Stroke Nursing Diagnosis: A Comprehensive Guide for Effective Nursing Care

A cerebrovascular accident (CVA), commonly known as a stroke, is a critical medical emergency that occurs when blood supply to the brain is disrupted. This interruption deprives brain tissue of oxygen and essential nutrients, leading to rapid cell damage. Understanding Stroke Nursing Diagnosis is paramount for healthcare professionals to deliver timely and effective care, minimize brain damage, and optimize patient recovery. This article provides an in-depth exploration of stroke nursing diagnoses, assessments, interventions, and care plans, aiming to enhance your expertise in stroke management.

Understanding Stroke Types: Ischemic and Hemorrhagic Strokes

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

Ischemic Strokes: These constitute the majority of stroke cases and are triggered by a blockage or reduction in blood flow to a region of the brain. This blockage can stem from various sources, including:

• Thrombosis: Formation of a blood clot within a cerebral artery, often associated with atherosclerosis.
• Embolism: Migration of a blood clot or other debris from another part of the body (e.g., heart) to a cerebral artery, causing an obstruction.
• Systemic Hypoperfusion: Reduced blood flow to all parts of the body, including the brain, often due to heart failure or severe hypotension.

The consequence of ischemia is rapid brain tissue death (infarction) due to oxygen and nutrient deprivation. Prompt recognition and intervention are crucial to salvage viable brain tissue and limit neurological deficits.

Hemorrhagic Strokes: Hemorrhagic strokes occur when a blood vessel in the brain ruptures, leading to bleeding within the brain tissue or the surrounding spaces. The primary causes include:

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

The accumulation of blood in the brain increases intracranial pressure, compressing brain tissue and causing further damage. Hemorrhagic strokes are often associated with higher mortality rates and require careful management to control bleeding and intracranial pressure.

Transient Ischemic Attacks (TIAs): Often referred to as “mini-strokes,” TIAs are characterized by temporary disruptions in blood flow to the brain. Symptoms are similar to those of a full stroke but resolve spontaneously, typically within minutes to hours (usually within one hour, and almost always within 24 hours), without causing permanent brain damage. TIAs are warning signs of potential future strokes and necessitate thorough evaluation and risk factor modification to prevent a more severe event.

Image alt text: Visual comparison of ischemic and hemorrhagic stroke types, illustrating blood vessel blockage in ischemic stroke and vessel rupture in hemorrhagic stroke.

The Nursing Process: A Cornerstone of Stroke Patient Care

The nursing process is fundamental to providing holistic and patient-centered care for individuals experiencing stroke. Patients exhibit a wide spectrum of disabilities following a stroke, influenced by stroke severity, time to treatment, and pre-existing health conditions. Nurses play a pivotal role in all phases of stroke care, from acute management to rehabilitation.

In the acute phase, often in intensive care units (ICU) or step-down units, specialized nurses with NIH Stroke Scale (NIHSS) certification are essential. The NIHSS is a standardized tool used to quantify neurological deficits in stroke patients, enabling consistent monitoring and communication among healthcare providers. Stroke symptoms can fluctuate rapidly and subtly, demanding astute clinical judgment and prompt interventions from nurses to prevent patient deterioration.

For severe strokes, patients may face profound disabilities, requiring total assistance with basic needs such as feeding, bathing, and mobility. Long-term stroke deficits can be emotionally and physically devastating for both patients and their families, often leading to depression and reduced quality of life. Nurses provide compassionate care, prioritizing patient safety, preserving dignity, and addressing their complex physical and psychosocial needs throughout the recovery journey.

Nursing Assessment: Gathering Crucial Data for Stroke Nursing Diagnosis

The nursing assessment is the initial and ongoing phase of the nursing process, involving systematic data collection to identify patient needs and formulate appropriate nursing diagnoses. In stroke care, the assessment encompasses physical, psychosocial, emotional, and diagnostic data.

Review of Health History: Subjective Data Collection

Obtaining a comprehensive health history is crucial for identifying stroke risk factors and understanding the patient’s presenting symptoms.

1. Elicit General Stroke Symptoms: Promptly inquire about sudden onset symptoms, which are hallmark indicators of stroke:

• Motor Weakness/Paralysis (Hemiparesis/Hemiplegia): Weakness or paralysis affecting the face, arm, and leg on one side of the body.
• Sensory Deficits (Paresthesias): Numbness, tingling, or altered sensation in the extremities.
• Swallowing Difficulties (Dysphagia): Problems with safely swallowing liquids or solids, increasing aspiration risk.
• Visual Disturbances: Sudden vision loss in one or both eyes, double vision (diplopia), or visual field deficits (hemianopsia).
• Speech Impairments (Aphasia, Dysarthria):
  • Expressive Aphasia (Broca’s Aphasia): Difficulty producing speech, although comprehension may be relatively intact.
  • Receptive Aphasia (Wernicke’s Aphasia): Difficulty understanding spoken language, often resulting in fluent but nonsensical speech.
  • Dysarthria: Slurred speech due to muscle weakness affecting articulation.
• Balance and Coordination Issues (Ataxia): Unsteady gait, loss of balance, and impaired coordination.
• Changes in Mental Status: Confusion, disorientation, decreased alertness, 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 “last known well” time is critical for determining eligibility for time-sensitive stroke treatments like thrombolysis.

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.
  • Prior Stroke or TIA: History of stroke or TIA significantly elevates future stroke risk.
  • Family History: Stroke in immediate family members, especially before age 65, increases individual risk.
  • Genetic Conditions: Certain genetic disorders like CADASIL predispose to stroke.

• Modifiable Risk Factors:

  • Hypertension: Uncontrolled high blood pressure is a leading stroke risk factor.
  • Hyperlipidemia: High cholesterol levels contribute to atherosclerosis.
  • Diabetes Mellitus: Diabetes damages blood vessels and increases clot risk.
  • Obesity: Excess weight is linked to hypertension, diabetes, and hyperlipidemia.
  • Obstructive Sleep Apnea: Associated with hypertension and atrial fibrillation.
  • Heart Disease: Conditions like coronary artery disease and valvular heart disease increase embolic stroke risk.
  • Atrial Fibrillation: This arrhythmia significantly raises stroke risk due to clot formation in the atria.
  • COVID-19 Infection: Emerging evidence suggests increased stroke risk following COVID-19.
  • Lifestyle Factors:
    • Unhealthy Diet: High in saturated and trans fats, cholesterol, and sodium.
    • Physical Inactivity: Lack of regular exercise.
    • Smoking: Damages blood vessels and increases clotting.
    • Excessive Alcohol Consumption: Contributes to hypertension and atrial fibrillation.
  • Medications:
    • Birth Control Pills/Hormone Therapy: Estrogen-containing medications can increase clotting risk.
    • Non-Adherence to Blood Pressure Medications: Leading to uncontrolled hypertension.

4. Review Medical History for Underlying Conditions: Explore pre-existing medical conditions that predispose to stroke, such as hypertension, diabetes, heart disease, atrial fibrillation, and hyperlipidemia.

5. Investigate Family History of Stroke: Determine if there is a family history of stroke, particularly in first-degree relatives and at a young age, which may indicate genetic predisposition.

6. Medication Review: Obtain a detailed medication history, including prescription medications, over-the-counter drugs, and supplements. Pay attention to:

• Anticoagulants/Antiplatelets: Use of aspirin, warfarin, heparin, or novel oral anticoagulants, which may indicate pre-existing conditions or increased bleeding risk.
• Hormone Replacement Therapy/Oral Contraceptives: Estrogen-containing medications increase stroke risk.
• Blood Pressure Medications: Assess adherence and effectiveness of antihypertensive therapy.

7. Assess for Substance Use: Inquire about the use of illicit substances, as drugs like cocaine, amphetamines, and heroin are linked to increased stroke risk.

8. Lifestyle Assessment: Evaluate lifestyle habits that impact stroke risk, including dietary patterns, exercise frequency, smoking status, and alcohol consumption.

Physical Assessment: Objective Data Collection

The physical assessment involves systematic examination to identify objective signs of stroke and neurological deficits.

1. Recognize F.A.S.T. Signs: Utilize the F.A.S.T. acronym, a widely recognized tool for rapid stroke identification:

• F – Face: Check for facial drooping or asymmetry when smiling or showing teeth.
• A – Arms: Assess for arm weakness by asking the patient to raise both arms; observe for downward drift in one arm.
• S – Speech: Evaluate speech for slurring, difficulty forming words, or inability to speak.
• T – Time: Emphasize the critical importance of noting the time of symptom onset and calling emergency services immediately.

2. Assess Airway, Breathing, and Circulation (ABCs): Prioritize assessment of vital functions:

• Airway: Ensure a patent airway and assess for any airway obstruction risk, especially in patients with impaired consciousness or swallowing difficulties.
• Breathing: Evaluate respiratory rate, depth, and effort. Stroke can affect respiratory centers in the brainstem, leading to respiratory compromise.
• Circulation: Assess heart rate, blood pressure, and peripheral pulses. Hypertension is common in acute stroke, but excessively high or low blood pressure can worsen brain injury.

3. Perform a Comprehensive Stroke Assessment using NIHSS: Administer the NIHSS to quantify neurological deficits. The NIHSS evaluates:

• Level of Consciousness (LOC): Alertness, orientation, and responsiveness to stimuli.
• Eye Movements (Gaze): Assess for gaze deviation or paralysis.
• Visual Fields: Test for visual field deficits (hemianopsia).
• Facial Movement (Facial Palsy): Assess facial symmetry and movement in upper and lower face.
• Motor Function – Arms and Legs (Motor Arm/Leg): Evaluate strength and movement in both arms and legs.
• Limb Ataxia: Assess coordination and balance in limbs.
• Sensory Function (Sensory): Test sensation to light touch and pinprick in different body regions.
• Language (Language): Evaluate speech fluency, comprehension, naming, and repetition.
• Speech Articulation (Dysarthria): Assess clarity and articulation of speech.
• Extinction and Inattention (Neglect): Assess for neglect of one side of the body or space.

4. Monitor Vital Signs Closely: Frequently monitor vital signs, particularly blood pressure. Hypertension is common in acute stroke and requires careful management. Avoid rapid blood pressure reduction, as it can compromise cerebral perfusion.

Image alt text: Illustration of the FAST acronym for stroke recognition, highlighting facial drooping, arm weakness, speech difficulty, and the importance of time.

Diagnostic Procedures: Confirming Stroke and Guiding Treatment

Diagnostic tests are essential to confirm stroke, differentiate between ischemic and hemorrhagic stroke, and identify potential underlying causes.

1. Rapid Blood Glucose Measurement: Immediately check blood glucose levels using a fingerstick glucose test. Hypoglycemia (low blood sugar) can mimic stroke symptoms and must be ruled out promptly.

2. Brain Imaging: Neuroimaging is paramount in stroke diagnosis and management:

• Non-Contrast Head CT Scan: The initial imaging modality of choice for suspected stroke. CT rapidly differentiates between ischemic and hemorrhagic stroke, guiding treatment decisions.
• CT Angiography (CTA) and CT Perfusion Scanning: CTA visualizes blood vessels in the brain, identifying blockages or aneurysms. CT perfusion assesses blood flow to different brain regions, helping to determine the extent of ischemic damage and potentially salvageable brain tissue (penumbra).
• Magnetic Resonance Imaging (MRI): MRI provides more detailed images of brain tissue than CT and is highly sensitive in detecting early ischemic changes and small hemorrhages. Diffusion-weighted imaging (DWI) MRI is particularly useful in identifying acute ischemic stroke.
• Carotid Duplex Ultrasound: Evaluates carotid arteries in the neck for stenosis (narrowing) due to plaque buildup, a common cause of ischemic stroke.
• Digital Subtraction Angiography (DSA): An invasive procedure providing detailed images of cerebral blood vessels, used to identify aneurysms, AVMs, or vasculitis (inflammation of blood vessels) when less invasive imaging is inconclusive.

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

• Complete Blood Count (CBC): Evaluates red blood cell count (polycythemia can increase blood viscosity) and platelet count (thrombocytopenia or thrombocytosis can affect clotting).
• Cardiac Biomarkers (Troponin, CK-MB): Assess for cardiac injury, as stroke can be associated with underlying heart disease.
• Toxicology Screen: Rule out drug intoxication as a cause of stroke-like symptoms, especially in younger patients.
• Fasting Lipid Profile: Measures cholesterol and triglyceride levels to identify hyperlipidemia, a risk factor for atherosclerosis.
• Coagulation Studies (PT/INR, aPTT): Assess blood clotting parameters before administering anticoagulants or antiplatelet agents.

4. Pregnancy Test for Women of Childbearing Age: Perform a urine pregnancy test in women of reproductive age before fibrinolytic therapy, as the safety of these drugs in pregnancy is not fully established.

5. Electrocardiogram (ECG): Obtain an ECG to assess heart rhythm and identify atrial fibrillation, a common cause of cardioembolic stroke.

Nursing Interventions: Restoring Perfusion and Promoting Recovery in Stroke Patients

Nursing interventions are crucial in the acute and rehabilitation phases of stroke care, focusing on restoring brain perfusion, preventing complications, and maximizing functional recovery.

Restoring Brain Perfusion: Time-Critical Interventions

1. Rapid Evaluation and Diagnostic Imaging: Within minutes of arrival in the emergency department, patients with suspected stroke should undergo a STAT non-contrast head CT scan. This rapid imaging is essential to differentiate ischemic from hemorrhagic stroke and guide immediate treatment decisions.

2. Thrombolytic Therapy for Ischemic Stroke: For confirmed ischemic stroke, initiate intravenous (IV) alteplase (tissue plasminogen activator – tPA) as rapidly as possible. Alteplase is a thrombolytic medication that dissolves blood clots and can significantly improve outcomes if administered within a specific time window (typically within 3-4.5 hours of symptom onset, depending on guidelines and patient criteria). Alteplase is contraindicated in hemorrhagic stroke due to the risk of exacerbating bleeding.

3. Continuous Neurologic Monitoring: Perform frequent and meticulous neurologic assessments to detect subtle changes in patient status and intervene promptly. Monitor:

• Pupil Size and Reactivity: Assess for changes in pupil size, equality, and reaction to light, which can indicate increasing intracranial pressure or brainstem involvement.
• Level of Consciousness, Speech, Memory, and Cognition: Monitor for changes in alertness, orientation, speech clarity, memory, and cognitive function.
• Mood Changes: Stroke can affect mood and emotional regulation; observe for signs of anxiety, agitation, or depression.
• Bilateral Strength and Coordination: Regularly assess motor strength and coordination in all extremities to detect worsening weakness or new deficits.

4. Medication Administration: Administer medications as prescribed to manage secondary complications and optimize cerebral perfusion:

• Antihypertensives: Manage blood pressure within recommended parameters. In the acute phase of ischemic stroke, permissive hypertension (allowing slightly elevated blood pressure) may be indicated to maintain cerebral perfusion, unless thrombolytic therapy is administered. Blood pressure management guidelines vary depending on stroke type, treatment, and time since onset.
• Antiseizure Medications: Seizure prophylaxis may be considered, particularly for hemorrhagic stroke or strokes involving the cerebral cortex, which have a higher risk of seizures.
• Stool Softeners/Laxatives: Prevent constipation and straining during bowel movements, as straining can increase intracranial pressure.

5. Blood Pressure Management: Maintain blood pressure within prescribed ranges. Blood pressure management in acute stroke is complex and depends on stroke type and treatment strategy.

• Ischemic Stroke: In patients receiving alteplase, maintain blood pressure below 180/105 mm Hg for the first 24 hours post-thrombolysis to minimize bleeding risk. In patients not receiving thrombolysis, current guidelines often recommend permissive hypertension in the initial 24-48 hours to maintain cerebral perfusion, unless there are compelling reasons for blood pressure reduction.
• Hemorrhagic Stroke: Aggressive blood pressure control is crucial in hemorrhagic stroke to limit hematoma expansion. The immediate goal is typically to reduce systolic blood pressure to around 140 mmHg, although specific targets may vary.

6. Prepare for Mechanical Thrombectomy: In patients with large vessel occlusion ischemic stroke, mechanical thrombectomy may be indicated. This procedure involves using a catheter, typically inserted through the femoral artery in the groin, to physically remove or dissolve the clot occluding a major cerebral artery.

7. Endovascular Procedures: For patients with carotid artery stenosis, endovascular procedures may be considered to improve cerebral blood flow and prevent future stroke:

• Carotid Endarterectomy: Surgical removal of plaque buildup from the carotid artery.
• Carotid Artery Stenting: Placement of a stent to widen a narrowed carotid artery and maintain blood flow.

Image alt text: Diagram illustrating thrombolytic therapy using tPA to dissolve a blood clot blocking blood flow in an ischemic stroke.

Stroke Recovery and Prevention: Long-Term Strategies

1. Stroke Rehabilitation Referrals: Initiate referrals to comprehensive stroke rehabilitation services, tailored to the patient’s specific deficits. Rehabilitation may include:

• Speech Therapy: Address speech, language, and swallowing difficulties (aphasia, dysarthria, dysphagia).
• Physical Therapy: Improve motor function, balance, gait, and mobility.
• Occupational Therapy: Enhance independence in activities of daily living (ADLs), such as dressing, bathing, and eating, and address upper extremity function and cognitive-perceptual deficits.
• Cognitive Therapy: Address cognitive impairments, such as memory, attention, and executive function.

2. Speech Deficit Management Education: For patients with aphasia or dysarthria, provide education and resources to facilitate communication:

• Communication Partner Training: Educate family members and caregivers on strategies to effectively communicate with individuals with aphasia.
• Speech Practice: Encourage consistent speech practice using flashcards, books, computer programs, and visual aids.
• Alternative Communication Methods: Introduce communication boards, pen and paper, or communication apps to support nonverbal communication.

3. Medication Education: Educate patients and caregivers about prescribed medications for secondary stroke prevention:

• Anticoagulants: If atrial fibrillation is present, oral anticoagulants (e.g., apixaban, dabigatran, rivaroxaban, warfarin) are typically prescribed to prevent cardioembolic stroke recurrence.
• Antiplatelet Agents: Aspirin or other antiplatelet medications (e.g., clopidogrel) may be prescribed to prevent atherothrombotic stroke recurrence.
• Blood Pressure Medications: Antihypertensive medications (e.g., diuretics, beta-blockers, calcium channel blockers, ACE inhibitors) are crucial for long-term blood pressure control and stroke prevention.
• Statins: Lipid-lowering medications (statins) are often prescribed to manage hyperlipidemia and reduce atherosclerotic risk.

4. Safety Strategies: Implement safety measures to prevent falls and injuries, considering residual motor and sensory deficits:

• Fall Precautions: Ensure bed rails are up, bed alarms are active, call light is within reach, and assistive devices (e.g., walkers, canes) are used as needed.
• Environmental Modifications: Assess the home environment for safety hazards and recommend modifications, such as removing rugs, improving lighting, and installing grab bars in bathrooms.

5. Support Group Referral: Encourage participation in stroke support groups for patients and caregivers. Support groups provide emotional support, peer interaction, and valuable resources.

6. Lifestyle Modification Education: Provide comprehensive education on lifestyle modifications to reduce future stroke risk:

• Healthy Diet: Emphasize a diet low in processed foods, saturated fats, and cholesterol, and 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: Provide resources and support for smoking cessation.
• Moderate Alcohol Consumption: Advise limiting alcohol intake.
• Weight Management: Encourage maintaining a healthy weight.

7. Treatment Regimen Adherence: Stress the importance of adherence to prescribed medications, follow-up appointments, and recommended lifestyle modifications to manage comorbidities (hypertension, diabetes, hyperlipidemia) and prevent secondary stroke.

Stroke Nursing Care Plans: Addressing Key Nursing Diagnoses

Nursing care plans are essential tools for organizing and delivering individualized care, prioritizing nursing diagnoses, and establishing short-term and long-term goals for stroke patients. Here are examples of common stroke nursing diagnoses and associated care plan components:

Impaired Verbal Communication

Stroke frequently impairs communication abilities. Patients may experience difficulties in understanding or expressing language, or have physical limitations affecting speech production.

Nursing Diagnosis: Impaired Verbal Communication

Related to:

• Prolonged cerebral occlusion leading to neurological damage
• Dysarthria (muscle weakness affecting speech articulation)
• Aphasia (language impairment affecting comprehension or production)

As evidenced by:

• Slurred speech
• Nonverbal communication
• Difficulty forming words
• Difficulty expressing thoughts
• Slow or delayed responses due to comprehension deficits
• Extremity weakness or paralysis affecting writing or typing

Expected Outcomes:

• Patient will establish effective communication methods to express needs and thoughts.
• Patient will actively participate in speech therapy to improve communication skills.
• Patient will utilize appropriate communication aids and resources.

Assessment:

1. Identify Type of Aphasia: Determine if the patient has global aphasia (severe impairment in both comprehension and expression), Wernicke’s aphasia (fluent but nonsensical speech with comprehension deficits), or Broca’s aphasia (non-fluent speech with relatively intact comprehension).
2. Observe Communication Methods: Identify the patient’s existing communication strategies, such as gestures, signals, or sounds. Collaborate with family members to understand the patient’s unique communication cues.

Interventions:

1. Use Simple, Direct Language: Speak clearly and slowly, facing the patient to facilitate lip reading and visual cues. Use short, direct sentences and avoid abstract concepts. Ask “yes” or “no” questions when possible.
2. Employ Alternative Communication Methods: Utilize writing, drawing, picture boards, flashcards, or communication devices as needed. Establish a system for nonverbal patients to communicate basic needs (e.g., thumbs up/down, eye blinks).
3. Encourage Speech Therapy: Emphasize the importance of speech-language therapy to improve language abilities, restore communication skills, and learn compensatory strategies and assistive technologies.
4. Promote Family Involvement: Engage family members in communication therapy sessions and educate them on techniques to support clear and effective communication with the patient.

Ineffective Cerebral Tissue Perfusion

Disrupted blood flow in stroke leads to oxygen deprivation and tissue damage.

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion

Related to:

• Interruption of cerebral blood flow
• Thrombus or embolus formation
• Cerebral artery occlusion
• Cerebral edema (swelling)
• Hemorrhage

As evidenced by:

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

Expected Outcomes:

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

Assessment:

1. Establish Baseline Neurological Status: Determine the patient’s pre-stroke baseline level of function to accurately assess for changes and monitor progress. Obtain the “last known well” time.
2. Perform Frequent Neurological Assessments: Conduct regular NIHSS assessments to monitor LOC, pupillary response, motor strength, sensory function, language, and other neurological parameters.
3. Review Brain Imaging Results: Evaluate CT scan or MRI findings to confirm stroke diagnosis, differentiate stroke type (ischemic vs. hemorrhagic), and assess the extent of brain damage.

Interventions:

1. Maintain Blood Pressure within Prescribed Parameters: Administer antihypertensive medications as ordered to maintain blood pressure within target ranges, balancing the need to control hypertension while ensuring adequate cerebral perfusion. Specific blood pressure targets vary depending on stroke type and treatment.
2. Administer Thrombolytic Therapy (if indicated): For ischemic stroke patients meeting criteria, administer alteplase within the appropriate time window to dissolve clots and restore blood flow.
3. Educate on Stroke Risk Factors and Prevention: Provide comprehensive patient education on modifiable stroke risk factors (hypertension, hyperlipidemia, diabetes, smoking, inactivity) and lifestyle modifications to reduce future stroke risk.
4. Instruct on Recognizing Stroke Symptoms (FAST): Educate patients and family members about the F.A.S.T. acronym to facilitate rapid stroke recognition and timely activation of emergency medical services.

Risk for Injury

Stroke-related impairments, including motor deficits, sensory loss, and cognitive-perceptual issues, increase the risk of falls and injuries.

Nursing Diagnosis: Risk for Injury

Related to:

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

Expected Outcomes:

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

Assessment:

1. Determine Stroke-Related Deficits: Assess specific physical, cognitive, and perceptual deficits resulting from the stroke, such as motor weakness, sensory loss, visual field deficits, spatial neglect, and impaired judgment.
2. Assess Sensory Awareness: Evaluate the patient’s ability to perceive pain, temperature, and pressure, particularly on the affected side, to identify risk for skin breakdown and injury.
3. Identify Neglect or Visual Disturbances: Assess for unilateral neglect (inattention to one side of the body or space) and visual field deficits (hemianopia), which significantly increase injury risk.

Interventions:

1. Implement Fall Precautions: Utilize bed and chair alarms, ensure bed in low position, keep side rails up as appropriate, provide non-slip footwear, and assist with ambulation.
2. Assist with Eating and Swallowing: For patients with dysphagia, provide modified diets (e.g., thickened liquids, pureed foods), position upright during meals, supervise eating, and monitor for signs of aspiration (coughing, choking, wet voice).
3. Teach Environmental Scanning: For patients with neglect or visual field deficits, teach techniques to scan the environment from left to right to compensate for visual field loss and improve awareness of the neglected side.
4. Frequent Skin Assessment and Turning: For patients with paralysis or sensory loss, perform skin assessments every 2 hours, turn and reposition frequently, use pressure-relieving devices, and ensure proper body alignment to prevent skin breakdown.

Self-Care Deficit

Motor weakness, sensory deficits, and cognitive impairments can significantly impact a patient’s ability to perform self-care activities.

Nursing Diagnosis: Self-Care Deficit (specify area: bathing/hygiene, dressing/grooming, feeding, toileting)

Related to:

• Neurobehavioral manifestations of stroke
• Muscle weakness (hemiparesis/hemiplegia)
• Musculoskeletal impairment
• Cognitive dysfunction
• Decreased motivation
• Impaired physical mobility
• Unilateral neglect

As evidenced by:

• Inability to independently complete bathing and hygiene tasks
• Inability to dress or undress independently
• Impaired ability to use eating utensils or self-feed
• Inability to access the bathroom or manage toileting needs

Expected Outcomes:

• Patient will maintain skin integrity and be free from body odor.
• Patient will verbalize satisfaction with bathing and hygiene practices, utilizing assistive devices effectively.
• Patient will dress and perform ADLs to their optimal potential.
• Patient will demonstrate competence in using assistive devices for self-care.
• Patient will feed themselves safely and effectively.
• Patient will maintain continence and prevent skin breakdown related to incontinence.

Assessment:

1. Assess Functional Abilities and Limitations: Evaluate the patient’s physical, cognitive, and emotional limitations impacting self-care abilities. Assess the level of assistance needed for each ADL.
2. Determine Patient Preferences: Inquire about patient preferences and routines related to hygiene, dressing, and eating to promote comfort and autonomy. Respect cultural and personal preferences.
3. Perform Risk Assessments: Routinely assess for fall risk (Morse Fall Scale), skin breakdown risk (Braden Scale), and swallowing safety (bedside swallow screen) to identify potential complications affecting self-care.

Interventions:

1. Establish Toileting Schedule: Implement a regular toileting schedule, offer assistance with toileting frequently, administer stool softeners as ordered, and ensure prompt response to requests for assistance to prevent constipation and incontinence.
2. Encourage Independence: Promote patient independence in self-care activities to the extent possible, providing assistance and encouragement as needed to maximize autonomy and self-esteem.
3. Ensure Adequate Mealtime: Allow sufficient time for meals, particularly for patients with dysphagia, to ensure safe and adequate oral intake.
4. Assist with Adaptive Equipment: Introduce and train patients on the use of adaptive equipment for dressing, bathing, grooming, eating, and toileting (e.g., button hooks, zipper pulls, shower chairs, long-handled utensils, reachers).
5. Consult with Therapy Professionals: Collaborate with physical and occupational therapists to develop individualized rehabilitation plans to improve motor skills, coordination, and ADL performance.

Unilateral Neglect

Unilateral neglect is a neurobehavioral condition resulting from stroke, characterized by reduced awareness of stimuli on one side of the body or space, typically the side contralateral to the brain lesion.

Nursing Diagnosis: Unilateral Neglect

Related to:

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

As evidenced by:

• Altered safety behaviors on the neglected side (e.g., bumping into objects)
• Failure to move eyes or head towards the neglected side
• Inability to move limbs on the neglected side
• Difficulty grooming or dressing the neglected side
• Unawareness of the position of the neglected limb

Expected Outcomes:

• Patient will demonstrate techniques to minimize unilateral neglect.
• Patient will safely 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 behaviors indicative of neglect, such as not attending to one side of the body, bumping into objects on the neglected side, eating food only on one side of the plate, or neglecting to groom one side of the body.
2. Assess Awareness of Neglect: Determine the patient’s level of awareness of their unilateral neglect, as anosognosia (lack of awareness of deficit) is common and impacts safety.
3. Assess Skin Integrity on Neglected Side: Carefully assess skin on the neglected side for signs of injury or breakdown, as patients may be unaware of discomfort or pressure on that side.

Interventions:

1. Implement Fall Precautions: Due to one-sided weakness and neglect, patients are at increased fall risk. Ensure bed alarms are activated, call light is accessible, and assist with transfers and ambulation.
2. Encourage Assistive Device Use: Promote the use of assistive devices (e.g., walkers, canes, reachers) to enhance safety and encourage attention to the neglected side.
3. Instruct on Neutral Body Positioning: Encourage maintaining neutral body alignment and regular position changes to prevent pain, joint subluxation, and contractures. Remind the patient to monitor their body position and be aware of the neglected side.
4. Position Belongings on Unaffected Side: Initially, place personal items and call light on the patient’s unaffected side to encourage interaction with that side and gradually introduce items to the neglected side to promote awareness. Approach the patient and encourage getting out of bed on the unaffected side to promote safety and awareness.
5. Coordinate Rehabilitation Program: Facilitate transfer to an appropriate rehabilitation program (physical, occupational, speech therapy) to address unilateral neglect and maximize functional recovery. Rehabilitation strategies for neglect often involve visual scanning training, sensory stimulation, and environmental adaptation.