Stroke Nursing Diagnosis Care Plan: A Comprehensive Guide

A cerebrovascular accident (CVA), commonly known as a stroke, is a critical medical condition characterized by the disruption of blood flow to the brain. This interruption prevents brain tissue from receiving essential oxygen and nutrients, leading to potential brain cell damage within minutes. Effective nursing care is paramount in managing stroke patients, focusing on rapid assessment, intervention, and rehabilitation. This guide provides a detailed Stroke Nursing Diagnosis Care Plan, essential for healthcare professionals in delivering optimal patient care.

Types of Stroke

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

Ischemic Strokes: These are the most prevalent type, accounting for approximately 87% of all strokes. Ischemic strokes occur due to a blockage or reduction in blood supply to a part of the brain. This blockage is often caused by:

• Thrombosis: Formation of a blood clot within a cerebral artery.
• Embolism: A blood clot or other debris traveling from another part of the body (often the heart) and lodging in a brain artery.
• Systemic Hypoperfusion: Reduced blood flow to all parts of the body, including the brain, usually due to heart problems or severe hypotension.

The lack of blood flow in ischemic stroke deprives brain tissue of oxygen and glucose, leading to a cascade of cellular injury and potentially irreversible damage if not promptly treated.

Hemorrhagic Strokes: Hemorrhagic strokes result from the rupture of a blood vessel in the brain, causing bleeding into the brain tissue or the surrounding spaces. This bleeding increases intracranial pressure and damages brain cells. Key causes include:

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

Hemorrhagic strokes are generally more severe and have a higher mortality rate than ischemic strokes.

Transient Ischemic Attacks (TIAs): Often referred to as “mini-strokes,” TIAs are temporary episodes of neurological dysfunction caused by brief interruptions in blood flow to the brain, spinal cord, or retina, without acute infarction. Symptoms are similar to those of a stroke but are transient, typically resolving within minutes to hours (usually within 1 hour) and always within 24 hours. TIAs are critical warning signs, as individuals who experience a TIA are at a significantly increased risk of having a full stroke in the future. Therefore, prompt medical evaluation and management of risk factors are essential following a TIA.

Image alt text: Diagram illustrating the two main types of stroke: ischemic stroke caused by blocked artery and hemorrhagic stroke caused by bleeding artery.

Nursing Process for Stroke Patients

The nursing process for stroke patients is a systematic approach to providing individualized and holistic care. It involves assessment, diagnosis, planning, implementation, and evaluation, tailored to the unique needs of each patient based on the severity and impact of their stroke. Given the potential for rapid neurological changes and the complexity of stroke care, nurses play a crucial role in monitoring, intervening, and advocating for stroke patients. Many nurses working with stroke patients hold the NIH Stroke Scale (NIHSS) certification to ensure competency in stroke assessment and monitoring.

Stroke severity and resulting disabilities vary widely. Some patients may experience minimal deficits and recover quickly, while others may suffer severe, long-term impairments requiring extensive care and rehabilitation. The nursing process addresses both the acute phase of stroke management and the ongoing needs for recovery and adaptation. Compassionate nursing care is essential to maintain patient safety, dignity, and quality of life throughout the stroke journey, addressing physical, psychological, and emotional needs.

Nursing Assessment for Stroke

The initial nursing assessment is crucial and sets the foundation for subsequent care planning and interventions. It involves gathering comprehensive data across physical, psychosocial, emotional, and diagnostic domains.

Review of Health History

A thorough health history is vital in identifying risk factors, understanding the patient’s baseline condition, and guiding acute and ongoing management.

1. General Symptom Inquiry: Promptly inquire about any 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 is a classic stroke sign.
• Sensory Deficits (Paresthesias): Numbness, tingling, or altered sensation in the extremities.
• Swallowing Difficulties (Dysphagia): Difficulty or inability to swallow safely, increasing aspiration risk.
• Visual Disturbances: Sudden vision loss, double vision (diplopia), or visual field deficits (hemianopsia).
• Speech Difficulties (Aphasia, Dysarthria):
  • Expressive Aphasia (Broca’s Aphasia): Difficulty producing speech, though comprehension may be relatively intact.
  • Receptive Aphasia (Wernicke’s Aphasia): Difficulty understanding spoken language, leading to nonsensical speech.
  • Dysarthria: Difficulty articulating words due to muscle weakness affecting speech.
• Balance and Coordination Issues (Ataxia): Unsteady gait, dizziness, or loss of balance.
• Cognitive and Mental Status Changes: Confusion, disorientation, memory problems, or altered level of consciousness.

2. Onset of Symptoms: Precise timing of symptom onset is critical. Determine when symptoms first appeared and, crucially, the last time the patient was known to be at their neurological baseline. This “last known well” time is a key factor in determining eligibility for thrombolytic therapy (tPA) and other acute stroke treatments.

3. Stroke Risk Factor Assessment: Identify and document modifiable and non-modifiable risk factors:

• Age: Risk increases significantly with age, especially after 55 years.
• Ethnicity: African Americans and Hispanics have a higher stroke incidence and mortality compared to Caucasians.
• Gender: Men have a slightly higher stroke risk overall, but stroke risk in women increases after menopause.
• Prior Stroke or TIA: History of stroke or TIA greatly increases the risk of future stroke.
• Hypertension: Uncontrolled high blood pressure is the leading modifiable risk factor for stroke.
• Hyperlipidemia: High cholesterol levels contribute to atherosclerosis and stroke risk.
• Diabetes Mellitus: Diabetes increases the risk of stroke and worsens stroke outcomes.
• Obesity and Physical Inactivity: Obesity and lack of exercise are significant modifiable risk factors.
• Smoking: Smoking damages blood vessels and significantly increases stroke risk.
• Atrial Fibrillation: This cardiac arrhythmia greatly increases the risk of embolic stroke.
• Carotid Artery Disease: Narrowing of the carotid arteries in the neck increases stroke risk.
• Sleep Apnea: Obstructive sleep apnea is linked to hypertension and increased stroke risk.
• COVID-19 Infection: Recent studies have shown an increased risk of stroke following COVID-19 infection.

4. Medical History Review: Explore pre-existing medical conditions that predispose to stroke:

• Cardiovascular Disease: Coronary artery disease, heart failure, and peripheral artery disease.
• Hypertension: History of high blood pressure and its management.
• Diabetes Mellitus: Type 1 or Type 2 diabetes and glycemic control.
• Hyperlipidemia: History of high cholesterol and lipid-lowering treatment.
• Obstructive Sleep Apnea: Diagnosis and treatment of sleep apnea.
• Atrial Fibrillation and other Arrhythmias: History of heart rhythm disorders.
• Migraine with Aura: Migraines, especially with aura, are associated with a slightly increased stroke risk.
• Hypercoagulable States: Conditions that increase blood clotting tendency.

5. Family History: Inquire about family history of stroke, particularly in first-degree relatives and at younger ages (before 65). Genetic conditions like CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) can predispose to stroke.

6. Medication Review: Meticulously review all current medications, including over-the-counter drugs and supplements:

• Hormone Replacement Therapy (HRT) and Oral Contraceptives: Estrogen-containing medications can increase stroke risk, especially in women who smoke or have other risk factors.
• Antihypertensives: Assess adherence and effectiveness of blood pressure medications.
• Anticoagulants and Antiplatelet Agents: Medications like aspirin, warfarin, heparin, and novel oral anticoagulants (NOACs) may be used for stroke prevention or treatment of underlying conditions like atrial fibrillation. Note any recent changes in dosage or adherence.

7. Substance Use History: Assess for use of illicit drugs:

• Cocaine, Amphetamines, Heroin: These substances are strongly linked to increased stroke risk, both ischemic and hemorrhagic.

8. Lifestyle Factors: Gather information on lifestyle habits:

• Diet: Dietary patterns high in saturated and trans fats, cholesterol, and sodium increase stroke risk.
• Physical Activity: Sedentary lifestyle is a major risk factor.
• Alcohol Consumption: Excessive alcohol intake increases stroke risk.
• Smoking: Current or past smoking history and pack-years smoked.

Image alt text: Nurse taking health history of a senior patient in a hospital setting, focusing on stroke risk factors and symptoms.

Physical Assessment

The physical examination is essential to identify neurological deficits and guide immediate stroke management.

1. F.A.S.T. Recognition: Immediately assess for the cardinal signs of stroke using the F.A.S.T. acronym:

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

2. ABCs Assessment: Prioritize assessment of Airway, Breathing, and Circulation. Stroke patients are at risk for aspiration, airway obstruction, and respiratory compromise due to neurological deficits and potential increased intracranial pressure.

3. Neurological Examination (NIHSS): Perform a comprehensive neurological examination, ideally using the National Institutes of Health Stroke Scale (NIHSS). The NIHSS is a standardized, validated tool to quantify stroke-related neurological deficits. It assesses:

• Level of Consciousness (LOC): Alertness, orientation, and responsiveness.
• Eye Movements: Horizontal gaze, visual fields.
• Facial Movement: Facial symmetry and strength.
• Motor Function (Arms and Legs): Strength and movement in upper and lower extremities.
• Limb Ataxia: Coordination of limb movements.
• Sensory Function: Sensation to touch or pinprick.
• Language: Aphasia assessment, including naming, repetition, and comprehension.
• Speech (Dysarthria): Clarity of speech.
• Neglect/Inattention: Awareness of stimuli in both visual fields.

4. Vital Signs: Monitor vital signs closely:

• Blood Pressure: Hypertension is common in acute stroke. Note baseline BP and trends. Avoid rapid blood pressure lowering in acute ischemic stroke unless specific criteria are met (e.g., thrombolytic therapy).
• Heart Rate and Rhythm: Assess for arrhythmias, particularly atrial fibrillation.
• Respiratory Rate and Oxygen Saturation: Monitor for respiratory distress, hypoxemia, and aspiration risk.
• Temperature: Fever can worsen neurological outcomes and should be managed.

Image alt text: Healthcare professional performing FAST assessment on a patient, checking for facial droop, arm weakness, and speech difficulty.

Diagnostic Procedures

Diagnostic tests are essential to confirm stroke, differentiate between ischemic and hemorrhagic stroke, identify the stroke etiology, and guide treatment decisions.

1. Blood Glucose Measurement: Immediately check capillary blood glucose (fingerstick glucose) to rule out hypoglycemia as a cause of neurological symptoms, as hypoglycemia can mimic stroke.

2. Brain Imaging: Neuroimaging is critical in acute stroke diagnosis.

• Non-contrast Head CT Scan: Typically the first-line imaging modality in suspected stroke for rapid differentiation between ischemic and hemorrhagic stroke. It is highly sensitive for detecting hemorrhage but less sensitive for early ischemic changes.
• CT Angiography (CTA) and CT Perfusion (CTP) Scanning: CTA visualizes cerebral blood vessels to identify large vessel occlusions, while CTP assesses cerebral blood flow and tissue viability, helping to determine the extent of ischemic penumbra (potentially salvageable tissue).
• Magnetic Resonance Imaging (MRI): MRI, particularly diffusion-weighted imaging (DWI), is highly sensitive in detecting early ischemic stroke and can provide more detailed information about infarct size and location. MRI is also useful for identifying small hemorrhages and posterior fossa strokes, which may be less evident on CT.
• Carotid Duplex Ultrasound: Evaluates carotid arteries in the neck for stenosis (narrowing) or plaque, a common cause of ischemic stroke.
• Digital Subtraction Angiography (DSA): Invasive angiography, typically reserved for specific situations, such as planning for endovascular thrombectomy or evaluating intracranial aneurysms or vascular malformations.

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

• Complete Blood Count (CBC): Evaluates for polycythemia (increased red blood cell count) or thrombocytopenia (low platelet count), which can contribute to stroke risk.
• Coagulation Studies (PT/INR, aPTT): Baseline coagulation tests are important before administering anticoagulants or thrombolytics.
• Cardiac Biomarkers (Troponin): Evaluate for myocardial infarction (heart attack) as a potential cause or comorbidity in stroke patients.
• Electrolytes, Renal Function, Liver Function Tests: Baseline metabolic panel to assess overall patient status and guide medication management.
• Lipid Profile (Fasting): Assess cholesterol and triglyceride levels as risk factors for atherosclerosis and stroke.
• Toxicology Screen: Rule out drug intoxication as a cause of stroke-like symptoms, especially in younger patients with unclear etiology.

4. Pregnancy Test (for Women of Childbearing Age): Perform urine pregnancy test in women of reproductive age before fibrinolytic therapy, as the safety of thrombolytics 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.

Nursing Interventions for Stroke

Nursing interventions are crucial in the acute and rehabilitation phases of stroke care, aiming to restore brain perfusion, prevent complications, support recovery, and optimize patient outcomes.

Restore Brain Perfusion

Prompt restoration of blood flow is the primary goal in acute ischemic stroke management to minimize brain damage.

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 be prepared for immediate brain imaging, ideally a STAT non-contrast head CT. This rapid triage and imaging are essential to determine stroke type (ischemic vs. hemorrhagic) and guide treatment decisions.

2. Thrombolytic Therapy (Alteplase): For eligible patients with confirmed ischemic stroke, initiate alteplase (tissue plasminogen activator, tPA) as rapidly as possible. Alteplase is an intravenous medication that dissolves blood clots and can significantly improve outcomes if administered within the appropriate time window (typically within 3-4.5 hours of symptom onset for selected patients). Alteplase is contraindicated in hemorrhagic stroke due to the risk of exacerbating bleeding. Strict adherence to inclusion and exclusion criteria for alteplase is crucial.

3. Continuous Neurological Monitoring: Frequent and meticulous neurological assessments are paramount post-stroke to detect any changes in neurological status promptly.

• Pupillary Examination: Monitor pupil size, equality, and reactivity to light. Changes can indicate increased intracranial pressure or brain herniation.
• Level of Consciousness (LOC): Regularly assess alertness, orientation, and responsiveness using scales like the Glasgow Coma Scale (GCS).
• Motor and Sensory Function: Monitor for changes in strength, movement, sensation, and reflexes in all extremities.
• Speech and Language: Assess for changes in speech fluency, comprehension, and naming abilities.
• Cognition and Memory: Evaluate cognitive function, attention, and memory.
• Mood and Behavior: Observe for mood changes, agitation, or emotional lability, which can occur post-stroke.

4. Medication Administration: Administer medications as prescribed to manage blood pressure, prevent secondary events, and address complications.

• Antihypertensives: Manage blood pressure according to established guidelines. In acute ischemic stroke, permissive hypertension may be allowed initially unless thrombolytic therapy is planned. For hemorrhagic stroke, stricter blood pressure control is typically indicated.
• Antiseizure Medications: Seizure prophylaxis may be initiated, particularly in hemorrhagic stroke or cortical strokes, as seizures can worsen neurological injury.
• Stool Softeners and Laxatives: Prevent constipation and straining during bowel movements, as straining can increase intracranial pressure.

5. Blood Pressure Management: Maintain blood pressure within target ranges based 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. For patients not receiving thrombolytics, current guidelines may allow for moderate hypertension in the acute phase to maintain cerebral perfusion, avoiding overly aggressive blood pressure lowering unless extremely elevated.
• Hemorrhagic Stroke: For intracerebral hemorrhage, initial goal is often to reduce systolic blood pressure to around 140 mmHg to limit hematoma expansion.

6. Mechanical Thrombectomy: For patients with large vessel occlusion ischemic stroke, mechanical thrombectomy may be indicated. This procedure involves using a catheter to physically remove the clot from the cerebral artery, often performed in specialized stroke centers. Ensure informed consent is obtained and prepare the patient for the procedure.

7. Endovascular Techniques: For carotid artery stenosis, procedures like 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 reduce future stroke risk.

Image alt text: Nurse monitoring patient’s neurological status, checking pupils and responsiveness to ensure adequate brain perfusion after stroke.

Stroke Recovery and Prevention

Rehabilitation and secondary stroke prevention are critical components of long-term stroke care.

1. Stroke Rehabilitation Referral: Initiate referrals to comprehensive stroke rehabilitation services, which are essential to maximize functional recovery and quality of life. Rehabilitation teams typically include:

• Physical Therapy: To improve motor skills, balance, gait, and mobility.
• Occupational Therapy: To enhance activities of daily living (ADLs), fine motor skills, and cognitive-perceptual skills.
• Speech Therapy: To address communication deficits (aphasia, dysarthria), swallowing difficulties (dysphagia), and cognitive-linguistic impairments.
• Cognitive Therapy/Neuropsychology: To address cognitive deficits, memory problems, and executive function issues.
• Rehabilitation Nursing: Specialized nursing care focused on promoting independence, managing bowel and bladder function, skin care, medication management, and patient/family education.
• Social Work/Case Management: To assist with discharge planning, accessing community resources, and addressing psychosocial needs.

2. Speech Deficit Management Education: For patients with aphasia or dysarthria, speech therapy is crucial. Educate patients and families on communication strategies:

• Communication Partner Training: Strategies to enhance communication between the patient and caregivers.
• Speech Practice: Encourage consistent practice using flashcards, books, apps, and visual aids.
• Alternative Communication Methods: Utilize communication boards, writing, gestures, and assistive technology as needed.

3. Medication Education: Provide thorough education on prescribed medications at discharge:

• Anticoagulants (e.g., Apixaban, Rivaroxaban, Dabigatran, Warfarin): For patients with atrial fibrillation or other indications for anticoagulation to prevent cardioembolic stroke. Emphasize adherence and monitoring (especially for warfarin).
• Antiplatelet Agents (e.g., Aspirin, Clopidogrel): Often prescribed to prevent recurrent ischemic stroke.
• Antihypertensives (e.g., Diuretics, ACE Inhibitors, Beta-Blockers, Calcium Channel Blockers): To manage hypertension and reduce secondary stroke risk. Emphasize adherence and regular blood pressure monitoring.
• Statins (Lipid-Lowering Medications): To manage hyperlipidemia and reduce atherosclerotic risk.

4. Safety Strategies: Implement and educate on safety measures to prevent falls and injuries due to stroke-related deficits:

• Fall Prevention: Ensure bed rails are up, bed alarms are in use, call light is within reach, and assistive devices (walkers, canes) are readily available and used correctly.
• Home Safety Modifications: Educate patients and families on home modifications to reduce fall risks (e.g., removing rugs, improving lighting, grab bars in bathrooms).

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

6. Lifestyle Modification Promotion and Education: Educate patients on modifiable risk factors and lifestyle changes to minimize the risk of recurrent stroke:

• Healthy Diet: Emphasize a diet low in saturated fats, trans fats, cholesterol, and sodium, and rich in fruits, vegetables, and whole grains (e.g., DASH diet, Mediterranean diet).
• Regular Exercise: Encourage at least 30 minutes of moderate-intensity exercise most days of the week.
• Smoking Cessation: Strongly advise and assist with smoking cessation.
• Moderate Alcohol Consumption: Limit alcohol intake.
• Weight Management: Achieve and maintain a healthy weight.

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

Stroke Nursing Care Plans: Examples

Nursing care plans are structured frameworks that guide nursing care by identifying patient-specific nursing diagnoses, setting goals, and outlining interventions. Here are examples of nursing care plans for common stroke-related nursing diagnoses.

Impaired Verbal Communication

Stroke frequently affects communication abilities. Patients may experience difficulty understanding or expressing speech, or have physical limitations affecting speech production.

Nursing Diagnosis: Impaired Verbal Communication

Related Factors:

• Prolonged cerebral occlusion due to stroke
• Dysarthria (weakness of speech muscles)
• Aphasia (language impairment affecting comprehension and/or expression)

Evidenced by:

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

Expected Outcomes:

• Patient will establish effective communication methods to express needs and thoughts within [specify timeframe].
• Patient will actively participate in speech therapy sessions to improve communication skills during hospitalization and rehabilitation.
• Patient will utilize available communication resources and assistive devices to support communication effectively.

Nursing Assessments:

1. Identify Type of Aphasia: Differentiate between global, Wernicke’s, Broca’s, or other types of aphasia to tailor communication strategies. Global aphasia is severe, affecting both expression and comprehension. Wernicke’s aphasia results in fluent but nonsensical speech with impaired comprehension. Broca’s aphasia affects speech production despite relatively intact comprehension.
2. Observe Current Communication Methods: Assess how the patient currently attempts to communicate (gestures, sounds, writing). Family input is valuable to understand patient-specific communication cues and preferences.

Nursing Interventions:

1. Use Simple, Direct Language: Speak clearly, face the patient, and use short, direct sentences. Avoid abstract language or complex sentence structures. “Yes” or “no” questions are often easiest to comprehend.
2. Implement Alternative Communication Methods: Utilize writing, drawing, picture boards, or flashcards if appropriate for the patient. Establish a simple communication system (e.g., thumbs up/down, eye blinks for yes/no) if the patient is nonverbal.
3. Facilitate Speech Therapy: Speech-language pathology is essential for communication rehabilitation. Therapy can improve language abilities, teach compensatory strategies, and introduce assistive communication devices.
4. Encourage Family Involvement: Family participation is crucial. Educate family members on effective communication strategies and encourage their involvement in therapy sessions to learn supportive communication techniques.

Image alt text: Nurse using flashcards to communicate with stroke patient with impaired verbal communication in a hospital room.

Ineffective Cerebral Tissue Perfusion

Interrupted blood flow deprives brain tissue of oxygen, leading to potential tissue death if not rapidly addressed.

Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion

Related Factors:

• Interruption of arterial blood flow to the brain
• Thrombus or embolus formation
• Cerebral artery occlusion
• Cerebral edema
• Hemorrhage

Evidenced by:

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

Expected Outcomes:

• Patient will demonstrate understanding of stroke symptoms and the importance of seeking immediate medical attention.
• Patient will exhibit improved cerebral tissue perfusion, evidenced by stable vital signs within ordered parameters and improved neurological status during hospitalization.
• Patient will demonstrate improvement in stroke-related deficits (speech, weakness, swallowing) by discharge from acute care setting.

Nursing Assessments:

1. Establish Baseline Neurological Status: Determine the “last known well” time to guide treatment decisions, particularly regarding thrombolytic therapy (time-sensitive intervention). Baseline assessment is crucial for monitoring changes and effectiveness of interventions.
2. Frequent Neurological Assessments: Perform serial neurological assessments using the NIH Stroke Scale or facility-specific stroke scales to monitor LOC, pupillary response, motor and sensory function, speech, and language.
3. Review Brain Imaging Results: Review CT or MRI findings to confirm stroke diagnosis, differentiate stroke type (ischemic vs. hemorrhagic), and determine the extent and location of brain injury.

Nursing Interventions:

1. Maintain Blood Pressure Parameters: Manage blood pressure according to physician orders and stroke type. For ischemic stroke, permissive hypertension may be initially allowed, while hemorrhagic stroke often requires more aggressive blood pressure reduction. Avoid rapid or excessive blood pressure lowering.
2. Administer Thrombolytics (if indicated): For eligible ischemic stroke patients, administer thrombolytic therapy (alteplase) within the established time window. Monitor for bleeding complications. Thrombolytics are contraindicated in hemorrhagic stroke.
3. Educate on Stroke Risk Factors: Provide patient and family education on modifiable stroke risk factors (hypertension, hyperlipidemia, diabetes, smoking, inactivity) to promote secondary prevention.
4. Stroke Symptom Education (F.A.S.T.): Educate patients and family members on recognizing stroke symptoms using the F.A.S.T. acronym (Face, Arms, Speech, Time) and the critical importance of calling emergency services immediately upon symptom onset. “Time is brain” in stroke management.

Risk for Injury

Stroke-related deficits, including perceptual issues, impaired judgment, weakness, and swallowing difficulties, increase the risk of injury.

Nursing Diagnosis: Risk for Injury

Related Factors:

• Impaired judgment and cognitive function
• Spatial-perceptual deficits (e.g., unilateral neglect, depth perception issues)
• Weakness, paralysis (hemiplegia)
• Poor motor coordination and balance
• Impaired sensory awareness (e.g., decreased sensation)
• Dysphagia and aspiration risk
• Communication deficits
• Short attention span and impulsivity

Expected Outcomes:

• Patient will remain free from falls and other injuries throughout hospitalization and rehabilitation.
• Patient will maintain intact skin integrity, without pressure ulcers or skin breakdown.
• Caregivers will implement a modified environment and safety measures to minimize patient injury risk.

Nursing Assessments:

1. Identify Stroke-Related Deficits: Assess specific neurological deficits related to the stroke location and impact on motor, sensory, cognitive, and perceptual functions. Right-brain strokes may result in impulsivity and perceptual deficits, while left-brain strokes are more likely to affect speech and swallowing.
2. Assess Sensory Awareness: Evaluate sensory function, including the ability to perceive pain, temperature, and pressure, especially in affected extremities. Decreased sensation increases risk of skin breakdown and injury.
3. Assess for Neglect and Visual Field Deficits: Determine if unilateral neglect (inattention to one side of the body or environment) or hemianopia (visual field loss) is present. These deficits significantly increase injury risk.

Nursing Interventions:

1. Implement Fall Precautions: Utilize bed and chair alarms, keep bed in low position, ensure nonskid footwear, clear pathways of clutter, and provide assistance with ambulation. Patients with right-brain strokes, particularly, may be impulsive and underestimate their deficits, increasing fall risk.
2. Assist with Feeding and Swallowing: For patients with dysphagia, implement swallowing precautions (thickened liquids, modified diet, positioning). Supervise meals, ensure proper chewing and swallowing, 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 systematically (e.g., left to right scanning) to improve awareness of hazards and reduce injury risk.
4. Skin Integrity Measures: For patients with paralysis or decreased sensation, implement pressure ulcer prevention strategies: turn and reposition every 2 hours, use pressure-relieving devices, keep skin clean and dry, and assess skin frequently for breakdown.

Self-Care Deficit

Stroke often results in physical and cognitive impairments that affect the ability to perform self-care activities.

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

Related Factors:

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

Evidenced by:

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

Expected Outcomes:

• Patient will maintain skin integrity and be free from body odor throughout hospitalization.
• Patient will demonstrate effective use of assistive devices and methods for bathing and hygiene.
• Patient will express satisfaction with bathing/hygiene experiences, even when requiring caregiver assistance.
• Patient will achieve optimal independence in dressing and performing ADLs within their capabilities.
• Patient will demonstrate competence in using adaptive equipment for self-care activities.
• Patient will safely and effectively feed themselves with appropriate assistance or adaptive equipment.
• Patient will maintain bowel and bladder continence or manage incontinence effectively, preventing skin breakdown.

Nursing Assessments:

1. Functional Ability and Limitations: Assess the patient’s functional status in all areas of self-care (bathing, dressing, feeding, toileting). Identify specific limitations in physical mobility, sensation, cognition, and emotional state that impact self-care abilities. This assessment guides care planning, rehabilitation, and discharge planning.
2. Patient Preferences: Inquire about patient preferences and usual routines for self-care activities (e.g., bathing time, hygiene products). Respecting preferences promotes comfort, dignity, and cooperation.
3. Risk Assessments: Regularly assess for risk factors that can complicate self-care and increase dependency:
   • Fall Risk: Utilize a fall risk assessment tool (e.g., Morse Fall Scale) due to mobility impairments.
   • Skin Risk: Use a skin assessment tool (e.g., Braden Scale) to identify pressure ulcer risk related to immobility and sensory deficits.
   • Swallowing Risk: Perform a bedside swallow screen before oral intake due to dysphagia risk.

Nursing Interventions:

1. Establish Toileting Schedule: Implement a regular toileting schedule to prevent incontinence and constipation. Offer toileting assistance frequently, especially after meals and before bedtime. Administer stool softeners as ordered.
2. Encourage Independence: Promote patient independence in self-care as much as possible, providing assistance only as needed. Encourage and praise patient efforts to enhance self-esteem and recovery.
3. Allow Adequate Mealtime: Provide sufficient time for meals, especially for patients with dysphagia or slow eating. Create a calm, unhurried environment.
4. Assistive Equipment: Introduce and train patients in the use of adaptive equipment for ADLs (e.g., button hooks, zipper pulls, long-handled reachers, shower chairs, specialized utensils).
5. Consult Therapy Services: Collaborate with physical and occupational therapists to develop individualized rehabilitation plans to improve self-care skills and functional independence.

Unilateral Neglect

Unilateral neglect is a neurological condition following stroke, characterized by reduced awareness of stimuli on one side of the body and space, typically the side contralateral to the brain lesion.

Nursing Diagnosis: Unilateral Neglect

Related Factors:

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

Evidenced by:

• Altered safety behavior on the neglected side (e.g., bumping into objects, ignoring one side of the body)
• Failure to move eyes or head toward the neglected side
• Inability to move limbs on the neglected side despite motor function being intact
• Difficulty grooming or dressing the neglected side of the body
• Unawareness of the position of the neglected limb in space
• Eating food only on one side of the plate

Expected Outcomes:

• Patient will demonstrate techniques to minimize unilateral neglect and improve awareness of the affected side within [specify timeframe].
• Patient will consistently attend to and care for both sides of the body, keeping the neglected side safe from injury.
• Patient will achieve the highest possible level of functional independence, considering individual goals and abilities, despite unilateral neglect.

Nursing Assessments:

1. Assess for Signs of Unilateral Neglect: Observe for behaviors indicative of neglect: failure to attend to one side of the body (grooming, dressing), bumping into objects on one side, eating only half the meal, not responding to stimuli on the affected side.
2. Assess Level of Awareness: Evaluate the patient’s insight into their neglect. Some patients may be completely unaware of their deficit, while others may be partially aware but struggle to compensate. Awareness is crucial for effective intervention.
3. Skin Assessment (Neglected Side): Carefully assess the skin on the neglected side for signs of injury, pressure, or breakdown. Patients with neglect are at increased risk for skin problems due to lack of awareness and repositioning of the affected side.

Nursing Interventions:

1. Initiate Fall Precautions: Patients with unilateral neglect have impaired spatial awareness and balance, increasing fall risk. Implement comprehensive fall precautions (bed alarms, clear environment, assistance with ambulation).
2. Encourage Assistive Devices: Introduce and encourage the use of assistive devices (e.g., walkers, reachers) to improve safety and promote awareness of the neglected side.
3. Neutral Body Positioning: Instruct and assist the patient in maintaining neutral body alignment and symmetrical posture to improve body awareness and prevent pain or contractures. Encourage regular position changes and attention to the neglected side.
4. Position Belongings on Unaffected Side: Initially, place personal items (call light, water, phone) on the patient’s unaffected side to encourage interaction and reduce frustration. Gradually progress to placing items on the affected side to promote awareness and scanning.
5. Rehabilitation Referral: Ensure timely referral to rehabilitation programs (physical therapy, occupational therapy) specializing in stroke rehabilitation and unilateral neglect management. Rehabilitation is essential to teach compensatory strategies and improve functional outcomes.