A stroke, or cerebrovascular accident (CVA), is a medical emergency that requires immediate nursing intervention and care. This comprehensive guide focuses on essential nursing diagnoses, interventions, and care plans to help nurses provide optimal care for stroke patients.
Understanding Stroke
A stroke occurs when blood flow to the brain is interrupted, either by a blockage (ischemic stroke) or bleeding (hemorrhagic stroke). As nurses, understanding the different types of strokes and their manifestations is crucial for providing appropriate care.
Types of Strokes:
Ischemic Stroke
- Caused by blood clots or blockages
- Accounts for approximately 87% of all strokes
- May result from atherosclerosis or embolism
Hemorrhagic Stroke
- Caused by bleeding in the brain
- More severe but less common
- Often related to hypertension or aneurysms
Transient Ischemic Attack (TIA)
- Often called “mini-strokes”
- Symptoms resolve within 24 hours
- Warning sign for future strokes
Key Nursing Assessment Areas
Primary Assessment
- Level of consciousness
- Vital signs
- Neurological status
- Speech and swallowing ability
- Motor function
- Sensory function
FAST Assessment:
- Face drooping
- Arm weakness
- Speech difficulties
- Time to call emergency services
Common Stroke Symptoms
Physical Symptoms:
- Hemiparesis or hemiplegia
- Balance problems
- Visual disturbances
- Difficulty swallowing
Cognitive Symptoms:
- Memory problems
- Confusion
- Difficulty concentrating
- Altered mental status
Communication Issues:
- Aphasia
- Dysarthria
- Difficulty understanding speech
Nursing Care Plans for Stroke Patients
1. Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to neuromuscular impairment secondary to stroke as evidenced by hemiplegia, decreased muscle strength, and impaired coordination.
Related Factors/Causes:
- Hemiplegia/hemiparesis
- Muscle weakness
- Balance impairment
- Sensory deficits
- Cognitive impairment
Nursing Interventions and Rationales:
Perform range of motion exercises every shift
- Prevents contractures and maintains joint mobility
Position the patient properly using supportive devices
- Prevents pressure ulcers and maintains proper body alignment
Implement early mobilization protocol as appropriate
- Promotes circulation and prevents complications
Assist with transfers using proper body mechanics
- Ensures patient safety and prevents falls
Collaborate with physical therapy for mobility plan
- Maximizes rehabilitation potential
Desired Outcomes:
- The patient will demonstrate improved mobility
- The patient will maintain proper body alignment
- The patient will participate in a physical therapy program
- The patient will remain free from falls
2. Risk for Aspiration
Nursing Diagnosis Statement:
Risk for Aspiration related to impaired swallowing mechanism secondary to neurological damage.
Related Factors/Causes:
- Dysphagia
- Impaired gag reflex
- Decreased level of consciousness
- Weak cough reflex
Nursing Interventions and Rationales:
Assess swallowing ability before oral intake
- Identifies aspiration risk
Position the patient upright at 90 degrees for meals
- Reduces risk of aspiration
Implement dysphagia precautions
- Ensures safe swallowing
Monitor oxygen saturation during meals
- Detects early signs of aspiration
Coordinate care with speech therapy
- Optimizes swallowing function
Desired Outcomes:
- The patient will demonstrate safe swallowing
- The patient will maintain adequate nutrition
- The patient will remain free from aspiration
- The patient will show improved swallowing ability
3. Acute Confusion
Nursing Diagnosis Statement:
Acute Confusion related to decreased cerebral perfusion as evidenced by disorientation, memory deficits, and altered cognitive function.
Related Factors/Causes:
- Cerebral hypoxia
- Electrolyte imbalances
- Medication effects
- Environmental changes
Nursing Interventions and Rationales:
Maintain consistent caregivers
- Reduces confusion and anxiety
Provide orientation cues
- Helps maintain temporal awareness
Implement safety measures
- Prevents injury
Monitor cognitive status regularly
- Tracks mental status changes
Create a structured environment
- Promotes orientation
Desired Outcomes:
- The patient will show improved orientation
- The patient will demonstrate better cognitive function
- The patient will maintain safety
- The patient will communicate needs effectively
4. Anxiety
Nursing Diagnosis Statement:
Anxiety related to the threat to current health status as evidenced by expressed concerns, restlessness, and increased tension.
Related Factors/Causes:
- Change in health status
- Fear of death
- Uncertainty about recovery
- Communication difficulties
Nursing Interventions and Rationales:
Provide clear, simple explanations
- Reduces fear of unknown
Establish therapeutic relationship
- Builds trust and security
Teach coping strategies
- Helps manage anxiety
Include family in care planning
- Enhances support system
Monitor for signs of increased anxiety
- Allows early intervention
Desired Outcomes:
- The patient will demonstrate reduced anxiety
- The patient will use effective coping strategies
- The patient will express an understanding of the condition
- The patient will show improved emotional status
5. Self-Care Deficit
Nursing Diagnosis Statement:
Self-care deficit related to neuromuscular impairment as evidenced by the inability to perform ADLs independently.
Related Factors/Causes:
- Physical limitations
- Cognitive impairment
- Fatigue
- Depression
- Pain
Nursing Interventions and Rationales:
Assess the level of independence
- Determines assistance needed
Provide adaptive equipment
- Promotes independence
Establish realistic goals
- Encourages participation
Teach compensatory techniques
- Enhances self-care ability
Involve occupational therapy
- Maximizes functional independence
Desired Outcomes:
- The patient will demonstrate increased independence in ADLs
- The patient will use adaptive equipment properly
- The patient will maintain personal hygiene
- The patient will show improved self-care ability
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- de Lau LM, den Hertog HM, van den Herik EG, Koudstaal PJ. Predicting and preventing stroke after transient ischemic attack. Expert Rev Neurother. 2009 Aug;9(8):1159-70. doi: 10.1586/ern.09.71. PMID: 19673605.
- Larramendi Embid, J., Medeiros, R., Mattos, C., Zerbino, C., & Gaiero, C. (2024). Functional studies of fibrin formation and fibrinolysis in cerebrovascular accident patients. Clinica Chimica Acta, 558, 118339. https://doi.org/10.1016/j.cca.2024.118339
- Mansfield A, Inness EL, Mcilroy WE. Stroke. Handb Clin Neurol. 2018;159:205-228. doi: 10.1016/B978-0-444-63916-5.00013-6. PMID: 30482315.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
