CEREBRO VASCULAR ACCIDENT

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.

EPIDIOMOLOGY:
 Third most common cause of death after cancer and ischaemic heart
disease
 Most common cause of severe physical disability
 Prevalence of stroke in India is about 1.54 per 1000
 Death rate is about 0.6 per 1000
 Incidence and prevalence of stroke is on the rise due to increasing
adoption of unhealthy lifestyle & an increasing life expectancy

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.

CAUSES:

 Brain's blood vessels become narrowed or blocked, causing severely

reduced blood flow (ischemia)
 Fatty deposits that build up in blood vessels or by blood clots or other
debris that travel through your bloodstream and lodge in the blood
vessels in your brain.
 Uncontrolled high blood pressure
 Overtreatment with blood thinners (anticoagulants)
 Bulges at weak spots in your blood vessel walls (aneurysms)
  Trauma (such as a Road Traffic accident)
 Protein deposits in blood vessel walls that lead to weakness in the
vessel wall (cerebral amyloid angiopathy)
 Ischemic stroke leading to hemorrhage
 A less common cause of bleeding in the brain is the rupture of an
abnormal tangle of thin-walled blood vessels.

RISK FACTORS:

The following are the non-modifiable and modifiable risk factors of

Cerebrovascular accident:
NON-MODIFIABLE:
 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

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.

Recognizing Stroke: BEFAST

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.

Prevention of stroke:

 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.

A stroke can sometimes cause temporary or permanent disabilities,

depending on how long the brain lacks blood flow and which part was
affected. Complications may include:

 Paralysis or loss of muscle movement. You may become

paralyzed on one side of your body, or lose control of certain muscles,
such as those on one side of your face or one arm.
 Difficulty talking or swallowing. A stroke might affect control of
the muscles in your mouth and throat, making it difficult for you to
talk clearly, swallow or eat. You also may have difficulty with
language, including speaking or understanding speech, reading, or
writing.
 Memory loss or thinking difficulties. Many people who have had
strokes experience some memory loss. Others may have difficulty
thinking, reasoning, making judgments and understanding concepts.
 Emotional problems. People who have had strokes may have more
difficulty controlling their emotions, or they may develop depression.
 Pain. Pain, numbness or other unusual sensations may occur in the
parts of the body affected by stroke. For example, if a stroke causes
you to lose feeling in your left arm, you may develop an
uncomfortable tingling sensation in that arm.
 Changes in behavior and self-care ability. People who have had
strokes may become more withdrawn. They may need help with
grooming and daily chores.

Assessment and Diagnostic Findings:

Any patient with neurologic deficits need a careful history and complete
physical and neurologic examination.

History collection: Ask for onset and progression of neurological

symptoms – completed stroke or stroke in evolution, History of previous
TIAs, History of hypertension & diabetes mellitus, History of heart
conditions like arrhythmias, RHD & prosthetic valves, History of seizures &
migraine, History of anticoagulant therapy, History of oral contraceptive
use, History of any hypercoagulable disorders like sickle cell anemia &
polycythemia vera, Substance abuse: cocaine, amphetamines.
Physical Examination & Neurological Examination: The neurological
examination is highly variable and depends on the location of the vascular
lesion. Skin: look for xanthelasma, rashes (arteritis, splinter
haemorrhages, livedo reticularis), limb ischemia (DVT) Eyes: look for
diabetic changes,retinal emboli,hypertensive changes,arcus senilis (refer to
ophthalmologist), CVS: hyper/hypotension, abnormal rhythm (atrial
fibrillation), murmurs (valvular anomaly), raised JVP (heart failure),
peripheral pulses and bruits (generalised arteriopathy) Respiratory
system: pulmonary edema, infection Abdomen: urinary retention
Locomotor system: injuries sustained during collapse with stroke, co-
morbities which influence functional abilities.

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).

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.

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.

Nursing Care Planning & Goals:

The major nursing care planning 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 Guidelines
The 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.