Acute Ischemic Stroke Nursing Diagnosis: Comprehensive Guide

A cerebrovascular accident (CVA), commonly known as a stroke, is a critical medical condition characterized by the disruption of blood flow to the brain. Among the different types of stroke, ischemic stroke, caused by a blockage in the arteries supplying blood to the brain, is the most prevalent. This article delves into the critical aspects of acute ischemic stroke, focusing specifically on the nursing diagnosis and essential nursing care strategies.

Understanding Ischemic Stroke

Strokes are broadly categorized into two primary types: ischemic and hemorrhagic.

Ischemic Strokes: These occur when the blood supply to a part of the brain is reduced or completely blocked. This deprivation of oxygen and nutrients leads to rapid brain tissue damage, often within minutes. Blockages are typically caused by fatty deposits (plaque), blood clots (thrombi or emboli), or other particles that travel through the bloodstream to the brain’s arteries. Ischemic strokes account for the majority of all stroke cases.

Hemorrhagic Strokes: These strokes result from the rupture of a blood vessel in the brain, causing bleeding into the brain tissue. The accumulating blood increases pressure within the skull, damaging brain cells. Hemorrhagic strokes can be caused by aneurysms, uncontrolled hypertension, head trauma, anticoagulant overuse, cerebral amyloid angiopathy, or even as a secondary complication of an ischemic stroke.

Transient Ischemic Attacks (TIAs): Often referred to as “mini-strokes,” TIAs are temporary episodes of reduced blood flow to the brain. Symptoms are similar to a full stroke but resolve within 24 hours, usually within an hour, without causing permanent brain damage. However, TIAs are significant warning signs, indicating an increased risk of future, more severe strokes. Recognizing and managing risk factors after a TIA is crucial.

The Nursing Process in Acute Ischemic Stroke

Patients experiencing an acute ischemic stroke present with a wide range of disabilities, depending on the stroke’s severity, the time elapsed before treatment initiation, and any pre-existing health conditions. Initial care is typically provided in intensive care units (ICU) or step-down units where continuous monitoring is available. Nurses specializing in stroke care often hold NIH Stroke Scale (NIHSS) certification, reflecting the necessity for specialized skills in monitoring and responding to the rapidly changing and often subtle neurological symptoms of stroke. Prompt recognition and intervention by nurses are vital to prevent neurological deterioration.

Severe ischemic strokes can result in significant long-term disabilities, requiring comprehensive and often total care for basic needs such as feeding, bathing, and mobility. The long-term effects can lead to depression and emotional distress for both patients and their families. Nurses play a critical role in providing compassionate care, ensuring patient safety and dignity, and addressing both the physical and psychosocial needs of stroke survivors and their families.

Nursing Assessment for Acute Ischemic Stroke

The cornerstone of effective nursing care is a thorough nursing assessment. This process involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic – to understand the patient’s condition. In the context of acute ischemic stroke, assessment is rapid and focused to facilitate timely interventions.

Review of Health History

1. Elicit Presenting Symptoms: Promptly inquire about any sudden onset symptoms, which are hallmark indicators of acute stroke:

• Motor Weakness/Paralysis: Hemiparesis (weakness) or hemiplegia (paralysis) affecting the face, arm, and leg on one side of the body.
• Sensory Deficits: Numbness or tingling sensations (paresthesias) in the extremities.
• Swallowing Difficulties: Dysphagia, indicating potential risk for aspiration.
• Visual Disturbances: Sudden loss of vision in one or both eyes, double vision, or visual field deficits (e.g., hemianopia – loss of half of the visual field).
• Speech Impairment:
  • Expressive Aphasia (Broca’s aphasia): Difficulty expressing thoughts verbally; understanding is typically intact.
  • Receptive Aphasia (Wernicke’s aphasia): Difficulty understanding spoken language; speech may be fluent but nonsensical.
  • Dysarthria: Difficulty forming words due to muscle weakness affecting speech.
• Balance and Coordination Issues: Ataxia (unsteady gait), dizziness, vertigo, or loss of balance.
• Altered Mental Status: Confusion, disorientation, decreased level of consciousness, or sudden behavioral changes.

2. Determine Time of Symptom Onset: Accurate determination of symptom onset is critical. Establish the exact time symptoms first appeared or the last time the patient was known to be at their baseline neurological function. This “last known well” time is crucial for determining eligibility for thrombolytic therapy (tPA) and other time-sensitive interventions.

3. Identify Stroke Risk Factors: Assess for modifiable and non-modifiable risk factors that increase stroke susceptibility:

• Age: Risk increases significantly with age, particularly over 55 years.
• Ethnicity: African Americans and Hispanics have a higher stroke incidence compared to Caucasians.
• Gender: Males have a slightly higher risk of stroke overall, although stroke is more common in older women.
• Prior Stroke or TIA: History of stroke or TIA significantly elevates future stroke risk.

4. Review Past Medical History: Explore pre-existing medical conditions that are strongly linked to ischemic stroke:

• Hypertension: Uncontrolled high blood pressure is a major risk factor.
• Hyperlipidemia: High cholesterol levels contribute to atherosclerosis.
• Diabetes Mellitus: Diabetes accelerates atherosclerosis and increases stroke risk.
• Obesity: Associated with hypertension, diabetes, and hyperlipidemia.
• Obstructive Sleep Apnea: Linked to hypertension and cardiovascular disease.
• Heart Disease: Coronary artery disease, heart failure, and valvular heart disease increase stroke risk.
• Atrial Fibrillation: A common arrhythmia that significantly increases the risk of embolic stroke.
• COVID-19 Infection: Recent studies have shown an increased risk of stroke following COVID-19 infection.

5. Family History of Stroke: Inquire about family history of stroke, especially in first-degree relatives and at younger ages (before 65 years). Genetic conditions like CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) can predispose to stroke.

6. Medication History: Obtain a detailed medication list, including over-the-counter drugs and supplements:

• Hormone Therapy: Estrogen-containing birth control pills or hormone replacement therapy can increase stroke risk.
• Antihypertensives: Non-adherence to blood pressure medications contributes to uncontrolled hypertension.
• Anticoagulants/Antiplatelets: Aspirin, warfarin, heparin, and novel oral anticoagulants may indicate pre-existing conditions that increase stroke risk (e.g., atrial fibrillation, clotting disorders).

7. Substance Use History: Assess for the use of illicit substances:

• Stimulants: Amphetamines, cocaine, and other stimulants are associated with increased stroke risk due to their effects on blood pressure and blood vessels.

8. Lifestyle Factors: Evaluate lifestyle habits that influence stroke risk:

• Diet: High intake of cholesterol, saturated fats, and trans fats promotes atherosclerosis.
• Physical Inactivity: Lack of regular exercise increases cardiovascular risk.
• Excessive Alcohol Consumption: Heavy alcohol use can contribute to hypertension and arrhythmias.
• Smoking: Smoking damages blood vessels and increases the risk of blood clots.

Physical Assessment

1. Rapid Stroke Recognition (F.A.S.T.): Utilize the F.A.S.T. acronym for immediate stroke symptom identification:

• F – Face: Check for facial drooping or asymmetry. Ask the person to smile.
• A – Arms: Assess for arm weakness. Ask the person to raise both arms. Observe if one arm drifts downward.
• S – Speech: Evaluate speech for slurring or difficulty. Ask the person to repeat a simple sentence.
• T – Time: Note the time of symptom onset and call emergency services immediately (911 in the US). “Time is brain” underscores the urgency of stroke care.

2. ABCs Assessment: Immediately assess Airway, Breathing, and Circulation. Stroke patients are at risk for airway compromise due to decreased level of consciousness, aspiration, and respiratory depression related to increased intracranial pressure.

3. Neurological Examination (NIHSS): Perform a comprehensive neurological assessment using the National Institutes of Health Stroke Scale (NIHSS). The NIHSS is a standardized tool to quantify neurological deficits and stroke severity. It evaluates:

• Level of Consciousness (LOC): Alertness, orientation, responsiveness.
• Eye Movements: Horizontal gaze, visual fields.
• Facial Movement: Facial palsy or weakness.
• Motor Function (Arms and Legs): Strength and movement in both arms and legs.
• Limb Ataxia: Coordination and balance in the limbs.
• Sensory Function: Sensation to touch or pinprick.
• Language: Aphasia – expressive and receptive language abilities.
• Speech (Dysarthria): Clarity of speech.
• Neglect/Inattention: Awareness of stimuli in both visual fields.

4. Vital Signs Monitoring: Closely monitor vital signs, especially blood pressure. Hypertension is common in acute stroke. However, rapid or aggressive blood pressure lowering can be detrimental in the acute phase of ischemic stroke as it can reduce cerebral perfusion.

Diagnostic Procedures

1. Blood Glucose Check: Perform a point-of-care blood glucose test immediately to rule out hypoglycemia, which can mimic stroke symptoms.

2. Brain Imaging (STAT): Prepare the patient for emergent brain imaging.

• Non-contrast Head CT Scan: The primary initial imaging modality to rapidly differentiate between ischemic and hemorrhagic stroke. It also helps rule out other conditions mimicking stroke.
• CT Angiography (CTA) and CT Perfusion (CTP) Scanning: May be used to visualize blood vessels, identify large vessel occlusions (LVO), and assess the extent of brain tissue at risk (penumbra) versus irreversibly damaged core. CTP can help guide patient selection for advanced interventions like thrombectomy.
• Magnetic Resonance Imaging (MRI): Provides more detailed images of brain tissue damage, particularly diffusion-weighted imaging (DWI) which is highly sensitive to early ischemic changes. MRI may be performed after initial CT for more comprehensive assessment, if time permits and contraindications are absent.
• Carotid Duplex Ultrasound: To assess for carotid artery stenosis, a common source of embolic ischemic stroke.
• Digital Subtraction Angiography (DSA): Invasive angiography, less commonly used acutely but may be considered for detailed vascular assessment in specific cases.

3. Laboratory Tests: Obtain blood samples for various lab tests to identify underlying causes and guide treatment:

• Complete Blood Count (CBC): To assess for polycythemia (increased red blood cell count, increasing blood viscosity) or thrombocytopenia (low platelets, relevant for anticoagulation decisions).
• Cardiac Biomarkers (Troponin, CK-MB): To evaluate for underlying cardiac disease, as cardiac conditions are frequently associated with stroke.
• Toxicology Screen: To rule out drug intoxication as a cause of stroke-like symptoms, particularly in younger patients.
• Fasting Lipid Profile: To assess cholesterol and triglyceride levels, important for long-term risk management.
• Coagulation Studies (PT/INR, aPTT): Baseline coagulation status before administering antiplatelet or anticoagulation therapies.

4. Pregnancy Test (for women of childbearing age): Perform a urine pregnancy test for women of reproductive age before considering fibrinolytic therapy, as the safety of tPA in pregnancy is not fully established.

5. Electrocardiogram (ECG): Obtain a 12-lead ECG to assess for cardiac arrhythmias, particularly atrial fibrillation, a major cause of cardioembolic stroke. Identifying atrial fibrillation is crucial for initiating anticoagulation to prevent secondary strokes.

Acute Ischemic Stroke Nursing Diagnosis: Prioritization

Based on the assessment findings, several nursing diagnoses may be relevant in acute ischemic stroke. Prioritized nursing diagnoses in the acute phase often include:

• Ineffective Cerebral Tissue Perfusion related to interruption of arterial blood flow (thrombus/embolism) as evidenced by altered level of consciousness, neurological deficits (weakness, speech impairment, visual disturbances), and abnormal vital signs. (This is the primary focus for acute ischemic stroke)
• Risk for Aspiration related to impaired swallowing and decreased level of consciousness.
• Impaired Physical Mobility related to hemiparesis/hemiplegia and impaired coordination.
• Impaired Verbal Communication related to aphasia and dysarthria.
• Risk for Injury related to weakness, balance deficits, perceptual deficits, and altered cognition.
• Self-Care Deficit related to motor and sensory deficits.
• Unilateral Neglect related to neurological deficits.

This article will further elaborate on Ineffective Cerebral Tissue Perfusion as the primary nursing diagnosis for acute ischemic stroke, along with other relevant diagnoses and corresponding nursing interventions.

Nursing Interventions for Acute Ischemic Stroke

Nursing interventions in acute ischemic stroke are aimed at restoring brain perfusion, minimizing secondary brain injury, and preventing complications.

Restoring Brain Perfusion (Critical in Ischemic Stroke)

1. Rapid Initial Evaluation and Diagnostic Imaging: Upon arrival in the emergency department, patients with suspected stroke should undergo immediate evaluation and STAT non-contrast head CT within 25 minutes of arrival, and ideally interpreted within 45 minutes. This is critical for differentiating ischemic from hemorrhagic stroke and determining treatment eligibility.

2. Thrombolytic Therapy (Alteplase): For confirmed acute ischemic stroke, initiate alteplase (tissue plasminogen activator – tPA) as rapidly as possible. Alteplase is an enzyme that dissolves blood clots and can significantly improve outcomes if administered within a specific time window.

• Time Window: Administer IV alteplase within 3 hours of symptom onset (or up to 4.5 hours in select patients meeting specific criteria as per AHA/ASA guidelines).
• Contraindications: Alteplase is contraindicated in hemorrhagic stroke and certain other conditions due to the risk of bleeding. Strict adherence to inclusion and exclusion criteria is essential.
• Administration: Administer alteplase as an IV infusion per protocol, with close monitoring for bleeding complications (intracranial hemorrhage, systemic bleeding), angioedema, and allergic reactions.

3. Continuous Neurological Monitoring: Frequent and meticulous neurological assessments are essential to detect changes in patient status and guide interventions.

• NIHSS Monitoring: Repeat NIHSS assessments at regular intervals (e.g., every 15-30 minutes during and immediately after tPA infusion, then hourly, and as needed) to monitor for improvement or deterioration.
• Pupillary Response: Monitor pupil size, equality, and reactivity to light, which can indicate changes in intracranial pressure or neurological status.
• Level of Consciousness (LOC): Continuously assess LOC using standardized scales (e.g., Glasgow Coma Scale) and report any decline.
• Speech, Cognition, and Memory: Assess for changes in speech fluency, comprehension, cognitive function, and memory.
• Motor Strength and Coordination: Regularly evaluate bilateral strength and coordination in all extremities.
• Mood and Behavior: Observe for mood changes, agitation, or new onset confusion.

4. Medication Management: Administer medications as prescribed to manage secondary events and optimize recovery.

• Blood Pressure Management: Maintain blood pressure within recommended parameters. In the first 24 hours post-alteplase, the target BP is generally <180/105 mm Hg. For patients not receiving thrombolysis, permissive hypertension may be allowed initially to maintain cerebral perfusion, but guidelines vary and should be individualized. Avoid rapid or excessive blood pressure lowering.
• Antihypertensives: Administer IV antihypertensives (e.g., labetalol, nicardipine) as ordered to control blood pressure.
• Seizure Prophylaxis/Management: Seizure prevention may be considered, particularly in hemorrhagic stroke or cortical strokes. If seizures occur, administer anti-seizure medications (e.g., phenytoin, levetiracetam) as prescribed.
• Stool Softeners/Laxatives: Prevent constipation and straining during bowel movements, as straining can increase intracranial pressure.

5. Blood Pressure Management (Specifics): Precise blood pressure management is crucial in acute ischemic stroke.

• Post-Thrombolysis: Maintain BP <180/105 mmHg for at least the first 24 hours after alteplase administration to reduce the risk of intracranial hemorrhage.
• No Thrombolysis: Guidelines for BP management in patients not receiving thrombolysis are more nuanced. Permissive hypertension (slightly elevated BP) may be acceptable in the initial 24-48 hours to maintain cerebral perfusion. However, excessively high BP should be treated. Specific targets should be determined by the physician based on individual patient factors.
• Avoid Rapid BP Reduction: Lowering blood pressure too quickly or aggressively can decrease cerebral blood flow and worsen ischemic injury.

6. Mechanical Thrombectomy: Prepare for mechanical thrombectomy for eligible patients with large vessel occlusions (LVOs).

• Eligibility: Patients with confirmed LVO in the anterior circulation (e.g., middle cerebral artery, internal carotid artery) within a specific time window (typically up to 6-24 hours from symptom onset, depending on clinical scenario and imaging).
• Procedure: Mechanical thrombectomy is an endovascular procedure using a catheter inserted through the groin to physically remove the clot from the cerebral artery.
• Informed Consent: Ensure informed consent is obtained from the patient or family after the provider explains the risks and benefits of the procedure.

7. Endovascular Procedures (Carotid Artery Disease): For patients with significant carotid artery stenosis, prepare for potential endovascular procedures.

• Carotid Endarterectomy (CEA): Surgical removal of plaque from the carotid artery to improve blood flow.
• Carotid Artery Stenting (CAS): Angioplasty and stent placement to open a narrowed carotid artery.
• Reperfusion and Secondary Prevention: These procedures aim to improve cerebral perfusion and reduce the risk of future stroke in patients with carotid artery disease.

Stroke Recovery and Secondary Prevention

1. Stroke Rehabilitation Referral: Initiate early referral to comprehensive stroke rehabilitation programs. Rehabilitation is critical for maximizing functional recovery and adapting to any residual deficits. Referrals may include:

• Physical Therapy: To improve motor function, balance, gait, and mobility.
• Occupational Therapy: To enhance activities of daily living (ADLs), fine motor skills, and cognitive-perceptual skills.
• Speech Therapy: To address communication deficits (aphasia, dysarthria), swallowing difficulties (dysphagia), and cognitive-linguistic impairments.
• Cognitive Therapy/Neuropsychology: To address cognitive deficits, memory problems, attention deficits, and executive function impairments.

2. Speech Deficit Management Education: Educate patients and families on strategies to manage speech deficits and support communication.

• Communication Partner Training: Techniques for family members and caregivers to effectively communicate with individuals with aphasia.
• Speech Practice: Encourage consistent speech practice using flashcards, books, apps, and visual aids as recommended by speech therapy.
• Alternative Communication Methods: Utilize communication boards, writing, gestures, and augmentative and alternative communication (AAC) devices as needed.

3. Medication Education (Discharge Planning): Provide thorough education on prescribed medications at discharge, focusing on secondary stroke prevention.

• Anticoagulants: For patients with atrial fibrillation or other cardioembolic stroke risk factors, oral anticoagulants (e.g., apixaban, rivaroxaban, dabigatran, warfarin) will be prescribed. Educate on medication adherence, monitoring (INR for warfarin), and bleeding precautions.
• Antiplatelet Agents: Aspirin, clopidogrel, or other antiplatelet agents may be prescribed to prevent secondary ischemic stroke.
• Antihypertensives: Emphasize the importance of blood pressure control and adherence to antihypertensive medications (e.g., diuretics, beta-blockers, ACE inhibitors, calcium channel blockers).
• Statins: For hyperlipidemia management and secondary stroke prevention, statins are often prescribed.

4. Safety Strategies: Implement and educate on safety measures to prevent falls and injuries.

• Fall Precautions: Ensure bed rails are up, bed alarms are active, call light is within reach, and assist with ambulation.
• Assistive Devices: Provide and educate on the use of mobility aids (walkers, canes), adaptive equipment for ADLs, and home safety modifications.

5. Support Group Referral: Encourage participation in stroke support groups for patients and caregivers. Support groups provide emotional support, peer interaction, and valuable resources.

6. Lifestyle Modification Education: Educate on lifestyle modifications to reduce future stroke risk.

• Dietary Changes: Recommend a heart-healthy diet low in saturated and trans fats, cholesterol, and sodium, and rich in fruits, vegetables, and whole grains.
• Regular Exercise: Encourage daily physical activity as tolerated.
• Smoking Cessation: Provide resources and support for smoking cessation.
• Moderate Alcohol Consumption: Advise limiting alcohol intake.
• Weight Management: Promote maintaining a healthy weight.

7. Adherence to Treatment Regimens: Emphasize the importance of adherence to all prescribed medications, follow-up appointments, and recommended lifestyle changes to manage comorbidities (hypertension, diabetes, hyperlipidemia) and prevent recurrent stroke.

Nursing Care Plans for Acute Ischemic Stroke: Examples

Nursing care plans provide a structured approach to care, prioritizing assessments and interventions to achieve patient-centered goals. Below are examples of nursing care plan components for key nursing diagnoses in acute ischemic stroke.

Ineffective Cerebral Tissue Perfusion (Primary Nursing Diagnosis for Acute Ischemic Stroke)

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion

Related to: Interruption of blood flow to the brain secondary to thrombus formation or arterial occlusion in acute ischemic stroke.

As evidenced by: Altered mental status, changes in vital signs, neurological deficits (hemiparesis, speech impairment, visual disturbances), abnormal findings on neurological examination (NIHSS).

Expected Outcomes:

• Patient will demonstrate improved cerebral tissue perfusion as evidenced by stable vital signs within ordered parameters, improved level of consciousness, and reduction or stabilization of neurological deficits.
• Patient will receive timely and appropriate interventions to restore cerebral blood flow (e.g., thrombolytic therapy, thrombectomy).
• Patient/family will verbalize understanding of the importance of recognizing stroke symptoms and seeking immediate medical attention.

Assessments:

1. Establish Baseline Neurological Status: Determine the patient’s baseline neurological function upon arrival, including “last known well” time, detailed neurological examination using NIHSS, and vital signs. This baseline is crucial for monitoring changes and evaluating treatment effectiveness.
2. Frequent Neurological Assessments: Perform neurological assessments at prescribed intervals and prn, monitoring LOC, pupillary response, motor strength, sensory function, speech, and cognitive status. Document findings accurately and promptly report any deterioration.
3. Monitor Vital Signs: Continuously monitor blood pressure, heart rate, respiratory rate, and oxygen saturation. Be vigilant for changes that may indicate worsening cerebral perfusion or complications.
4. Review Brain Imaging Results: Carefully review CT scan or MRI results to confirm ischemic stroke, identify the location and extent of the infarct, and rule out hemorrhage. Understand the implications of imaging findings for treatment planning.

Interventions:

1. Maintain Blood Pressure within Prescribed Parameters: Administer antihypertensive medications as ordered to maintain blood pressure within target ranges, carefully titrating medications to avoid hypotension or hypertension extremes. Closely monitor BP response to medications.
2. Administer Thrombolytic Therapy (Alteplase) if Indicated: Ensure timely administration of alteplase if the patient meets inclusion criteria and time window. Double-check medication dosage and infusion rate. Monitor closely for bleeding complications during and after tPA administration.
3. Prepare for Mechanical Thrombectomy if Indicated: Facilitate rapid transfer to interventional radiology for mechanical thrombectomy in eligible patients with LVO. Ensure pre-procedure checklist is completed, informed consent is obtained, and patient is hemodynamically stable for transfer.
4. Optimize Patient Positioning: Elevate the head of the bed to 30 degrees (unless contraindicated) to promote venous drainage and reduce intracranial pressure. Avoid neck flexion or rotation that could impede cerebral blood flow.
5. Maintain Normothermia: Manage fever aggressively with antipyretics and cooling measures, as hyperthermia can exacerbate brain injury.
6. Ensure Adequate Oxygenation: Maintain oxygen saturation >94%. Administer supplemental oxygen as needed based on oxygen saturation levels and arterial blood gas results.
7. Monitor for and Manage Complications: Be vigilant for complications such as increased intracranial pressure, seizures, cerebral edema, and aspiration pneumonia. Implement appropriate interventions promptly.
8. Educate Patient/Family on Stroke Recognition and Action: Provide education to the patient and family about stroke risk factors, warning signs (F.A.S.T.), and the critical importance of calling emergency services immediately upon symptom onset.

Risk for Injury (Related to Neurological Deficits)

Nursing Diagnosis: Risk for Injury

Related to: Impaired judgment, spatial-perceptual deficits, weakness, poor motor coordination, balance deficits, impaired sensory awareness, dysphagia, communication difficulties, hemiplegia, and potential impulsivity secondary to acute ischemic stroke.

Expected Outcomes:

• Patient will remain free from falls and other injuries during hospitalization.
• Patient will demonstrate understanding and adherence to safety precautions.
• Caregivers will implement a safe environment to prevent injury post-discharge.

Assessments:

1. Assess Neurological Deficits Affecting Safety: Identify specific deficits that increase injury risk, such as hemiparesis, impaired balance, visual field deficits (hemianopia), neglect, impaired sensation, and cognitive impairments.
2. Evaluate Mobility and Fall Risk: Use a standardized fall risk assessment tool (e.g., Morse Fall Scale). Assess gait, balance, and need for assistive devices.
3. Assess Swallowing Function (Dysphagia Screening): Perform a bedside swallow screen prior to any oral intake to identify patients at risk for aspiration.
4. Assess Environmental Hazards: Evaluate the patient’s immediate environment for potential hazards (e.g., cluttered bedside, spills, equipment cords).

Interventions:

1. Implement Fall Prevention Measures: Activate bed and chair alarms, keep bed in low position, ensure side rails are up as appropriate, provide non-slip footwear, and assist with ambulation.
2. Provide Safe Feeding Environment: For patients with dysphagia, ensure proper positioning (upright), thickened liquids as prescribed, small bites, slow feeding rate, and suction equipment at bedside. Supervise meals closely and monitor for signs of aspiration.
3. Address Perceptual Deficits: For patients with neglect or visual field deficits, teach scanning techniques (e.g., turning head to affected side), position belongings within unaffected visual field, and approach patient from the unaffected side initially.
4. Ensure Skin Integrity: Implement pressure ulcer prevention measures, including frequent turning and repositioning (every 2 hours), pressure-redistributing mattress, skin assessment, and moisture management, especially in areas of impaired sensation or mobility.
5. Educate Patient and Caregivers on Safety: Provide comprehensive education to patient and family on stroke-related safety risks, home safety modifications, use of assistive devices, and strategies to prevent falls and injuries post-discharge.

Impaired Verbal Communication (Related to Aphasia/Dysarthria)

Nursing Diagnosis: Impaired Verbal Communication

Related to: Prolonged cerebral occlusion leading to neurological damage affecting speech centers, resulting in dysarthria (weakness of speech muscles) or aphasia (impaired language comprehension or production).

As evidenced by: Slurred speech, difficulty forming words, inability to express thoughts verbally, difficulty understanding spoken language, nonverbal communication attempts, frustration with communication attempts.

Expected Outcomes:

• Patient will establish effective alternative methods of communication to express needs and thoughts.
• Patient will participate in speech therapy to improve communication skills.
• Patient and family will utilize communication strategies to facilitate understanding.

Assessments:

1. Assess Type and Severity of Aphasia: Determine the specific type of aphasia (expressive, receptive, global, mixed) and severity using standardized assessments or clinical observation. Understand the patient’s specific communication challenges.
2. Observe Communication Attempts: Note how the patient attempts to communicate (gestures, sounds, writing, drawing). Identify any existing communication strategies used by the patient or family.
3. Assess Comprehension: Evaluate the patient’s ability to understand simple and complex verbal commands, written language, and nonverbal cues.

Interventions:

1. Use Simple, Direct Language: Speak slowly, clearly, and directly to the patient, using short sentences and simple vocabulary. Face the patient when speaking to allow lip reading and visual cues.
2. Utilize Alternative Communication Methods: Employ a variety of communication methods such as writing, drawing, gestures, picture boards, communication apps, and yes/no questions. Work with the patient and family to identify the most effective methods.
3. Encourage Speech Therapy: Facilitate early and ongoing speech therapy. Speech-language pathologists are essential for assessing communication deficits, developing individualized therapy plans, and providing strategies for improving communication.
4. Promote Family Involvement: Encourage family members to participate in speech therapy sessions and learn communication techniques. Family support and consistent use of communication strategies are crucial for patient progress.
5. Create a Supportive Communication Environment: Be patient and allow ample time for the patient to communicate. Minimize distractions and create a calm, supportive environment. Acknowledge and validate the patient’s frustration with communication difficulties.
6. Use Assistive Technology: Introduce and train the patient and family on the use of assistive communication devices and technology as appropriate, based on speech therapy recommendations.

This comprehensive guide provides a framework for understanding Acute Ischemic Stroke Nursing Diagnosis and care. Nurses play a pivotal role in the rapid assessment, intervention, and rehabilitation of patients experiencing this critical condition. By focusing on restoring cerebral perfusion, preventing complications, and supporting patient recovery, nurses significantly contribute to improved outcomes for individuals affected by acute ischemic stroke.

References

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