This NCLEX review will discuss stroke (CVA), also called cerebrovascular accident.
As a nursing student, you must be familiar with this neuro disease along with how to provide care to a patient experiencing this condition.
Don’t forget to take the stroke quiz.
You will learn the following from this NCLEX review:
- Definition of stroke
- Signs and Symptoms
- Nursing Interventions
Stroke NCLEX Lecture
Cerebrovascular Accident (CVA) Stroke NCLEX Review
What is a stroke? It is a condition that develops when blood rich in oxygen can NOT reach brain cells (due to either a blockage or bleeding). This causes the brain cells to die.
Type of Strokes
–Ischemic (most common): due to a blood clot within a blood vessel or stenosis of an artery that feeds the brain tissue. This limits the blood that can reach the brain cells. This type of stroke can happen due to:
- Embolism: where a clot has left a part of the body (example the heart: this can happen due to a heart valve problem or atrial fibrillation). The clot develops in the heart and travels to the brain, which stops blood flow.
- Thrombosis: Clot forms within the artery wall within the neck or brain. This is seen in patients with hyperlipidemia or atherosclerosis
–Hemorrhagic: this occurs when there is bleeding in the brain due to a break in a blood vessel. Therefore, no blood will perfuse to the brain cells. In addition, this can lead to excessive swelling from the leakage of blood in the brain. Causes of this type of stroke includes: rupture of a brain aneurysm, uncontrolled hypertension, or aging blood vessels (older age).
-TIA (transient ischemic attack) also called a mini-stroke. This is where signs and symptoms of a stroke occurs but last only a few minutes to hours and resolves. It is a warning signs an impending stroke may occur. If this occurs the patient needs to seek treatment.
To understand strokes, let’s talk about the BRAIN”S function and anatomy!
Blood supply to the brain? The blood supply to the brain comes for the carotid and vertebral arteries, which then branch into other arteries that feed the brain. If any of these areas of the artery become blocked or burst open it decreases the blood supply to the brain cells. Brain cells are very sensitive and within 5 minutes these cells start to become damaged, and the damage can become IRREVERSIBLE.
The cells in the brain control how our body functions and depending on where the cells are located they are responsible for specific functions. Therefore, it is super important to be familiar with the function of each lobe and the difference between the right and left hemispheres of the brain.
Let’s look at the lobes of the brain and their functions:
Now strokes tend to affect ONE side of the body. So be familiar with the functions of the right side vs the left side:
The right side of the brain is the CREATIVE side while the left side is the LOGICAL side.
Right Side’s Functions:
- Attention span
- Showing emotions
- Ability to solve every day problems by making decisions/plans
- Reasoning (understanding jokes…reading in between the lines)
- Making judgement calls
- Music/art awareness
- Control the left side of the body
If a patient has right side brain damage, what do you think the patient will experience?
- Left side weakness: Hemiplegia
- Impairment in creativity: arts and music
- Confused on date, time, place
- Cannot recognize faces or the person’s name
- Loss of depth perception
- Trouble staying on topic when talking
- Can’t see things on left side: LEFT SIDE NEGLECT (unilateral neglect)
- (Ignores left side of body)
- Trouble with maintaining proper grooming
- Emotionally: not going to think things through….very impulsive
- Poor ability to make decisions and assessing spatial qualities….shapes
- Denial about limitations
- Not able to read nonverbal language or understand the hidden meaning of things
- Very short attention span
Left Side’s Functions:
- Math skills
- Analyzing info
If a patient has left side brain damage, what do you think the patient will experience?:
- Right side Hemiplegia
- Aphasia (trouble formulating words and comprehending them)
- Aware of their limits…experiences depression, anger, frustration
- Trouble understanding written text
- Can’t write (agraphia)
- Impaired math skills
- Memory intact
- Issues with seeing on the right side
So, as you can see when there is brain cell death in a certain area it will cause specific signs and symptoms. The amount of brain damage depends on how long it took for blood to return to the affected brain cells.
Risk Factors for stroke
-be familiar the risk factors and which ones are modifiable (things a person can change) vs. unmodifiable (things a person CAN’T change
Rhythm changes (a-fib/flutter)
Kin (family history)
Elevated blood sugar (diabetes mellitus)
Signs and Symptoms of a Stroke
Happens suddenly: need to act fast as the nurse to help save brain cells
- call rapid response so patient can receive appropriate treatment or call 911 (if outside of the hospital in the United States)
- NOTE the exact time the signs and symptoms appears…important for stroke treatment
Face: drooping or uneven smile
Arm: numbness, weakness, drift (raise both arms)
Speech: can’t repeat a phrase, slurred speech
Time: to call rapid response and note the time
**National Stroke Association recommends using the mnemonic F.A.S.T. to help assess for signs and symptoms quickly.
The patient can also have the following as well:
Bowel and bladder incontinence or retention
Important Stroke Terms:
remember these terms because exams love to ask you about them.
Aphasia: unable to speak (comprehending or producing it)
- Receptive Aphasia: unable to comprehend speech (Wernicke’s area)
- Expressive Aphasia: comprehends speech but can’t respond back with the correct words, if at all (Broca’s area)
- Mixed Aphasia: combination of the two types of aphasia.
- Global Aphasia: complete inability to understand speech or produce it.
Dysarthria: unable to hear speech clearly due to weak muscles (hard to understand the patient’s speech….it may be slurred)
Apraxia: can’t perform voluntarily movements (winking/moving arm to scratch an itch) even though muscles function is normal.
Agraphia: loss the ability to write
Alexia: loss the ability to read…doesn’t understand or recognize the words
Agnosia: doesn’t understand sensations or recognize known objects or people
Dysphagia: issues swallowing (weak muscles)
Hemianopia: limited vision in half of the visual field
Hemiparesis: weakness on one side of the body
- CT scan
Medication for Ischemic Strokes:
tPA (tissue plasminogen activator): for ischemia strokes ONLY not hemorrhagic!
How does it work? It dissolves the clot within the blood vessel by activating the protein that causes fibrinolysis.
REMEMBER: It must be given within 3 hours from the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF strict criteria is met.
To receive tPA the patient should have a:
- CT of head that is NEGATIVE for hemorrhage
- labs within normal limits (glucose, INR, platelets)
- BP needs to be controlled SBP <185 and DBP <110
- glucose controlled (increases rise of hemorrhage)
- not receiving heparin or other types of anticoagulants
Nurse’s Role: monitor for BLEEDING, neuro checks around the clock, blood pressure medication if needed for hypertension, vital signs, labs, glucose, preventing injury (bedrest), avoid unnecessary venipunctures, avoid IM injections, will go to ICU to be monitored
Nursing Interventions for Stroke
Monitor vital signs and neuro status:
- especially blood pressure (notify MD is hypertensive)
- airway (difficulty swallowing….at risk for aspiration HOB 30’ with suction at bedside)
- turn every 2 hours with proper alignment and watch for increased ICP (intracranial pressure) during acute stage
- headache, nausea and vomiting, increased blood pressure and decreased HR and decreased RR, decrease in mental status from baseline, pupils don’t respond
Assess with NIH Stroke Scale
- Score ranges from 0 to 42
- 0: no stroke symptoms
- 21-42: severe symptoms
- 11 assessments area are scored
- Level of consciousness, gaze, visual, facial palsy, motor function of extremities, sensory, best language, dysarthria, extinction/inattention
Check cranial nerves: pupil responses, motor function, gag reflex
Monitor bowel and bladder function (may be incontinent or retaining)
Passive ROM with extremities and preventing contractions
Interventions for aphasia
Communication is key (just because the patient can’t communicate doesn’t mean they have a mental deficit). They just can’t get it out and it takes them time. The nurse’s role is to help bridge the gap and make it less frustrating for the patient.
- Receptive Aphasia: unable to comprehend speech (Wernicke’s area)
-use short phrases
-use gestures or point while giving a command
-be patient and not expect a fast response
- Expressive Aphasia: comprehends speech but can’t respond back with speech (Broca’s area)
-be patient and let them speak
-be direct and simple when asking questions…..give options
-communication via a dry erase board
Stroke care is a multidisciplinary approach: need to involve family as much as possible because they will be providing care when patient is discharged. In addition, it is important to be always be communicating with the speech language pathologist, physical therapy, occupational therapy etc.
Diet: evaluated by speech language pathologist
- may need thicken liquids and mechanical soft foods
- assist with eating and monitor for pouching of food in cheek (on the affected side). This increases risk of aspiration.
- Have patient tuck in chin to their chest while swallowing.
Watch for neglect syndrome: (tends to happen in right side brain damage). The patient is at risk for injury because patient ignores the affected side.
- Remind patient to use and touch both sides of body daily (must make a conscious effort to do so).
- Educate the patient about the importance of turning head side-to-side to prevent injuring the affected side.
Hemianopsia interventions: turning head side-to-side to see all visual fields to prevent injury
- How Is a Stroke Diagnosed? – NHLBI, NIH. Nhlbi.nih.gov. Retrieved 5 December 2017, from https://www.nhlbi.nih.gov/health/health-topics/topics/stroke/diagnosis
- NIH Stroke Scale Booklet. Retrieved from https://stroke.nih.gov/documents/NIH_Stroke_Scale_Booklet.pdf
- Stroke Information | cdc.gov. Cdc.gov. Retrieved 4 December 2017, from https://www.cdc.gov/stroke/