Nursing Diagnosis for Stroke: A Comprehensive Guide for Nurses

A stroke, medically termed a cerebrovascular accident (CVA), 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 essential nutrients, leading to rapid cell damage and potential long-term disability. Understanding the nuances of stroke and the crucial role of nursing care, particularly in identifying and addressing key nursing diagnoses, is paramount for effective patient management and improved outcomes.

Understanding Stroke: Types and Impact

Strokes are broadly classified into two primary categories: ischemic and hemorrhagic, each with distinct causes and requiring different management strategies. Recognizing these differences is fundamental in nursing care.

Ischemic Stroke: Blockage of Blood Flow

Ischemic strokes, accounting for the majority of stroke cases, are triggered by a reduction or complete cessation of blood flow to a specific brain area. This blockage is often a result of clots that obstruct arteries leading to the brain. Without a continuous supply of oxygen and glucose, brain cells in the affected region begin to die within minutes, leading to neurological deficits.

These blockages can stem from various sources:

• 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 (like fatty plaque) that travels from another part of the body (often the heart or large arteries) and lodges in a smaller brain artery.
• Systemic Hypoperfusion: Reduced blood flow to all parts of the brain, often due to severe hypotension (low blood pressure).

Nursing considerations for ischemic stroke focus on rapid recognition, timely intervention to restore blood flow (often through thrombolytic therapy or mechanical thrombectomy), and vigilant monitoring for neurological changes and complications.

Hemorrhagic Stroke: Bleeding in the Brain

Hemorrhagic strokes occur when a blood vessel in the brain ruptures, leading to bleeding within the brain tissue or the spaces surrounding the brain. This bleeding increases pressure within the skull, damaging brain cells and disrupting normal brain function.

Common causes of hemorrhagic stroke include:

• Intracerebral Hemorrhage: Bleeding directly into the brain tissue, often linked to hypertension, arteriovenous malformations (AVMs), or amyloid angiopathy.
• Subarachnoid Hemorrhage: Bleeding into the space between the brain and the surrounding membrane (subarachnoid space), frequently caused by ruptured aneurysms.

Nursing care for hemorrhagic stroke centers around controlling bleeding and intracranial pressure, preventing secondary injury, and managing neurological deficits. Thrombolytic therapy is contraindicated in hemorrhagic stroke due to the risk of exacerbating bleeding.

Transient Ischemic Attacks (TIAs): Warning Signs

Transient ischemic attacks (TIAs), sometimes called “mini-strokes,” are characterized by temporary disruptions of blood flow to the brain. Symptoms of TIA are similar to those of a full stroke but are transient, typically resolving within minutes to hours (almost always within 24 hours) without causing permanent brain damage.

Despite their temporary nature, TIAs are significant warning signs. They indicate an increased risk of future, more severe strokes. Therefore, patients experiencing TIAs require prompt medical evaluation to identify the underlying cause and implement preventive strategies, including lifestyle modifications and medication management to mitigate future stroke risk. Nursing plays a vital role in educating patients about TIA symptoms and the importance of seeking immediate medical attention.

The Nursing Process in Stroke Care

The nursing process—assessment, diagnosis, planning, implementation, and evaluation—is the cornerstone of effective stroke care. Given the rapid and potentially devastating impact of stroke, a systematic and timely nursing approach is crucial for optimizing patient outcomes.

Importance of Systematic Nursing Process

In stroke management, the nursing process is not just a procedural framework; it is a dynamic and responsive approach that guides nurses in:

• Early Detection: Recognizing subtle and rapidly changing stroke symptoms.
• Accurate Assessment: Gathering comprehensive data about the patient’s neurological status, medical history, and risk factors.
• Prioritization of Care: Identifying immediate life-threatening issues and planning interventions to stabilize the patient.
• Individualized Care Planning: Developing tailored care plans based on specific nursing diagnoses and patient needs.
• Continuous Monitoring and Evaluation: Assessing the effectiveness of interventions and adjusting the care plan as needed.

Role of NIH Stroke Scale (NIHSS)

The National Institutes of Health Stroke Scale (NIHSS) is a standardized and widely used tool for quantifying the neurological deficit in stroke patients. Nurses certified in NIHSS administration play a critical role in performing these assessments accurately and reliably. The NIHSS provides:

• Objective Measurement: A numerical score reflecting the severity of the stroke.
• Baseline Assessment: Establishing a starting point for monitoring neurological changes.
• Communication Tool: Facilitating clear communication among healthcare team members about the patient’s condition.
• Prognostic Indicator: NIHSS scores can help predict stroke outcome and guide treatment decisions.

Regular NIHSS assessments, often performed at frequent intervals in the acute stroke phase, enable nurses to detect subtle deteriorations or improvements in neurological function, prompting timely interventions.

Compassionate Care and Holistic Approach

Beyond the technical aspects of stroke care, compassionate nursing is essential. Stroke can lead to profound physical, emotional, and psychosocial challenges for patients and their families. Nurses provide holistic care by:

• Maintaining Patient Safety and Dignity: Ensuring a safe environment and respecting the patient’s dignity, especially when patients are dependent on care for basic needs.
• Addressing Psychosocial Needs: Recognizing and addressing the emotional impact of stroke, including depression, anxiety, and frustration related to disability.
• Providing Emotional Support: Offering empathy, reassurance, and support to both patients and their families during a stressful and uncertain time.
• Facilitating Rehabilitation: Collaborating with the interdisciplinary team to plan and implement rehabilitation strategies that maximize functional recovery and quality of life.

Image alt text: Diagram illustrating the two main types of stroke, ischemic (blocked artery) and hemorrhagic (bleeding artery), with brief descriptions of each.

Comprehensive Nursing Assessment for Stroke

A thorough nursing assessment is the first critical step in providing effective care for stroke patients. This assessment encompasses both subjective and objective data collection, focusing on neurological status, risk factors, and overall patient condition.

Subjective Data: Review of Health History

Gathering subjective data involves obtaining information directly from the patient (if possible) or family members about the patient’s symptoms, medical history, and lifestyle.

General Symptoms: Recognizing Stroke Onset

Sudden onset of neurological symptoms is the hallmark of stroke. Nurses should inquire about and document the presence of any of the following:

• Hemiparesis or Hemiplegia: Weakness or paralysis affecting one side of the body, typically involving the face, arm, and leg on the same side.
• Sensory Deficits: Numbness, tingling, or loss of sensation in the face, arm, or leg, often unilateral.
• Dysphagia: Difficulty swallowing, which increases the risk of aspiration pneumonia.
• Visual Disturbances: Sudden changes in vision, such as blurred vision, double vision, loss of vision in one or both eyes, or visual field deficits (e.g., hemianopia – loss of half of the visual field).
• Speech Difficulties:
  • Expressive Aphasia (Broca’s Aphasia): Difficulty producing speech, understanding language remains relatively intact.
  • Receptive Aphasia (Wernicke’s Aphasia): Difficulty understanding spoken language, speech may be fluent but nonsensical.
  • Dysarthria: Difficulty articulating words due to muscle weakness affecting speech.
• Ataxia: Uncoordinated movements, unsteady gait, and balance problems.
• Alterations in Balance and Coordination: Sudden dizziness, vertigo, or loss of balance.
• Changes in Mental Status: Confusion, disorientation, decreased alertness, or loss of consciousness.

Onset of Symptoms: Time is Critical

Documenting the precise time of symptom onset or “last known well” (the last time the patient was known to be at their baseline neurological function) is crucial. This time window is critical for determining eligibility for time-sensitive treatments like thrombolytic therapy.

Risk Factors: Identifying Predisposing Conditions

Identifying stroke risk factors helps in understanding the patient’s susceptibility and guides long-term prevention strategies. Key risk factors to assess include:

• Age: Risk increases significantly with age, especially after 55 years.
• Ethnicity: African Americans and Hispanics have a higher stroke incidence compared to Caucasians.
• Gender: Stroke is more common in men, although women account for more stroke deaths.
• Prior Stroke or TIA: History of stroke or TIA significantly increases future stroke risk.

Medical History: Underlying Conditions

Certain medical conditions significantly elevate stroke risk, primarily ischemic stroke, which constitutes about 87% of all strokes. These conditions include:

• Hypertension: High blood pressure is the most significant modifiable risk factor for stroke.
• Obesity: Excess weight increases the risk of hypertension, diabetes, and hyperlipidemia, all stroke risk factors.
• Hypercholesterolemia: High cholesterol levels contribute to atherosclerosis.
• Diabetes Mellitus: Diabetes damages blood vessels and increases clot risk.
• Obstructive Sleep Apnea: Associated with hypertension, atrial fibrillation, and other cardiovascular risks.
• Heart Disease: Conditions like coronary artery disease, heart failure, and valve disorders increase stroke risk.
• Atrial Fibrillation: A common arrhythmia that significantly increases the risk of embolic stroke due to clot formation in the atria.
• COVID-19 Infection: Emerging evidence suggests an increased risk of stroke following COVID-19 infection.

Family History: Genetic Predisposition

A family history of stroke, particularly in first-degree relatives before age 65, increases an individual’s stroke risk. Genetic conditions like CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) are rare but can predispose to stroke.

Medication Review: Medications and Stroke Risk

A thorough medication review is essential. Certain medications can increase stroke risk or indicate pre-existing conditions that elevate risk:

• Birth Control Pills and Hormone Replacement Therapy (HRT): Estrogen-containing medications can increase clotting risk, especially in women who smoke or have other risk factors.
• Non-adherence to Blood Pressure Medications: Uncontrolled hypertension is a major stroke risk.
• Anticoagulants (Aspirin, Heparin, Warfarin, Enoxaparin): While used to prevent clots, their use may indicate pre-existing conditions like atrial fibrillation or clotting disorders, increasing overall stroke risk in some contexts.

Substance Use: Illegal Drug Link

Use of illicit substances, particularly stimulants like cocaine, amphetamines, and heroin, is linked to increased stroke risk, both ischemic and hemorrhagic.

Lifestyle Factors: Modifiable Risks

Lifestyle choices play a significant role in stroke risk. Assess for:

• Diet: High intake of cholesterol, saturated fats, and trans fats promotes atherosclerosis.
• Physical Inactivity: Lack of exercise increases cardiovascular risk factors.
• Excessive Alcohol Consumption: Heavy drinking can raise blood pressure and increase bleeding risk.
• Smoking: Damages blood vessels, promotes clot formation, and increases blood pressure.

Objective Data: Physical Assessment

Objective data is gathered through direct observation and physical examination.

F.A.S.T. Recognition: Immediate Stroke Signs

Utilize the F.A.S.T. acronym to rapidly assess for key stroke symptoms:

• F – Face: Ask the person to smile. Check for facial drooping or asymmetry.
• A – Arms: Ask the person to raise both arms. Observe for arm weakness or drift.
• S – Speech: Ask the person to repeat a simple sentence. Check for slurred speech or difficulty speaking.
• T – Time: Note the time of symptom onset and call emergency services immediately if any of these signs are present.

ABCs Assessment: Initial Stabilization

Perform a rapid initial assessment focusing on Airway, Breathing, and Circulation (ABCs). Stroke patients are at risk for airway compromise due to decreased level of consciousness, aspiration, and respiratory depression from increased intracranial pressure.

NIH Stroke Scale (NIHSS) Examination: Detailed Neurological Assessment

A comprehensive neurological examination using the NIHSS is crucial. It assesses:

• Level of Consciousness (LOC): Alertness, orientation, and responsiveness to stimuli.
• Gaze: Extraocular movements and presence of gaze deviation.
• Visual Fields: Assess for visual field deficits like hemianopia.
• Facial Palsy: Observe for facial droop and weakness.
• Motor Arm: Strength and movement in both arms.
• Motor Leg: Strength and movement in both legs.
• Limb Ataxia: Coordination of limb movements.
• Sensory: Sensation to pinprick in limbs and trunk.
• Language: Assess for aphasia (expressive and receptive), naming ability, and repetition.
• Dysarthria: Assess clarity of speech articulation.
• Inattention (Neglect): Awareness of stimuli in both visual fields and body sides.

Vital Signs: Monitoring Hemodynamics

Monitor vital signs closely, particularly blood pressure. Hypertension is common in acute stroke. However, excessively rapid blood pressure reduction can be detrimental, especially in ischemic stroke, as it can reduce cerebral perfusion.

Diagnostic Procedures: Confirming Stroke and Guiding Treatment

Diagnostic procedures are essential to confirm the diagnosis of stroke, differentiate between ischemic and hemorrhagic stroke, and identify potential underlying causes.

Blood Glucose Check: Rule Out Hypoglycemia

Perform a fingerstick glucose test immediately to rule out hypoglycemia, as its symptoms can mimic stroke.

Brain Imaging: Differentiating Stroke Types

Neuroimaging is paramount.

• Non-contrast Head CT: The initial imaging modality of choice for rapid evaluation. It effectively distinguishes between ischemic and hemorrhagic stroke. Hemorrhage is readily visible on CT, while early ischemic changes may be subtle or not immediately apparent.
• CT Angiography (CTA) and CT Perfusion (CTP) Scanning: CTA visualizes cerebral blood vessels to identify blockages or aneurysms. CTP assesses cerebral blood flow and tissue perfusion, helping to determine the extent of ischemic damage and potentially salvageable brain tissue (penumbra).
• Magnetic Resonance Imaging (MRI): MRI is more sensitive than CT in detecting early ischemic changes, particularly in the first few hours after stroke onset. Diffusion-weighted imaging (DWI) is highly sensitive to acute ischemia. MRI can also provide detailed information about hemorrhagic strokes and underlying vascular abnormalities.
• Carotid Duplex Scanning: Ultrasound imaging of the carotid arteries in the neck to detect stenosis (narrowing) due to plaque buildup, a common source of embolic stroke.
• Digital Subtraction Angiography (DSA): Invasive procedure providing detailed images of cerebral blood vessels, used less frequently due to its invasive nature but can be helpful in complex cases or for interventional procedures.

Laboratory Tests: Identifying Underlying Causes

Blood tests help identify potential underlying causes and guide treatment and prevention.

• Complete Blood Count (CBC): Evaluates for polycythemia (increased red blood cell count, increasing blood viscosity) or thrombocytopenia (low platelet count, affecting coagulation).
• Cardiac Biomarkers (Troponin, CK-MB): Assess for cardiac injury or myocardial infarction, which can be associated with cardioembolic stroke.
• Toxicology Screen: Rule out drug intoxication as a cause of stroke-like symptoms, especially in younger patients.
• Fasting Lipid Profile: Identifies hyperlipidemia, a major risk factor for atherosclerosis.
• Coagulation Studies (PT, aPTT, INR): Baseline coagulation status before administering anticoagulants or antiplatelet agents.

Pregnancy Test: For Women of Childbearing Age

Perform a urine pregnancy test for women of childbearing age before considering fibrinolytic therapy, as the safety of thrombolytics in pregnancy is not well-established.

Electrocardiogram (ECG): Detecting Cardiac Arrhythmias

An ECG helps detect cardiac arrhythmias, particularly atrial fibrillation, a common cause of cardioembolic stroke. Identifying and managing atrial fibrillation is crucial for secondary stroke prevention.

Image alt text: Nurse assessing a stroke patient’s facial droop using the FAST method, highlighting the importance of rapid stroke symptom recognition.

Essential Nursing Interventions for Stroke Patients

Nursing interventions are crucial throughout the stroke continuum, from acute management to rehabilitation and secondary prevention.

Restoring Brain Perfusion: Acute Stroke Management

The primary goal in acute ischemic stroke management is to restore blood flow to the ischemic penumbra (the area of brain tissue surrounding the core infarct that is potentially salvageable).

Initial Evaluation and Imaging: Time is Brain

Within minutes of arrival in the emergency department, patients with suspected stroke should undergo brain imaging, ideally a STAT non-contrast head CT. This is essential to rapidly differentiate between ischemic and hemorrhagic stroke and determine treatment eligibility.

Alteplase Administration: Thrombolytic Therapy

For eligible patients with confirmed ischemic stroke, intravenous alteplase (tissue plasminogen activator – tPA) is the gold standard treatment. Alteplase is a thrombolytic agent that dissolves blood clots, restoring blood flow.

• Eligibility Criteria: Strict criteria must be met, including symptom onset within a specific time window (typically within 3 hours, and up to 4.5 hours in select patients based on AHA/ASA guidelines), absence of contraindications (e.g., recent surgery, bleeding disorders, hemorrhagic stroke).
• Contraindications: Alteplase is absolutely contraindicated in hemorrhagic stroke due to the risk of worsening bleeding.
• Administration: Administered intravenously, typically as a bolus followed by an infusion over 60 minutes.
• Nursing Responsibilities: Meticulous monitoring during and after alteplase administration for signs of bleeding (intracranial hemorrhage, systemic bleeding), neurological deterioration, and allergic reactions.

Neurologic Status Monitoring: Frequent Assessments

Following stroke and especially after thrombolytic therapy, frequent neurological assessments are paramount to detect changes promptly and intervene as needed.

• Frequency: Neurological assessments, including NIHSS, are typically performed every 15-30 minutes during and immediately after alteplase infusion, then less frequently (e.g., hourly, then every 2-4 hours) as the patient stabilizes.
• Key Assessments: Monitor LOC, pupil size and reactivity, speech, memory, cognition, mood changes, and bilateral strength and coordination.

Medication Management: Secondary Prevention and Symptom Control

Medications are essential for managing secondary complications and preventing stroke recurrence.

• Blood Pressure Medications: Maintain blood pressure within target ranges. In the acute phase of ischemic stroke, permissive hypertension may be allowed initially to maintain cerebral perfusion, especially if thrombolysis is not performed. However, excessively high blood pressure needs to be managed. For hemorrhagic stroke, blood pressure control is crucial to limit hematoma expansion.
• Seizure Prophylaxis: Anticonvulsants may be considered for short-term prophylaxis, particularly in hemorrhagic stroke or strokes involving the cerebral cortex, if there is a high risk of seizures.
• Stool Softeners/Laxatives: Prevent constipation and straining during bowel movements, as straining can increase intracranial pressure, which is particularly detrimental in hemorrhagic stroke.

Blood Pressure Management: Target Ranges

Blood pressure management in acute stroke is nuanced and depends on the stroke type and treatment strategy.

• Ischemic Stroke: For patients receiving IV alteplase, the recommended blood pressure target is generally less than 180/105 mm Hg for the first 24 hours post-treatment to reduce the risk of intracranial hemorrhage. For patients not receiving thrombolysis, current guidelines often recommend allowing moderate hypertension in the acute phase to maintain cerebral perfusion, unless there are compelling reasons to lower it (e.g., aortic dissection, myocardial infarction). Blood pressure is typically lowered gradually over days to weeks to manage underlying hypertension.
• Hemorrhagic Stroke: Aggressive blood pressure control is often indicated to limit hematoma expansion. Guidelines typically recommend a target systolic blood pressure of around 140 mmHg or lower.

Mechanical Thrombectomy: Advanced Clot Removal

For patients with large vessel occlusions (blockages in major cerebral arteries), mechanical thrombectomy is a highly effective intervention. This procedure involves inserting a catheter, typically through the femoral artery in the groin, to physically remove the clot.

• Eligibility: Patients must meet specific criteria, including large vessel occlusion confirmed by imaging and symptom onset within a certain time window (extended compared to alteplase).
• Nursing Role: Pre-procedure preparation, post-procedure monitoring for bleeding at the insertion site, neurological changes, and vascular complications. Ensure informed consent is obtained and that family understands risks and benefits.

Endovascular Techniques: Carotid Artery Disease

For patients with significant carotid artery stenosis, endovascular procedures may be indicated to reduce stroke risk.

• Carotid Endarterectomy: Surgical removal of plaque from the carotid artery.
• Carotid Artery Stenting: Placement of a stent to open up a narrowed carotid artery.
• Nursing Care: Pre- and post-procedure care includes monitoring for neurological changes, bleeding, infection, and vascular complications.

Stroke Recovery and Prevention: Rehabilitation and Long-Term Management

Stroke recovery is a multifaceted process that often requires ongoing rehabilitation and lifestyle modifications to prevent future strokes.

Stroke Rehabilitation Referral: Multidisciplinary Approach

Early referral to stroke rehabilitation is crucial to maximize functional recovery. Rehabilitation is typically interdisciplinary, involving:

• Physical Therapy: Improving motor skills, mobility, balance, and strength.
• Occupational Therapy: Enhancing activities of daily living (ADLs), fine motor skills, and cognitive-perceptual skills.
• Speech Therapy: Addressing communication and swallowing difficulties (aphasia, dysarthria, dysphagia).
• Cognitive Therapy: Improving cognitive function, memory, attention, and problem-solving.
• Rehabilitation Nursing: Coordinating care, providing ongoing support and education, and managing medical needs during rehabilitation.

Managing Speech Deficits: Communication Strategies

Speech therapy is central to managing aphasia and dysarthria. Nursing interventions to support communication include:

• Communication Partner Training: Educating family and caregivers on effective communication strategies.
• Speech Practice: Encouraging and facilitating speech practice using various tools (flashcards, apps, books).
• Alternative Communication Methods: Utilizing communication boards, writing, gestures, or assistive technology as needed.
• Patience and Encouragement: Creating a supportive and patient environment for communication attempts.

Medication Education: Adherence and Understanding

Comprehensive medication education is vital for long-term management and secondary stroke prevention. Common medications include:

• Anticoagulants (Apixaban, Dabigatran, Rivaroxaban, Warfarin, Heparin, Enoxaparin): Prescribed for patients with atrial fibrillation or other conditions that increase clot risk to prevent embolic stroke. Education includes dosage, timing, monitoring (INR for warfarin), and signs of bleeding.
• Antiplatelet Agents (Aspirin, Clopidogrel): Used to prevent platelet aggregation and reduce ischemic stroke risk. Education includes dosage and potential side effects.
• Blood Pressure Medications (Diuretics, Beta-blockers, ACE Inhibitors, Calcium Channel Blockers): To manage hypertension. Education includes medication names, dosages, timing, and importance of adherence.
• Statins: To lower cholesterol levels and reduce atherosclerotic risk. Education includes medication name, dosage, and potential side effects.

Safety Strategies: Fall Prevention

Stroke-related deficits, such as weakness, balance problems, and visual field deficits, significantly increase fall risk. Safety measures include:

• Bed and Chair Alarms: To alert staff if a patient attempts to get out of bed or chair unassisted.
• Bed Rails: Raising bed rails for safety, as appropriate.
• Call Light within Reach: Ensuring the patient can easily call for assistance.
• Assistive Devices: Providing walkers, canes, or wheelchairs as needed.
• Environmental Safety: Removing clutter, ensuring adequate lighting, and addressing hazards in the patient’s environment.

Support Groups: Emotional and Social Support

Referral to stroke support groups is invaluable for both patients and caregivers. Support groups provide:

• Emotional Support: A sense of community and shared experience, reducing feelings of isolation and anxiety.
• Practical Advice: Sharing coping strategies and resources.
• Hope and Encouragement: Seeing others who have navigated similar challenges and achieved recovery.

Lifestyle Modifications: Risk Factor Management

Educating patients on lifestyle modifications to reduce stroke risk is crucial for secondary prevention. This includes:

• Dietary Changes: Adopting a heart-healthy diet low in saturated and trans fats, cholesterol, and sodium, and high in fruits, vegetables, and whole grains.
• Regular Exercise: Encouraging at least 30 minutes of moderate-intensity exercise most days of the week.
• Smoking Cessation: Providing resources and support to quit smoking.
• Limiting Alcohol Consumption: Advising moderation or abstinence.
• Weight Management: Achieving and maintaining a healthy weight.

Adherence to Treatment Regimens: Comorbidity Management

Ensuring adherence to treatment regimens for coexisting conditions like hypertension, diabetes, hyperlipidemia, and atrial fibrillation is vital for long-term stroke prevention. This involves:

• Medication Adherence: Reinforcing the importance of taking medications as prescribed.
• Follow-up Appointments: Encouraging attendance at all scheduled medical appointments.
• Monitoring and Testing: Ensuring patients undergo recommended monitoring (e.g., blood pressure checks, blood glucose monitoring, lipid panels).

Common Nursing Diagnoses for Stroke and Care Plans

Nursing diagnoses provide a framework for organizing and prioritizing nursing care for stroke patients. Several common nursing diagnoses are frequently identified in stroke care.

Impaired Verbal Communication

Stroke often affects communication abilities. Patients may experience aphasia (language impairment), dysarthria (speech articulation difficulty), or both.

Nursing Diagnosis: Impaired Verbal Communication

Related to:

• Prolonged cerebral occlusion
• Dysarthria (weakened muscles used for speech)
• Aphasia (impaired ability to comprehend or produce language)

As evidenced by:

• Slurred speech
• Nonverbal communication
• Difficulty forming words
• Difficulty expressing thoughts
• Slow to respond due to delayed comprehension
• Extremity weakness or paralysis impacting writing/typing

Expected Outcomes:

• Patient will establish a functional communication method to express needs and thoughts.
• Patient will actively participate in speech therapy to improve communication skills.
• Patient will effectively utilize communication resources and devices as needed.

Assessment:

1. Note type of aphasia: Differentiate between global, Wernicke’s, and Broca’s aphasia to understand the specific communication deficits.
2. Observe communication methods: Identify any gestures, signals, or sounds the patient uses to communicate. Family input is valuable in understanding these.

Interventions:

1. Speak in short, direct sentences: Use clear, simple language, face the patient, and use visual cues. “Yes/No” questions may be easiest.
2. Utilize alternative communication methods: Employ writing, drawing, flashcards, or picture boards. Establish nonverbal signals like thumbs up/down.
3. Encourage speech therapy: Speech-language therapy is crucial for rehabilitation and improving communication skills.
4. Encourage family participation: Family involvement in therapy and learning communication strategies is essential for support at home.

Ineffective Cerebral Tissue Perfusion

Impaired blood flow to the brain is the fundamental pathophysiology of stroke, leading to ineffective cerebral tissue perfusion.

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion

Related to:

• Interruption of blood flow to the brain
• Thrombus formation
• Artery occlusion
• Cerebral edema
• Hemorrhage

As evidenced by:

• Altered mental status
• Blurred vision
• Slurred speech
• Extremity weakness

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 ordered parameters.
• Patient will show improvement in stroke deficits (speech, weakness, swallowing) by discharge.

Assessment:

1. Determine baseline presentation: Establish the patient’s “last known well” state to assess for changes and guide treatment timing (e.g., thrombolytics).
2. Perform neurological assessments: Frequent NIHSS assessments to monitor LOC, motor, sensory, speech, and visual changes.
3. Obtain brain imaging (CT/MRI): Confirm stroke diagnosis, differentiate type, and guide treatment decisions.

Interventions:

1. Maintain blood pressure: Adhere to prescribed blood pressure parameters to optimize cerebral perfusion. May involve permissive hypertension in ischemic stroke initially, or aggressive lowering in hemorrhagic stroke.
2. Administer thrombolytics (if indicated): Timely administration of alteplase for ischemic stroke within the appropriate time window.
3. Educate on stroke risk factors: Educate patients and families about modifiable risk factors (hypertension, diabetes, smoking, etc.) for secondary prevention.
4. Instruct on stroke symptoms using FAST: Teach F.A.S.T. recognition to facilitate rapid response to future stroke symptoms. “Time is brain.”

Risk For Injury

Stroke-related impairments increase the risk of falls, aspiration, and other injuries.

Nursing Diagnosis: Risk For Injury

Related to:

• Impaired judgment
• Spatial-perceptual deficits
• Weakness
• Poor motor coordination
• Poor balance
• Poor concept of time
• Impaired sensory awareness
• Dysphagia
• Inability to communicate
• Hemiplegia
• Short attention span
• Impulsivity

Expected Outcomes:

• Patient will remain free from falls during hospitalization.
• Patient will maintain intact skin integrity.
• Caregivers will create a safe environment and provide support to prevent injury post-discharge.

Assessment:

1. Determine deficits related to brain injury area: Right-brain stroke may cause spatial-perceptual deficits and impulsivity; left-brain stroke may affect speech and swallowing.
2. Assess sensory awareness: Evaluate for impaired sensation to pain, temperature, or pressure, increasing skin breakdown risk.
3. Note neglect or visual disturbances: Assess for unilateral neglect and visual field deficits (hemianopia) which increase injury risk.

Interventions:

1. Use bed and chair alarms: Especially for impulsive patients or those with spatial neglect.
2. Assist with eating: Provide appropriate diet textures, thickened liquids for dysphagia; supervise eating to prevent aspiration.
3. Teach to scan the environment: For patients with neglect or hemianopia, teach visual scanning techniques to improve awareness of surroundings.
4. Turn and assess skin frequently: Regular skin assessments and turning schedules for immobile or paralyzed patients to prevent pressure ulcers.

Self-Care Deficit

Stroke often results in physical and cognitive impairments that hinder self-care abilities.

Nursing Diagnosis: Self-Care Deficit

Related to:

• Neurobehavioral manifestations
• Weakness
• Musculoskeletal impairment
• Cognitive dysfunction
• Decreased motivation
• Impaired physical mobility
• Unilateral neglect

As evidenced by:

• Inability to independently complete cleansing activities
• Inability to independently dress or undress
• Impaired ability to use eating utensils, prepare food, or self-feed
• Inability to access the bathroom or perform toileting

Expected Outcomes:

• Patient will maintain skin integrity and be free from body odor.
• Patient will verbalize successful use of assistive devices for bathing.
• Patient will express dignity and satisfaction with assisted bathing.
• Patient will dress and perform ADLs to optimal potential.
• Patient will demonstrate competence in using assistive devices.
• Patient will feed themselves safely and effectively.
• Patient will remain continent and maintain skin integrity in perineal area.

Assessment:

1. Assess functional ability and limitations: Evaluate physical, sensory, cognitive, and emotional impairments affecting self-care.
2. Assess patient preferences: Respect patient preferences and cultural needs in hygiene, feeding, and self-care.
3. Perform risk assessments routinely: Assess fall risk (Morse Fall Scale), skin breakdown risk (Braden Scale), and swallowing risk before oral intake.

Interventions:

1. Establish a toileting schedule: Regular toileting schedule, stool softeners to prevent constipation.
2. Encourage independence when possible: Promote self-care to maximize autonomy and rebuild self-esteem.
3. Ensure adequate mealtime: Allow sufficient time for meals, especially for patients with dysphagia.
4. Assist with adaptive equipment: Provide and train on assistive devices for dressing, bathing, grooming, and eating.
5. Consult physical and occupational therapy: Rehabilitation therapies to relearn skills and compensate for deficits.

Unilateral Neglect

Unilateral neglect is a condition where patients are unaware of one side of their body or space, commonly resulting from stroke.

Nursing Diagnosis: Unilateral Neglect

Related to:

• Disease process (stroke)
• Brain trauma or damage
• Ischemia of cerebral tissue

As evidenced by:

• Altered safety behavior on the neglected side
• Failure to move eyes or limbs in the neglected hemisphere
• Difficulty grooming neglected side
• Unawareness of neglected limb positioning

Expected Outcomes:

• Patient will demonstrate techniques to minimize unilateral neglect.
• Patient will care for both sides of the body and protect the neglected side from harm.
• 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 neglecting one side of the body during self-care, eating only from one side of the plate, or not responding to stimuli on the affected side.
2. Assess awareness of neglect: Evaluate the patient’s insight into their neglect and willingness to learn compensatory strategies.
3. Assess skin on the neglected side: Monitor for injury or skin breakdown due to lack of awareness or movement.

Interventions:

1. Initiate fall precautions: Due to one-sided weakness and neglect, fall risk is high. Use bed alarms and ensure call light is accessible.
2. Encourage assistive devices: Use of assistive devices can help patients attend to the neglected side and improve safety.
3. Instruct on neutral body positioning: Promote neutral alignment and regular position changes to prevent pain and contractures. Encourage awareness of neglected side.
4. Position belongings on unaffected side: Place items on the unaffected side initially to encourage interaction, then gradually move to the affected side to promote awareness.
5. Coordinate rehabilitation program: Early rehabilitation is essential to improve outcomes, self-care, and confidence in managing neglect.

References

References were not provided in the original text, thus, are not included in this rewritten version. In a real-world scenario, credible sources would be essential to validate the clinical information presented.