding pattern and offer urinal or bedpan
on patient’s voiding schedule.
• Assist the male patient to an upright posture for voiding.
• Provide highfiber diet and adequate fluid intake (2 to 3
L/day), unless contraindicated.
• Establish a regular time (after breakfast) for toileting.
Improving Thought Processes
• Reinforce structured training program using cognitive,
perceptual retraining, visual imagery, reality
orientation, and cueing procedures to compensate
for losses.
• Support patient: Observe performance and progress,
give positive feedback, convey an attitude of
confidence and hopefulness; provide other
interventions as used for improving cognitive
function after a head injury.
Improving Communication
• Reinforce the individually tailored program.
• Jointly establish goals, with the patient taking an active
part.
• Make the atmosphere conducive to
communication, remaining sensitive to patient’s
reactions and needs and responding to them in an
appropriate manner; treat the patient as an adult.
• Provide strong emotional support and understanding
to allay anxiety; avoid completing patient’s
sentences.
• Be consistent in schedule, routines, and repetitions. A
written schedule, checklists, and audiotapes may
help with memory and concentration; a
communication board may be used.
• Maintain patient’s attention when talking with the
patient, speak slowly, and give one instruction at a
time; allow the patient time to process.
• Talk to aphasic patients when providing care activities
to provide social contact.
Maintaining Skin Integrity
• Frequently assess skin for signs of breakdown, with
emphasis on bony areas and dependent body parts.
• Employ pressure relieving devices; continue regular turning
and positioning (every 2 hours minimally);
minimize shear and friction when positioning.
• Keep skin clean and dry, gently massage the healthy dry
skin and maintain adequate nutrition.
Improving Family Coping
• Provide counseling and support to the family.
• Involve others in patient’s care; teach stress
management techniques and maintenance of
personal health for family coping.
• Give family information about the expected outcome of the
stroke, and counsel them to avoid doing things for
the patient that he or she can do.
• Develop attainable goals for the patient at home by
involving the total health care team, patient, and
family.
• Encourage everyone to approach the patient with a
supportive and optimistic attitude, focusing on
abilities that remain; explain to the family that
emotional lability usually improves with time.
Helping the Patient Cope with Sexual Dysfunction
• Perform indepth assessment to determine sexual
history before and after the stroke.
• Interventions for patient and partner focus on
providing relevant information, education,
reassurance, adjustment
• of medications, counseling regarding coping skills,
suggestions for alternative sexual positions, and a
means of sexual expression and satisfaction.
Teaching points
• Teach patient to resume as much self care as possible;
provide assistive devices as indicated.
• Have occupational therapist make a home assessment
and recommendations to help the patient become
more independent.
• Coordinate care provided by numerous health care
professionals; help family plan aspects of care.
• Advise family that patient may tire easily, become irritable
and upset by small events, and show less interest
in daily events.
• Make a referral for home speech therapy. Encourage
family involvement. Provide family with practical
instructions to help patient between speech therapy
sessions.
• Discuss patient’s depression with the physician for
possible antidepressant therapy.
• Encourage patient to attend community-based stroke
clubs to give a feeling of belonging and fellowship to
others.
• Encourage patient to continue with hobbies,
recreational and leisure interests, and contact with
friends to prevent social isolation.
• Encourage family to support patient and give
positive reinforcement.
• Remind spouse and family to attend to personal health and
wellbeing.
Evaluation
Expected patient outcomes may include the following:
• Improved mobility.
• Absence of shoulder pain.
• Self-care achieved.
• Relief of sensory and perceptual deprivation.
• Prevention of aspiration.
• Continence of bowel and bladder.
• Improved thought processes.
• Achieved a form of communication.
• Maintained skin integrity.
• Restored family functioning.
• Improved sexual function.
• Absence of complications.
Discharge and Home Care Guidelines
Patient and family education is a fundamental component of
rehabilitation.
• Consult an occupational therapist. An occupational
therapist may be helpful in assessing the home
environment and recommending modifications to
help the patient become more independent.
• Physical therapy. A program of physical therapy may be
beneficial, whether it takes place in the home or in
 an outpatient program.
• Antidepressant therapy. Depression is a common and
serious problem in the patient who has had a stroke.
• Support groups. Community-based stroke support groups
may allow the patient and the family to learn from
others with similar problems and to share their
experiences.
• Assess caregivers. Nurses should assess caregivers for
signs of depression, as depression is also common
among caregivers of stroke survivors.

Documentation GuidelinesThe focus of documentation should

involve:

 Individual findings including level of function and

ability to participate in specific or desired

activities.

 Needed resources and adaptive devices.

 Results of laboratory tests, diagnostic studies,

and mental status or cognitive evaluation.

 SO/family support and participation.

 Plan of care and those involved in planning.

 Teaching plan.

 Response to interventions, teaching, and actions

performed.

 Attainment or progress toward desired outcomes.

 Modifications to plan of care.