A stroke occurs when the blood supply to part of the brain is interrupted, either because of a clot or internal bleeding. The cells in the brain begin to die and brain damage begins immediately which causes impairment/disability.
In this article, we’re going to give you the full explanation of the nursing care plan for CVA.
A Cerebral Vascular Accident (CVA) is also known as a ‘brain attack’ which disrupts the supply of blood to the brain, resulting in damage or death to brain cells.
It is an emergency condition requiring immediate treatment.
Nursing diagnoses for CVA are as follows:
- Impaired physical mobility related to muscle weakness
- Risk for aspiration related to changes in swallowing or loss of protective airway reflexes
- Impaired skin integrity related to immobility, sensory deficits, and pressure ulcer
- Chronic confusion related to increased ICP and CVA damage
- Disturbed thought processes related to brain injury
- Anxiety/Fear related to the effects of a stroke on the individual
- Impaired verbal communication related to dysphasia (language disturbance) and dysarthria (speech impairment)
- Risk for other-directed violence related to loss of control over own body parts, emotions, behaviors, etc.
- Risk for self-directed violence related to lack of impulse control due to brain damage
- Impaired urinary elimination related to immobility and urinary retention
- Risk for deficient fluid volume related to diuretics, high output congestive heart failure, vomiting, diarrhea, etc.
- Risk for electrolyte imbalance related to diuretics, nausea/vomiting, diarrhea, etc.
The CVA nursing care plan discusses the assessment, planning, and interventions for non-traumatic, sudden onset of a loss of function due to a cerebral vascular accident.
This is a brief assessment with four main sections dedicated to the following areas:
- nursing diagnoses
- outcomes, and measurable parameters
- expected patient response to the treatment outlined in the plan
- rational/rationale for the nursing care plan
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Table of Contents
Nursing care plan for CVA impaired physical mobility
Nursing care plan for CVA impaired physical mobility is all about identifying the problem, identifying the cause of the problem, and providing support to the patient.
The nursing care plan for CVA impaired physical mobility is aimed at preventing further impairment or disability resulting from reduced mobility.
This care plan is applicable for individuals with CVA who are no longer able to walk due to muscle weakness caused by stroke-related brain damage.
Patient history: CVA, muscle weakness
Physical assessment: Change in the walking pattern when walking with assistance, inability to climb steps or negotiate curbs without help, etc.
The rationale for the care plan: The patient is at risk of further decline in physical health because of limited mobility caused by reduced strength in the lower extremities. This could lead to further decline in functional status and possible immobility as a result.
Implementing the nursing care plan for CVA
1. Provide physical support to sit up in bed, stand and walk with assistance as much as possible. Assess whether the patient is able to do so without any help or if additional physical aid is required.
2. Assess patient’s ability to get up from sitting position and get into wheelchair or bed unassisted
3. Assess the current level of nutritional intake and plan for an increased nutritional intake in order to maintain optimum weight and constitution while preventing malnutrition
4. Assist the patient with a range of motion exercises as often as possible. Teach family members or other caregivers to assist and supervise patients in performing a range of motion exercises.
See also: Can Nurses Treat Family Members?
5. Assist patient with performing activities of daily living including feeding, grooming, toileting, hygiene, etc. Teach family members or other caregivers to assist with ADLs if necessary. Monitor the ability of the patient to do ADL independently or without any help.
6. Educate patients and families or caregivers in skincare to reduce the risk of skin breakdown. Recommend use of protective cushioning, positioning, and support surfaces when performing a range of motion exercises.
7. Teach patient/family about safety awareness for the prevention of injury, including at home, in the community, etc. Emphasize the importance of safety measures for preventing injuries.
8. Monitor coordination of patient’s arms and legs, wrist and hand functions, etc. Notify physician to adjust medications if necessary if coordination is not improving as expected.
9. Assist with ambulation as appropriate. If the patient is able to walk on his own, provide a wheelchair as needed when the patient wants to get up and walk.
10. Provide education on how to perform a range of motion exercises correctly. Teach family members or other caregivers how to do a range of motion exercises if necessary. Provide guidelines for measuring a commensurate level of activity.
11. Assess the ability of the patient to use a wheelchair independently according to the guidelines.
12. Provide education on safety measures to prevent injury. Emphasize the importance of wearing a helmet for proper protection when cycling, skiing, etc. Advise patient on precautions required for safe ambulation at all times irrespective of environment.
13. Encourage participation in the therapeutic exercise as appropriate according to the guidelines. Monitor patient’s progress in terms of improvement in the level of endurance and strength.
14. Assess appetite and address nutritional needs accordingly. Monitor patient’s weight on a regular basis to monitor progress towards desired outcomes.
15. Educate family or caregiver about important guidelines related to therapeutic exercises for patients with CVA impaired physical mobility. Emphasize the importance of performing a range of motion exercises as per guidelines on a regular basis.
16. Monitor patient’s response to therapeutic exercise on a regular basis. Monitor progress towards desired outcomes and modify treatment plan as required.
17. Assess swelling in lower extremities as appropriate according to the guidelines as CVA patients are at higher risk of developing edema.
18. Provide education on the importance of performing a range of motion exercises with knee and ankle joints to improve muscle strength in leg muscles.
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19. Monitor patient for return of normal sensation. If no response after 6 weeks, advise the physician on the same.
20. Teach family members or caregivers about how to make necessary arrangements at home to ensure that patient is able to do ADLs independently without any help. Provide necessary equipment to enhance independence in activities of daily living.
For a CVA patient who has impaired physical mobility, the following range of motion exercises are important:
- Sitting from a lying position and lying down from a sitting position
- Moving the limbs in all possible directions
- Moving from a sitting to a standing position without help
- Stretching and strengthening exercises for the arms and legs
See also: Nursing Care Plan for DVT
Example of nursing care plan for CVA
To give you a clear picture of the nursing care plan for CVA, let us discuss various examples of nursing care plans.
Example 1
An older adult had a stroke and the doctors did a craniotomy to help him recover.
The patient is now being moved from the ICU to a transitional care unit. He has left hemiparesis on his right side, but he can get around with the use of his walker or cane.
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He can communicate effectively and his cognition is intact. There are no other complications that need to be addressed.
Category 1 problem for a patient:
Patient’s left hemiparesis on the right side – Activity plan to improve the ability to perform ADLs independently without any help. Include safety measures to prevent injury.
Patient’s cognitive ability is intact – Teach family members or caregivers about how to make necessary arrangements at home to ensure that patient is able to do ADLs independently without any help.
Provide necessary equipment to enhance independence in activities of daily living.
There are no complications that need to be addressed – Patients should be educated about nutritional needs according to body size and other factors such as physical activity.
A physical therapist should assess the patient’s ability to use a wheelchair independently according to the guidelines.
The patient should be taught about safety measures to prevent injury. The problem is resolved.
Category 2 problem for a patient:
The patient can communicate effectively and his cognition is intact – It is important to monitor the patient’s response towards therapeutic exercise on a regular basis.
The patient’s progress has to be monitored and the treatment plan has to be modified as required if deviations are noted in any aspect of an activity (i.e. ROM exercise).
The problem is resolved.
Example 2
An obese male who had been diagnosed with heart disease 10 years ago is being admitted to the hospital with complaints of chest discomfort.
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He has a history of hypertension and is on medications for high cholesterol. The patient also has type 2 diabetes mellitus.
See also:
You expect to do an angiogram on him, but you learn that he stopped taking his blood pressure meds because he was “feeling better”.
Category 1 problem for a patient:
Patient’s left hemiparesis on the right side – Activity plan to improve the ability to perform ADLs independently without any help. Include safety measures to prevent injury. The problem is resolved.
Category 2 problem for a patient:
The patient has hypertension, high cholesterol, and type 2 diabetes mellitus – Monitor swelling in lower extremities as appropriate according to the guidelines as CVA patients are at higher risk of developing edema.
The patient stopped taking his blood pressure meds – It is important to monitor the patient’s response towards therapeutic exercise on a regular basis.
The patient’s progress has to be monitored and the treatment plan has to be modified as required if deviations are noted in any aspect of an activity (i.e. ROM exercise).
The problem is resolved.
Example 3
A patient recently diagnosed with a seizure disorder is being admitted to the hospital for treatment. You have been assigned to care for this patient and you need some information about his condition.
Category 1 problem for a patient:
The patient has a seizure disorder – Teach family members or caregivers about how to make necessary arrangements at home to ensure that patient is safe.
Monitor patient’s response towards prescribed medication on a regular basis. The problem is resolved.
Category 2 problem for a patient:
The patient has newly diagnosed seizure disorder – Ask colleagues about the patient’s condition and try to find out information regarding the patient’s condition (i.e. Electroencephalography and imaging studies).
The patient was recently diagnosed with a seizure disorder – Monitor the patient’s response towards prescribed medication on a regular basis. The problem is resolved.
Category 3 problem for a patient:
The patient has a newly diagnosed seizure disorder and he is not aware of this – Educate the patient about his condition. Monitor compliance in taking prescribed medication on a regular basis.
The problem is resolved.
Example 4
A patient with CVA complains of right-sided shoulder pain after discharge from the hospital. You ask him if he had any injury or accident, which might have led to this issue.
He tells you that while he was at home, he fell down the stairs.
Category 1 problem for a patient:
The patient complains of right-sided shoulder pain after discharge from the hospital – Explain to the patient how to prevent injuries while performing ADLs independently.
Educate about safety measures. The problem is resolved.
Category 2 problem for a patient:
Patient falls down the stairs – Teach proper techniques to perform ADLs independently. Ensure patient safety while performing ADLs.
Monitor patient’s response towards prescribed medication on a regular basis.
The problem is resolved.
Category 3 problem for a patient:
Patient fell down the stairs and complains of right-sided shoulder pain after discharge from the hospital – Ask colleagues about the patient’s condition and try to find out information regarding the patient’s condition (i.e. Imaging studies).
Patient falls down the stairs – Educate patient about his condition. Monitor compliance in taking prescribed medication on a regular basis.
The problem is resolved.
Conclusion: Nursing Care Plan CVA
CVA is a leading cause of disability worldwide and has a significant impact on those who have had the disease as well as their families.
It is important to know about various factors that increase the risk for CVA, diagnostic procedures, and treatment options.
These factors can help reduce morbidity and mortality associated with CVA.
Developing a nursing care plan according to the guidelines, goals, and objectives can be set to help accomplish therapeutic goals.
This will ensure that patient is safe as well as his caregivers.
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