Cerebrovascular accident, also known as stroke, cerebral infarction, brain attack, is any functional or structural abnormality of the brain caused by pathological condition of the cerebral vessels of the entire cerebrovascular system. It is the sudden impairment of cerebral circulation in one or more of the blood vessels supplying the brain. This pathology either causes hemorrhage from a tear in the vessel wall or impairs the cerebral circulation by a partial or complete occlusion of the vessel lumen with transient or permanent effects. The sooner the circulation returns to normal after a stroke, the better the chances are for complete recovery. However, about half of those who survived a stroke remain disabled permanently and experience the recurrence within weeks, months, or years.
Thrombosis, embolism, and hemorrhage are the primary causes for CVA, with thrombosis being the main cause of both CVAs and transient ischemic attacks (TIAs). The most common vessels involved are the carotid arteries and those of the vertebrobasilar system at the base of the brain.
A thrombotic CVA causes a slow evolution of symptoms, usually over several hours, and is “completed” when the condition stabilizes. An embolic CVA occurs when a clot is carried into cerebral circulation and causes a localized cerebral infarct. Hemorrhagic CVA is caused by other conditions such as a ruptured aneurysm, hypertension, arteriovenous (AV) malformations, or other bleeding disorders.
Nursing Care Plans
During the acute phase of CVA, efforts should focus on survival needs and prevention of further complications. Care revolves around efficient continuing neurologic assessment, support of respiration, continuous monitoring of vital signs, careful positioning to prevent aspiration and contractures, management of GI problems, and careful monitoring of electrolyte, and nutritional status. Nursing care should also include measures to prevent complications.
Here are 10+ nursing diagnosis for cerebrovascular accident (stroke) nursing care plans:
1. Ineffective Cerebral Tissue Perfusion
Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.
Nursing Diagnosis
- - Ineffective Cerebral Tissue Perfusion
May be related to
- - Interruption of blood flow: occlusive disorder, hemorrhage; cerebral vasospasm, cerebral edema
Possibly evidenced by
- - Altered level of consciousness; memory loss
- - Changes in motor/sensory responses; restlessness
- - Sensory, language, intellectual, and emotional deficits
- - Changes in vital signs
Desired Outcomes
Common desired outcomes for this:
- - Maintain usual/improved level of consciousness, cognition, and motor/sensory function.
- - Demonstrate stable vital signs and absence of signs of increased ICP.
- - Display no further deterioration/recurrence of deficits
| Nursing Interventions | Rationale |
|---|
| Assess factors related to individual situation for decreased cerebral perfusion and potential for increased ICP. | Assessment will determine and influence the choice of interventions. Deterioration in neurological signs or failure to improve after initial insult may reflect decreased intracranial adaptive capacity requiring patient to be transferred to critical area for monitoring of ICP, other therapies. If the stroke is evolving, patient can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence. |
| Closely assess and monitor neurological status frequently and compare with baseline. | Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression of damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA. |
| Monitor vital signs: |
- - changes in blood pressure, compare BP readings in both arms.
| Fluctuations in pressure may occur because of cerebral injury in vasomotor area of the brain. Hypertension or postural hypotension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse). Increased ICP may occur because of tissue edema or clot formation. Subclavian artery blockage may be revealed by difference in pressure readings between arms. |
- - Heart rate and rhythm, assess for murmurs.
| Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (stroke after MI or from valve dysfunction). |
- - Respirations, noting patterns and rhythm (periods of apnea after hyperventilation), Cheyne-Stokes respiration.
| Irregularities can suggest location of cerebral insult or increasing ICP and need for further intervention, including possible respiratory support. |
| Evaluate pupils, noting size, shape, equality, light reactivity. | Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined by balance between parasympathetic and sympathetic innervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves. |
| Document changes in vision: reports of blurred vision, alterations in visual field, depth perception. | Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions. |
| Assess higher functions, including speech, if patient is alert. | Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate deterioration or increased ICP. |
| Position with head slightly elevated and in neutral position. | Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion. |
| Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit duration of procedures. | Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage. |
| Prevent straining at stool, holding breath. | Valsalva maneuver increases ICP and potentiates risk of rebleeding. |
| Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity. | Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may reflect increased ICP or cerebral injury, requiring further evaluation and intervention. |
| Administer supplemental oxygen as indicated. | Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema formation. |
| Administer medications as indicated: |
- - Alteplase (Activase), t-PA;
| Thrombolytic agents are useful in dissolving clot when started within 3 hr of initial symptoms. Thirty percent are likely to recover with little or no disability. Treatment is based on trying to limit the size of the infarct, and use requires close monitoring for signs of intracranial hemorrhage. Note: These agents are contraindicated in cranial hemorrhage as diagnosed by CT scan. |
- - Anticoagulants: warfarin sodium (Coumadin), low-molecular-weight heparin (Lovenox);
| May be used to improve cerebral blood flow and prevent further clotting when embolism and/or thrombosis is the problem. |
- - Antiplatelet agents: aspirin (ASA), dipyridamole (Persantine), ticlopidine (Ticlid);
| Contraindicated in hypertensive patients because of increased risk of hemorrhage. |
- - Antifibrinolytics: aminocaproic acid (Amicar);
| Used with caution in hemorrhagic disorder to prevent lysis of formed clots and subsequent rebleeding. |
|
| Chronic hypertension requires cautious treatment because aggressive management increases the risk of extension of tissue damage. |
- - Peripheral vasodilators: cyclandelate (Cyclospasmol), papaverine (Pavabid), isoxsuprine (Vasodilan).
| Transient hypertension often occurs during acute stroke and resolves often without therapeutic intervention.Used to improve collateral circulation or decrease vasospasm. |
Steroids:
- - dexamethasone (Decadron).
| Use is controversial in control of cerebral edema. |
- - Neuroprotective agents: calcium channel blockers, excitatory amino acid inhibitors, gangliosides.
| These agents are being researched as a means to protect the brain by interrupting the destructive cascade of biochemical events (influx of calcium into cells, release of excitatory neurotransmitters, buildup of lactic acid) to limit ischemic injury. |
| Phenytoin (Dilantin), phenobarbital. | May be used to control seizures and/or for sedative action. Note: Phenobarbital enhances action of antiepileptics. |
| Stool softeners. | Prevents straining during bowel movement and corresponding increase of ICP. |
| Prepare for surgery, as appropriate: endarterectomy, microvascular bypass, cerebral angioplasty. | May be necessary to resolve situation, reduce neurological symptoms of recurrent stroke. |
| Monitor laboratory studies as indicated: prothrombin time (PT) and/or activated partial thromboplastin time (aPTT) time, Dilantin level. | Provides information about drug effectiveness and/or therapeutic level. |
2. Impaired Physical Mobility
Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.
Nursing Diagnosis
- - Impaired Physical Mobility
May be related to
- - Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic paralysis
- - Perceptual/cognitive impairment
Possibly evidenced by
- - Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength/control
Desired Outcomes
- - Maintain/increase strength and function of affected or compensatory body part.
- - Maintain optimal position of function as evidenced by absence of contractures, foot drop.
- - Demonstrate techniques/behaviors that enable resumption of activities.
- - Maintain skin integrity.
| Nursing Interventions | Rationale |
|---|
| Assess extent of impairment initially and on a regular basis. Classify according to 0–4 scale. | Identifies strengths and deficiencies that may provide information regarding recovery. Assists in choice of interventions, because different techniques are used for flaccid and spastic paralysis. |
| Change positions at least every 2 hr (supine, side lying) and possibly more often if placed on affected side. | Reduces risk of tissue injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown. |
| Position in prone position once or twice a day if patient can tolerate. | Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe. |
| Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head. | Prevents contractures and footdrop and facilitates use when function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side. |
| Use arm sling when patient is in upright position, as indicated. | During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and shoulder-hand syndrome. |
| Evaluate need for positional aids and/or splints during spastic paralysis: | Flexion contractures occur because flexor muscles are stronger than extensors. |
| Place pillow under axilla to abduct arm | Prevents adduction of shoulder and flexion of elbow. |
| Elevate arm and hand | Promotes venous return and helps prevent edema formation. |
| Place hard hand-rolls in the palm with fingers and thumb opposed. | Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in a functional position. |
| Place knee and hop in extended position; | Maintains functional position. |
| Maintain leg in neutral position with a trochanter roll; | Prevents external hip rotation. |
| Discontinue use of footboard, when appropriate. | Continued use (after change from flaccid to spastic paralysis) can cause excessive pressure on the ball of the foot, enhance spasticity, and actually increase plantar flexion. |
| Observe affected side for color, edema, or other signs of compromised circulation. | Edematous tissue is more easily traumatized and heals more slowly. |
| Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary. | Pressure points over bony prominences are most at risk for decreased perfusion. Circulatory stimulation and padding help prevent skin breakdown and decubitus development. |
| Begin active or passive ROM to all extremities (including splinted) on admission. Encourage exercises such as quadriceps/gluteal exercise, squeezing rubber ball, extension of fingers and legs/feet. | Minimizes muscle atrophy, promotes circulation, helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. Note: Excessive stimulation can predispose to rebleeding. |
| Assist patient with exercise and perform ROM exercises for both the affected and unaffected sides. Teach and encourage patient to use his unaffected side to exercise his affected side. | |
| Assist patient to develop sitting balance by raising head of bed, assist to sit on edge of bed, having patient to use the strong arm to support body weight and move using the strong leg. Assist to develop standing balance by putting flat walking shoes, support patient’s lower back with hands while positioning own knees outside patient’s knees, assist in using parallel bars. | Aids in retraining neuronal pathways, enhancing proprioception and motor response. |
| Get patient up in chair as soon as vital signs are stable, except following cerebral hemorrhage. | Helps stabilize BP (by restoring vasomotor tone), promotes maintenance of extremities in a functional position and emptying of bladder, reducing risk of urinary stones and infections from stasis. Note: If stroke is not completed, activity increases risk of additional bleed. |
| Pad chair seat with foam or water-filled cushion, and assist patient to shift weight at frequent intervals. | To prevent pressure on the coccyx and skin breakdown. |
| Set goals with patient and SO for participation in activities and position changes. | Promotes sense of expectation of improvement, and provides some sense of control and independence. |
| Encourage patient to assist with movement and exercises using unaffected extremity to support and move weaker side. | May respond as if affected side is no longer part of body and needs encouragement and active training to “reincorporate” it as a part of own body. |
| Provide egg-crate mattress, water bed, flotation device, or specialized beds, as indicated. | Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown and decubitus formation. Specialized beds help with positioning, enhance circulation, and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia. |
| Position the patient and align his extremities correctly. Use high-top sneakers to prevent footdrop and contracture and convoluted foam, flotation, or pulsating mattresses or sheepskin. | These are measures to prevent pressure ulcers. |
3. Impaired Verbal Communication
Impaired Verbal Communication: Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols.
Nursing Diagnosis
- - Communication, impaired verbal [and/or written]
May be related to
- - Impaired cerebral circulation; neuromuscular impairment, loss of facial/oral muscle tone/control; generalized weakness/fatigue
Possibly evidenced by
- - Impaired articulation; does not/cannot speak (dysarthria)
- - Inability to modulate speech, find and name words, identify objects; inability to comprehend written/spoken language
- - Inability to produce written communication
Desired Outcomes
- - Indicate an understanding of the communication problems.
- - Establish method of communication in which needs can be expressed.
- - Use resources appropriately.
| Nursing Interventions | Rationale |
|---|
| Assess extent of dysfunction: patient cannot understand words or has trouble speaking or making self understood. Differentiate aphasia from dysarthria. | Helps determine area and degree of brain involvement and difficulty patient has with any or all steps of the communication process. Patient may have receptive aphasia or damage to the Wernicke’s speech area which is characterized by difficulty of understanding spoken words. He may also have expressive aphasia or damage to the Broca’s speech areas, which is difficulty in speaking words correctly, or may experience both. Choice of interventions depends on type of impairment. Aphasia is a defect in using and interpreting symbols of language and may involve sensory and/or motor components (inability to comprehend written and/or spoken words or to write, make signs, speak). A dysarthricperson can understand, read, and write language but has difficulty forming and pronouncing words because of weakness and paralysis of oral musculature. Patient may lose ability to monitor verbal output and be unaware that communication is not sensible. |
| Listen for errors in conversation and provide feedback. | Feedback helps patient realize why caregivers are not understanding or responding appropriately and provides opportunity to clarify meaning. |
| Ask patient to follow simple commands (“Close and open your eyes,” “Raise your hand”); repeat simple words or sentences; | Tests for receptive aphasia. |
| Point to objects and ask patient to name them. | Tests for expressive aphasia. Patient may recognize item but not be able to name it. |
| Have patient produce simple sounds (“Dog,” “meow,” “Shh”). | Identifies dysarthria, because motor components of speech (tongue, lip movement, breath control) can affect articulation and may or may not be accompanied by expressive aphasia. |
| Ask patient to write his name and a short sentence. If unable to write, have patient read a short sentence. | Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia. |
| Write a notice at the nurses’ station and patient’s room about speech impairment. Provide a special call bell that can be activated by minimal pressure if necessary. | Allays anxiety related to inability to communicate and fear that needs will not be met promptly. |
| Provide alternative methods of communication: writing, pictures. | Provides communication needs of patient based on individual situation and underlying deficit. |
| Anticipate and provide for patient’s needs. | Helpful in decreasing frustration when dependent on others and unable to communication desires. |
| Talk directly to patient, speaking slowly and distinctly. Phrase questions to be answered simply by yes or no. Progress in complexity as patient responds. | Reduces confusion and allays anxiety at having to process and respond to large amount of information at one time. As retraining progresses, advancing complexity of communication stimulates memory and further enhances word and idea association. |
| Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Avoid pressing for a response. | Patient is not necessarily hearing impaired, and raising voice may irritate or anger patient. Forcing responses can result in frustration and may cause patient to resort to “automatic” speech (garbled speech, obscenities). |
| Encourage SO/visitors to persist in efforts to communicate with patient: reading mail, discussing family happenings even if patient is unable to respond appropriately. | It is important for family members to continue talking to patient to reduce patient’s isolation, promote establishment of effective communication, and maintain sense of connectedness with family. |
| Discuss familiar topics, e.g., weather, family, hobbies, jobs. | Promotes meaningful conversation and provides opportunity to practice skills. |
| Respect patient’s preinjury capabilities; avoid “speaking down” to patient or making patronizing remarks. | Enables patient to feel esteemed, because intellectual abilities often remain intact. |
| Consult and refer patient to speech therapist. | Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits/therapy needs. |
4. Disturbed Sensory Perception
Disturbed Sensory Perception: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.
Nursing Diagnosis
- - Disturbed Sensory Perception
May be related to
- - Altered sensory reception, transmission, integration (neurological trauma or deficit)
- - Psychological stress (narrowed perceptual fields caused by anxiety)
Possibly evidenced by
- - Disorientation to time, place, person
- - Change in behavior pattern/usual response to stimuli; exaggerated emotional responses
- - Poor concentration, altered thought processes/bizarre thinking
- - Reported/measured change in sensory acuity: hypoparesthesia; altered sense of taste/smell
- - Inability to tell position of body parts (proprioception)
- - Inability to recognize/attach meaning to objects (visual agnosia)
- - Altered communication patterns
- - Motor incoordination
Desired Outcomes
- - Regain/maintain usual level of consciousness and perceptual functioning.
- - Acknowledge changes in ability and presence of residual involvement.
- - Demonstrate behaviors to compensate for/overcome deficits.
| Nursing Interventions | Rationale |
|---|
| Review pathology of individual condition. | Awareness on the type and areas of involvement aid in assessing specific deficit and planning of care. |
| Observe behavioral responses: crying, inappropriate affect, agitation, hostility, agitation, hallucination. | Individual responses are variable, but commonalities such as emotional lability, lowered frustration threshold, apathy, and impulsiveness may complicate care. |
| Establish and maintain communication with the patient. Set up a simple method of communicating basic needs. Remember to phrase your questions so he’ll be able to answer using this system. Repeat yourself quietly and calmly and use gestures when necessary to help in understanding. | Note: even an unresponsive patient may be able to hear, so don’t say anything in his presence you wouldn’t want him to hear and remember. |
| Eliminate extraneous noise and stimuli as necessary. | Reduces anxiety and exaggerated emotional responses and confusion associated with sensory overload. |
| Speak in calm, comforting, quiet voice, using short sentences. Maintain eye contact. | Patient may have limited attention span or problems with comprehension. These measures can help patient attend to communication. |
| Ascertain patient’s perceptions. Reorient patient frequently to environment, staff, procedures. | Assists patient to identify inconsistencies in reception and integration of stimuli and may reduce perceptual distortion of reality. |
| Evaluate for visual deficits. Note loss of visual field, changes in depth perception (horizontal and/or vertical planes), presence of diplopia (double vision). | Presence of visual disorders can negatively affect patient’s ability to perceive environment and relearn motor skills and increases risk of accident and injury. |
| Approach patient from visually intact side. Leave light on; position objects to take advantage of intact visual fields. Patch affected eye if indicated. | Helps the patient to recognize the presence of persons or objects and may help with depth perception problems. This also prevents patient from being startled. Patching the eye may decrease sensory confusion of double vision. |
| Assess sensory awareness: dull from sharp, hot from cold, position of body parts, joint sense. | Diminished sensory awareness and impairment of kinesthetic sense negatively affects balance and positioning and appropriateness of movement, which interferes with ambulation, increasing risk of trauma. |
| Stimulate sense of touch. Give patient objects to touch, and hold. Have patient practice touching walls boundaries. | Aids in retraining sensory pathways to integrate reception and interpretation of stimuli. Helps patient orient self spatially and strengthens use of affected side. |
| Protect from temperature extremes; assess environment for hazards. Recommend testing warm water with unaffected hand. | Promotes patient safety, reducing risk of injury. |
| Note inattention to body parts, segments of environment, lack of recognition of familiar objects/persons. | Agnosia, the loss of comprehension of auditory, visual, or other sensations, may lead result to unilateral neglect, inability to recognize environmental cues, considerable self-care deficits, and disorientation or bizarre behavior. |
| Encourage patient to watch feet when appropriate and consciously position body parts. Make patient aware of all neglected body parts: sensory stimulation to affected side, exercises that bring affected side across midline, reminding person to dress/care for affected (“blind”) side. | Use of visual and tactile stimuli assists in reintegration of affected side and allows patient to experience forgotten sensations of normal movement patterns. |
5. Ineffective Coping
Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.
Nursing Diagnosis
May be related to
- - Situational crises, vulnerability, cognitive perceptual changes
Possibly evidenced by
- - Inappropriate use of defense mechanisms
- - Inability to cope/difficulty asking for help
- - Change in usual communication patterns
- - Inability to meet basic needs/role expectations
- - Difficulty problem solving
Desired Outcomes
- - Verbalize acceptance of self in situation.
- - Talk/communicate with SO about situation and changes that have occurred.
- - Verbalize awareness of own coping abilities.
- - Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.
| Nursing Interventions | Rationale |
|---|
| Assess extent of altered perception and related degree of disability. Determine Functional Independence Measure score. | Determination of individual factors aids in developing plan of care/choice of interventions and discharge expectations. |
| Identify meaning of the dysfunction and change to patient. Note ability to understand events, provide realistic appraisal of the situation. | Independence is highly valued in American culture but is not as significant in some cultures. Some patients accept and manage altered function effectively with little adjustment, whereas others may have considerable difficulty recognizing and adjust to deficits. In order to provide meaningful support and appropriate problem-solving, healthcare providers need to understand the meaning of the stroke/limitations to patient. |
| Determine outside stressors: family, work, future healthcare needs. | Helps identify specific needs, provides opportunity to offer information and begin problem-solving. Consideration of social factors, in addition to functional status, is important in determining appropriate discharge destination. |
| Provide psychological support and set realistic short-term goals. Involve the patient’s SO in plan of care when possible and explain his deficits and strengths. | To increase the patient’s sense of confidence and can help in compliance to therapeutic regimen. |
| Encourage patient to express feelings, including hostility or anger, denial, depression, sense of disconnectedness. | Demonstrates acceptance of patient in recognizing and beginning to deal with these feelings. |
| Note whether patient refers to affected side as “it” or denies affected side and says it is “dead.” | Suggests rejection of body part and negative feelings about body image and abilities, indicating need for intervention and emotional support. |
| Acknowledge statement of feelings about betrayal of body; remain matter-of-fact about reality that patient can still use unaffected side and learn to control affected side. Use words (weak, affected, right-left) that incorporate that side as part of the whole body. | Helps patient see that the nurse accepts both sides as part of the whole individual. Allows patient to feel hopeful and begin to accept current situation. |
| Identify previous methods of dealing with life problems. Determine presence of support systems. | Provides opportunity to use behaviors previously effective, build on past successes, and mobilize resources. |
| Emphasize small gains either in recovery of function or independence. | Consolidates gains, helps reduce feelings of anger and helplessness, and conveys sense of progress. |
| Support behaviors and efforts such as increased interest/participation in rehabilitation activities. | Suggest possible adaptation to changes and understanding about own role in future lifestyle. |
| Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope, lethargy, withdrawal. | May indicate onset of depression (common after effect of stroke), which may require further evaluation and intervention. |
| Refer for neuropsychological evaluation and/or counseling if indicated. | May facilitate adaptation to role changes that are necessary for a sense of feeling/being a productive person. Note: Depression is common in stroke survivors and may be a direct result of the brain damage and/or an emotional reaction to sudden-onset disability. |
6. Self-Care Deficit
Self-Care Deficit: Impaired ability to perform or complete bathing/hygiene, dressing/grooming, feeding or toileting activities for oneself.
Nursing Diagnosis
May be related to
- - Neuromuscular impairment, decreased strength and endurance, loss of muscle control/coordination
- - Perceptual/cognitive impairment
- - Pain/discomfort
- - Depression
Possibly evidenced by
- - Impaired ability to perform ADLs, e.g., inability to bring food from receptacle to mouth; inability to wash body part(s), regulate temperature of water; impaired ability to put on/take off clothing; difficulty completing toileting tasks
Desired Outcomes
- - Demonstrate techniques/lifestyle changes to meet self-care needs.
- - Perform self-care activities within level of own ability.
- - Identify personal/community resources that can provide assistance as needed.
| Nursing Interventions | Rationale |
|---|
| Assess abilities and level of deficit (0–4 scale) for performing ADLs. | Aids in planning for meeting individual needs. |
| Avoid doing things for patient that patient can do for self, but provide assistance as necessary. | To maintain self-esteem and promote recovery, it is important for the patient to do as much as possible for self. These patients may become fearful and independent, although assistance is helpful in preventing frustration. |
| Be aware of impulsive actions suggestive of impaired judgment. | May indicate need for additional interventions and supervision to promote patient safety. |
| Maintain a supportive, firm attitude. Allow patient sufficient time to accomplish tasks. Don’t rush the patient. | Patients need empathy and to know caregivers will be consistent in their assistance. |
| Provide positive feedback for efforts and accomplishments. | Enhances sense of self-worth, promotes independence, and encourages patient to continue endeavors. |
| Create plan for visual deficits that are present: Place food and utensils on the tray related to patient’s unaffected side; Situate the bed so that patient’s unaffected side is facing the room with the affected side to the wall; Position furniture against wall/out of travel path. | Patient will be able to see to eat the food. Will be able to see when getting in/out of bed and observe anyone who comes into the room. Provides for safety when patient is able to move around the room, reducing risk of tripping/falling over furniture. |
| Provide self-help devices: extensions with hooks for picking things up from the floor, toilet risers, long-handled brushes, drinking straw, leg bag for catheter, shower chair. Encourage good grooming and makeup habits. | To enable the patient to manage for self, enhancing independence and self-esteem, reduce reliance on others for meeting own needs, and enables the patient to be more socially active. |
| Encourage SO to allow patient to do as much as possible for self. | Reestablishes sense of independence and fosters self-worth and enhances rehabilitation process. Note: This may be very difficult and frustrating for the caregiver, depending on degree of disability and time required for patient to complete activity. |
| Assess patient’s ability to communicate the need to void and/or ability to use urinal, bedpan. Take patient to the bathroom at periodic intervals for voiding if appropriate. | Patient may have neurogenic bladder, be inattentive, or be unable to communicate needs in acute recovery phase, but usually is able to regain independent control of this function as recovery progresses. |
| Identify previous bowel habits and reestablish normal regimen. Increase bulk in diet, encourage fluid intake, increased activity. | Assists in development of retraining program (independence) and aids in preventing constipation and impaction (long-term effects). |
| Teach the patient to comb hair, dress, and wash. | To promote sense o f independence and self-esteem. |
| Refer patient to physical and occupational therapist. | Rehabilitation helps to relearn skills that are lost when part of the brain is damaged. It also teaches new ways of performing tasks to circumvent or compensate for any residual disabilities. |
7. Risk for Impaired Swallowing
Impaired Swallowing: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function.
Nursing Diagnosis
- - Risk for Impaired Swallowing
Risk factors may include
- - Neuromuscular/perceptual impairment
Desired Outcomes
- - Demonstrate feeding methods appropriate to individual situation with aspiration prevented.
- - Maintain desired body weight.
| Nursing Interventions | Rationale |
|---|
| Review individual pathology and ability to swallow, noting extent of the paralysis: clarity of speech, tongue involvement, ability to protect airway, episodes of coughing, presence of adventitious breath sounds. Weigh periodically as indicated. | Nutritional interventions and choices of feeding route are determined by these factors. |
| Have suction equipment available at bedside, especially during early feeding efforts. | Timely intervention may limit untoward effect of aspiration. |
| Promote effective swallowing: Schedule activities and medications to provide a minimum of 30 min rest before eating. | Promotes optimal muscle function, helps to limit fatigue. |
| Provide pleasant and unhurried environment free of distractions. | Promotes relaxation and allows patient to focus on task of eating. |
| Assist patient with head control, and position based on specific dysfunction. | Counteracts hyperextension, aiding in prevention of aspiration and enhancing ability to swallow. Optimal positioning can facilitate intake and reduce risk of aspiration head back for decreased posterior propulsion of tongue, head turned to weak side for unilateral pharyngeal paralysis, lying down on either side for reduced pharyngeal contraction. |
| Place patient in upright position during and/or after feeding as appropriate. | Uses gravity to facilitate swallowing and reduces risk of aspiration. |
| Provide oral care based on individual need prior to meal. | Patients with dry mouth require moisturizing agents like alcohol-free mouthwashes, before and after eating. Patients with excessive saliva will benefit from use of drying agents before meal and moisturizing agents afterward. |
| Season food with herbs, spices, lemon juice, etc. according to patient’s preference, within dietary restrictions; | Increases salivation, improving bolus formation and swallowing effort. |
| Serve foods at customary temperature and water always chilled. | Lukewarm temperatures are less likely to stimulate salivation so foods and fluids should be served cold or warm as appropriate. Note: Water is the most difficult to swallow. |
| Stimulate lips to close or manually open mouth by light pressure on lips or under the chin if needed. | Aids in sensory retraining and promotes muscular control. |
| Place food of appropriate consistency in unaffected side of mouth. | Provides sensory stimulation (including taste), which may increase salivation and trigger swallowing efforts, enhancing intake. Food consistency is determined by individual deficit. For example: Patients with decreased range of tongue motion require thick liquids initially, progressing to thin liquids, whereas patients with delayed pharyngeal swallow will handle thick liquids and thicker foods better. Note: Pureed food is not recommended because patient may not be able to recognize what is being eaten; and most milk products, peanut butter, syrup, and bananas are avoided because they produce mucus and are sticky. |
| Touch parts of the cheek with tongue blade and apply ice to weak tongue. | Can improve tongue movement and control (necessary for swallowing), and inhibits tongue protrusion. |
| Feed slowly, allowing 30–45 min for meals. | Feeling rushed can increase stress and level of frustration, may increase risk of aspiration, and may result in patient’s terminating meal early. |
| Offer solid foods and liquids at different times. | Prevents patient from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after patient has finished eating foods. |
| Limit or avoid use of drinking straw for liquids; | Although use may strengthen facial and swallowing muscles, if patient lacks tight lip closure to accommodate straw or if liquid is deposited too far back in mouth, risk of aspiration may be increased. |
| Encourage SO to bring favorite foods. | Provides familiar tastes and preferences. Stimulates feeding efforts and may enhance swallowing or intake. |
| Maintain upright position for 45–60 min after eating. | Helps patient manage oral secretions and reduces risk of regurgitation. |
| Maintain accurate I&O; record calorie count. | Alternative methods of feeding may be used if swallowing efforts are not sufficient to meet fluid and nutritional needs. |
| Encourage participation in exercise program. | May increase release of endorphins in the brain, promoting a sense of general well-being and increasing appetite. |
| Administer IV fluids and/or tube feedings | May be necessary for fluid replacement and nutrition if patient is unable to take anything orally. |
| Coordinate multidisciplinary approach to develop treatment plan that meets individual needs. | Inclusion of dietitian, speech and occupational therapists can increase effectiveness of long-term plan and significantly reduce risk of silent aspiration. |
8. Activity Intolerance
Motor deficits are the most obvious effect of stroke. Symptoms are caused by the destruction of motor neurons in the pyramidal pathways (nerve fibers in the brain and passing through the spinal cord to motor tract.)
Medical Diagnosis : Cerebrovascular Accident
Problem: Activity Intolerance RT Generalized Weakness
Assessment
Subjective: (none)
Objective:
- - right hemiplegia
- - increase BP
- - pt may manifest:
- - electro cardiographic changes reflecting dysrythmias
- - abnormal heart rate in response to activity
- - weakness
Nursing Diagnosis
- - Activity Intolerance r/t Generalized weakness secondary to CVA
Scientific Explanation
- - Motor deficits are the most obvious effect of stroke. Symptoms are caused by the destruction of motor neurons in the pyramidal pathways(nerve fibers in the brain and passing through the spinal cordto motor tract.)
Planning
- - Short Term : After 4 hrs of NI, pt will be able to participate willingly on necessary/desired activities.
- - Long Term : After 2 days of NI, patient will be able to demonstrate adecrease in physiologic signs of intolerance (HR,BP remain within normal range)
Interventions
- - establish rapport
- - monitor vital signs
- - evaluate current limitations (degreeof deficit in light of visual status)
- - assess cardiopulmonary response to physical activity, changes BP
- - assist patient with activities
- - plan care with restperiods between activities
- - increase activity gradually
- - encourage expression of feelings resulting from the condition
Rationale
- - to promote cooperation
- - to have a baseline data
- - provide comparative baseline data
- - to note progress of fatigue
- - to protect from injury
- - to decrease fatigue
- - to manage activity within limits
- - assist pt deal with contributing factor
Evaluation
- Short Term: Pt. shall have participated willingly innecessary /desired activities.
- Long Term : Pt shall have demonstrated a decrease in physiologic sings of intolerance(HR,BP remains in normal range)
9. Risk for Unilateral Neglect
A stroke is an upper motor neuron lesion and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate (cross), a disturbance of voluntary motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. The most common motor dysfunction is hemiplegia (paralysis on one side of the body).
Medical Diagnosis: Cerebrovascular Accident
Problem: Risk for Unilateral Neglect RT Hemiparesis
Assessment
Subjective:(none)
Objective:
- - slight irritability
- - right hemiplegia
- - muscle strengthtest of rightarm:0/5; rightleg:o/5; left arm:5/5; left leg:5/5
- - needs assistance inperforming ADLs
- - decrease attentionto the affectedside
NursingDiagnosis
- Risk for unilateral neglect r/the miparesis secondary to CVA
Scientific Explanation
- - An ischemic stroke,cerebrovascular accident (CVA), or “brain attack” is a sudden loss of functionresulting from disruption of the blood supply to a partof the brain. In an ischemicbrain attack, there isdisruption of the cerebralbloodflow due toobstruction of abloodvessel. This can causea wide variety of neurologic deficitsdepending on the locationof the lesion with whichvessels are obstructed. Astroke is an upper motorneuron lesion and resultsin loss of voluntary controlover motor movements.Because the upper motorneurons decussate (cross),a disturbance of voluntarymotor control on one sideof the body may reflectdamage to the uppermotor neurons on theopposite side of the brain.The most common motordysfunction is hemiplegia(paralysis on one side of the body).
Planning
- - Short Term: After 1-2 hrs of NI, thept will participate in the performance of range of motionexercises on the extremities.
- - Long Term : After 2-3 days of NI,the pt will increase the utilization of the affected extremities with due assistance from the SO
Interventions
- - Established rapport
- - Monitored and assessed vital signs
- - Assessed patient’s general physical condition
- - Performed AM care
- - Monitored vital signs frequently
- - Instructed pt to alow fat, low saltdiet with SAP
- - Performed muscle strength test
- - Instructed pt on a PROM on the right extremities
- - Promoted adequate rest
- - Assisted pt withself-care activities
- - Maintain body alignment infunctional position
- - Shift pt’s attention to wards the affected side
- - Administer due meds
Rationale
- - To gain trust
- - To obtain baseline data
- - To note for any abnormality
- - To enhance well-being & provide comfort
- - To note significant changes in vital signs
- - To help reducerisk of second attack & preventa rise in BP
- - To determine muscle functioning on the extremities
- - To increase strength and mobility
- - To promote comfort and relaxation
- - To prevent injury
- - To promote and stimulate circulation
- - To stimulate and increase pt’s awareness on the affected side
- - To treat underlying medical condition
Evaluation
- - Short Term: The pt shall have participated in the performance of range of motion exercises on the extremities.
- - Long Term: The pt shall have increased the utilization of the affected extremities with due assistance from the SO.
10. Deficient Knowledge
Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
Nursing Diagnosis
May be related to
- - Lack of exposure; unfamiliarity with information resources
- - Cognitive limitation, information misinterpretation, lack of recall
Possibly evidenced by
- - Request for information
- - Statement of misconception
- - Inaccurate follow-through of instructions
- - Development of preventable complications
Desired Outcomes
- - Participate in learning process.
- - Verbalize understanding of condition/prognosis and potential complications.
- - Verbalize understanding of therapeutic regimen and rationale for actions.
- - Initiate necessary lifestyle changes.
| Nursing Interventions | Rationale |
|---|
| Assess type and degree of sensory perceptual involvement. | This will affect the choice of teaching methods and content complexity of instruction. |
| Include SO and/or family in discussions and teaching. | These individuals will be providing support/care and have great impact on patient’s quality of life.These people will be providing support and care thus will have a great impact on the patient’s quality of life and home health-care. |
| Discuss specific pathology and individual potentials. | Aids in establishing realistic expectations and promotes understanding of current situation and needs. |
| Identify signs and symptoms requiring further follow-up: changes or decline in visual, motor, sensory functions; alteration in mentation or behavioral responses; severe headache. | Prompt evaluation and intervention reduces risk of complications and further loss of function. |
| Review current restrictions and discuss potential resumption of activities (including sexual relations). | Promotes understanding, provides hope for future, and creates expectation of resumption of more “normal” life. |
| Reinforce current therapeutic regimen, including use of medications to control hypertension, hypercholesterolemia, diabetes, as indicated; aspirin or similar-acting drugs, for example, ticlopidine (Ticlid), warfarin sodium (Coumadin). Identify ways of continuing program after discharge. | Recommended activities, limitations, and medication and/or therapy needs are established on the basis of a coordinated interdisciplinary approach. Follow-through is essential to progression of recovery and prevention of complications. Note: Long-term anticoagulation may be beneficial for patients older than 45 years of age who are prone to clot formation; however, use of these drugs is not effective for CVA resulting from vascular aneurysm or vessel rupture. |
| Provide written instructions and schedules for activity, medication, important facts. | Provides visual reinforcement and reference source after discharge. |
| Encourage patient to refer to written communications or notes instead of depending on memory. | Provides aids to support memory and promotes improvement in cognitive skills. |
| Discuss plans for meeting self-care needs. | Varying levels of assistance may be need to be planned for based on individual situation. |
| Refer to home care supervisor or a visiting nurse. | Home environment may require evaluation and modifications to meet individual needs. |
| Suggest patient reduce environmental stimuli, especially during cognitive activities. | Multiple stimuli may aggravate confusion, overwhelm the patient, and impair mental abilities. |
| Recommend patient seek assistance in problem-solving process and validate decisions, as indicated. | Some patients (especially those with right CVA) may display impaired judgment and impulsive behavior, compromising ability to make sound decisions. |
| Identify individual risk factors (e.g., hypertension, cardiac dysrhythmias, obesity, smoking, heavy alcohol use, atherosclerosis, poor control of diabetes, use of oral contraceptives) and discuss necessary lifestyle changes. | Promotes general well-being and may reduce risk of recurrence. Note: Obesity in women has been found to have a high correlation with ischemic stroke. |
| Review importance of balanced diet, low in cholesterol and sodium if indicated. Discuss role of vitamins and other supplements. | Improves general health and well-being and provides energy for life activities. |
| Reinforce importance of follow-up care by rehabilitation team: physical and occupational therapists, vocational therapists, speech therapist, dietician. | Consistent work may eventually lead to minimized or overcoming of residual deficits. |
11. Other Nursing Diagnoses
You can also make a care plan with these nursing diagnoses:
- - Risk for Injury: general weakness, visual deficits, balancing difficulties, reduced large/small muscle or hand-eye coordination, cognitive impairment.
- - Imbalanced Nutrition: Less Than Body Requirements: inability to prepare/ingest food, cognitive limitations, limited financial resources.
- - Self-care Deficit: decreased strength/endurance, perceptual/cognitive impairment, neuromuscular impairment, muscular pain, depression.
- - Impaired Home Maintenance: individual physical limitations, inadequate support systems, insufficient finances, unfamiliarity with neighborhood resources.
- - Situational Low Self-Esteem: cognitive/perceptual impairment, perceived loss of control in some aspect of life, loss of independent functioning.
- - Risk for Caregiver Role Strain: severity of illness/deficits of care receiver, duration of caregiving required, complexity/ amount of caregiving task, caregiver isolation/lack of respite.
- - Risk for Aspiration: This is due to depressed or absent cough reflex due to infarction of a brain area.
- - Risk for Hyperthermia: This may be due to bleeding or edema of the hypothalamus which can lead to ischemia and thus changes in the thermoregulatory center of the brain.
- - Risk for Impaired Skin Integrity: This is due to the loss of protective sensation and decreased ability to move away from injury.
- - Impaired Verbal Communication: Loss of verbal communication may be due to ischemia and may be frustrating to the patient.
- - Ineffective Coping: Management of stroke requires a strong need for healthy lifestyle or change, this may be difficult for the patient.
- - Disturbed Thought Process.
- - Disturbed Sensory Perception: Visual
References and Sources :
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