Cerebrovascular Accident CVA Stroke Nursing Diagnosis and Nursing Care Plan

Stroke NCLEX Review and Nursing Care Plans

Stroke is a medical emergency that occurs when a part of the brain’s blood supply is cut off causing oxygen deprivation and death to brain tissues. It is also known as cerebrovascular accident CVA.

Stroke can affect the brain’s functions and the effect depends on which part of the brain is affected.

Stroke can be categorized as hemorrhagic or ischemic depending on its cause.

Signs and Symptoms of Stroke

The clinical manifestations of stroke may occur suddenly. It is critical to seek immediate medical help as soon as possible to achieve a better outcome from treatment.   

• Difficulty speaking and understanding what others are saying – people having stroke may become confused and have slurred speech and have difficulty understanding other people’s words.
• Sudden paralysis of the face, arm, or leg – sudden onset of weakness, typically on one side of the body, is often noted in people having stroke.
• Problems with vision in one or both eyes – vision changes may occur when having stroke. The person may complain of sudden double vision or loss of vision.
• Headache – a person having stroke may complain of a sudden severe headache mostly accompanied by vomiting, dizziness, or confusion.
• Unsteady gait – weakness may affect the person’s coordination and alter the ability to walk.

Organizations and health institutions are recommending the use of the acronym “FAST” which refers to the following:

F – Face – a drop in one side of the face when the person smiles.

A – Arms – one arm will drop when both arms are raised at the same time.

S – Speech – slurred speech when asked to repeat a simple phrase.

T – Time – call for help when the above signs are observed.

Causes of Stroke

Like the other organs in the body, brain cells need oxygen to survive. Anything that can cause disruption to the blood supply in the brain can cause stroke.

The causes of stroke can be categorized as hemorrhagic or ischemic.

Hemorrhagic stroke – occurs when a blood vessel in the brain bursts allowing blood to seep through the brain which causes the surrounding brain cells to die. The following are the common causes of blood vessel rupture:

• High blood pressure
• Overuse of blood thinners or anticoagulants
• Aneurysm
• Trauma such as in a car accident
• Having protein deposits in the blood vessel wall such as in cases of cerebral amyloid angiopathy
• Ischemic stroke leading to hemorrhage

Ischemic stroke – occurs when a blood vessel is severely narrowed or occluded causing a significant reduction or total loss of blood supply in the brain.

This is the most common cause of stroke accounting to about 85% of cases reported.

The most common cause is a blood clot from elsewhere in the body that gets dislodged in one of the blood vessels in the brain.

One of the risks of having Atrial Fibrillation is that the condition can cause a stroke.

Another condition that may occur is transient ischemic attack (TIA) or “mini” stroke. It is a condition where the blood supply is cut off temporarily.

It only lasts for a few minutes to about 24 hours. It is often a warning sign to a full-blown stroke in the future hence prompt treatment is also necessary.

Complications of Stroke

1. Paralysis. Paralysis on one side of the body is quite a common complication following stroke.
2. Problem talking and swallowing. Stroke can affect the muscles responsible for talking and swallowing. Slurring of speech is often seen in people who had stroke.
3. Memory loss and problems with logical thinking
4. Emotional issues. Stroke can be challenging to some people and coping with it can affect their emotional state.
5. Pain. Some people with stroke can develop pain from the loss of sensation on one side of the body.
6.  Difficulty to carry out activities of daily living. Stroke can have lasting side effects that reduce the ability to carry out simple tasks.

Diagnosis of Stroke

• Blood tests – to measure the clotting ability, blood sugar level, and possible presence of infection.
• CT scan of the brain –helpful in the diagnosis of stroke. It will give detailed images of the brain that can show the presence of bleeding, ischemia, or tumor.
• MRI scan – another form of brain imaging that can be done if the CT scan is inconclusive or if a more detailed image of the brain is needed.
• Carotid scan – an ultrasound study of the carotid artery may be performed to observe for plaques in the arterial wall and assess the blood flow towards the brain.
• Echocardiogram – to look for possible blood clots in the heart that could cause ischemia to blood vessels in the brain.

Treatment of Stroke

Immediate medical attention is critical to prevent permanent disability.

For Ischemic Stroke:

1. Administration of drugs to break up clots through intravenous injection – drugs that can dissolve clots will restore blood supply to the brain and prevent further damage. Giving the drugs intravenously allows for quicker delivery of drugs where it is needed.
2. Emergency endovascular procedures
   • Administration of medications to break clots directly into the brain – medications can be administered directly into the brain through endovascular procedures. A catheter is inserted into the groin through an artery which will then thread to the brain.
   • Removal of the blood clot through a stent retriever – a procedure to retrieve the clot can also be performed via stent insertion. A catheter is inserted to thread into the brain and then a stent is inserted in the tube to reach the part of the brain where the clot is.
3. Carotid endarterectomy – this procedure involves the removal of plaque build-up in the carotid artery. This procedure carries risks especially in people with heart problems.
4. Angioplasty and stents – the use of angioplasty balloons and stents can open a narrowed blood vessel.

For Hemorrhagic Stroke:

Controlling the bleeding is the focus of treatment in hemorrhagic stroke.

1. Emergency procedures includes the following:
   • Use of drugs to counteract the effects of blood thinning medications
   • Blood transfusion – to thicken blood by improving blood volume
   • Anti-hypertensives – drugs to lower blood pressure
2. Surgical intervention – in cases of severe bleeding, surgical procedures to evacuate the blood and repair blood vessels may be required.
3. Surgical clipping – this procedure involves the clipping of an aneurysm to prevent it from bursting or to control the bleeding if it has already ruptured.
4. Endovascular embolization – a procedure that involves the use of coils to block the ruptured blood vessel.
5. Surgical AVM removal – this procedure is only performed if the AVM is easily accessible in the brain.
6. Stereotactic radiosurgery – this procedure involves the use of highly focused radiation to correct blood vessel malformations.

Stroke CVA Nursing Diagnosis

Nursing Care Plan for Stroke 1

Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral) related to cerebral edema and increased intracranial pressure (ICP) secondary to stroke as evidenced by drowsiness, confusion, headache, irritability, and memory problems

 Desired Outcome: The patient will re-establish effective cerebral tissue perfusion as evidenced by increased level of consciousness (i.e. awake and alert) and will show orientation with persons, places, and things.

Nursing Interventions for Stroke	Rationales
Assess the patient’s vital signs and neurological status at least every 4 hours, or more frequently if there is a change in them.	To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment for stroke.
Observe and monitor the patient for any signs and symptoms of further increase in ICP, such as sudden headache, vomiting, and decreased alertness.	To facilitate early detection and management of increased ICP. Increased ICP can be life-threatening as it may lead to further brain damage or coma.
Administer osmotic diuretics as prescribed.	To promote blood flow to the brain and to reduce cerebral edema.
Elevate the head of the bed at 30 degrees.	To promote venous drainage from the patient’s head to the rest of the body in order to decrease ICP and reduce cerebral edema.
Advise the patient to avoid straining when passing stool. Monitor bowel movements and administer appropriate laxatives (e.g. stool softeners) as needed.	Valsalva maneuver or straining during elimination may increase the ICP even further, worsening the condition.
Prepare the patient for surgery as indicated.	Surgical intervention such as cerebral angioplasty, endarterectomy, or microvascular bypass may be indicated to resolve ineffective tissue perfusion in the cerebrum.

Nursing Care Plan for Stroke 2

Nursing Diagnosis: Impaired physical mobility related to paralysis of one side of the body secondary to stroke as difficulty of movement, unsteady gait, generalized weakness, inability to do activities of daily living (ADLs) as normal, and verbalization of overwhelming tiredness/ fatigue

Desired Outcome: The patient will be able to perform activities of daily living within the limits of the present condition.

Nursing Interventions for Stroke	Rationales
Assess the patient’s level of functional mobility and ability to perform ADLs.	To assist in creating an accurate diagnosis and monitor effectiveness of treatment and therapy.
Assist the patient during exercises and when performing activities of daily living.	To encourage the patient to perform muscle-strengthening exercises and promote dignity by allowing the patient to perform their ADLs while maintaining safety.
Ensure the safety of the environment. Check that the call bell is within reach, the bed rails are up when the patient is on the bed, the bed is in the lowest level, the room is well-lit, the floor is not slippery, and that important things like phone and eyeglasses are easy to reach.	To maintain patient safety and reduce the risk of falls.
Encourage the patient to perform range of motion (ROM) exercises in all extremities.	To improve venous return, muscle strength, and stamina while preventing stiffness and contracture deformation.
Refer to the physiotherapy and occupational therapy team.	To provide a specialized care for the patient to gain physical and mental support in performing ADLs and mobilizing.

Nursing Care Plan for Stroke 3

Nursing Diagnosis: Self-Care Deficit related to physical limitations secondary to stroke as evidenced by inability to bathe, get dressed, and perform toileting activities as normal, and decreased level of strength and endurance

Desired Outcome: The patient will be able to demonstrate optimal performance of ADLs or activities of daily living.

Nursing Interventions for Stroke	Rationale
Observe the patient’s functional ability to perform self-care activities, especially toileting. Use functioning assessment (from 0 to 4) scale.	To determine the functional capability of the patient.
Assess the patient’s limitation and barriers to self-care by asking open-ended questions.	To explore the patient’s self-care limitations and needs while allowing him/her to express his/her personal thoughts and feelings related to ADLs.
Offer appropriate pain medication as prescribed at least 30 minutes before the patient performs self-care activities.	Pain might discourage the patient to mobilize and carry out self-care activities.
Ensure that the patient takes medications on time and as prescribed.	To ensure adherence to medical regimen.
Allow the patient to have sufficient time to complete activities of daily living. Advise the client to be patient with one’s self when performing self-care.	To build patient’s confidence and allow him/her to have a greater sense of self-worth.
Refer the patient to occupational therapist.	Occupational therapists are skilled professionals in helping clients achieve optimal performance in their daily activities like bathing, dressing, and personal hygiene tasks.
Encourage the patient to use assistive devices and grooming aids as needed.	To promote autonomy when performing self-care activities.

Nursing Care Plan for Stroke 4

Risk for Unilateral Neglect

Nursing Diagnosis: Risk for Unilateral Neglect related to neurologic illness secondary to stroke

Desired Outcomes:

• The patient will exhibit and practice techniques that can be used to reduce unilateral neglect
• The patient will verbalize ways how to care for both sides of his/her body away from harm.
• The patient will demonstrate an optimized functioning level.
• The patient’s safety will be maintained and free from harm.
• The patient will adapt to physical disability.

Nursing Interventions for Stroke	Rationale
Check the patient for signs and symptoms of unilateral neglect,  such as: Inability to wash, shave and dress on the other side of the body. Inappropriate lying on the affected side of the body. Changes in safety behaviors on the other side of the body. Inability to move body parts such as the eyes, head, limbs, and trunk on the affected side of the body. Also, observe symptoms of vertical visual field loss.	To evaluate the signs and symptoms of unilateral neglect which will allow the nurse to and healthcare team to create a suitable care plan.
Encourage the patient to increase the ability to manage unilateral neglect and encourage patient participation during rehabilitation activities which will help in achieving the intervention goals.	Unilateral neglect happens in the first month after the stroke and with continuing recovery. Rehabilitation helps the patient to be independent as possible to do everyday activities. Rehabilitation can be started as soon as the patient ca. Utilization of appropriate interventions for the patient to increase functioning must be included in the goal of care.
Explain to the patient the use of assistive devices and other rehabilitation support.	Using of assistive devices is important, especially for older patients after a stroke to help increase stability and improve muscle actions. Assistive devices also promote safety and help with the decreased risk of falls. Patients should be instructed on how to use assistive devices correctly.
Explain to the patient the recovery process of the patient’s after having a stroke.	Inform the patient that recovery of patients varies for different patients the process can be slow and indefinite.
Keep the patient’s safety at all times. Instruct the patient’s family and significant others on ways to keep the patient safe and away from injury.	Patients with stroke have the risk of falling because of the patient’s limitations in moving, reduced muscle strength, and limitations in doing activities of daily living.
Teach the patient’s family and significant others the proper position of the bed at home and encourage their participation inpatient care.	Participation from the family and significant others will help for the fast improvement of the patient’s condition. This will help the patient to be more motivated for his/her recovery.
Talk to the patient in a quiet, comforting voice and keep eye contact.	The attention span of the patient may be limited with comprehension. These ways can help the nurse to communicate well with the patient. Comfort care includes palliative care for the patients with stroke will help for the full recovery of the patient.
Instruct the patient to scan the environment by turning the head and eyes.	This may help detect visual field loss and may help the awareness of the environment.
Instruct the family and significant others to check the alignment of the limbs and check the patient’s skin regularly.	Pressure injuries may occur in patients because of decreased sensation and a decrease in positional awareness after having a stroke.
Advise the patient to continue prescribed rehabilitation activities as well as neuropsychological therapies.	Continuous rehabilitation maximize recovery and improves independence for the patient. Neuropsychological treatments help in improving the daily functioning of the patient by minimizing deficits in the behavioral and cognitive processes of the patient.
Evaluate the effectiveness of the interventions and rehabilitation done to the patient.	Check the patient’s response to rehabilitation and interventions to determine whether the interventions increase the activation of the affected side of the body and help in evaluating the optimal functioning of the patient in their daily living.

Nursing Care Plan for Stroke 5

Risk for Disuse Syndrome

Nursing Diagnosis: Risk for Disuse Syndrome related to physical immobilization secondary to stroke

Desired Outcomes:

• The patient will express understanding of the methods to decrease immobilization.
• The patient’s relatives will demonstrate methods to help the patient to ambulate and do a diversional activity.
• The patient will express comfort after the rehabilitation interventions.
• The patient’s relative will demonstrate proper transfer techniques.

Nursing Interventions for Stroke	Rationale
Teach the patient to evaluate their extremities and place the patient properly before instructing the patient to ambulate. Note for the signs of severe pain, swelling, and difficulty moving the joints.	It is important to assess the extremities of the patients, to prevent the patient from falling. Instruct the patient to be more careful when extending and raising the foot when ambulating.
Provide support such as pillows or lapboards when positioning the patient to promote correct alignment. Instruct the patient about the use of active/passive Range of motion exercises.	Range of motion exercise will avoid contractures and will help the increasing strength of the muscles. Range of motion exercises helps to prevent the adaptive muscle shortening as well as the shortening of the capsule, ligaments, and tendons.
Ensure the correct position of the patient leaning on the stronger side.	Positioning the patient properly helps the patients prevent further complications and improve the patient’s condition. Positioning is also important for bedsore prevention, foot drops, and contractures.
Avoid pulling the arm of the patient and encourage the use of an arm sling.	These interventions will help to avoid subluxation and deformity. An arm sling is used to support the upper arm, forearm, and wrist. When using the arm sling place the arm across the patient’s body and the hand near the opposite shoulder.
Teach the patient to use the correct footwear and advise the patient to use well-fitting footwear instead of using slippers.	Using well-fitted footwear gives comfort to the patient and helps to prevent falls well-fitted footwear that is too tight or too wide.
Instruct the patient and the patient’s family and significant others on proper transfer techniques with techniques in avoiding injury. Transfer techniques  and principles that can be applied include: The weight should be on the patient’s stronger side.Teach the relatives of the patient to transfer most simply and safely to the unaffected side. The patient should be put on the side closest to the bed or chair if the patient wanted to be transferred. Put the affected leg under with the foot flat while transferring the patient. The patient’s wheelchair should be locked near the patient’s stronger side.Safety should always be a priority.	Proper transfer techniques should be practiced, it can also help to work efficiently, and comfortably and it can avoid injury.
Instruct the patient to avoid putting on or putting hands around the neck of the assistant as support.	Utilizing the knees and feet is important to support the feet and knees of weak clients.
Refer the patient to a physical therapist and occupational therapist as needed to reinforce special mobilization techniques.	Mobilization techniques include proprioceptive neuromuscular rehabilitation, neurodevelopmental treatment, and constraint-induced movement therapy. Mobilization helps to manage musculoskeletal dysfunctions. The physical therapist focuses on the ability of the patient to move their body while the occupational therapist focuses on the improvement of the patient’s ability to do activities of daily living.
Evaluate the patient’s development after the interventions. Encourage the patient to verbalize understanding about the techniques that would help the patient to cope with the condition.	Evaluating the development of intervention helps the nurse to assess if there are still interventions needed to be added for the development of care and rehabilitation techniques.

Nursing Care Plan for Stroke 6

Acute Pain

Nursing Diagnosis: Acute Pain related to hemiplegia secondary to stroke as evidenced by the patient’s verbalization of shoulder stiffness, immobility, spasticity, and contractures.

Desired Outcomes:

• The patient expresses that the pain scale lessen.
• The patient will show understanding regarding recovery and rehabilitation techniques.
• The patient will verbalize the absence of side effects from the pain medications.
• The patient will show understanding of the diversional activities and relaxation skills.

Nursing Interventions for Stroke	Rationale
Check for the characteristics, intensity, location, and pain scale. Get the vital signs of the patient and note the increase in blood pressure, respiratory rate, and heart rate. Assess for hemiplegic shoulder pain which is a common complication of stroke that happens on the side of the patient that is paralyzed.	A patient’s verbalization of pain and pain scale is one of the most accurate ways to know a patient’s level of pain. The nurse should also check the signs of pain such as: Protecting the part, facial grimaces, restlessness, and crying.  Symptoms like sweating, changes in the result of blood pressure, heart rate, respiratory rate, and dilation of pupils, may also be seen.   Shoulder pains may affect the patient’s quality of life after a stroke.
Ask the patient about the history of previous pain and allergies to medications. Check for the presence of the patient’s central post-stroke pain syndrome.	Determining the previous history of pain is important for developing a plan of care. The nurse should note the previous medications the patient used to reduce pain and the effectiveness of the previous treatment and management The nurse should also need to note the allergies to pain medications to avoid possible undesirable effects of the medications on the patients. Central post-stroke pain syndrome occurs after a cerebrovascular accident which is characterized by abnormalities in the body parts and pain because of cerebrovascular lesions.
Evaluate the patient’s awareness of pain, and ask the patient how the patient feels about the pain.	Let the patient express his/her feelings about the pain. Gaining the trust of the patient will help achieve the goal of care. Note that the patient’s pain varies for each patient. Encourage the patient
Monitor for the patient’s vital signs regularly.	Results of the patient’s vital signs may be changed due to the pain that the patient is experiencing. The blood pressure, heart rate, and respiratory rate may increase when the patient is experiencing pain.
Check for the need for sling and assistive devices.	Using a sling for the shoulders will prevent dangling and promote the normal position of the scapula.
Help the patient when changing of position is needed. Position the patient’s shoulder appropriately.	Never pull and lift the patient’s flaccid shoulder because this will cause pain.  Proper ways of positioning and turning will prevent overstretching of the affected area. The arms should be lifted slowly and be rotated outward. It is also important to elevate the arm and hand to prevent edema. Change the patient’s position several times to a prone position.
Demonstrate a range of movement exercises as a therapeutic technique by external rotation and holding the humerus under the axilla.	This technique produces a better range of flexion of the shoulders. Improper handling of patients may cause tearing of the rotator cuff.
Give pain medications to the patient as prescribed by the physician.	Medications for pain help to decrease pain after stroke. Non-steroidal anti-inflammatory medications may be given to the patient after stroke.
Encourage the patient’s family and significant others to support the patient and show an optimistic attitude towards the patient’s condition.	Emotional support from the family and significant others prevents stress, fatigue, and discouragement. Providing counseling to the family is essential.
Explain to the patient the importance of doing breathing exercises to alleviate pain.	Breathing exercises increase the resistance of respiratory muscles and help in alleviating pain and provide relaxation.
Evaluate the effectiveness of the interventions by asking the patients pain scale, and evaluate the effectiveness of the medications that were given for pain as prescribed by the physician.	The effectiveness of the interventions will be based on the patient’s verbalization of reduced pain. Evaluation of the care given to the patient will help the nurse to formulate additional interventions and give medications if needed and as prescribed by the physician.

More Nursing Diagnosis for Stroke CVA

• Impaired Verbal Communication
• Disturbed Sensory Perception
• Risk for Impaired Swallowing
• Risk for Injury/ Fall

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon