Nursing Diagnoses Related to Cerebrovascular Accident (CVA) – A Comprehensive Guide for Stroke Care

A cerebrovascular accident (CVA), commonly known as a stroke, is a critical medical condition that occurs when blood supply to the brain is interrupted. This disruption deprives brain tissue of essential oxygen and nutrients, leading to rapid cell damage and neurological deficits. Understanding the complexities of stroke and its subsequent impact on patients is crucial for nurses to provide effective and holistic care. This article delves into the essential nursing diagnoses related to CVA, equipping healthcare professionals with the knowledge to deliver optimal patient outcomes.

Types of Stroke: Understanding the Underlying Mechanisms

Strokes are broadly categorized into two primary types, each with distinct causes and implications for nursing care: ischemic and hemorrhagic strokes.

Ischemic Strokes: These constitute the majority of stroke cases and arise from a blockage in the arteries supplying blood to the brain. This blockage, often due to blood clots, fatty deposits (plaque), or other emboli, obstructs blood flow, leading to ischemia and potential infarction of brain tissue. The rapid onset of oxygen and nutrient deprivation necessitates prompt recognition and intervention to minimize irreversible damage.

Hemorrhagic Strokes: In contrast, hemorrhagic strokes are caused by the rupture of a blood vessel within the brain. This rupture results in bleeding into the brain tissue, increasing intracranial pressure and causing direct damage to brain cells. Hemorrhagic strokes can be further classified based on the location of bleeding, such as intracerebral hemorrhage (bleeding within the brain tissue) or subarachnoid hemorrhage (bleeding in the space surrounding the brain). Common causes include hypertension, aneurysms, arteriovenous malformations, and anticoagulant use.

Transient ischemic attacks (TIAs), often referred to as “mini-strokes,” are transient episodes of neurological dysfunction caused by temporary cerebral ischemia without acute infarction. Symptoms are similar to those of a stroke but resolve within a short period, usually within an hour and almost always within 24 hours. TIAs serve as a critical warning sign of increased stroke risk and necessitate thorough evaluation and risk factor modification.

Alt text: Illustration comparing ischemic and hemorrhagic stroke types, highlighting the blockage in ischemic stroke and bleeding in hemorrhagic stroke.

The Nursing Process in Stroke Management

Managing a patient post-stroke requires a comprehensive nursing process, encompassing assessment, diagnosis, planning, implementation, and evaluation. The severity of stroke and the extent of neurological deficits vary widely among individuals, influencing the level of care and rehabilitation required. Patients often require initial intensive care or step-down unit monitoring due to the dynamic nature of stroke symptoms and the need for vigilant observation. Nurses specializing in stroke care often hold NIH Stroke Scale (NIHSS) certification, demonstrating their expertise in neurological assessment and timely intervention.

Severe strokes can result in profound disabilities, necessitating comprehensive care for basic needs such as feeding, hygiene, and mobility. The long-term consequences of stroke can significantly impact a patient’s quality of life, leading to physical, emotional, and psychosocial challenges. Nurses play a pivotal role in providing compassionate care, ensuring patient safety, preserving dignity, and addressing the multifaceted needs of both patients and their families throughout the stroke journey.

Comprehensive Nursing Assessment for Stroke Patients

The cornerstone of effective stroke nursing care is a thorough and ongoing assessment. This involves gathering subjective and objective data to understand the patient’s condition, identify potential nursing diagnoses, and guide individualized care planning.

Review of Health History: Uncovering Clues to Stroke

A detailed health history provides valuable insights into the patient’s risk factors, symptom onset, and pre-existing conditions, all crucial for stroke diagnosis and management.

1. Eliciting General Stroke Symptoms: Prompt recognition of stroke symptoms is paramount. Nurses should inquire about the sudden onset of any of the following neurological deficits:

• Hemiparesis or hemiplegia: Weakness or paralysis affecting one side of the body, typically the face, arm, and leg on the same side.
• Sensory deficits: Numbness, tingling, or loss of sensation in extremities (paresthesias).
• Dysphagia: Difficulty swallowing, posing a risk for aspiration.
• Visual disturbances: Sudden loss of vision in one or both eyes, double vision, or visual field deficits (e.g., hemianopia).
• Speech difficulties:
  • Expressive aphasia: Difficulty expressing thoughts verbally, resulting in halting or incomprehensible speech.
  • Receptive aphasia: Impaired comprehension of spoken language, making it difficult to understand instructions or conversations.
  • Dysarthria: Difficulty articulating words due to muscle weakness affecting speech production.
• Ataxia: Uncoordinated movements and unsteady gait.
• Balance and coordination alterations: Sudden dizziness, vertigo, or loss of balance.
• Changes in mental status: Confusion, disorientation, lethargy, or decreased level of consciousness.

2. Establishing Symptom Onset: The time of symptom onset is critical for determining eligibility for thrombolytic therapy (tPA) and other time-sensitive interventions. Nurses should meticulously document when symptoms first appeared or the last time the patient was known to be at their baseline neurological function.

3. Identifying Stroke Risk Factors: Assessing for modifiable and non-modifiable risk factors is essential for stroke prevention and secondary prevention. Key risk factors include:

• Age: Risk increases significantly with age, particularly after 55 years.
• Ethnicity: African Americans and Hispanics have a higher stroke incidence compared to Caucasians.
• Gender: Males have a slightly higher risk of stroke overall, although stroke is more common in women after menopause.
• Prior stroke or TIA: A history of stroke or TIA significantly increases the risk of future stroke events.

4. Reviewing Medical History: Certain medical conditions are strongly associated with increased stroke risk, particularly ischemic stroke. These conditions contribute to the formation of blood clots, plaque buildup, or other vascular issues:

• Hypertension: Uncontrolled high blood pressure is a major risk factor for both ischemic and hemorrhagic stroke.
• Obesity: Obesity is linked to several stroke risk factors, including hypertension, diabetes, and hyperlipidemia.
• Hypercholesterolemia: Elevated cholesterol levels contribute to atherosclerosis and plaque formation in arteries.
• Diabetes Mellitus: Diabetes increases the risk of atherosclerosis and small vessel disease, predisposing to stroke.
• Obstructive Sleep Apnea: Sleep apnea is associated with hypertension, atrial fibrillation, and other cardiovascular risk factors for stroke.
• Heart disease: Conditions like coronary artery disease, heart failure, and valvular heart disease increase stroke risk.
• Atrial fibrillation: This arrhythmia significantly elevates stroke risk due to the formation of blood clots in the atria.
• COVID-19 infection: Emerging evidence suggests an increased risk of stroke following COVID-19 infection.

5. Exploring Family History: A family history of stroke, particularly in first-degree relatives and before the age of 65, increases an individual’s stroke risk. Genetic conditions like CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) can also predispose to stroke.

6. Medication Review: A thorough medication review is crucial, as certain medications can influence stroke risk or interact with stroke treatments.

• Estrogen-containing contraceptives or hormone replacement therapy: These medications can slightly increase stroke risk, particularly in women with other risk factors.
• Antihypertensive medications: Non-adherence to blood pressure medications can lead to uncontrolled hypertension and increased stroke risk.
• Aspirin or other anticoagulants (enoxaparin, heparin, warfarin): These medications may indicate pre-existing conditions that increase stroke risk, or they may be used for stroke prevention in high-risk individuals.

7. Assessing Substance Use: Illicit substance use, particularly stimulants like amphetamines, cocaine, and heroin, is linked to increased stroke risk due to their effects on blood pressure and blood vessels.

8. Evaluating Lifestyle Factors: Lifestyle choices significantly impact stroke risk. Nurses should assess for:

• Dietary habits: A diet high in cholesterol, saturated fats, and trans fats promotes atherosclerosis and stroke.
• Physical inactivity: Lack of regular exercise increases the risk of obesity, hypertension, and other stroke risk factors.
• Excessive alcohol consumption: Heavy alcohol use can contribute to hypertension and heart disease, increasing stroke risk.
• Smoking: Smoking damages blood vessels, promotes clot formation, and significantly elevates stroke risk.

Alt text: Image listing modifiable and non-modifiable stroke risk factors, such as age, family history, high blood pressure, smoking, and diabetes.

Physical Assessment: Recognizing the Signs of Stroke

A rapid and focused physical assessment is essential for identifying stroke symptoms and guiding immediate interventions.

1. Employing the F.A.S.T. Acronym: The F.A.S.T. acronym is a widely recognized and effective tool for rapid stroke recognition:

• F – Face: Check for facial drooping or asymmetry when the person smiles or talks.
• A – Arms: Ask the person to raise both arms. Observe for arm weakness or drift.
• S – Speech: Listen to the person’s speech. Note any slurring, difficulty forming words, or inability to speak.
• T – Time: Time is critical. Note the time of symptom onset and call emergency services (911 in the US) immediately.

2. Assessing the ABCs (Airway, Breathing, Circulation): Prioritize assessing and ensuring the patient’s airway, breathing, and circulation. Stroke patients are at risk for aspiration, respiratory distress due to increased intracranial pressure, and hemodynamic instability.

3. Performing a Comprehensive Stroke Assessment: A neurological examination is crucial for quantifying stroke severity and identifying specific deficits. The National Institutes of Health Stroke Scale (NIHSS) is the gold standard tool for standardized stroke assessment. It evaluates:

• Level of consciousness (LOC): Alertness, responsiveness to stimuli, and orientation.
• Eye gaze: Ability to follow commands to move eyes horizontally and vertically.
• Visual fields: Assessment of peripheral vision and visual field deficits.
• Facial palsy: Assessment of facial muscle weakness or paralysis.
• Motor arm: Strength and movement in both arms.
• Motor leg: Strength and movement in both legs.
• Limb ataxia: Coordination and balance in the limbs.
• Sensory: Response to touch and pain stimuli.
• Language: Assessment of speech production, comprehension, and naming abilities.
• Dysarthria: Assessment of speech clarity and articulation.
• Inattention (Neglect): Awareness of stimuli in both visual fields and body sides.

4. Monitoring Vital Signs: Hypertension is commonly observed in acute stroke. Careful blood pressure management is crucial, avoiding rapid or excessive blood pressure reduction, particularly in ischemic stroke, as it can compromise 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.

1. Blood Glucose Level Check: Hypoglycemia can mimic stroke symptoms. A rapid fingerstick glucose test should be performed immediately to rule out hypoglycemia as the cause of neurological changes.

2. Brain Imaging: Neuroimaging is crucial for stroke diagnosis and management.

• Non-contrast head CT: This is the primary imaging modality for acute stroke, rapidly differentiating between ischemic and hemorrhagic stroke.
• CT angiography (CTA) and CT perfusion (CTP) scanning: These advanced CT techniques provide detailed information about blood vessels, blood flow, and brain tissue perfusion, aiding in treatment planning, particularly for thrombectomy.
• Magnetic resonance imaging (MRI): MRI provides more detailed images of brain tissue and can detect early ischemic changes not always visible on CT. Diffusion-weighted imaging (DWI) is particularly sensitive to acute ischemic stroke.
• Carotid duplex scanning: Ultrasound imaging of the carotid arteries to assess for stenosis (narrowing) or plaque buildup, a potential source of embolic stroke.
• Digital subtraction angiography (DSA): An invasive procedure used to visualize cerebral blood vessels, often reserved for complex cases or when intervention is planned.

3. Laboratory Tests: Blood tests can help identify underlying conditions contributing to stroke and guide treatment decisions.

• Complete blood count (CBC): Evaluates for conditions like polycythemia (increased red blood cell count) or thrombocytopenia (low platelet count) that can affect stroke risk or management.
• Cardiac biomarkers (troponin, CK-MB): Assess for underlying cardiac conditions like myocardial infarction or coronary artery disease, which can be associated with stroke.
• Toxicology screen: Rules out intoxication as a cause of stroke-like symptoms, particularly in younger patients.
• Fasting lipid profile: Identifies elevated cholesterol levels, a major stroke risk factor.
• Coagulation studies (PT/INR, aPTT): Evaluates blood clotting parameters before administering antiplatelet or anticoagulation medications.

4. Pregnancy Test for Women of Childbearing Age: Pregnancy testing is essential in women of reproductive age before considering fibrinolytic therapy (tPA), as the safety of tPA in pregnancy is not fully established.

5. Electrocardiogram (ECG): ECG helps detect cardiac arrhythmias, particularly atrial fibrillation, a significant cause of cardioembolic stroke. Identifying atrial fibrillation is crucial for initiating anticoagulation to prevent recurrent stroke.

Alt text: Image illustrating CT and MRI scans used for stroke diagnosis, showing differences between normal brain and stroke affected brain.

Essential Nursing Interventions for Stroke Patients

Prompt and effective nursing interventions are vital for optimizing stroke patient recovery and minimizing long-term disability.

Restoring Brain Perfusion: Time-Sensitive Interventions

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

1. Rapid Initial Evaluation and Diagnostic Imaging Preparation: Within minutes of arrival in the emergency department, patients with suspected stroke should undergo a rapid neurological assessment and be prepared for immediate STAT non-contrast head CT imaging. This crucial step differentiates ischemic from hemorrhagic stroke, guiding subsequent treatment.

2. Restoring Cerebral Blood Flow with Thrombolytic Therapy: For confirmed ischemic stroke, alteplase (tissue plasminogen activator – tPA) is the cornerstone of acute treatment. Alteplase is a thrombolytic medication that dissolves blood clots and restores blood flow to the brain. It is contraindicated in hemorrhagic stroke due to the risk of exacerbating bleeding. Administer IV alteplase as rapidly as possible to eligible patients who meet inclusion criteria and have a symptom onset or last known normal baseline within the recommended timeframe (typically within 3-4.5 hours of symptom onset, depending on guidelines).

3. Continuous Neurological Status Monitoring: Frequent neurological assessments are essential to detect subtle changes in a patient’s condition and facilitate timely intervention. Nurses should regularly monitor:

• Pupil size and reactivity: Changes in pupil size or reactivity can indicate increased intracranial pressure or neurological deterioration.
• Speech, memory, and cognition: Assess for changes in language skills, memory, and cognitive function.
• Mood changes: Stroke can affect mood and emotional regulation.
• Bilateral strength and coordination: Monitor for worsening weakness or coordination deficits.

4. Medication Administration as Prescribed: Manage secondary complications and optimize neurological recovery through prescribed medications.

• Blood pressure medications: Maintain blood pressure within target ranges, carefully managing hypertension while avoiding hypotension, especially in the acute phase.
• Seizure prophylaxis: Anticonvulsant medications may be initiated, particularly for hemorrhagic stroke or cortical strokes, to prevent seizures.
• Stool softeners or laxatives: Prevent constipation and straining during bowel movements, which can increase intracranial pressure.

5. Blood Pressure Management: Blood pressure management in acute stroke is nuanced and depends on stroke type and treatment strategy.

• Ischemic stroke: In patients receiving IV alteplase, maintain blood pressure below 180/105 mm Hg for the first 24 hours post-treatment. In patients not receiving thrombolysis, permissive hypertension may be allowed initially to maintain cerebral perfusion, with gradual blood pressure reduction thereafter.
• Hemorrhagic stroke: Aggressive blood pressure control is crucial to limit hematoma expansion. The immediate goal is often to reduce systolic blood pressure to 140 mmHg or lower, based on current guidelines.

6. Mechanical Thrombectomy Preparation (if indicated): For patients with large vessel occlusion ischemic stroke, mechanical thrombectomy, a catheter-based procedure to remove the clot, may be indicated. Nurses prepare patients for this procedure, ensure informed consent is obtained, and provide post-procedure care.

7. Endovascular Techniques Preparation: For patients with carotid artery stenosis, carotid endarterectomy (surgical removal of plaque) or carotid artery stenting (placement of a stent to open the artery) may be performed to improve cerebral blood flow and prevent future stroke. Nurses prepare patients for these procedures and provide pre and post-operative care.

Stroke Recovery and Secondary Prevention: Long-Term Care

Stroke recovery is an ongoing process that often requires rehabilitation and lifestyle modifications to minimize disability and prevent recurrent stroke.

1. Stroke Rehabilitation Referral: Referrals to comprehensive stroke rehabilitation programs are essential to address physical, cognitive, and communication deficits. Rehabilitation services may include:

• Speech therapy: For communication and swallowing difficulties (aphasia, dysarthria, dysphagia).
• Physical therapy: To improve motor function, mobility, balance, and coordination.
• Occupational therapy: To enhance independence in activities of daily living (ADLs), such as dressing, bathing, and eating.
• Cognitive therapy: To address cognitive impairments, such as memory, attention, and executive function.

2. Speech Deficit Management Education: Educate patients and families on strategies to improve communication skills and manage aphasia. This may include:

• Communication partner training: Educating family members and caregivers on effective communication techniques.
• Speech practice: Utilizing flashcards, books, computer programs, and visual aids to facilitate speech practice.
• Augmentative and alternative communication (AAC) devices: Communication boards, pen and paper, or apps to assist with communication.

3. Medication Education: Provide thorough education on prescribed medications for secondary stroke prevention and management of comorbidities.

• Anticoagulants: For patients with atrial fibrillation or other cardioembolic stroke risk factors, oral anticoagulants (e.g., apixaban, dabigatran, rivaroxaban, warfarin) are crucial to prevent clot formation. Low-dose heparin or enoxaparin may be used for deep vein thrombosis (DVT) prophylaxis. Aspirin or other antiplatelet agents may be prescribed for secondary stroke prevention in non-cardioembolic stroke.
• Blood pressure medications: Antihypertensive medications (e.g., diuretics, beta-blockers, calcium channel blockers, ACE inhibitors) are essential for long-term blood pressure control and stroke prevention.
• Cholesterol-lowering medications (statins): For patients with hyperlipidemia, statins reduce cholesterol levels and decrease the risk of atherosclerosis.
• Antidiabetic medications: For patients with diabetes, medications to manage blood glucose levels are crucial for stroke prevention.

4. Safety Strategies Implementation: Address safety concerns related to stroke-related deficits, such as weakness, impaired coordination, and perceptual deficits.

• Fall prevention measures: Ensure bed rails are up, bed alarms are active, and call lights are within reach. Provide assistive devices for mobility.
• Dysphagia precautions: Implement dietary modifications (e.g., thickened liquids, pureed foods) and swallowing strategies to prevent aspiration.

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

6. Lifestyle Modification Promotion: Educate patients on lifestyle modifications to reduce stroke risk:

• Heart-healthy diet: Emphasize limiting processed foods, saturated fats, and trans fats, and increasing fruits, vegetables, and whole grains.
• Regular physical exercise: Encourage daily physical activity to maintain a healthy weight, improve cardiovascular health, and reduce stroke risk.
• Smoking cessation: Provide resources and support for quitting smoking.
• Moderate alcohol consumption: Advise limiting alcohol intake.
• Weight management: Encourage maintaining a healthy weight.

7. Treatment Regimen Adherence Reinforcement: Emphasize the importance of adhering to prescribed medications, follow-up appointments, and recommended lifestyle changes to minimize the risk of recurrent stroke.

Nursing Care Plans for Common Stroke-Related Nursing Diagnoses

Nursing care plans provide a structured framework for addressing specific patient needs based on identified nursing diagnoses. Here are examples of care plans for common nursing diagnoses related to stroke:

Impaired Verbal Communication

Stroke frequently affects communication abilities due to neurological damage. Patients may experience aphasia, dysarthria, or both, impacting their ability to understand and express language.

Nursing Diagnosis: Impaired Verbal Communication

Related Factors:

• Prolonged cerebral occlusion
• Dysarthria (weakness of speech muscles)
• Aphasia (language impairment)

Evidenced by:

• Slurred speech
• Nonverbal communication
• Difficulty forming words
• Difficulty expressing thoughts
• Slow response due to comprehension delays
• Extremity weakness/paralysis hindering 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 utilize available communication resources and devices effectively.

Nursing Assessments:

1. Identify type of aphasia: Differentiate between global, Wernicke’s, and Broca’s aphasia to tailor communication strategies.
2. Observe communication methods: Recognize and utilize patient’s preferred nonverbal cues, gestures, or sounds. Involve family in understanding patient’s unique communication style.

Nursing Interventions:

1. Use simple, direct language: Speak clearly, face the patient, use short sentences, and ask yes/no questions.
2. Implement alternative communication methods: Utilize writing, drawing, flashcards, communication boards, or technology-based aids.
3. Promote speech therapy: Encourage and facilitate speech-language therapy to restore language abilities and teach compensatory strategies.
4. Engage family in communication strategies: Involve family members in therapy sessions and educate them on effective communication techniques to support the patient.

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Alt text: Image illustrating communication strategies for patients with aphasia, including using visual aids, gestures, and simple sentences.

Ineffective Cerebral Tissue Perfusion

Interruption of blood flow to the brain leads to oxygen deprivation and potential brain tissue damage.

Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral)

Related Factors:

• Interrupted cerebral blood flow
• Thrombus formation
• Arterial occlusion
• Cerebral edema
• Hemorrhage

Evidenced by:

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

Expected Outcomes:

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

Nursing Assessments:

1. Establish baseline neurological status: Determine the patient’s pre-stroke functional level to assess for changes and track progress. Note the “last known well” time for thrombolytic therapy eligibility.
2. Perform frequent neurological assessments: Utilize stroke scales (e.g., NIHSS) to monitor LOC, visual changes, facial movement, motor function, sensory changes, and speech/language deficits.
3. Review brain imaging results: Assess CT or MRI findings to confirm stroke type (ischemic or hemorrhagic) and guide treatment.

Nursing Interventions:

1. Maintain blood pressure within prescribed parameters: Manage blood pressure to optimize cerebral perfusion, adhering to specific guidelines for ischemic and hemorrhagic stroke.
2. Administer thrombolytic therapy (tPA) as indicated: Administer tPA for eligible ischemic stroke patients within the therapeutic window. Contraindicated in hemorrhagic stroke.
3. Educate on stroke risk factors: Provide patient education on modifiable risk factors (hypertension, heart disease, diabetes, smoking, stress) for secondary stroke prevention.
4. Instruct on stroke symptom recognition (F.A.S.T.): Teach patients and families to recognize F.A.S.T. signs and emphasize the importance of immediate action (“Time is brain”).

Risk for Injury

Stroke-related neurological deficits, including impaired judgment, perceptual issues, weakness, and coordination problems, increase the risk of falls and injuries.

Nursing Diagnosis: Risk for Injury

Related Factors:

• Impaired judgment
• Spatial-perceptual deficits
• Weakness
• Poor motor coordination
• Poor balance
• Impaired sensory awareness
• Dysphagia
• Communication difficulties
• Hemiplegia
• Short attention span
• Impulsivity

Expected Outcomes:

• Patient will remain free from falls and injuries.
• Patient will maintain intact skin integrity.
• Caregivers will create a safe environment and support patient safety.

Nursing Assessments:

1. Determine stroke-related deficits: Identify specific deficits based on the affected brain area (e.g., right-brain stroke: spatial deficits; left-brain stroke: swallowing/speech).
2. Assess sensory awareness: Evaluate for sensory deficits (pain, temperature, touch) that increase injury risk.
3. Note neglect or visual disturbances: Assess for unilateral neglect and visual field deficits (hemianopia) that compromise safety.

Nursing Interventions:

1. Implement bed and chair alarms: Utilize alarms, especially for impulsive patients or those with right-brain strokes, to prevent falls.
2. Assist with eating and dysphagia precautions: Provide mealtime assistance, implement dysphagia precautions (modified diet, thickened liquids), and monitor for aspiration signs.
3. Teach environmental scanning: Instruct patients with neglect or visual field deficits to scan their environment to compensate for visual limitations.
4. Frequent skin assessment and turning: Turn immobile patients every 2 hours, provide pressure relief, and ensure proper body alignment to prevent skin breakdown.

Self-Care Deficit

Hemiparesis and other stroke-related impairments can significantly impact a patient’s ability to perform self-care activities.

Nursing Diagnosis: Self-Care Deficit

Related Factors:

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

Evidenced by:

• Inability to perform cleansing activities independently
• Difficulty dressing/undressing
• Impaired feeding ability
• Inability to manage toileting independently

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 their optimal potential.
• Patient will demonstrate competence in using assistive devices.
• Patient will feed themselves safely and effectively.
• Patient will maintain continence and skin integrity in perineal area.

Nursing Assessments:

1. Assess functional abilities and limitations: Evaluate physical, sensory, cognitive, and emotional impairments affecting self-care.
2. Determine patient preferences: Respect patient preferences for hygiene, food, and self-care to promote comfort and confidence.
3. Perform routine risk assessments: Utilize tools like Morse Fall Scale, Braden Scale (pressure ulcer risk), and swallowing assessments to identify potential complications impacting self-care.

Nursing Interventions:

1. Establish a toileting schedule: Implement a regular toileting schedule and address constipation to promote continence and skin integrity.
2. Encourage independence: Promote patient independence in ADLs to maximize autonomy and self-esteem.
3. Allow adequate mealtime: Provide sufficient time for meals, especially for patients with dysphagia or feeding difficulties.
4. Provide and instruct on assistive equipment: Introduce and train patients on using adaptive equipment (button hooks, reachers, shower chairs, specialized utensils) to enhance self-care abilities.
5. Consult physical and occupational therapy: Collaborate with therapists to develop individualized rehabilitation plans to improve motor skills, ADL performance, and compensatory strategies.

Unilateral Neglect

Unilateral neglect is a common consequence of stroke, particularly right-hemisphere strokes, characterized by a lack of awareness of one side of the body and surrounding space.

Nursing Diagnosis: Unilateral Neglect

Related Factors:

• Disease process (stroke)
• Brain trauma/damage
• Cerebral tissue ischemia

Evidenced by:

• Altered safety behavior on the neglected side
• Failure to move eyes toward the neglected side
• Inability to move limbs on the neglected side
• Difficulty grooming neglected side
• Unawareness of neglected limb position

Expected Outcomes:

• Patient will demonstrate techniques to minimize unilateral neglect.
• Patient will care for both sides of the body and protect the affected side from harm.
• Patient will achieve the highest possible level of functioning based on individual goals and abilities.

Nursing Assessments:

1. Assess for unilateral neglect signs: Observe for neglecting one side of the body during self-care, leaning to one side, eating from only one side of the plate, and lack of response to stimuli on the affected side.
2. Assess awareness of neglect: Evaluate patient’s insight into their neglect and their ability to implement compensatory strategies.
3. Skin assessment on neglected side: Monitor skin on the neglected side for potential injury due to lack of awareness and repositioning.

Nursing Interventions:

1. Implement fall precautions: Activate bed alarms and ensure call light is accessible to prevent falls related to neglect and one-sided weakness.
2. Encourage assistive device use: Promote the use of assistive devices to compensate for neglect and enhance safety.
3. Instruct neutral body positioning: Encourage maintaining neutral body alignment and frequent position changes to prevent pain, joint subluxation, and contractures.
4. Position belongings on unaffected side: Place personal items on the unaffected side to encourage patient to turn and attend to the neglected side. Approach patient and encourage getting out of bed from the unaffected side.
5. Coordinate rehabilitation program referral: Refer patient to rehabilitation services (physical, occupational, speech therapy) to address neglect and maximize functional recovery.

References

• [References from original article, if available, should be listed here following a consistent citation style.]

This comprehensive guide provides a detailed overview of nursing diagnoses related to cerebrovascular accident (CVA), offering a robust framework for nurses to deliver evidence-based and patient-centered care to individuals experiencing stroke. By understanding these diagnoses and implementing appropriate nursing interventions, healthcare professionals can significantly contribute to improved patient outcomes and enhanced quality of life post-stroke.