Nursing Diagnosis Care Plans for Stroke: Comprehensive Guide for Caregivers

A cerebrovascular accident (CVA), commonly known as a stroke, is a critical medical condition that occurs when the blood supply to the brain is interrupted or severely reduced. This disruption deprives brain tissue of oxygen and vital nutrients, leading to rapid cell damage and potential long-term disabilities. Understanding the nuances of stroke, its various types, and the comprehensive nursing care required is paramount for healthcare professionals. This article delves into the essential aspects of nursing care plans for stroke patients, providing a detailed guide for effective patient management and recovery.

Types of Stroke: Ischemic and Hemorrhagic

Strokes are broadly categorized into two primary types, each with distinct causes and requiring different management strategies: ischemic and hemorrhagic strokes.

Ischemic Strokes: These are the most prevalent type, accounting for approximately 87% of all stroke cases. Ischemic strokes are triggered by a blockage in the arteries that supply blood to the brain. This blockage can be caused by:

• Thrombosis: Formation of a blood clot within a cerebral artery, often associated with atherosclerosis (plaque buildup).
• Embolism: A blood clot or other debris that travels from another part of the body (commonly the heart) to the brain and lodges in a smaller artery, obstructing blood flow.
• Systemic hypoperfusion: Reduced blood flow to all parts of the body, including the brain, often due to heart failure or severe hypotension.

The immediate consequence of ischemia is oxygen and nutrient deprivation to brain tissue. Without prompt restoration of blood flow, brain cells begin to die within minutes, leading to irreversible neurological damage.

Hemorrhagic Strokes: Hemorrhagic strokes occur when a blood vessel in the brain ruptures, causing bleeding into the brain tissue. This bleeding can be categorized as:

• Intracerebral hemorrhage: Bleeding directly into the brain tissue itself. Common causes include:
  • Hypertension: Chronic high blood pressure weakens blood vessel walls, making them prone to rupture.
  • Cerebral amyloid angiopathy: Protein deposits in blood vessels weaken their walls.
  • Vascular malformations: Abnormalities in blood vessels that predispose them to rupture.
  • Anticoagulant medications: Overuse can increase bleeding risk.
  • Illicit drug use: Cocaine and amphetamines can cause sudden blood pressure spikes and vessel rupture.
• Subarachnoid hemorrhage: Bleeding in the space between the brain and the surrounding membrane (subarachnoid space). This is often caused by the rupture of a brain aneurysm (a bulge in a blood vessel wall).

Blood accumulation in the brain tissue elevates intracranial pressure (ICP), further damaging brain cells by compression and disruption of normal brain function.

Transient Ischemic Attacks (TIAs): Often referred to as “mini-strokes,” TIAs are temporary episodes of neurological dysfunction caused by brief interruptions in blood flow to the brain. Symptoms are similar to those of a stroke but resolve spontaneously, typically within minutes to hours, and always within 24 hours, without causing permanent brain damage. TIAs are critical warning signs, indicating a significantly increased risk of a future stroke. Individuals experiencing TIAs require immediate medical evaluation and management to mitigate future stroke risk factors.

The Nursing Process for Stroke Patients

Nursing care for stroke patients is a dynamic and multifaceted process that requires a systematic approach. The nursing process, encompassing assessment, diagnosis, planning, implementation, and evaluation, provides a framework for delivering comprehensive and individualized care. Stroke patients often present with a wide spectrum of disabilities, influenced by stroke severity, time to treatment, affected brain area, and pre-existing health conditions. Initial care is typically provided in intensive care units (ICUs) or specialized stroke units where continuous monitoring and immediate interventions are available. Nurses specializing in stroke care often hold NIH Stroke Scale (NIHSS) certification, demonstrating their expertise in neurological assessment and stroke management.

Severe strokes can lead to profound physical and cognitive impairments, necessitating total care for basic needs such as feeding, bathing, and mobility. Long-term deficits can significantly impact the patient’s quality of life and emotional well-being, often leading to depression and distress for both patients and their families. The nurse plays a pivotal role in providing compassionate care, ensuring patient safety and dignity, and addressing the complex physical and psychosocial needs throughout the stroke recovery journey.

Nursing Assessment for Stroke

The initial step in providing effective nursing care is a thorough nursing assessment. This involves gathering comprehensive data across physical, psychosocial, emotional, and diagnostic domains.

Review of Health History: Subjective Data Collection

1. Eliciting General Stroke Symptoms: Prompt recognition of stroke symptoms is crucial for timely intervention. Nurses should inquire about the sudden onset of any of the following:

• Motor Weakness:
  • Hemiparesis or hemiplegia: Weakness or paralysis affecting one side of the body (face, arm, and leg on the same side).
• Sensory Disturbances:
  • Numbness or tingling: Paresthesias, typically affecting extremities.
• Swallowing Difficulties:
  • Dysphagia: Difficulty swallowing, posing a risk for aspiration.
• Visual Impairments:
  • Visual field deficits: Hemianopsia (loss of half of the visual field) or peripheral vision loss.
  • Diplopia: Double vision.
• Speech and Language Difficulties:
  • Expressive aphasia: Difficulty producing speech, although comprehension may be intact (Broca’s aphasia).
  • Receptive aphasia: Difficulty understanding spoken language (Wernicke’s aphasia).
  • Dysarthria: Difficulty articulating words due to muscle weakness.
• Balance and Coordination Problems:
  • Ataxia: Unsteady gait, lack of coordination.
  • Dizziness or vertigo: Sensation of spinning or imbalance.
• Cognitive and Mental Status Changes:
  • Confusion: Disorientation to time, place, or person.
  • Memory deficits: Difficulty recalling recent or past events.
  • Decreased level of consciousness: Drowsiness, lethargy, or unresponsiveness.
  • Agitation or irritability: Unusual restlessness or frustration.
  • Seizures: Sudden, uncontrolled electrical disturbances in the brain.
  • Severe headache: Especially sudden onset and described as “thunderclap headache” (more indicative of hemorrhagic stroke).

2. Determining Symptom Onset: Precise documentation of symptom onset is critical. Establish the exact time when symptoms first appeared and the last time the patient was known to be at their baseline neurological function. This “last known well” time is a key factor in determining eligibility for thrombolytic therapy (tPA) for ischemic stroke.

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

• Non-modifiable risk factors:
  • Age: Risk increases significantly after age 55.
  • Race/Ethnicity: African Americans and Hispanics have a higher stroke incidence.
  • Gender: Males have a slightly higher risk overall, but stroke risk increases for women after menopause.
  • Family history: Stroke in a first-degree relative, especially before age 65, increases risk.
  • Prior stroke or TIA: History of stroke or TIA significantly elevates future stroke risk.
  • Genetic conditions: Certain genetic disorders 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: High cholesterol levels contribute to atherosclerosis.
  • Diabetes mellitus: Diabetes damages blood vessels and increases clot risk.
  • Obesity and Overweight: Excess weight increases the risk of hypertension, diabetes, and hyperlipidemia.
  • Smoking: Damages blood vessels and increases blood clot formation.
  • Atrial fibrillation: Irregular heart rhythm increases the risk of emboli formation.
  • Carotid artery disease: Narrowing of carotid arteries in the neck restricts blood flow to the brain.
  • Physical inactivity: Lack of exercise contributes to other risk factors.
  • Unhealthy diet: High in saturated and trans fats, cholesterol, and sodium.
  • Excessive alcohol consumption: Heavy drinking increases stroke risk.
  • Obstructive sleep apnea: Interrupted breathing during sleep can lead to hypertension and cardiovascular stress.
  • COVID-19 infection: Emerging evidence suggests increased stroke risk following COVID-19.

4. Reviewing Medical History: Certain medical conditions significantly elevate stroke risk:

• Cardiovascular diseases: Coronary artery disease, heart failure, peripheral artery disease.
• Hypercoagulable states: Conditions that increase blood clotting tendency.
• Migraine with aura: Migraine headaches with neurological symptoms.

5. Family History Review: A family history of stroke, particularly at a young age, warrants attention due to potential genetic predispositions.

6. Medication Review: Medication history is crucial to identify potential risk factors or contraindications for stroke treatments:

• Hormone replacement therapy and oral contraceptives: Estrogen-containing medications increase stroke risk, especially in smokers and women over 35.
• Antihypertensives: Non-adherence to blood pressure medications contributes to uncontrolled hypertension.
• Anticoagulants (aspirin, warfarin, heparin, enoxaparin): While used to prevent clots, they can also increase the risk of hemorrhagic stroke, and their use might indicate pre-existing conditions that increase stroke risk.

7. Substance Use Assessment: Illicit drug use is a significant stroke risk factor:

• Cocaine, amphetamines, heroin: These substances can cause vasospasm, hypertension, and cardiac arrhythmias, all increasing stroke risk.

8. Lifestyle Factor Assessment: Lifestyle choices play a significant role in stroke risk:

• Dietary habits: High intake of saturated and trans fats, cholesterol, and sodium.
• Physical activity level: Sedentary lifestyle.
• Alcohol consumption: Excessive alcohol intake.
• Smoking status: Current or past smoking history.

Physical Assessment: Objective Data Collection

1. Rapid Stroke Recognition: F.A.S.T. Assessment: Utilize the F.A.S.T. acronym for rapid stroke screening:

• F – Face: Ask the patient to smile. Observe for facial drooping or asymmetry.
• A – Arms: Ask the patient to raise both arms. Observe for arm weakness or drift.
• S – Speech: Ask the patient to repeat a simple sentence. Assess for slurred speech or difficulty understanding.
• T – Time: Note the time of symptom onset and call emergency services immediately.

2. Assessing the ABCs (Airway, Breathing, Circulation): Prioritize basic life support assessment:

• Airway: Ensure a patent airway. Stroke patients may be at risk for aspiration due to impaired swallowing or decreased consciousness.
• Breathing: Assess respiratory rate, depth, and effort. Stroke can affect respiratory control centers in the brain.
• Circulation: Check heart rate, blood pressure, and peripheral pulses. Hypertension is common in acute stroke.

3. Comprehensive Neurological Examination: The NIH Stroke Scale (NIHSS) is the gold standard for quantifying stroke severity. It assesses:

• Level of Consciousness (LOC): Alertness, responsiveness to stimuli.
• Language: Speech fluency, comprehension, naming, repetition.
• Visual Fields: Visual field deficits, hemianopsia.
• Extraocular Movements: Eye movements, gaze deviation.
• Facial Palsy: Facial muscle weakness.
• Motor Function (Arms and Legs): Strength and movement in upper and lower extremities.
• Limb Ataxia: Coordination and balance.
• Sensory Function: Sensation to touch and pain.
• Dysarthria: Speech articulation.
• Neglect/Inattention: Awareness of stimuli in both visual fields and body sides.

4. Vital Signs Monitoring: Closely monitor vital signs:

• Blood pressure: Hypertension is common. Monitor for both elevated and excessively low blood pressure.
• Heart rate and rhythm: Assess for bradycardia, tachycardia, or arrhythmias.
• Respiratory rate and oxygen saturation: Monitor for respiratory distress or hypoxemia.
• Temperature: Fever can exacerbate brain injury.

Diagnostic Procedures for Stroke

1. Blood Glucose Level Check: Rule out hypoglycemia as a cause of neurological symptoms. Hypoglycemia can mimic stroke symptoms.

2. Brain Imaging: Neuroimaging is essential for stroke diagnosis and differentiation:

• Non-contrast Head CT Scan: The initial imaging modality of choice, rapidly differentiates between ischemic and hemorrhagic stroke. It can detect hemorrhage but may not show early ischemic changes.
• CT Angiography (CTA) and CT Perfusion (CTP) Scanning: CTA visualizes blood vessels to identify blockages or aneurysms. CTP assesses cerebral blood flow and tissue perfusion, helping to determine the extent of ischemic damage and identify salvageable brain tissue (penumbra).
• Magnetic Resonance Imaging (MRI): More sensitive than CT for detecting early ischemic changes and small hemorrhages. Diffusion-weighted MRI (DWI) is highly accurate in identifying acute ischemic stroke within minutes of symptom onset.
• Carotid Duplex Ultrasound: Evaluates carotid arteries in the neck for stenosis (narrowing) or plaque buildup, a common cause of ischemic stroke.
• Digital Subtraction Angiography (DSA): Invasive procedure providing detailed visualization of cerebral blood vessels, used when less invasive imaging is inconclusive or for interventional procedures.

3. Laboratory Tests: Blood tests help identify underlying causes and guide treatment:

• Complete Blood Count (CBC): Evaluates red blood cell count (polycythemia can increase blood viscosity), white blood cell count (infection), and platelet count (thrombocytopenia or thrombocytosis can affect clotting).
• Cardiac Biomarkers (Troponin, CK-MB): Assess for cardiac injury or myocardial infarction, which can be a source of cardioembolic stroke.
• Coagulation Studies (PT/INR, PTT): Evaluate blood clotting function, especially important before administering anticoagulants or thrombolytics.
• Lipid Profile (Fasting Cholesterol, Triglycerides, LDL, HDL): Assess for hyperlipidemia, a risk factor for atherosclerosis.
• Electrolyte and Renal Function Tests: Evaluate overall metabolic status and kidney function.
• Toxicology Screen: Rule out drug intoxication as a cause of stroke-like symptoms.

4. Pregnancy Test (for women of childbearing age): Essential for women of reproductive age before considering fibrinolytic therapy, as safety in pregnancy is not established.

5. Electrocardiogram (ECG): Detect cardiac arrhythmias, particularly atrial fibrillation, a major cause of cardioembolic stroke.

Nursing Interventions for Stroke

Nursing interventions are crucial for stroke patients, focusing on restoring brain perfusion, preventing complications, and facilitating rehabilitation.

Restoring Brain Perfusion: Acute Stroke Management

1. Rapid Initial Evaluation and Diagnostic Imaging: Within minutes of arrival, prioritize neurological assessment and STAT non-contrast head CT to confirm stroke and differentiate ischemic from hemorrhagic stroke.

2. Restoring Blood Flow in Ischemic Stroke:

• Thrombolytic Therapy (Alteplase/tPA): Administer IV alteplase as rapidly as possible within the eligible time window (typically within 3-4.5 hours of symptom onset, in select patients up to 24 hours for certain interventions). Alteplase is a tissue plasminogen activator that dissolves blood clots, restoring blood flow to ischemic brain tissue. Strict inclusion and exclusion criteria must be met to minimize bleeding risks.
• Mechanical Thrombectomy: For large vessel occlusions, mechanical thrombectomy is a highly effective intervention. A catheter is inserted into a major artery (usually femoral artery in the groin) and guided to the blocked cerebral artery to physically remove the clot. Thrombectomy can be performed up to 24 hours from symptom onset in carefully selected patients.

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

• NIHSS reassessments: Regularly repeat NIHSS to monitor for neurological improvement or deterioration.
• Pupillary checks: Assess pupil size, equality, and reactivity to light.
• Level of consciousness monitoring: Use Glasgow Coma Scale (GCS) or similar scales to track LOC changes.
• Speech, memory, and cognition assessment: Monitor for changes in language abilities, memory, and cognitive function.
• Mood and emotional status: Observe for mood changes, anxiety, or depression.
• Bilateral strength and coordination: Regularly assess motor strength and coordination in all extremities.

4. Medication Administration: Manage secondary complications and prevent further neurological damage:

• Antihypertensives: Carefully manage blood pressure within recommended ranges. In acute ischemic stroke, permissive hypertension may be allowed initially to maintain cerebral perfusion, unless thrombolytic therapy is administered. For hemorrhagic stroke, aggressive blood pressure control is crucial to limit bleeding.
• Antiseizure Medications: Prophylactic anticonvulsants may be considered in hemorrhagic stroke or cortical strokes, especially if seizures occur.
• Stool Softeners/Laxatives: Prevent constipation and straining during bowel movements, which can increase ICP.

5. Blood Pressure Management: Maintain blood pressure within target ranges:

• Ischemic Stroke: Permissive hypertension may be allowed initially (e.g., <220/120 mmHg if not receiving thrombolytics). If receiving alteplase, maintain BP <180/105 mmHg for at least 24 hours post-tPA. Gradual blood pressure reduction after the acute phase to manage underlying hypertension.
• Hemorrhagic Stroke: Aggressive blood pressure reduction is indicated to limit hematoma expansion. Target systolic BP of 140-160 mmHg or lower as per guidelines.

6. Mechanical Thrombectomy Preparation: If indicated, prepare the patient for thrombectomy:

• Ensure informed consent: Verify that the physician has discussed risks and benefits with the patient and family and that informed consent is obtained.
• Pre-procedure checklist: Complete pre-procedure checklist, including NPO status, allergies, and medication review.

7. Endovascular Techniques and Carotid Artery Disease Management:

• Carotid Endarterectomy (CEA): Surgical removal of plaque from the carotid artery to improve blood flow.
• Carotid Artery Stenting (CAS): Placement of a stent in the carotid artery to widen the narrowed artery and improve blood flow. These procedures are considered for patients with significant carotid artery stenosis to prevent future stroke.

Stroke Recovery and Prevention: Rehabilitation and Long-Term Management

1. Stroke Rehabilitation Referral: Early and comprehensive rehabilitation is crucial for maximizing functional recovery:

• Physical Therapy (PT): Improves mobility, balance, strength, and coordination.
• Occupational Therapy (OT): Focuses on regaining independence in activities of daily living (ADLs), such as dressing, bathing, and eating.
• Speech Therapy (ST): Addresses communication and swallowing difficulties (aphasia, dysarthria, dysphagia).
• Cognitive Therapy: Helps improve cognitive deficits such as memory, attention, and problem-solving.
• Rehabilitation settings: Inpatient rehabilitation facilities, outpatient therapy, home health therapy.

2. Managing Speech Deficits: Speech therapy is essential for patients with aphasia or dysarthria:

• Communication Partner Training: Educate family and caregivers on strategies to facilitate communication.
• Speech Practice: Utilize flashcards, books, computer programs, and visual aids for speech exercises.
• Augmentative and Alternative Communication (AAC) devices: Communication boards, pen and paper, apps for communication.

3. Medication Education: Educate patients on prescribed medications:

• Anticoagulants (Apixaban, Dabigatran, Rivaroxaban, Warfarin, Heparin, Enoxaparin): Prevent blood clot formation, especially in atrial fibrillation. Aspirin for secondary stroke prevention.
• Antiplatelet agents (Aspirin, Clopidogrel): Prevent platelet aggregation and clot formation, used for secondary stroke prevention.
• Antihypertensives (Diuretics, Beta-blockers, Calcium channel blockers, ACE inhibitors, ARBs): Control hypertension to reduce stroke risk.
• Statins: Lower cholesterol levels to reduce atherosclerosis.
• Antidiabetic medications: Manage diabetes to reduce vascular complications.

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

• Fall precautions: Bed alarms, chair alarms, side rails, clear pathways, non-slip footwear.
• Assistive devices: Walkers, canes, wheelchairs, grab bars, raised toilet seats.
• Home safety modifications: Remove hazards, improve lighting, install handrails.

5. Support Group Encouragement: Refer patients and families to stroke support groups for emotional support, peer interaction, and shared experiences.

6. Lifestyle Modification Education: Educate on modifiable risk factors and lifestyle changes:

• Healthy diet: Low in saturated and trans fats, cholesterol, and sodium; high in fruits, vegetables, and whole grains.
• Regular exercise: Aim for at least 30 minutes of moderate-intensity exercise most days of the week.
• Smoking cessation: Provide resources and support for quitting smoking.
• Limit alcohol consumption: Moderate alcohol intake or abstinence.
• Weight management: Achieve and maintain a healthy weight.
• Stress management techniques: Yoga, meditation, relaxation exercises.

7. Adherence to Treatment Regimens: Emphasize the importance of medication adherence and follow-up care for managing comorbidities like hypertension, diabetes, and hyperlipidemia.

Nursing Care Plans for Stroke: Addressing Common Nursing Diagnoses

Nursing care plans are essential tools for organizing and prioritizing nursing care for stroke patients. They are structured around identified nursing diagnoses, outlining expected outcomes, and guiding nursing interventions. Here are examples of nursing care plans for common nursing diagnoses in stroke patients:

1. Impaired Verbal Communication

Stroke frequently affects communication abilities. Patients may experience difficulty understanding or expressing language due to neurological damage.

Nursing Diagnosis: Impaired Verbal Communication

Related to:

• Prolonged cerebral occlusion leading to neurological damage.
• Dysarthria (weakness of speech muscles).
• Aphasia (language impairment affecting comprehension and/or production).

As evidenced by:

• Slurred speech.
• Nonverbal communication.
• Difficulty forming words (expressive aphasia).
• Difficulty understanding spoken language (receptive aphasia).
• Slow or delayed responses due to comprehension difficulties.
• Extremity weakness or paralysis hindering written communication.

Expected Outcomes:

• Patient will establish effective communication methods to express needs and thoughts.
• Patient will actively participate in speech therapy to improve communication skills.
• Patient will utilize assistive communication devices and resources as needed.

Assessment:

1. Determine type of aphasia: Differentiate between global aphasia (severe impairment of both comprehension and expression), Wernicke’s aphasia (fluent but nonsensical speech with impaired comprehension), and Broca’s aphasia (non-fluent speech with relatively preserved comprehension).
2. Observe communication methods: Identify patient’s attempts to communicate through gestures, sounds, or nonverbal cues. Involve family to understand the patient’s communication style.

Interventions:

1. Use simple and direct language: Speak slowly and clearly, face the patient, use short sentences and concrete language. Avoid abstract concepts. Ask yes/no questions.
2. Employ alternative communication methods: Utilize writing, drawing, picture boards, flashcards, or communication apps. Establish a system of nonverbal cues (e.g., thumbs up/down, eye blinks).
3. Encourage speech therapy: Speech-language pathologists are crucial for language rehabilitation, improving speech, comprehension, and swallowing. Therapy can help restore language abilities and teach compensatory strategies and device use.
4. Promote family involvement: Family education and participation in therapy sessions are essential. Families can learn communication techniques to support the patient at home.

2. Ineffective Cerebral Tissue Perfusion

Stroke directly impairs blood flow to the brain, leading to oxygen deprivation and potential brain tissue damage.

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion

Related to:

• Interruption of cerebral blood flow due to stroke.
• Thrombus or embolus formation (ischemic stroke).
• Arterial rupture and hemorrhage (hemorrhagic stroke).
• Cerebral edema (swelling).
• Increased intracranial pressure (ICP).

As evidenced by:

• Altered mental status (confusion, decreased LOC).
• Blurred vision or visual disturbances.
• Slurred speech.
• Extremity weakness or paralysis.
• Changes in vital signs (hypertension, bradycardia).

Expected Outcomes:

• Patient will recognize stroke symptoms and seek prompt medical attention in the future.
• Patient will demonstrate improved cerebral perfusion, evidenced by stable vital signs within prescribed parameters and improved neurological status.
• Patient will show improvement in stroke-related deficits (speech, weakness, swallowing) by discharge.

Assessment:

1. Establish baseline neurological status: Determine the “last known well” time to guide treatment decisions (thrombolytics). Use baseline assessment for comparison to detect changes.
2. Perform frequent neurological assessments: Use NIHSS and other neurological assessments as per facility protocol. Monitor LOC, pupillary responses, motor function, sensory function, speech, and language.
3. Review brain imaging results (CT, MRI): Confirm stroke diagnosis and type (ischemic or hemorrhagic) to guide treatment strategy.

Interventions:

1. Maintain blood pressure within ordered parameters: Manage BP to optimize cerebral perfusion while avoiding extremes. Follow physician’s orders for target BP ranges, which vary depending on stroke type and treatment.
2. Administer thrombolytics (for ischemic stroke): If indicated and within the time window, administer alteplase to dissolve clots and restore blood flow. Monitor for bleeding complications.
3. Educate about stroke risk factors: Provide patient and family education on modifiable risk factors (hypertension, diabetes, smoking, hyperlipidemia, heart disease, inactivity, unhealthy diet, stress) for secondary stroke prevention.
4. Instruct on stroke symptom recognition using FAST: Educate patient and family about F.A.S.T. (Face, Arms, Speech, Time) to promote rapid recognition and response to stroke symptoms. Emphasize “Time is brain.”

3. Risk for Injury

Stroke-related impairments, including motor deficits, sensory loss, and cognitive changes, significantly increase the risk of falls and other injuries.

Nursing Diagnosis: Risk for Injury

Related to:

• Impaired judgment and cognitive deficits.
• Spatial-perceptual deficits.
• Muscle weakness (hemiparesis).
• Poor motor coordination and balance.
• Impaired sensory awareness (e.g., loss of sensation).
• Dysphagia and aspiration risk.
• Communication difficulties.
• Hemiplegia or paralysis.
• Short attention span and impulsivity.
• Unilateral neglect.

Expected Outcomes:

• Patient will remain free from falls and other injuries during hospitalization and rehabilitation.
• Patient will maintain intact skin integrity and prevent pressure ulcers.
• Caregivers will create a safe environment and utilize strategies to minimize injury risk.

Assessment:

1. Determine stroke-related deficits: Identify specific impairments based on the affected brain area. Right-brain strokes may lead to spatial-perceptual issues and impulsivity, while left-brain strokes may affect speech and swallowing.
2. Assess sensory awareness: Test for sensation to light touch, pain, and temperature to identify sensory deficits that increase injury risk.
3. Assess for neglect and visual disturbances: Evaluate for unilateral neglect (inattention to one side of the body or environment) and visual field deficits (hemianopsia), which increase risk of falls and collisions.

Interventions:

1. Implement fall precautions: Utilize bed and chair alarms, keep bed in low position, ensure side rails are up (as appropriate), provide non-slip footwear, maintain clear pathways, and assist with ambulation.
2. Assist with eating and swallowing: For patients with dysphagia, implement aspiration precautions, provide thickened liquids and pureed foods as ordered, ensure upright positioning during meals, and monitor for signs of aspiration (coughing, choking).
3. Teach environmental scanning: For patients with neglect or visual field deficits, teach scanning techniques (systematically turning head to view the neglected side) to improve awareness of surroundings and reduce collision risk.
4. Provide skin care and pressure ulcer prevention: For patients with paralysis or sensory loss, implement regular turning and repositioning (every 2 hours), pressure-relieving mattresses and cushions, and skin assessments to prevent pressure ulcers.

4. Self-Care Deficit

Stroke-related physical and cognitive impairments can significantly impact a patient’s ability to perform self-care activities.

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

Related to:

• Neurobehavioral manifestations of stroke.
• Muscle weakness (hemiparesis, hemiplegia).
• Musculoskeletal impairment.
• Cognitive dysfunction (impaired memory, attention, executive function).
• Decreased motivation.
• Impaired physical mobility.
• Unilateral neglect.

As evidenced by:

• Inability to independently perform bathing and hygiene activities.
• Inability to dress or undress independently.
• Impaired ability to use eating utensils, prepare food, or self-feed.
• Inability to access the bathroom or manage toileting needs independently.

Expected Outcomes:

• Patient will maintain skin integrity and be free from body odor.
• Patient will effectively utilize assistive devices and methods for bathing and hygiene.
• Patient will report satisfaction with bathing and hygiene, even with caregiver assistance.
• Patient will be able to dress and perform ADLs to their optimal potential.
• Patient will demonstrate competence in using assistive devices for ADLs.
• Patient will be able to feed themselves safely and effectively.
• Patient will maintain bowel and bladder continence, or manage incontinence effectively, and maintain skin integrity in perineal area.

Assessment:

1. Assess functional ability and limitations: Evaluate the patient’s ability to perform ADLs (bathing, dressing, feeding, toileting) and identify specific limitations due to physical, cognitive, or sensory deficits.
2. Assess patient preferences: Inquire about patient’s preferences and routines for self-care activities to promote comfort and dignity.
3. Perform risk assessments:
   • Fall risk assessment (Morse Fall Scale): Identify fall risk factors.
   • Skin assessment (Braden Scale): Assess pressure ulcer risk.
   • Swallowing assessment: Evaluate swallowing ability before oral intake to prevent aspiration.

Interventions:

1. Establish a toileting schedule: Promote bowel and bladder regularity, especially for patients with decreased mobility and risk of constipation. Offer toileting assistance regularly.
2. Encourage independence: Promote patient independence in self-care activities as much as possible, providing assistance only as needed.
3. Ensure adequate mealtime: Allow sufficient time for meals, especially for patients with dysphagia or slow eating pace.
4. Assist with adaptive equipment: Introduce and train patients on the use of adaptive equipment for dressing, bathing, feeding, and toileting (button hooks, zipper pulls, shower chairs, long-handled utensils, etc.).
5. Consult with physical and occupational therapy: Refer to PT and OT for rehabilitation to improve motor skills, coordination, and ADL skills.

5. Unilateral Neglect

Unilateral neglect is a common consequence of stroke, particularly right-hemisphere strokes, where patients are unaware of or inattentive to one side of their body or environment.

Nursing Diagnosis: Unilateral Neglect

Related to:

• Brain damage from stroke, especially affecting the parietal lobe.
• Ischemia of cerebral tissue.
• Sensory and perceptual deficits.

As evidenced by:

• Altered safety behavior on the neglected side (e.g., bumping into objects on one side).
• Failure to move eyes or head towards the neglected side (hemianopsia).
• Inability to move limbs on the neglected side (hemiparesis/hemiplegia).
• Difficulty grooming or attending to the neglected side of the body.
• Unawareness of the position of the neglected limb in space.
• Eating food only on one side of the plate.
• Ignoring people or objects on the neglected side.

Expected Outcomes:

• Patient will demonstrate techniques to minimize unilateral neglect and increase awareness of the affected side.
• Patient will safely care for both sides of the body and prevent injury to the neglected side.
• Patient will achieve the highest possible level of function based on individual goals and abilities.

Assessment:

1. Assess for signs of unilateral neglect: Observe for behaviors indicating neglect, such as ignoring one side of the body, bumping into objects, eating only half of the meal, or not responding to stimuli on the affected side.
2. Assess level of awareness of neglect: Determine if the patient is aware of their neglect and to what extent. Patient education and practice are needed to improve awareness.
3. Assess skin on the neglected side: Inspect skin for injury or breakdown, as patients may be unaware of pain or pressure on the neglected side.

Interventions:

1. Initiate fall precautions: Patients with unilateral neglect are at high fall risk due to impaired awareness of their surroundings and potential one-sided weakness. Implement fall precautions.
2. Encourage assistive devices: Recommend and train on the use of assistive devices (e.g., walkers, reachers) to compensate for neglect and enhance safety.
3. Instruct on neutral body positioning: Encourage maintaining neutral body alignment and regular position changes to prevent pain, joint subluxation, and contractures. Promote self-monitoring of body position.
4. Position belongings on the unaffected side: Initially place personal items and call light on the patient’s unaffected side to encourage interaction and reduce frustration. Gradually encourage reaching towards the affected side.
5. Coordinate rehabilitation program: Refer to physical, occupational, and speech therapy for comprehensive rehabilitation to address neglect, improve awareness, and maximize functional recovery. Rehabilitation strategies for neglect may include visual scanning training, limb activation techniques, and environmental adaptation.

References

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

Alt text: Infographic depicting the FAST acronym for stroke assessment: Face drooping, Arm weakness, Speech difficulty, Time to call emergency services.

Alt text: Chart outlining components of the National Institutes of Health Stroke Scale (NIHSS) used for neurological assessment.

Alt text: Image showcasing a multidisciplinary stroke rehabilitation team including physical therapist, occupational therapist, speech therapist, and nurse working with a stroke patient.