Nursing Diagnosis for Hemiplegia Post-Stroke: Comprehensive Guide

A cerebrovascular accident (CVA), commonly known as a stroke, 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 neurological deficits. Stroke is a critical medical emergency requiring immediate intervention to minimize brain damage and long-term disability. Hemiplegia, or paralysis of one side of the body, is a frequent and devastating consequence of stroke, significantly impacting a patient’s mobility, independence, and quality of life. Understanding the nursing diagnoses associated with hemiplegia post-stroke is crucial for effective patient care and rehabilitation.

Types of Stroke

Strokes are broadly classified into two primary categories: ischemic and hemorrhagic, each with distinct underlying mechanisms and treatment approaches.

Ischemic Strokes: These are the most prevalent type, accounting for approximately 87% of all stroke cases. Ischemic strokes arise from a blockage in the arteries supplying blood to the brain. This blockage, often caused by blood clots, fatty deposits (plaque), or other emboli, obstructs blood flow, leading to ischemia and infarction of brain tissue. The lack of oxygen and glucose quickly initiates a cascade of cellular damage, potentially resulting in permanent neurological impairment. Common causes of ischemic stroke include atherosclerosis, atrial fibrillation (leading to cardioembolic stroke), and small vessel disease.

Hemorrhagic Strokes: Hemorrhagic strokes occur when a blood vessel in the brain ruptures, causing bleeding into the brain tissue or the surrounding spaces. This bleeding increases intracranial pressure, compresses brain tissue, and disrupts normal brain function. Hemorrhagic strokes are further categorized into intracerebral hemorrhage (bleeding within the brain tissue) and subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane). Causes of hemorrhagic stroke include hypertension, aneurysms, arteriovenous malformations (AVMs), and anticoagulant medications. Hemorrhagic strokes are often more severe and have a higher mortality rate than ischemic strokes.

Transient Ischemic Attacks (TIAs): Often referred to as “mini-strokes,” TIAs are characterized by temporary disruptions in blood flow to the brain. The symptoms of a TIA are similar to those of a stroke but are transient, typically resolving within minutes to hours, and almost always within 24 hours, without causing permanent brain damage. TIAs serve as a critical warning sign of an increased risk of future stroke. Individuals experiencing TIA symptoms require prompt medical evaluation and management to identify and modify underlying risk factors and prevent a subsequent, more severe stroke.

Nursing Process

Following a stroke, patients exhibit a wide spectrum of disabilities, the severity of which is determined by factors such as the stroke’s location and extent, the time elapsed before treatment initiation, and pre-existing health conditions. Initial management of stroke patients typically occurs in intensive care units (ICUs) or step-down units, where specialized nursing care and continuous monitoring are available. Nurses caring for stroke patients often hold NIH Stroke Scale (NIHSS) certification, demonstrating their expertise in neurological assessment and stroke management. The dynamic and subtle nature of stroke symptoms necessitates vigilant monitoring, critical thinking, and swift nursing interventions to prevent neurological deterioration and optimize patient outcomes.

Severe strokes frequently result in significant disabilities, including hemiplegia, rendering patients dependent on others for basic needs such as feeding, bathing, and mobility. Long-term stroke deficits can be profoundly debilitating, leading to emotional distress and depression for both the patient and their family. Nurses play a crucial role in providing compassionate and holistic care, prioritizing patient safety and dignity while addressing their complex physical, psychological, and social needs throughout the stroke recovery journey. This includes focusing on specific nursing diagnoses related to common stroke sequelae like hemiplegia.

Nursing Assessment

The cornerstone of nursing care is a comprehensive nursing assessment, encompassing the collection of physical, psychosocial, emotional, and diagnostic data. This assessment guides the identification of relevant nursing diagnoses, such as those related to hemiplegia, and the subsequent development of individualized care plans.

Review of Health History

1. Elicit General Stroke Symptoms: Promptly inquire about the sudden onset of symptoms, as stroke manifestations are typically abrupt. Key indicators of a potential stroke include:

• Hemiparesis or Hemiplegia: Weakness or paralysis affecting the face, arm, and leg on one side of the body (contralateral to the brain lesion). Hemiplegia is a critical finding that directs nursing diagnosis and care planning.
• Sensory Deficits: Numbness or tingling (paresthesias) in the extremities, often on one side of the body.
• Dysphagia: Difficulty swallowing, increasing the risk of aspiration pneumonia and nutritional deficits.
• Visual Disturbances: Sudden vision loss in one or both eyes, double vision (diplopia), or visual field deficits like hemianopsia (loss of half of the visual field).
• Speech Difficulties:
  • Expressive Aphasia (Broca’s aphasia): Difficulty producing speech, despite understanding language. Patients may struggle to find words or form coherent sentences.
  • Receptive Aphasia (Wernicke’s aphasia): Difficulty understanding spoken language. Patients may speak fluently but their speech may be nonsensical.
  • Dysarthria: Difficulty articulating words due to muscle weakness affecting speech production.
• Ataxia: Unsteady gait, loss of balance and coordination.
• Balance and Coordination Alterations: Sudden dizziness, vertigo, or loss of balance.
• Changes in Mental Status: Confusion, disorientation, decreased level of consciousness, or sudden behavioral changes.

2. Determine Symptom Onset: Precisely document the time of symptom onset and the last known time the patient was at their neurological baseline. This information is critical for determining eligibility for thrombolytic therapy (alteplase), which has a narrow time window for administration in ischemic stroke.

3. Identify 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.
  • Ethnicity: African Americans and Hispanics have a higher stroke incidence.
  • Gender: Males have a slightly higher risk than females, although stroke is more common in 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.

• Modifiable Risk Factors:

  • Hypertension: Uncontrolled high blood pressure is a leading risk factor.
  • Hyperlipidemia: Elevated cholesterol and triglyceride levels contribute to atherosclerosis.
  • Diabetes Mellitus: Diabetes increases the risk of both ischemic and hemorrhagic stroke.
  • Obesity and Overweight: Excess body weight is linked to hypertension, diabetes, and hyperlipidemia.
  • Smoking: Smoking damages blood vessels and increases clot formation.
  • Excessive Alcohol Consumption: Heavy alcohol intake increases blood pressure and stroke risk.
  • Physical Inactivity: Lack of regular exercise contributes to cardiovascular risk factors.
  • Unhealthy Diet: Diets high in saturated and trans fats, cholesterol, and sodium increase stroke risk.
  • Obstructive Sleep Apnea: OSA can lead to hypertension and other cardiovascular problems.
  • Heart Disease: Conditions like coronary artery disease, atrial fibrillation, and heart failure increase stroke risk.
  • COVID-19 Infection: Recent studies suggest an increased stroke risk following COVID-19 infection.

4. Review Medical History: Explore the patient’s past medical conditions, focusing on conditions that predispose to stroke.

• Cardiovascular Diseases: Hypertension, coronary artery disease, atrial fibrillation, carotid artery stenosis.
• Metabolic Disorders: Diabetes mellitus, hyperlipidemia, obesity.
• Hematologic Disorders: Polycythemia vera, thrombocythemia (less common but relevant).
• Autoimmune Diseases: Lupus, rheumatoid arthritis (increased risk of vascular inflammation).
• History of Migraines with Aura: Associated with a slightly increased stroke risk.

5. Family History Review: Inquire about family history of stroke, particularly in first-degree relatives and at a young age. Genetic conditions like CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) can predispose to stroke.

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

• Hormone Therapy and Oral Contraceptives: Estrogen-containing medications can increase stroke risk, particularly in women who smoke or have other risk factors.
• Antihypertensives: Assess adherence to blood pressure medications and blood pressure control.
• Anticoagulants and Antiplatelet Agents: Use of aspirin, warfarin, heparin, or novel oral anticoagulants (NOACs) may indicate a history of cardiovascular disease or clotting disorders.
• Statins: Used to lower cholesterol levels and reduce atherosclerotic risk.

7. Substance Use History: Assess for the use of illicit substances, as stimulants like cocaine and amphetamines are associated with increased stroke risk, both ischemic and hemorrhagic.

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 Levels: Determine frequency, intensity, and type of exercise.
• Alcohol Consumption: Quantify alcohol intake (type, frequency, and amount).
• Smoking History: Pack-years, current smoking status, and history of smoking cessation attempts.

Physical Assessment

1. Implement F.A.S.T. Assessment: Utilize the F.A.S.T. acronym for rapid stroke symptom recognition:

• F – Face: Ask the patient to smile and observe for facial drooping or asymmetry.
• A – Arms: Ask the patient to raise both arms and check for arm weakness or drift. Hemiplegia often manifests as arm weakness or inability to raise one arm.
• S – Speech: Assess speech for slurring, difficulty forming words, or inability to speak.
• T – Time: Note the time of symptom onset and emphasize the urgency of seeking immediate medical attention. “Time is brain.”

2. Assess Airway, Breathing, and Circulation (ABCs): Prioritize assessment of vital functions. Stroke patients are at risk for airway obstruction (due to decreased consciousness or dysphagia), respiratory compromise (due to aspiration or increased intracranial pressure), and circulatory instability.

3. Perform Neurological Examination: Conduct a thorough neurological assessment, including:

• Level of Consciousness (LOC): Use the Glasgow Coma Scale (GCS) or a simplified LOC assessment (alert, verbal, pain, unresponsive – AVPU scale).
• Pupillary Examination: Assess pupil size, equality, and reactivity to light. Unequal or sluggish pupils may indicate increased intracranial pressure or brain herniation.
• Ocular Movements: Assess extraocular movements (EOMs), gaze preference, and nystagmus.
• Visual Fields: Test visual fields by confrontation to detect hemianopsia or visual field deficits.
• Facial Nerve Function: Assess facial symmetry, smile, brow raise, and eye closure. Facial droop is a hallmark of stroke.
• Motor Function: Evaluate strength and tone in all extremities, comparing right and left sides. Assess for hemiplegia or hemiparesis. The NIHSS motor arm and leg assessments are crucial here.
• Cerebellar Function: Assess coordination, balance, and gait (if possible). Tests include finger-to-nose, heel-to-shin, and Romberg test. Ataxia is a sign of cerebellar involvement.
• Sensory Function: Test light touch, pain, temperature, and proprioception in all extremities, comparing sides. Sensory deficits are common in stroke.
• Language and Speech: Assess speech fluency, comprehension, repetition, naming, and reading. Identify aphasia (expressive, receptive, or global) or dysarthria.
• Swallowing Assessment: Screen for dysphagia before allowing oral intake. Observe for cough, choking, or wet voice after swallowing. Formal swallow evaluations may be necessary.
• Cognitive Function: Briefly assess orientation, attention, memory, and executive function.

The National Institutes of Health Stroke Scale (NIHSS) is a standardized tool widely used to quantify neurological deficits in stroke patients. It provides a numerical score reflecting stroke severity and is used to monitor changes in neurological status over time. The NIHSS includes detailed assessments of LOC, gaze, visual fields, facial palsy, motor function (arm and leg), limb ataxia, sensory function, language, dysarthria, and neglect. The motor components are particularly relevant to assessing hemiplegia.

4. Monitor Vital Signs: Closely monitor blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature. Hypertension is common in acute stroke. Permissive hypertension may be allowed in ischemic stroke (unless thrombolysis is planned) to maintain cerebral perfusion pressure. However, excessively high blood pressure can exacerbate hemorrhagic stroke. Hypotension should be avoided as it can worsen ischemia.

Diagnostic Procedures

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

2. Prepare for Brain Imaging: Neuroimaging is essential to confirm stroke diagnosis, differentiate between ischemic and hemorrhagic stroke, and guide treatment.

• Non-contrast Head CT: Usually the initial imaging modality of choice due to its speed and ability to rapidly rule out hemorrhage. It can detect hemorrhagic stroke and large ischemic strokes, but early ischemic changes may be subtle.
• CT Angiography (CTA): Visualizes cerebral blood vessels and can identify large vessel occlusions, carotid stenosis, and aneurysms. Useful for planning thrombectomy.
• CT Perfusion (CTP): Assesses cerebral blood flow and can identify ischemic penumbra (potentially salvageable brain tissue) versus core infarct. Helps guide treatment decisions, especially for extended time window thrombectomy.
• Magnetic Resonance Imaging (MRI): More sensitive than CT for detecting early ischemic stroke, small infarcts, and posterior fossa strokes. Diffusion-weighted imaging (DWI) is highly sensitive for acute ischemia. MRI is also useful for characterizing hemorrhagic stroke and underlying causes.
• Carotid Duplex Ultrasound: Non-invasive ultrasound to assess carotid artery stenosis, a risk factor for ischemic stroke.
• Digital Subtraction Angiography (DSA): Invasive angiography, considered the gold standard for visualizing cerebral vasculature. Used less frequently now due to less invasive options like CTA and MRA, but may be used for complex cases or intervention planning.

3. Obtain Laboratory Tests: Blood tests help identify underlying causes and contributing factors to stroke.

• Complete Blood Count (CBC): Evaluates for polycythemia (increased blood viscosity) or thrombocytopenia (bleeding risk).
• Coagulation Studies (PT/INR, PTT): Baseline coagulation status, especially important before thrombolysis or anticoagulation.
• Cardiac Biomarkers (Troponin, CK-MB): Assess for myocardial injury, as cardiac conditions like atrial fibrillation are common stroke causes.
• Electrolytes, BUN, Creatinine, Glucose: Baseline metabolic panel.
• Lipid Profile (Fasting): Evaluates cholesterol and triglyceride levels, risk factors for atherosclerosis.
• Toxicology Screen: If substance abuse is suspected as a contributing factor.

4. Pregnancy Test: Perform a urine pregnancy test for women of childbearing age before fibrinolytic therapy, as safety in pregnancy is not well-established.

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

Image illustrating the two main types of stroke: ischemic, caused by a blockage, and hemorrhagic, caused by bleeding in the brain.

Nursing Interventions

Nursing interventions are crucial for optimizing stroke patient recovery and minimizing long-term disability, particularly in managing hemiplegia and related deficits.

Restore Brain Perfusion

1. Rapid Initial Evaluation and Diagnostic Imaging: Within minutes of arrival in the emergency department, patients with suspected stroke should undergo a rapid neurological assessment and STAT non-contrast head CT scan. This is the critical first step to determine stroke presence and type (ischemic or hemorrhagic).

2. Re-establish Cerebral Blood Flow in Ischemic Stroke:

• Thrombolytic Therapy (Alteplase): Administer intravenous alteplase (tissue plasminogen activator – tPA) as rapidly as possible to eligible patients with confirmed ischemic stroke. Alteplase dissolves blood clots and can restore blood flow. It is contraindicated in hemorrhagic stroke due to bleeding risk. Administer within 3 hours of symptom onset (or up to 4.5 hours in select patients per guidelines). Strict inclusion and exclusion criteria must be met.
• Mechanical Thrombectomy: For patients with large vessel occlusion ischemic stroke, mechanical thrombectomy may be indicated. This involves using a catheter inserted through a groin artery to physically remove the clot from the cerebral artery. Thrombectomy can be effective up to 24 hours from symptom onset in select patients.

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

• Monitor Level of Consciousness (LOC): Assess for changes in alertness, orientation, and responsiveness.
• Pupillary Checks: Regularly assess pupil size, equality, and reactivity.
• Assess Motor Strength and Sensation: Monitor for changes in hemiplegia or hemiparesis, sensory deficits.
• Speech and Language Assessment: Track speech fluency, comprehension, and any changes in aphasia.
• Cognitive Assessment: Monitor for confusion, agitation, or cognitive decline.
• Observe for Mood Changes: Stroke can affect mood and behavior.

4. Medication Administration: Manage secondary complications and optimize stroke recovery with medications.

• Antihypertensives: Maintain blood pressure within target ranges as per guidelines. Avoid rapid blood pressure lowering, especially in ischemic stroke, unless extremely elevated or thrombolysis is planned. For hemorrhagic stroke, stricter blood pressure control is needed.
• Antiseizure Medications: Seizure prophylaxis may be initiated, especially in hemorrhagic stroke or cortical strokes. Treat seizures promptly if they occur.
• Stool Softeners and Laxatives: Prevent constipation and straining during bowel movements, which can increase intracranial pressure.

5. Blood Pressure Management: Maintain blood pressure within recommended parameters, which vary depending on stroke type and treatment.

• Ischemic Stroke: Permissive hypertension may be allowed initially to maintain cerebral perfusion pressure. Avoid aggressive blood pressure lowering in the acute phase unless extremely high or thrombolysis is planned. Guidelines vary, but generally aim for <180/105 mmHg if thrombolysis is given, and may allow higher pressures if not. Gradually lower blood pressure after the acute phase to manage underlying hypertension.
• Hemorrhagic Stroke: More stringent blood pressure control is required to prevent hematoma expansion. Guidelines often recommend a target systolic blood pressure of 140-160 mmHg in the acute phase.

6. Prepare for Mechanical Thrombectomy (if indicated): Ensure rapid transfer to a thrombectomy-capable center if the patient is a candidate. Verify informed consent is obtained.

7. Prepare for Endovascular Procedures or Carotid Endarterectomy (if indicated): For patients with carotid stenosis, carotid endarterectomy (surgical removal of plaque) or carotid artery stenting may be considered to prevent recurrent stroke.

Stroke Recovery and Prevention

1. Stroke Rehabilitation Referral: Early and comprehensive rehabilitation is crucial for maximizing functional recovery after stroke, especially for patients with hemiplegia. Referrals should include:

• Physical Therapy (PT): Focuses on improving motor function, balance, gait, strength, and mobility affected by hemiplegia.
• Occupational Therapy (OT): Addresses activities of daily living (ADLs), upper extremity function, fine motor skills, and adaptive equipment training. Crucial for patients with hemiplegia to regain independence in self-care.
• Speech Therapy (ST): Evaluates and treats communication deficits (aphasia, dysarthria), swallowing difficulties (dysphagia), and cognitive-linguistic impairments.
• Cognitive Therapy/Neuropsychology: Addresses cognitive deficits, memory problems, attention deficits, and executive dysfunction.
• Rehabilitation Nursing: Provides ongoing support, education, and coordination of care throughout the rehabilitation process.

2. Educate on Speech Deficit Management: For patients with aphasia or dysarthria, provide education and support for communication strategies.

• Communication Partner Training: Educate family and caregivers on effective communication techniques.
• Speech Practice: Encourage consistent speech practice using flashcards, apps, books, and visual aids.
• Alternative Communication Methods: Introduce communication boards, writing, drawing, or communication apps as needed.

3. Medication Education: Educate patients and families about prescribed medications at discharge.

• Anticoagulants (e.g., Apixaban, Rivaroxaban, Dabigatran, Warfarin): For atrial fibrillation and other cardioembolic stroke risks. Emphasize adherence and monitoring (INR for warfarin).
• Antiplatelet Agents (e.g., Aspirin, Clopidogrel): For secondary stroke prevention in non-cardioembolic stroke.
• Antihypertensives (e.g., Diuretics, ACE inhibitors, Beta-blockers, Calcium Channel Blockers): For long-term blood pressure control.
• Statins: To lower cholesterol and reduce atherosclerotic risk.

4. Implement Safety Strategies: Address safety concerns related to stroke deficits, especially hemiplegia and balance problems, to prevent falls and injuries.

• Fall Precautions: Bed alarms, chair alarms, side rails, non-slip footwear, clear pathways, assistive devices (walkers, canes).
• Home Safety Assessment: Recommend home modifications to improve safety (grab bars, ramps, removing hazards).
• Assistive Devices: Train patients and families on the use of assistive devices for mobility and ADLs.

5. Encourage Support Group Attendance: Recommend stroke support groups for patients and caregivers. These groups provide emotional support, peer interaction, and shared experiences.

6. Promote Lifestyle Modifications: Educate patients on modifiable risk factors and lifestyle changes for secondary stroke prevention.

• Dietary Changes: Heart-healthy diet, low in saturated and trans fats, cholesterol, sodium, and processed foods, rich in fruits, vegetables, and whole grains.
• Regular Exercise: Recommend at least 30 minutes of moderate-intensity exercise most days of the week.
• Smoking Cessation: Strongly advise and support smoking cessation.
• Moderate Alcohol Consumption: Limit alcohol intake or abstain.
• Weight Management: Achieve and maintain a healthy weight.

7. Ensure Adherence to Treatment Regimens: Emphasize the importance of medication adherence, follow-up appointments, and managing comorbidities (hypertension, diabetes, hyperlipidemia) to prevent future strokes.

Nursing Care Plans

Nursing care plans provide a structured framework for prioritizing nursing diagnoses and guiding interventions for stroke patients, addressing both short-term and long-term goals. Several key nursing diagnoses are particularly relevant to patients with hemiplegia post-stroke.

Impaired Physical Mobility

Hemiplegia directly results in impaired physical mobility, impacting a patient’s ability to move and control one side of their body. This is a primary nursing diagnosis for stroke patients with hemiplegia.

Nursing Diagnosis: Impaired Physical Mobility

Related to:

• Neuromuscular impairment (hemiplegia) secondary to stroke
• Muscle weakness and paralysis
• Impaired balance and coordination
• Decreased muscle strength and endurance

As evidenced by:

• Inability to intentionally move one or more extremities
• Limited range of motion in affected extremities
• Difficulty with transfers (bed to chair, chair to stand)
• Unsteady gait or inability to ambulate independently
• Impaired balance and coordination
• Muscle weakness or paralysis on one side of the body

Expected Outcomes:

• Patient will achieve and maintain optimal level of mobility within their limitations.
• Patient will demonstrate safe transfers and ambulation with or without assistive devices.
• Patient will participate in physical therapy to improve strength, range of motion, and mobility.
• Patient will utilize adaptive equipment or assistive devices as needed to enhance mobility.

Assessment:

1. Assess Motor Function and Strength: Evaluate muscle strength and range of motion in all extremities, focusing on the affected side. Use a standardized muscle strength scale (0-5). Assess for presence and degree of hemiplegia.

2. Assess Balance and Coordination: Evaluate balance in sitting and standing positions. Observe gait and coordination during ambulation (if possible). Assess risk for falls.

3. Assess Functional Mobility: Determine the patient’s ability to perform functional movements such as rolling in bed, sitting up, transferring, and walking. Assess level of assistance needed.

Interventions:

1. Physical Therapy Referral: Initiate early physical therapy consultation for individualized exercise programs to improve strength, range of motion, balance, and mobility.

2. Range of Motion (ROM) Exercises: Perform passive or active-assisted ROM exercises to affected extremities to prevent contractures and maintain joint mobility. Teach patient and family how to perform ROM exercises.

3. Positioning and Alignment: Proper positioning is crucial to prevent contractures and pressure ulcers. Use pillows and supports to maintain proper body alignment. Turn and reposition patient regularly (every 2 hours).

4. Transfer Training: Provide training and assistance with safe transfers (bed to chair, chair to commode, etc.). Use proper body mechanics and transfer aids as needed (transfer belt, slide board).

5. Ambulation Training: Initiate ambulation training as soon as medically stable and as tolerated, with appropriate assistive devices (walker, cane, ankle-foot orthosis – AFO). Provide support and supervision to prevent falls.

6. Assistive Devices: Introduce and train patient on the use of appropriate assistive devices to enhance mobility and independence (walkers, canes, wheelchairs, braces).

7. Encourage Independence: Encourage patient participation in mobility activities and self-care to the extent possible, promoting independence and self-esteem.

8. Fall Prevention Measures: Implement comprehensive fall precautions, including bed alarms, clear pathways, non-slip footwear, and environmental safety modifications.

Self-Care Deficit

Hemiplegia significantly impairs self-care abilities, making it challenging for patients to perform ADLs independently.

Nursing Diagnosis: Self-Care Deficit

Related to:

• Neuromuscular impairment (hemiplegia)
• Decreased strength and coordination
• Cognitive dysfunction
• Perceptual deficits (unilateral neglect)
• Fatigue

As evidenced by:

• Inability to independently perform bathing/hygiene
• Inability to independently dress/groom
• Inability to independently feed self
• Inability to independently toilet

Expected Outcomes:

• Patient will achieve maximum level of independence in self-care activities within their limitations.
• Patient will utilize adaptive equipment or assistive devices to perform self-care activities.
• Patient will maintain skin integrity and hygiene.
• Patient will express satisfaction with their level of self-care and dignity.

Assessment:

1. Assess Functional Abilities: Evaluate the patient’s ability to perform ADLs (bathing, dressing, feeding, toileting) using a functional assessment tool (e.g., Barthel Index, Functional Independence Measure – FIM). Identify specific areas of self-care deficit and level of assistance required.

2. Assess Contributing Factors: Determine the factors contributing to self-care deficit, such as motor weakness, cognitive impairment, perceptual deficits, or fatigue.

3. Assess Patient Preferences: Inquire about patient’s preferences and routines for self-care to promote dignity and individualize care.

Interventions:

1. Occupational Therapy Referral: Consult occupational therapy for assessment and intervention to improve ADL skills and recommend adaptive equipment.

2. Adaptive Equipment Training: Introduce and train patient on the use of adaptive equipment to facilitate self-care (e.g., long-handled reachers, button hooks, dressing sticks, adapted utensils, shower chairs, commodes).

3. Task Simplification and Modification: Break down self-care tasks into smaller steps. Modify the environment and tasks to make them easier for the patient to perform.

4. Provide Assistance as Needed: Assist with self-care activities as necessary, while encouraging patient participation and independence to the extent possible.

5. Maintain Skin Integrity: Pay particular attention to skin care, especially in areas prone to pressure ulcers. Ensure regular skin assessment, turning and repositioning, and pressure relief measures.

6. Promote Dignity and Privacy: Provide self-care assistance in a manner that respects the patient’s dignity and privacy.

7. Encourage Independence: Encourage and praise patient efforts to perform self-care independently.

Risk for Injury

Hemiplegia, combined with potential cognitive and perceptual deficits, significantly increases the risk of falls and other injuries.

Nursing Diagnosis: Risk for Injury

Related to:

• Impaired physical mobility (hemiplegia)
• Balance and coordination deficits
• Perceptual deficits (unilateral neglect, spatial disorientation)
• Cognitive impairment
• Weakness
• Sensory deficits

As evidenced by:

(Risk diagnosis – evidenced by risk factors, not signs and symptoms of injury)

• Presence of hemiplegia
• Impaired balance and coordination
• Unilateral neglect
• Cognitive deficits
• Sensory deficits
• Weakness
• History of falls (if applicable)

Expected Outcomes:

• Patient will remain free from falls and other injuries.
• Patient will demonstrate safe ambulation and transfers.
• Patient will utilize safety measures and assistive devices to prevent injury.
• Patient’s environment will be modified to minimize injury risk.

Assessment:

1. Fall Risk Assessment: Perform a formal fall risk assessment using a validated tool (e.g., Morse Fall Scale). Identify specific risk factors for falls.

2. Assess Mobility and Balance: Evaluate mobility, balance, and gait. Identify any limitations that increase fall risk.

3. Assess Perceptual and Cognitive Function: Assess for unilateral neglect, spatial disorientation, cognitive impairments, and impulsivity, which increase injury risk.

4. Assess Sensory Function: Evaluate sensory deficits, especially loss of sensation in the affected extremities, which can increase risk of burns or pressure injuries.

Interventions:

1. Implement Fall Prevention Measures: Implement comprehensive fall precautions (as described in Impaired Physical Mobility interventions).

2. Environmental Safety Modifications: Ensure a safe environment: clear clutter, remove tripping hazards, adequate lighting, grab bars in bathroom, raised toilet seat, non-slip mats.

3. Bed and Chair Alarms: Use bed and chair alarms, especially for patients with impulsivity or decreased awareness of limitations.

4. Supervise Ambulation and Transfers: Provide supervision and assistance during ambulation and transfers, especially for patients with balance deficits or hemiplegia.

5. Assistive Devices: Ensure proper use of assistive devices (walkers, canes, wheelchairs) and regular equipment checks.

6. Education on Safety: Educate patient and family on fall prevention strategies, home safety modifications, and safe use of assistive devices.

7. Skin Integrity Measures: Implement measures to prevent skin breakdown, especially in areas with decreased sensation or mobility. Turn and reposition regularly, use pressure-relieving devices, and inspect skin daily.

Unilateral Neglect

Unilateral neglect is a common perceptual deficit after stroke, particularly with right hemisphere lesions, and is highly relevant in patients with hemiplegia affecting the left side of the body.

Nursing Diagnosis: Unilateral Neglect

Related to:

• Neurological deficits secondary to stroke (typically right hemisphere lesions)
• Perceptual impairment
• Sensory deficits

As evidenced by:

• Consistent inattention to stimuli on the neglected side (usually left side)
• Failure to acknowledge or use the affected side of the body (hemiplegic side)
• Difficulty with spatial orientation on the neglected side
• Eating food only on one side of the plate
• Dressing only one side of the body
• Bumping into objects on the neglected side
• Lack of awareness of the neglected side of the body

Expected Outcomes:

• Patient will demonstrate awareness of the neglected side of the body.
• Patient will utilize compensatory strategies to attend to the neglected side.
• Patient will participate in rehabilitation activities to improve awareness and attention to the neglected side.
• Patient will maintain safety on the neglected side.

Assessment:

1. Observe for Neglect Behaviors: Assess for signs of unilateral neglect during ADLs, mobility, and interactions. Observe if the patient ignores stimuli or objects on one side, neglects to groom or dress one side of the body, or bumps into objects on one side.

2. Visual Field Assessment: Rule out hemianopsia (visual field cut), which can mimic neglect but is a visual deficit, not a perceptual one. Neglect is present even when visual fields are intact.

3. Line Bisection Test: Use a line bisection test to assess for spatial neglect. Ask the patient to bisect a horizontal line. Patients with neglect often bisect the line to one side (usually rightward in left neglect).

4. Cancellation Tests: Use cancellation tests (e.g., letter cancellation, shape cancellation) to assess for visual neglect. Patient may omit items on the neglected side.

Interventions:

1. Awareness Training: Bring the patient’s attention to the neglected side. Verbally cue the patient to attend to the neglected side (“Look to your left,” “Use your left arm”).

2. Visual Scanning Training: Train the patient to actively scan the environment from the neglected side to the non-neglected side (e.g., left to right scanning). Use visual cues and verbal prompts.

3. Tactile and Auditory Stimulation: Provide tactile and auditory stimulation to the neglected side to increase awareness (e.g., touch, vibration, auditory cues).

4. Environmental Adaptation: Place objects (call light, water, personal items) on the affected side to encourage attention to that side. Approach the patient from the affected side.

5. Bilateral Activities: Engage the patient in bilateral activities that require using both sides of the body to improve awareness of the neglected side.

6. Mirror Therapy: Mirror therapy may be used to improve awareness and motor function in the neglected limb.

7. Safety Precautions: Implement safety measures to protect the neglected side from injury (e.g., padding, positioning, frequent skin checks).

Impaired Verbal Communication

While hemiplegia primarily affects motor function, stroke can also impact communication, particularly if the dominant hemisphere is involved, leading to aphasia or dysarthria.

Nursing Diagnosis: Impaired Verbal Communication

(This diagnosis and associated interventions are similar to those in the original article and remain relevant for stroke patients, including those with hemiplegia.)

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 resulting in an inability to write or type

Expected Outcomes:

• Patient will establish a form of communication to express their thoughts and needs.
• Patient will participate in speech therapy to improve communication.
• Patient will utilize resources and devices to support communication.

Assessment:

1. Note Type of Aphasia: Determine the type of aphasia (expressive, receptive, global, etc.) to guide communication strategies.

2. Observe Communication Methods: Identify how the patient currently communicates (gestures, sounds, writing).

Interventions:

1. Speak Clearly and Simply: Use short, direct sentences. Speak slowly and clearly, facing the patient.

2. Utilize Alternative Communication Methods: Use writing, drawing, gestures, communication boards, or apps.

3. Encourage Speech Therapy: Speech-language therapy is essential for communication rehabilitation.

4. Family Involvement: Involve family in communication strategies and therapy sessions.

Ineffective Cerebral Tissue Perfusion

This nursing diagnosis addresses the underlying pathophysiology of stroke and is critical in the acute phase of care.

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion

(This diagnosis and associated interventions are similar to those in the original article and remain fundamental in stroke care.)

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 (including hemiplegia)

Expected Outcomes:

• Patient will recognize symptoms of stroke and seek immediate medical attention in the future.
• Patient will display improved cerebral perfusion as evidenced by stable vital signs and neurological status.
• Patient will demonstrate improvement in stroke deficits (e.g., speech, weakness, swallowing) by discharge.

Assessment:

1. Determine Baseline Presentation: Establish the patient’s baseline neurological status and time of symptom onset.

2. Perform Neurological Assessments: Regularly monitor neurological status using NIHSS or facility-specific stroke scales.

3. Obtain Brain Imaging: Review CT or MRI results to confirm stroke type and extent.

Interventions:

1. Maintain Blood Pressure within Ordered Parameters: Adhere to blood pressure guidelines for ischemic and hemorrhagic stroke.

2. Administer Thrombolytics (if indicated): Administer alteplase for ischemic stroke within the appropriate time window and criteria.

3. Educate on Stroke Risk Factors and Symptoms (FAST): Provide patient and family education on stroke prevention and symptom recognition.

Conclusion

Nursing care for patients with hemiplegia post-stroke requires a comprehensive and individualized approach. Focusing on key nursing diagnoses such as Impaired Physical Mobility, Self-Care Deficit, Risk for Injury, Unilateral Neglect, Impaired Verbal Communication, and Ineffective Cerebral Tissue Perfusion allows nurses to address the multifaceted needs of these patients. By implementing evidence-based interventions, collaborating with interdisciplinary teams, and providing patient and family education, nurses play a vital role in optimizing functional recovery, preventing complications, and enhancing the quality of life for individuals living with hemiplegia after stroke. Patient-centered care, emphasizing dignity, respect, and maximizing independence, is paramount throughout the stroke recovery journey.

References

(Keep original references as provided in the source article)