Hemiparesis Nursing Diagnosis: Comprehensive Guide for Stroke Care

A cerebrovascular accident (CVA), widely recognized as a stroke, occurs when blood supply to the brain is interrupted. This disruption deprives brain tissue of oxygen and vital nutrients, leading to potential brain cell damage within minutes. Hemiparesis, or weakness on one side of the body, is a common and significant consequence of stroke, presenting unique challenges for nursing care and rehabilitation. Understanding the nursing diagnosis of hemiparesis in stroke patients is crucial for effective management and improved patient outcomes.

In this article, we will delve into the nursing diagnosis of hemiparesis following a stroke, providing a comprehensive guide for healthcare professionals. We will explore the types of stroke, the nursing assessment process, relevant nursing diagnoses including hemiparesis, essential nursing interventions, and care plans to optimize patient recovery and quality of life.

Types of Stroke

Strokes are broadly categorized into two primary types: ischemic and hemorrhagic. Recognizing the type of stroke is fundamental as it dictates the treatment approach and nursing care strategies.

Ischemic strokes are the most prevalent, accounting for approximately 87% of all stroke cases. They arise from a reduction or complete cessation of blood flow to a brain region, often due to a blockage in an artery. This blockage can be caused by:

• Thrombosis: Formation of a blood clot within a cerebral artery, often associated with atherosclerosis (plaque buildup in arteries).
• Embolism: A blood clot or other debris (embolus) that travels from another part of the body (commonly the heart or carotid artery) and lodges in a cerebral artery, obstructing blood flow.
• Systemic hypoperfusion: Reduced blood flow to the brain due to systemic issues like severe hypotension or cardiac arrest.

The lack of oxygen and glucose in ischemic stroke rapidly leads to neuronal injury and infarction (tissue death) in the affected brain area.

Hemorrhagic strokes occur when a blood vessel in the brain ruptures, causing bleeding into the brain tissue. This bleeding increases intracranial pressure and damages brain cells through direct compression and chemical irritation. Hemorrhagic strokes are further classified into:

• Intracerebral hemorrhage: Bleeding directly into the brain tissue, often linked to hypertension, cerebral amyloid angiopathy (protein deposits weakening blood vessels), or arteriovenous malformations (AVMs).
• Subarachnoid hemorrhage: Bleeding into the space between the brain and the surrounding membrane (subarachnoid space), frequently caused by ruptured aneurysms or head trauma.

Transient ischemic attacks (TIAs), often referred to as “mini-strokes,” are temporary episodes of neurological dysfunction caused by a transient blockage of blood flow to the brain. Symptoms are similar to stroke but resolve spontaneously, usually within minutes to hours, and always within 24 hours, without causing permanent brain damage. TIAs serve as a critical warning sign, indicating a heightened risk of future stroke. Prompt medical evaluation and risk factor modification are crucial for individuals experiencing TIAs.

Alt text: Diagram illustrating the two main types of stroke: ischemic stroke caused by blockage and hemorrhagic stroke caused by bleeding.

Nursing Process

The nursing process is fundamental to providing patient-centered care for individuals who have experienced a stroke. Stroke often results in varying degrees of disability, influenced by stroke severity, time to treatment, and pre-existing health conditions. Nurses play a pivotal role in all phases of stroke care, from acute management to rehabilitation and long-term support.

Initial stroke management typically takes place in intensive care units (ICUs) or step-down units, where specialized nurses monitor patients closely. Nurses often hold NIH Stroke Scale (NIHSS) certification, demonstrating expertise in stroke assessment and monitoring. The NIHSS is a standardized tool used to quantify stroke-related neurological deficits. Given the potential for rapid and subtle changes in stroke symptoms, critical thinking and timely nursing interventions are essential to prevent neurological deterioration.

Severe strokes can lead to profound disabilities, necessitating comprehensive care for basic needs such as feeding, hygiene, and mobility. Long-term deficits can significantly impact patients’ and families’ lives, potentially leading to depression and reduced quality of life. Nurses provide compassionate care, prioritizing patient safety, preserving dignity, and addressing physical and psychosocial needs throughout the stroke recovery journey. A key aspect of this care is addressing hemiparesis and its implications for the patient’s functional abilities and overall well-being.

Nursing Assessment

A thorough nursing assessment is the cornerstone of effective stroke care. It involves systematic data collection encompassing physical, psychosocial, emotional, and diagnostic aspects. This section focuses on subjective and objective data relevant to stroke and the nursing diagnosis of hemiparesis.

Review of Health History

1. Elicit the patient’s general symptoms. Sudden onset of specific symptoms is highly indicative of stroke. Key symptoms to inquire about include:

• Hemiparesis or hemiplegia: Weakness (paresis) or paralysis (plegia) affecting the face, arm, and leg on one side of the body. This is a critical indicator for the nursing diagnosis of hemiparesis.
• Sensory deficits: Numbness, tingling, or loss of sensation (paresthesias) in extremities, often on one side of the body.
• Dysphagia: Difficulty swallowing, which poses a risk for aspiration pneumonia.
• Visual disturbances: Sudden vision loss in one or both eyes, double vision (diplopia), or visual field deficits (e.g., hemianopia – loss of half of the visual field).
• Speech difficulties:
  • Dysarthria: Slurred speech or difficulty articulating words due to muscle weakness.
  • Aphasia: Language impairment affecting the ability to understand (receptive aphasia) or express (expressive aphasia) speech.
  • Apraxia of speech: Difficulty planning and coordinating the movements needed for speech.
• Ataxia: Uncoordinated movements and unsteady gait, often resulting in balance problems.
• Balance and coordination alterations: Sudden dizziness, vertigo, or loss of balance.
• Changes in mental status: Confusion, disorientation, lethargy, or decreased level of consciousness.

2. Determine the symptom onset. Stroke symptoms manifest abruptly. Accurately documenting the time of symptom onset or when the patient was last known to be at their baseline neurological function is critical. This “last known well” time is a crucial factor in determining eligibility for time-sensitive stroke treatments like thrombolysis.

3. Identify stroke risk factors. Assessing for modifiable and non-modifiable risk factors is essential for stroke prevention and secondary prevention. Key risk factors include:

• Non-modifiable risk factors:
  • Age: Risk increases significantly with age, particularly after 55 years.
  • Race/ethnicity: African Americans and Hispanics have a higher stroke incidence compared to Caucasians.
  • Gender: Men have a slightly higher risk of stroke overall, but women’s risk increases after menopause.
  • Family history of stroke or TIA: Genetic predisposition increases stroke risk.
  • Prior stroke or TIA: Individuals with a history of stroke or TIA are at significantly higher risk for recurrence.
  • Genetic conditions: Conditions like CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) increase stroke risk.
• Modifiable risk factors:
  • Hypertension: High blood pressure is the most significant modifiable risk factor.
  • Hyperlipidemia: Elevated cholesterol and triglyceride levels contribute to atherosclerosis.
  • Diabetes mellitus: Diabetes increases the risk of atherosclerosis and stroke.
  • Obesity and overweight: Excess weight is linked to hypertension, diabetes, and hyperlipidemia.
  • Smoking: Smoking damages blood vessels and increases clot formation risk.
  • Atrial fibrillation: This heart rhythm disorder increases stroke risk due to clot formation in the heart.
  • Carotid artery stenosis: Narrowing of the carotid arteries in the neck reduces blood flow to the brain.
  • Obstructive sleep apnea: Sleep apnea is associated with hypertension, atrial fibrillation, and stroke.
  • Unhealthy diet: Diets high in saturated and trans fats, cholesterol, and sodium increase stroke risk.
  • Physical inactivity: Lack of exercise contributes to several stroke risk factors.
  • Excessive alcohol consumption: Heavy alcohol use increases blood pressure and stroke risk.
  • Illicit drug use: Cocaine, amphetamines, and heroin are linked to increased stroke risk.
  • Certain medications: Birth control pills and hormone replacement therapy containing estrogen can slightly increase stroke risk, especially in women who smoke or have other risk factors.

4. Review the patient’s medical history. Certain medical conditions significantly elevate stroke risk, particularly ischemic stroke. These conditions include:

• Hypertension
• Hyperlipidemia
• Diabetes mellitus
• Atrial fibrillation
• Coronary artery disease
• Carotid artery disease
• Obesity
• Obstructive sleep apnea
• Migraine with aura
• Sickle cell disease
• Hypercoagulable states (increased tendency to form blood clots)
• COVID-19 infection (associated with increased risk of thrombotic events)

5. Review family history. A family history of stroke, especially in first-degree relatives at a young age (before 65), increases an individual’s stroke risk. Genetic factors and shared lifestyle habits contribute to this increased risk.

6. Medication review. A thorough medication history is crucial. Note all prescription medications, over-the-counter drugs, and herbal supplements. Pay attention to:

• Antihypertensive medications: Non-adherence can lead to uncontrolled hypertension and increased stroke risk.
• Anticoagulants and antiplatelet agents (e.g., aspirin, warfarin, heparin, clopidogrel): These medications may indicate pre-existing conditions (atrial fibrillation, history of clots) that increase stroke risk or may be used for stroke prevention.
• Hormone-containing medications: Estrogen-containing birth control pills and hormone replacement therapy can increase stroke risk in some women.

7. Illicit substance use. Inquire about the use of illicit drugs, including amphetamines, cocaine, heroin, and others. These substances are associated with a significantly elevated risk of both ischemic and hemorrhagic strokes.

8. Lifestyle assessment. Evaluate lifestyle factors that contribute to stroke risk:

• Dietary habits: Assess intake of saturated and trans fats, cholesterol, sodium, fruits, and vegetables.
• Physical activity level: Determine frequency, intensity, and type of exercise.
• Alcohol consumption: Quantify alcohol intake and assess for excessive or binge drinking patterns.
• Smoking history: Document current smoking status, pack-years history for former smokers, and exposure to secondhand smoke.

Physical Assessment

1. Recognize F.A.S.T. Immediate recognition of stroke symptoms is paramount for timely intervention. Utilize the acronym F.A.S.T. to rapidly assess for stroke:

• Face: Check for facial drooping or asymmetry. Ask the person to smile and observe for unevenness.
• Arms: Assess for arm weakness. Ask the person to raise both arms. Observe if one arm drifts downward or cannot be raised. This directly assesses for hemiparesis.
• Speech: Evaluate speech difficulties. Listen for slurred speech or difficulty understanding or producing words. Ask the person to repeat a simple sentence.
• Time: Note the time of symptom onset and call emergency services (911 or local equivalent) immediately if any of these signs are present. Time is critical in stroke treatment.

2. Assess ABCs. Conduct an initial assessment focusing on Airway, Breathing, and Circulation (ABCs). Stroke patients are at risk for airway compromise due to decreased level of consciousness, dysphagia, and potential aspiration. Respiratory issues may arise from increased intracranial pressure or neurological dysfunction. Cardiovascular stability is also crucial.

3. Perform a stroke assessment. Patients suspected of stroke require a comprehensive neurological examination. The NIHSS is the gold standard tool for quantifying stroke severity and neurological deficits. It assesses the following:

• Level of consciousness (LOC): Alertness, orientation, and responsiveness to stimuli.
• Gaze: Extraocular movements and presence of gaze deviation.
• Visual fields: Peripheral vision and visual field deficits.
• Facial palsy: Facial muscle weakness or paralysis (e.g., nasolabial fold flattening, facial droop).
• Motor arm: Strength and motor function in both arms, assessing for hemiparesis or hemiplegia.
• Motor leg: Strength and motor function in both legs, assessing for hemiparesis or hemiplegia.
• Limb ataxia: Coordination and balance in the limbs.
• Sensory: Sensation to touch, pain, and proprioception (body position awareness).
• Language: Speech fluency, comprehension, naming, and repetition.
• Dysarthria: Clarity of speech articulation.
• Inattention (Neglect): Awareness of stimuli in both visual fields and body sides.

4. Vital signs assessment. Monitor vital signs closely. Hypertension is commonly observed in acute stroke. However, rapid or excessive blood pressure lowering can be detrimental, especially in ischemic stroke, as it can reduce cerebral perfusion. Fever should be promptly addressed as it can worsen neurological outcomes.

Diagnostic Procedures

1. Blood glucose check. Immediately check blood glucose levels using a fingerstick glucose test. Hypoglycemia (low blood sugar) can mimic stroke symptoms. Ruling out hypoglycemia is crucial for accurate diagnosis and appropriate treatment.

2. Brain imaging. Neuroimaging is essential to confirm stroke diagnosis, differentiate between ischemic and hemorrhagic stroke, and guide treatment decisions.

• Non-contrast head CT scan: Typically the initial imaging modality of choice for rapid evaluation in suspected stroke. It can quickly identify hemorrhage and rule out other conditions (e.g., tumors). Ischemic stroke may not be evident on initial CT, especially in the early hours.
• CT angiography (CTA) and CT perfusion (CTP) scanning: CTA visualizes blood vessels and can identify large vessel occlusions, which are targets for mechanical thrombectomy. CTP assesses cerebral blood flow and can identify areas of ischemic penumbra (potentially salvageable brain tissue).
• Magnetic resonance imaging (MRI): MRI is more sensitive than CT in detecting early ischemic stroke and provides detailed information about infarct size and location. Diffusion-weighted imaging (DWI) is particularly useful in identifying acute ischemic stroke.
• Carotid duplex ultrasound: Evaluates carotid arteries in the neck for stenosis (narrowing) that may be a source of ischemic stroke.
• Digital subtraction angiography (DSA): Invasive procedure providing detailed images of cerebral blood vessels. Reserved for specific situations, such as evaluating aneurysms or AVMs.

3. Laboratory tests. Blood tests aid in identifying underlying causes of stroke, guiding treatment, and assessing overall patient status. Common lab tests include:

• Complete blood count (CBC): Evaluates red blood cells, white blood cells, and platelets. Polycythemia (increased red blood cells) and thrombocytosis (increased platelets) can contribute to stroke risk. Thrombocytopenia (low platelets) is relevant in hemorrhagic stroke risk.
• Coagulation studies (PT/INR, PTT): Assess blood clotting function, particularly important before administering anticoagulants or thrombolytics.
• Cardiac biomarkers (troponin, CK-MB): Evaluate for cardiac injury, as stroke can be associated with underlying cardiac disease.
• Lipid profile (fasting cholesterol, triglycerides, LDL, HDL): Identifies hyperlipidemia as a stroke risk factor.
• Electrolytes, BUN, creatinine, glucose: Assess overall metabolic status and kidney function.
• Toxicology screen: If substance abuse is suspected as a contributing factor.

4. Pregnancy test. Perform urine pregnancy tests for women of childbearing age before administering fibrinolytic therapy (alteplase), as its safety in pregnancy is not established.

5. Electrocardiogram (ECG). Obtain a 12-lead ECG to assess for cardiac arrhythmias, particularly atrial fibrillation, which is a common cause of cardioembolic stroke.

Alt text: Nurse performing a neurological assessment on a patient, checking for facial droop, arm weakness, and speech difficulties as part of stroke evaluation.

Nursing Interventions

Nursing interventions are critical for stroke patients, focusing on restoring brain perfusion, managing complications, facilitating recovery, and preventing future strokes. For patients with hemiparesis, specific interventions are necessary to address motor deficits, prevent complications, and promote functional independence.

Restore Brain Perfusion

1. Initial evaluation and diagnostic imaging preparation. Rapid assessment and brain imaging are paramount. Within one hour of arrival at the emergency department, patients with suspected stroke should undergo a STAT non-contrast head CT scan. This differentiates between ischemic and hemorrhagic stroke, guiding immediate treatment decisions.

2. Restore adequate cerebral blood flow. For ischemic stroke, thrombolytic therapy with alteplase (tissue plasminogen activator or tPA) is the primary treatment to dissolve blood clots and restore blood flow. Alteplase is contraindicated in hemorrhagic stroke due to the bleeding risk. Administer IV alteplase as soon as possible to eligible patients who meet inclusion criteria and symptom onset within 3 hours (or up to 4.5 hours in select patients based on AHA/ASA guidelines).

3. Continuous neurological monitoring. Frequent neurological assessments are essential to detect changes in neurological status and guide timely interventions. Monitor:

• Level of consciousness (LOC) using Glasgow Coma Scale (GCS) or NIHSS LOC items.
• Pupil size, equality, and reactivity to light.
• Motor strength and sensation in extremities, focusing on hemiparesis.
• Speech, language, and cognitive function.
• Changes in mood or behavior.
• Signs of increased intracranial pressure (ICP): headache, vomiting, altered LOC, Cushing’s triad (bradycardia, hypertension, irregular respirations).

4. Medication administration. Administer medications as prescribed to manage secondary complications and optimize recovery.

• Antihypertensive medications: Manage blood pressure within target ranges. Permissive hypertension may be allowed in acute ischemic stroke unless thrombolysis is planned. Lower blood pressure targets are indicated for hemorrhagic stroke.
• Antiseizure medications: Prophylactic antiseizure medication may be considered, especially for hemorrhagic stroke or stroke involving the cerebral cortex. Treat seizures promptly if they occur.
• Stool softeners and laxatives: Prevent constipation and straining during bowel movements, which can increase ICP.
• Antiplatelet agents or anticoagulants: Initiated for secondary stroke prevention once the acute phase has passed and hemorrhage has been ruled out.

5. Blood pressure management. Maintain blood pressure within recommended parameters.

• Ischemic stroke: In patients receiving IV alteplase, maintain blood pressure below 180/105 mmHg for the first 24 hours post-treatment. In patients not receiving thrombolysis, current guidelines suggest permissive hypertension in the acute phase, avoiding aggressive blood pressure lowering unless extremely elevated. Gradually manage underlying hypertension after the acute phase (2-3 days).
• Hemorrhagic stroke: More stringent blood pressure control is required to limit hematoma expansion. Guidelines generally recommend a target systolic blood pressure of 140 mmHg or lower in acute intracerebral hemorrhage.

6. Mechanical thrombectomy preparation. For patients with large vessel occlusion ischemic stroke, mechanical thrombectomy is a highly effective intervention to physically remove the clot using a catheter inserted through the groin. Ensure informed consent is obtained and prepare the patient for the procedure.

7. Endovascular techniques preparation. For patients with carotid artery stenosis, carotid endarterectomy (surgical removal of plaque) or carotid artery stenting (placement of a stent to open the artery) may be performed to improve cerebral blood flow and reduce stroke risk. Prepare patients for these procedures as indicated.

Stroke Recovery and Prevention

1. Stroke rehabilitation referral. Early and comprehensive rehabilitation is crucial to maximize functional recovery after stroke, especially for hemiparesis. Refer patients to:

• Physical therapy (PT): Focuses on improving motor function, balance, gait, and mobility affected by hemiparesis.
• Occupational therapy (OT): Addresses activities of daily living (ADLs), fine motor skills, and upper extremity function, crucial for hemiparesis management.
• Speech therapy (ST): Evaluates and treats communication and swallowing disorders (dysphagia, aphasia, dysarthria).
• Cognitive therapy: Addresses cognitive deficits (memory, attention, executive function).
• Rehabilitation nursing: Provides 24-hour care and coordination of rehabilitation efforts.

2. Speech deficit management education. For patients with aphasia or dysarthria, speech therapy is essential. Educate patients and families on communication strategies:

• “Communication partner training” for family members to improve communication effectiveness.
• Speech practice using flashcards, books, computer programs, and visual aids.
• Use of communication boards, pen and paper, or communication apps for non-verbal communication.
• Patience and creating a supportive communication environment.

3. Medication education. Educate patients about prescribed medications upon discharge:

• Anticoagulants: For atrial fibrillation or other thromboembolic risk factors (e.g., apixaban, rivaroxaban, dabigatran, warfarin). Emphasize adherence and bleeding precautions.
• Antiplatelet agents: Aspirin, clopidogrel, or combination therapy for secondary stroke prevention.
• Antihypertensive medications: For long-term blood pressure control (e.g., diuretics, beta-blockers, ACE inhibitors, calcium channel blockers). Stress importance of adherence and regular monitoring.
• Statins: For hyperlipidemia management.
• Antidiabetic medications: For diabetes management.

4. Safety strategies initiation. Stroke-related motor deficits, sensory loss, and cognitive impairment increase fall risk and injury risk. Implement safety measures:

• Bed and chair alarms for patients at high fall risk, especially those with impulsivity or impaired judgment.
• Bed rails up and bed in low position.
• Call light within reach.
• Assistive devices for mobility (walkers, canes, wheelchairs).
• Home safety modifications (removing hazards, grab bars, adequate lighting).
• Education on fall prevention strategies.

5. Support group encouragement. Refer patients and caregivers to stroke support groups. Support groups provide emotional support, peer interaction, practical advice, and resources, enhancing coping and recovery.

6. Lifestyle modification promotion and education. Educate patients on modifiable risk factors and lifestyle changes to prevent recurrent stroke:

• Healthy diet: Emphasize fruits, vegetables, whole grains, lean protein, and low saturated and trans fats. Limit processed foods, sodium, and sugary drinks.
• Regular exercise: Recommend at least 30 minutes of moderate-intensity exercise most days of the week.
• Smoking cessation: Provide resources and support for quitting smoking.
• Moderate alcohol consumption: Limit alcohol intake or abstain altogether.
• Weight management: Achieve and maintain a healthy weight.
• Stress management: Teach stress reduction techniques.

7. Treatment regimen adherence assurance. Emphasize the importance of adherence to prescribed medications and follow-up appointments for managing comorbidities (hypertension, diabetes, hyperlipidemia) and preventing future strokes.

Nursing Care Plans

Nursing care plans provide a structured framework for organizing and delivering individualized nursing care. They prioritize nursing diagnoses, guide assessments and interventions, and establish short-term and long-term goals for stroke patients. Several common nursing diagnoses are relevant in stroke care, particularly in relation to hemiparesis.

Impaired Verbal Communication

Stroke frequently affects communication abilities. Patients may experience difficulty understanding or expressing language, as well as physical impairments affecting speech production.

Nursing Diagnosis: Impaired Verbal Communication

Related to:

• Prolonged cerebral occlusion
• Neurological damage from stroke
• Dysarthria (weakness of speech muscles)
• Aphasia (language impairment)
• Cognitive deficits

As evidenced by:

• Slurred speech
• Difficulty forming words or sentences
• Use of incorrect words
• Inability to understand spoken or written language
• Frustration with communication attempts
• Nonverbal communication attempts (gestures, pointing)
• Extremity weakness or paralysis affecting writing or typing

Expected Outcomes:

• Patient will establish effective communication methods to express needs and thoughts.
• Patient will participate in speech therapy to improve communication skills.
• Patient will utilize assistive communication devices or strategies as needed.
• Patient will demonstrate reduced frustration related to communication difficulties.

Assessment:

1. Determine type and severity of aphasia. Different types of aphasia impact communication differently.

• Global aphasia: Severe impairment in both language comprehension and expression.
• Broca’s aphasia (expressive aphasia): Difficulty producing speech, but comprehension is relatively preserved.
• Wernicke’s aphasia (receptive aphasia): Fluent speech that may be nonsensical; impaired comprehension.
• Anomic aphasia: Difficulty with word finding, particularly naming objects.

2. Observe patient’s communication attempts. Note verbal and nonverbal communication strategies used by the patient (gestures, sounds, facial expressions). Family input is valuable in understanding the patient’s usual communication patterns.

Interventions:

1. Use simple, direct language. Speak clearly and slowly, facing the patient. Use short sentences and avoid complex or abstract language. Yes/no questions may be easier to process.

2. Utilize alternative communication methods. Employ visual aids, writing, drawing, gestures, communication boards, or electronic devices. Work with the patient to identify preferred communication methods.

3. Encourage speech therapy. Speech-language pathologists are essential for assessment and treatment of communication disorders. Therapy can improve language skills and teach compensatory strategies.

4. Promote family involvement. Family members play a vital role in supporting communication. Encourage family participation in therapy sessions and education on communication techniques.

5. Create a supportive communication environment. Be patient, attentive, and avoid interrupting. Provide ample time for the patient to respond. Minimize distractions and noise.

Ineffective Cerebral Tissue Perfusion

Reduced blood flow to the brain deprives brain tissue of oxygen, leading to cellular injury and potential irreversible damage. This is the core pathophysiology of stroke and directly related to neurological deficits like hemiparesis.

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion

Related to:

• Interruption of arterial blood flow to the brain
• Thrombosis or embolism
• Cerebral hemorrhage
• Cerebral edema
• Increased intracranial pressure (ICP)

As evidenced by:

• Altered mental status (confusion, lethargy, decreased LOC)
• Changes in vital signs (hypertension, bradycardia, irregular respirations)
• Neurological deficits: hemiparesis, hemiplegia, speech deficits, visual disturbances, sensory loss, ataxia
• Restlessness, agitation

Expected Outcomes:

• Patient will maintain adequate cerebral perfusion as evidenced by stable vital signs, improved LOC, and reduction in neurological deficits.
• Patient will recognize stroke symptoms and seek prompt medical attention in the future.
• Patient will demonstrate understanding of modifiable risk factors for stroke.

Assessment:

1. Establish baseline neurological status. Determine the patient’s pre-stroke functional level and neurological status to monitor for changes and assess for improvement or deterioration. Note the “last known well” time.

2. Frequent neurological assessments. Perform serial neurological assessments using NIHSS or other stroke scales as per facility protocol. Monitor LOC, pupillary response, motor strength, sensation, speech, and vital signs.

3. Monitor vital signs closely. Pay attention to blood pressure, heart rate, respiratory rate, and temperature. Report significant changes promptly.

4. Review brain imaging results. CT or MRI findings confirm stroke diagnosis, differentiate stroke type (ischemic vs. hemorrhagic), and guide treatment.

Interventions:

1. Optimize blood pressure management. Maintain blood pressure within prescribed parameters. Avoid rapid or excessive blood pressure lowering, especially in acute ischemic stroke (unless thrombolysis is planned). Follow specific blood pressure guidelines for ischemic and hemorrhagic stroke.

2. Administer thrombolytic therapy (alteplase) for ischemic stroke. Administer alteplase promptly to eligible patients within the appropriate time window. Monitor closely for bleeding complications.

3. Prepare for endovascular procedures. For large vessel occlusion ischemic stroke, prepare patient for mechanical thrombectomy. For carotid stenosis, prepare for carotid endarterectomy or stenting if indicated.

4. Manage intracranial pressure (ICP). Elevate head of bed to 30 degrees, maintain normothermia, avoid hypervolemia, and administer osmotic diuretics (mannitol) or hypertonic saline as ordered to reduce ICP.

5. Educate on stroke risk factors and prevention. Provide comprehensive education on modifiable stroke risk factors (hypertension, hyperlipidemia, diabetes, smoking, atrial fibrillation) and lifestyle modifications to reduce future stroke risk. Emphasize the importance of recognizing stroke symptoms (F.A.S.T.) and seeking immediate medical help.

Risk For Injury

Stroke-related neurological deficits, particularly hemiparesis, impaired balance, sensory loss, and cognitive impairments, significantly increase the risk of falls and other injuries.

Nursing Diagnosis: Risk For Injury

Related to:

• Impaired mobility and balance (hemiparesis, ataxia)
• Sensory deficits (proprioceptive loss, visual field deficits)
• Cognitive impairments (impaired judgment, impulsivity, neglect)
• Dysphagia (risk of aspiration)
• Communication deficits
• Weakness and fatigue
• Medication side effects

Note: Risk for nursing diagnoses are not evidenced by signs and symptoms because the problem has not yet occurred. Interventions are directed at prevention.

Expected Outcomes:

• Patient will remain free from falls and other injuries during hospitalization and rehabilitation.
• Patient and caregivers will implement safety measures to prevent injury at home.
• Patient will demonstrate safe use of assistive devices and adaptive equipment.
• Patient will maintain skin integrity and prevent pressure ulcers.

Assessment:

1. Assess neurological deficits contributing to injury risk. Evaluate motor strength, balance, coordination, sensation, vision, cognition, and communication abilities. Identify specific deficits that increase injury risk (e.g., hemiparesis, neglect, impaired judgment).

2. Assess fall risk. Use a validated fall risk assessment tool (e.g., Morse Fall Scale). Identify specific fall risk factors.

3. Assess swallowing function (dysphagia screening). Perform a dysphagia screening before oral intake to identify aspiration risk.

4. Assess skin integrity. Regularly assess skin for breakdown, especially in pressure-prone areas, due to immobility and sensory loss.

Interventions:

1. Implement fall precautions.

• Keep bed in low position and locked.
• Ensure side rails are raised as appropriate.
• Bed and chair alarms for high-risk patients.
• Clear pathways of clutter.
• Adequate lighting.
• Non-skid footwear.
• Assistive devices (walkers, canes).
• Supervision and assistance with ambulation and transfers.
• Educate patient and family on fall prevention strategies.

2. Implement aspiration precautions for dysphagia.

• Maintain NPO status until swallow evaluation is completed.
• Position patient upright (90 degrees) during and after meals.
• Provide thickened liquids and pureed or soft foods as prescribed by speech therapy.
• Encourage small bites and slow eating.
• Monitor for signs of aspiration (coughing, choking, wet voice, respiratory distress).
• Suction equipment readily available.

3. Implement skin integrity precautions.

• Regular skin assessments, especially in pressure areas.
• Reposition patient at least every 2 hours.
• Pressure-relieving devices (specialty mattresses, cushions).
• Keep skin clean and dry.
• Adequate nutrition and hydration.

4. Educate patient and caregivers on safety measures. Provide instructions on home safety modifications, safe transfers, use of assistive devices, medication safety, and emergency procedures.

Self-Care Deficit

Hemiparesis and other stroke-related deficits often impair the ability to perform self-care activities, impacting independence and quality of life.

Nursing Diagnosis: Self-Care Deficit (Bathing/Hygiene, Dressing/Grooming, Feeding, Toileting)

Related to:

• Neuromuscular impairment (hemiparesis, weakness, paralysis)
• Cognitive dysfunction
• Perceptual deficits (unilateral neglect)
• Fatigue and decreased endurance
• Pain
• Depression and decreased motivation

As evidenced by:

• Inability to independently perform or complete bathing, dressing, feeding, or toileting activities.
• Need for assistance with self-care tasks.
• Poor hygiene or grooming.
• Reluctance or refusal to perform self-care.
• Frustration or dependence on others for self-care.

Expected Outcomes:

• Patient will participate in self-care activities to the extent possible.
• Patient will maintain adequate hygiene and skin integrity.
• Patient will utilize assistive devices and adaptive equipment effectively to enhance independence in self-care.
• Patient will express satisfaction with their level of self-care and maintain dignity.

Assessment:

1. Assess functional abilities and limitations in ADLs. Evaluate the patient’s ability to perform bathing, dressing, feeding, toileting, and grooming tasks. Identify specific deficits and level of assistance needed.

2. Assess patient preferences and cultural considerations. Respect patient preferences regarding hygiene, grooming, and self-care routines. Consider cultural or religious practices.

3. Assess for factors contributing to self-care deficit. Identify underlying causes such as motor deficits, cognitive impairments, perceptual problems, fatigue, pain, or depression.

4. Perform risk assessments.

• Fall risk assessment (Morse Fall Scale).
• Skin assessment (Braden Scale for pressure ulcer risk).
• Swallowing assessment (dysphagia screening).

Interventions:

1. Encourage independence and participation in self-care. Promote patient autonomy and self-esteem by encouraging participation in self-care tasks to the maximum extent possible.

2. Provide assistance as needed. Offer assistance with self-care tasks as necessary, while still encouraging patient participation. Be patient and allow adequate time for the patient to complete tasks.

3. Utilize assistive devices and adaptive equipment. Introduce and train patients on the use of assistive devices for bathing, dressing, feeding, and toileting (e.g., long-handled sponges, dressing sticks, built-up utensils, raised toilet seats).

4. Consult with occupational therapy. OT can provide specialized assessment and interventions to improve ADL skills and recommend adaptive equipment.

5. Establish a toileting schedule. Implement a regular toileting schedule to prevent incontinence and promote bowel and bladder management.

6. Ensure adequate time for meals. Allow sufficient time for patients with dysphagia or motor deficits to eat safely and comfortably.

7. Maintain skin integrity. Implement skin care measures to prevent skin breakdown, especially in immobile patients.

Unilateral Neglect

Unilateral neglect, also known as hemispatial neglect, is a common consequence of stroke, particularly right hemisphere stroke. It involves a lack of awareness of stimuli on one side of the body or in the space contralateral to the brain lesion. Patients with hemiparesis often experience unilateral neglect, compounding their functional limitations.

Nursing Diagnosis: Unilateral Neglect

Related to:

• Brain injury from stroke (typically right hemisphere)
• Perceptual deficits
• Sensory deficits

As evidenced by:

• Consistent inattention to stimuli on the neglected side (visual, auditory, tactile).
• Failure to acknowledge or use the affected side of the body (e.g., not grooming, dressing, or moving the neglected arm or leg).
• Eating food only on one side of the plate.
• Bumping into objects on the neglected side.
• Spatial disorientation and difficulty navigating the environment.
• Lack of awareness of the deficit.

Expected Outcomes:

• Patient will demonstrate awareness of unilateral neglect and implement compensatory strategies.
• Patient will attend to and care for both sides of the body appropriately.
• Patient will participate in rehabilitation activities to minimize the impact of unilateral neglect.
• Patient will remain safe and free from injury related to neglect.

Assessment:

1. Assess for signs of unilateral neglect. Observe for behaviors indicating neglect, such as:

• Ignoring stimuli on the affected side (e.g., not responding to sounds or touch).
• Leaving food on one side of the plate.
• Not dressing or grooming the affected side of the body.
• Bumping into objects on the affected side.
• Turning head and eyes away from the affected side.
• Line bisection test: drawing a line off-center when asked to bisect a horizontal line.
• Cancellation tests: omitting items on the affected side when asked to cross out specific targets on a page.

2. Assess patient’s awareness of neglect. Determine if the patient is aware of their neglect and its impact on their functioning. Lack of awareness is common in unilateral neglect.

3. Assess skin on the neglected side. Inspect skin for injury, breakdown, or signs of neglect due to lack of attention to that side of the body.

Interventions:

1. Increase patient’s awareness of the neglected side.

• Approach patient from the affected side.
• Place objects (call light, personal items) on the affected side to encourage attention.
• Use verbal and tactile cues to direct attention to the neglected side.
• Teach patient to visually scan the environment to the affected side.
• Mirror therapy: using a mirror to create a visual illusion of movement in the affected limb.

2. Encourage bilateral activities. Promote activities that require use of both sides of the body to increase awareness of the neglected side (e.g., bilateral reaching, clapping, washing face with both hands).

3. Provide environmental modifications.

• Arrange environment to encourage attention to the neglected side.
• Remove clutter from the affected side.
• Ensure adequate lighting on the affected side.
• Position bed and furniture to promote interaction with the affected side.

4. Ensure safety precautions.

• Fall precautions (bed alarm, supervision).
• Protect neglected limbs from injury (positioning, padding).
• Educate patient and caregivers on safety strategies.

5. Coordinate rehabilitation therapies. PT, OT, and speech therapy are crucial for addressing unilateral neglect and improving functional outcomes. Rehabilitation strategies may include visual scanning training, limb activation techniques, and sensory stimulation.

References

• American Heart Association/American Stroke Association (AHA/ASA) guidelines.
• National Institute of Neurological Disorders and Stroke (NINDS).
• Nursing textbooks and journals specializing in neurological and stroke care.
• Evidence-based nursing practice resources.