Nursing Care Plans Stroke with Nursing Diagnosis

Stroke:

Before learning nursing care plans stroke, we learn about some important facts about stroke

Cell death of brain tissue due to interruption of blood supply to parts of the brain, resulting in neurological deficits that cause disabilities such as paralysis or speech disorders.

A stroke, cerebrovascular accident (CVA) or cerebral infarction is the sudden interruption of O2 supply to the brain. This may be due to rupture of one or more blood vessels supplying the brain or loss of cerebral blood flow, which often results from hypoperfusion or a reduction in O2 supply.

Types of strokes

A. Ischemic stroke
B. Hemorrhagic stroke

A. Ischemic stroke

Disturbance of blood flow to the brain caused by partial or complete occlusion of a blood vessel, with temporary or permanent effects. Accounts for 87% of all strokes.

Ischemic stroke has three main mechanisms: 

• Thrombosis, 
• embolism, 
• and systemic hypoperfusion. 

Thrombosis or embolism results in interruption of blood supply to brain tissue. The resulting ischemia, if prolonged, causes necrosis of brain tissue, cerebral edema, and increased intracranial pressure. Most thrombotic strokes are caused by blockage of large vessels due to atherosclerosis. Thrombi in small penetrating arteries cause “lacunar” strokes. Most embolic strokes are cardiogenic and the result of emboli caused by valvular heart disease or when the heart is in atrial fibrillation. Ischemic strokes caused by systemic hypoperfusion are usually the result of decreased cerebral blood flow due to circulatory failure. Causes of circulatory failure include hypovolemia, hypotension, and cardiac arrhythmias. Hypoxia of any cause can also precipitate this syndrome.

Etiology of Ischemic Stroke

• Thrombotic and embolic strokes in large vessels result from hypoperfusion, hypertension, and emboli that migrate from large arteries to distal branches.
• Thrombotic strokes in small vessels are typically due to plaque, diabetes mellitus, or hypertension.
• Cardioembolic strokes result from atrial fibrillation, valvular disease, or ventricular thrombi.
• Other types of ischemic strokes are caused by hyperglycemia and hyperinsulinemia, arterial dissection, arteritis, and drug abuse.

Nursing assessment in stroke

Because of the narrow window of opportunity to reverse permanent neurological damage, it is important to teach patients not to ignore symptoms and to call 911 immediately in the following cases:

• Sudden numbness or weakness in the face, arms or legs, especially on one side of the body
• Sudden confusion, difficulty in speaking or understanding
• Sudden visual disturbances in one or both eyes
• Sudden difficulty walking, dizziness, loss of balance or coordination
• Sudden, severe headache with no known cause

General findings: 

Classically, symptoms occur on the side of the body opposite the injured area. Thus, a stroke in the left side of the brain results in symptoms in the right arm and leg. 

When the stroke affects the cranial nerves, the symptoms of cranial nerve deficit occur on the same side as the injury site. 

Similarly, obstruction of an anterior cerebral artery can cause bilateral symptoms, as can severe hemorrhage or multiple emboli. Hemiplegia is relatively common. Initially, the patient usually has flaccid paralysis. As the spinal cord depression resolves, tone becomes more normal and hyperactive reflexes appear.

Physical assessment: 

• Papilledema, 
• arteriosclerotic retinal changes,
• hemorrhagic retinal areas on ophthalmic examination.
• Hyperactive deep tendon reflexes (DTRs), decreased.
• superficial reflexes, and positive Babinski’s sign also may be present. To check for Babinski’s response, stroke the lateral aspect of the sole of the foot (from the heel to the ball of the
• foot) with a hard object. 
• Dorsiflexion of the great toe with Fanning of the other toes is a positive sign. 
• Positive Kernig’s or Brudzinski’s sign indicates meningeal irritation.

Risk factors: 

• hypertension; 
• Atherosclerosis;
• high serum cholesterol or triglycerides; 
• high homocysteine levels;
• diabetes mellitus; 
• gout; 
• smoking; 
• obesity; 
• cardiac valve diseases, such as those that may result from rheumatic fever,
• valve prosthesis, and atrial fibrillation; 
• cardiac surgery; 
• Blood dyscrasias; 
• anticoagulant therapy; 
• neck vessel trauma; 
• Oral contraceptive use; 
• cocaine or methamphetamine use; 
• Family predisposition for arteriovenous malformation (AVM); 
• aneurysm;
• advanced age;  
• previous stroke.

Rating Scales (GCS and NIHSS):

The Glasgow Coma Scale (GCS) is useful for assessing the state of consciousness

State of Consciousness (LOC).

The National Institutes of Health Stroke Scale (NIHSS) is used not only to assess unconsciousness but also to assess deficits and provides a standardized approach to neurological testing. An overall NIHSS score of 0-1 is normal; 1-4 is mild stroke; 5-15 is moderate stroke; 15-20 is moderate stroke; and more than 20 is severe stroke.

DIAGNOSTIC TESTS

CT scan: to determine the site of infarction, hematoma and displacement of brain structures. CT scan is especially valuable for early detection of blood leaking from hemorrhagic strokes. CT is the examination of choice for unstable patients.

MRI examination: to detect infarct focus, hematoma, displacement of brain structure, and cerebral edema. MRI diffusion and perfusion-weighted studies are particularly valuable for early detection of ischemic strokes and differentiation between acute and chronic lesions.

Laboratory tests:

Serum electrolytes, 

Complete blood count including differential and platelet count, prothrombin time with international normalized ratio, and partial thromboplastin time are performed immediately to determine contraindications such as hypoglycemia or coagulation abnormalities if the patient is a candidate for thrombolytic therapy. Depending on the patient, other tests may be performed (e.g., toxicology screening, pregnancy testing, blood cultures and erythrocyte sedimentation rate in endocarditis or vasculitis, hemoglobin AIC in diabetics). A lipid panel, C-reactive protein, and homocysteine levels may also be determined.

Electrocardiogram: to screen for atrial fibrillation and myocardial ischemia.

Phonoangiography/Doppler ultrasonography: to detect hemorrhage from partial occlusion of the carotid arteries.

Other common diagnostic tests for shock.

Transcranial Doppler ultrasound: Provides information about pressure and flow in intracranial arteries.

Swallow examination/videofluoroscopy: All patients should be evaluated for dysphagia.  

Videofluoroscopy identifies the problem or pathology, determines the most appropriate treatment, and allows for learning of proper swallowing technique. This test is not performed on individuals known to aspirate saliva because it involves swallowing a barium-containing liquid, semisolid and/or solid.

Positron Emission Tomography: 

It provides information about cerebral metabolism and blood flow characteristics. This test is helpful in detecting ischemic stroke because it reveals areas of reduced glucose metabolism.

Single photon emission CT: 

Used to determine cerebral blood flow.

Electroencephalography:

Shows abnormal nerve impulse transmissions and the extent of brain wave activity present.

Lumbar puncture and cerebrospinal fluid (CSF) testing:

Cerebral and carotid angiography: 

Digital subtraction angiography: used to visualize cerebral blood flow and detect vascular abnormalities, such as stenoses, aneurysms, and hematomas.

Echocardiography (transthoracic and transesophageal):

To examine valvular structures for thrombi and myocardial walls for mural thrombi, which may be a source of emboli.

Evoked Response Test: 

Allows measurement of the brain’s ability to process and respond to various sensory stimuli. Responses to these sensory stimuli may indicate abnormal areas in the brain.

Electronystagmography: used to evaluate patients suffering from vertigo, dizziness, or balance disorders and to objectively assess oculomotor and vestibular systems.

21 Nursing diagnosis for stroke

1. ineffective cerebral Tissue Perfusion
2. impaired physical Mobility
3. impaired verbal Communication
4.  Self-Care Deficit
5. deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
6. Unilateral Neglect
7. risk for impaired Swallowing
8. ineffective Coping
9. disturbed Sensory Perception
10. Risk for Aspiration
11. Ineffective Airway Clearance
12. Risk for Bleeding
13. Decreased Intracranial Adaptive Capacity
14. Risk for Falls
15. Risk for Injury
16. Impaired Tissue Integrity:
17. Risk for Deficient Fluid Volume
18. Imbalanced Nutrition: Less Than Body Requirements
19. Impaired Oral Mucous Membrane
20. Excess Fluid Volume
21. Risk for Infection

Nursing care plans stroke

Ineffective cerebral Tissue Perfusion

May be associated with.

• Embolism,
• Cerebral aneurysm,
• Hypertension, brain tumor,
• Abnormal prothrombin/partial thromboplastin time

Recognizable by

• Altered level of consciousness;
• Memory loss;
• Sensory, language, intellectual, or emotional deficits
• Changes in motor or sensory responses

Desired outcomes

• Maintenance of usual or improved LOC, cognition, and motor and sensory functions.
• Stable vital signs and no evidence of increased ICP.
• No further deterioration or recurrence of deficits.

NURSING INTERVENTIONS	RATIONALE
Determine factors related to individual situation, cause of coma, decreased cerebral perfusion, and potential for increased ICP.	Influences choice of interventions. Worsening of neurologic signs and symptoms or failure to improve after the initial insult may indicate decreased intracranial adaptive capacity, and the patient may need to be admitted to the ICU for monitoring of ICP and implementation of specific therapies aimed at keeping ICP within a certain range. In a developing stroke, the patient’s condition may deteriorate rapidly and require repeated examinations and progressive treatment. In a “completed” stroke, the neurologic deficit is not progressive, and treatment is aimed at rehabilitation and prevention of recurrence.
Monitor and document neurologic status frequently and compare to baseline. (See CP: Traumatic Brain Injury – Acute Rehabilitation Phase, ND: Ineffective Cerebral Tissue perfusion for a complete neurological assessment).	Assesses trends in unconsciousness and potential for increased ICP and is useful for determining location, extent, and progression or resolution of CNS damage. May also reveal a TIA that may resolve without further symptoms or precede a thrombotic CVA.
Vital signs monitoring: Hypertension or hypotension; compare blood pressures in both arms.	Pressure fluctuations may occur because of intracranial pressure or injury in the vasomotor area of the brain. Hypertension or hypotension may have been a precipitating factor. Hypotension may occur after stroke due to circulatory collapse.
Heart rate and rhythm; auscultation for heart murmurs.	Changes in heart rate, especially bradycardia, may occur because of brain injury. Cardiac arrhythmias and murmurs may reflect cardiac disease that precipitated the stroke, such as stroke after myocardial infarction or valvular dysfunction.
Breathing, recording of breathing patterns and rhythms, apnea after hyperventilation, Cheyne-Stokes breathing.	Irregularities may indicate cerebral insult or elevated ICP and need for further intervention, including possible respiratory support. (See CP: traumatic brain injury-acute rehabilitation phase, ND: risk for Ineffective Breathing Pattern.
Assess pupils, noting size, shape, sameness, and light reactivity.	Pupillary responses are controlled by the oculomotor nerve (III) and are useful to determine if the brainstem is intact. Pupil size and equality are determined by the balance between parasympathetic and sympathetic enervation. The response to light reflects the combined function of the optic nerve (II) and oculomotor (III) cranial nerves.
Posture with head slightly elevated and in neutral position.	Lowers arterial pressure by promoting venous outflow and may improve cerebral circulation and blood flow.
Maintain bed rest, provide a quiet environment, and limit visitors or activities when indicated. Rest between care activities and limit the duration of procedures. Avoid straining during bowel movements or holding one’s breath.	Constant stimulation may increase ICP. Absolute rest may be required in hemorrhagic stroke to prevent recurrence of bleeding. The Valsalva maneuver increases ICP and potentiates the risk of bleeding.

Impaired physical Mobility

May be associated with

• Neuromuscular impairment;
• decreased muscle strength/control;
• decreased endurance Sensory or cognitive impairment

Possibly detectable by

• Uncoordinated movements, limited range of motion Postural instability, gait changes

Desired outcomes

• Consequences of immobility: Physiological
• Maintenance or increase in strength and function of the affected or compensatory body part.
• Maintenance of an optimal functional position as evidenced by the absence of contractures and foot drop.
• Demonstration of techniques and behaviors that allow resumption of activities.
• Maintenance of skin integrity.

NURSING INTERVENTIONS	RATIONALE
Assessment of functional ability and level of impairment at baseline and periodically. Grading on a scale of 0 to 4.	Indicates strengths and deficits and can provide information for recovery. Helps select interventions because different techniques are used for flaccid and spastic paralysis.
Change position (supine, lateral) at least every 2 hours, possibly more frequently if lying on affected side.	Reduces risk of tissue ischemia and injury. Affected side has poorer blood supply, decreased sensation, and is more susceptible to skin injury and pressure ulcers.
Positioning in prone position once or twice daily if patient can tolerate it.	Helps maintain functional hip extension; however, may increase anxiety, especially regarding ability to breathe.
Support extremities in functional position; use footboard during period of flaccid paralysis. Maintain neutral position of head.	Prevents contractures and foot drop and facilitates use when function returns. Flaccid paralysis may affect the ability to support the head, while spastic paralysis may cause the head to deviate to one side.
Use arm sling when patient is in upright position as indicated.	In flaccid paralysis, the use of a sling may reduce the risk of shoulder subluxation and shoulder-hand syndrome.
Begin active or passive movement of all extremities (including splinted) on admission. Encourage exercises such as quadriceps or gluteal exercises, squeezing a rubber ball, and extension of the fingers, legs, and feet.	Minimizes muscle atrophy, promotes circulation, and helps prevent contractures. Reduces the risk of hypercalciuria and osteoporosis when the underlying problem is bleeding. Note: Excessive and careless stimulation may promote recurrence of bleeding.
Assist the client in developing balance while sitting (e.g., raising the head of the bed; assisting the client to sit on the edge of the bed, using the strong arm to support the weight of the body and the strong leg to move the affected leg; increasing the length of time the client sits) and balance while standing-dress the client in flat walking shoes, support the client’s lower back with the hands while positioning the client’s own knees outside the client’s knees, and assist the client in using parallel bars and walkers.	Helps retrain neural pathways, improves proprioception and motor response.
Encourage client to assist with movements and exercises by using the unaffected limb to support and move the weaker side.	May react as if the affected side is no longer part of the body and needs encouragement and active training to “reintegrate it as part of one’s body”.

Impaired verbal Communication

May be related to

• Decreased blood flow to the brain, alteration of the central nervous system (CNS).
• Weakened musculoskeletal system

Recognizable by

• Does not or cannot speak; verbalizes with difficulty
• Difficulty forming words or sentences; difficulty expressing thoughts verbally – apathy
• Inability to use facial expressions
• Difficulty understanding or maintaining usual patterns of communication [oral or written]

Desired Outcomes

• Communication.
• Demonstrate understanding of communication problems.
• Determine a method of communication to express needs.
• Appropriate use of resources.

NURSING INTERVENTION	RATIONALE
Assess the nature and severity of the patient’s aphasia. Avoid nonverbal innuendo in this process. Assess the patient’s ability to speak clearly without slurring words, use words appropriately, point or look at a specific object, follow simple directions, understand yes/no questions, understand complex questions, repeat both simple and complex words, repeat sentences, name objects shown, demonstrate or explain the purpose or function of objects, comply with written requests, write and read requests. In assessing aphasia, be aware that the patient may be responding to nonverbal cues and may understand less than you think. Document this assessment with simple descriptions and concrete examples of aphasia symptoms. Use it as the basis for a communication plan.	Aphasia is the partial or complete inability to use or understand language and symbols and can occur when there is damage to the dominant (left) hemisphere. It is not the result of hearing or intelligence impairment. There are many different types of aphasias. Usually, patients have a combination of aphasias with varying degrees of severity. Fluent aphasia (e.g., Wernicke’s aphasia, sensory aphasia, or receptive aphasia) is characterized by the inability to recognize or understand spoken words. It is as if a foreign language is being spoken or the patient has word deafness. The patient can often respond well to nonverbal cues. In non-fluent aphasia (e.g., Broca’s aphasia, motor aphasia, or expressive aphasia), the ability to understand and comprehend language remains, but the patient has difficulty expressing words or naming objects. Gestures, moans, cursing, or nonsensical words may be used.
Ask the patient to repeat unclear words, speaking slowly in short sentences. If this fails, ask the patient to use another word or give a nonverbal cue.	Do not pretend to understand if you do not. Say. Non-verbal cues, pointing, basic needs flashcards, mime, paper/pencil, spelling, or a picture board can facilitate communication.
Get a referral to a speech therapist or pathologist if needed. Give the therapist a list of words that would improve the patient’s independence and/or care. Also, ask him or her for tips that may improve communication with the patient.	Patients may need the expertise of a specialist to improve their communication skills.
When communicating with the patient, try to reduce distractions in the environment, such as television or other people talking.	This will focus the patient’s attention on communication.
Ensure that the patient is well rested.	Fatigue impairs the ability to communicate.
Communicate with the patient as much as possible. Use gestures, facial expressions, and mime to complement and reinforce your message. Give short, simple instructions and repeat them as needed to ensure they are understood. Use concrete terms	These are general principles for patients who cannot recognize or understand the spoken word. Other suggestions include: Look at the patient and make eye contact, speak slowly and clearly, allow the patient time to process your message and respond, keep your messages short and simple, stick to a clearly defined topic, avoid questions with multiple possible answers but phrase questions so they can be answered “yes” or “no,” and use the same words each time you repeat a statement or question.
Treat the patient as an adult. Be respectful.	It is not necessary to increase the volume of your voice unless the patient is hard of hearing.
Distinguish aphasia from dysarthria.	The choice of interventions depends on the type of impairment. Aphasia is a disorder in the use and interpretation of language symbols and may include sensory and/or motor components, such as the inability to understand or write written or spoken words, make signs, and speak. A dysarthric person can understand, read, and write speech but has difficulty forming or pronouncing words due to weakness and paralysis of the mouth muscles, resulting in silent speech.
Speak directly to the client, slowly and clearly. Use yes/no questions at the beginning and increase complexity as the client responds.	Reduces confusion and anxiety of having to process and answer a large amount of information at once. As retraining progresses, increasing complexity of communication stimulates memory and promotes association of words and ideas.
Speak at a normal volume and avoid speaking too quickly. Give the client adequate time to respond. Speak without pressing for a response.	The client is not necessarily hearing impaired, and a higher volume may irritate or annoy the client. Forcing responses may lead to frustration and cause the client to resort to “automatic” language, such as garbled speech and profanity.
Encourage SO and visitors to continue to make efforts to communicate with the client, such as reading mail and discussing family events, even if the client is unable to respond appropriately.	It is important that family members continue to talk with the client to reduce isolation, promote the establishment of effective communication, and maintain a sense of connection with the family.

Self-Care Deficit

May be associated with

• Neuromuscular impairment,
• Weakness,
• Limited mobility Perceptual or cognitive impairment Pain,
• Discomfort

Possibly detectable by

• Impaired ability to perform ADLs, such as inability to move food from vessel to mouth
• inability to wash body parts or regulate water temperature; impaired ability to put on and take off clothes
• difficulty completing toileting tasks

Desired Outcomes 

• Demonstrate techniques and lifestyle changes to meet self-care needs.
• Perform self-care activities within one’s abilities.
• Identification of personal and community resources that can provide support when needed.

NURSING INTERVENTION	RATIONALE
Assessment of ability and degree of deficit (0 to 4 scale) in performing ADLs.	Helps anticipate and plan for meeting individual needs.
Avoid doing things for the client that they can do for themselves and offer assistance as needed.	These clients can become anxious and dependent, and although help is helpful to avoid frustration, it is important that the client do as much as possible on their own to maintain self-esteem and promote recovery.
Watch for impulsive behavior or actions that indicate impaired judgment	May indicate that additional intervention and supervision is needed to ensure the client’s safety.
Maintain a supportive, firm attitude. Give client adequate time to complete tasks.	Clients need empathy and reassurance that caregivers will consistently help them.
Provide positive feedback for efforts and successes.	Strengthens self-esteem, promotes independence, and encourages client to continue to strive.
Provide self-help devices, such as button or zipper hooks, knife-fork combinations, long-handled brushes, extensions to pick things up off the floor, toilet elevator, leg bag for catheter and shower chair. Support and encourage good grooming and make-up habits.	Enables client to care for self, increasing independence and self-esteem; decreases dependence on others to meet own needs and enables client to be more socially active.

Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs

May be related to

• Lack of exposure,
• Unfamiliarity with information sources Cognitive impairment,
• Misinterpretation of information,
• Poor recall

Evidenced by

• Report of the problem
• Inaccurate following of instructions

Desired outcomes  

• Knowledge: stroke management
• Participate in the learning process.
• Verbalize understanding of condition, prognosis, and possible complications.
• Verbalize understanding of therapeutic regimen and rationale for action.
• Initiate necessary lifestyle changes.

NURSING INTERVENTION	RATIONALE
Assess type and degree of sensory-perceptual impairment.	Deficits impact choice of teaching methods and content and complexity of instruction.
Involve SO and family in discussions and instruction.	These individuals provide support and care and have a major impact on the client’s quality of life.
Discuss specific pathology and individual potential.	Helps build realistic expectations and promotes understanding of current situation and needs.
Recognize signs and symptoms that require further observation, such as changes or worsening of visual, motor, and sensory functions; changes in thinking or behavior; and severe headaches.	Early screening and intervention reduces the risk of complications and further loss of function.
Review current limitations and discuss planned or possible resumption of activities, including sexual Relationships.	Promotes understanding, provides hope for the future, and raises expectations for resuming “normal” life.
Suggest client reduce or limit environmental stimuli, especially cognitive activities.	Multiple or simultaneous stimuli can exacerbate confusion and impair mental abilities.
Advise the client to seek help with the problem-solving process and to validate his or her choices when necessary.	Some clients, particularly those with right CVA, may exhibit impaired judgment and impulsive behavior, which impairs the ability to Ability to make informed decisions.
Identify individual risk factors-hypertension, arrhythmias, obesity, smoking, heavy alcohol use, atherosclerosis, poorly controlled diabetes, and use of oral contraceptives-and discuss necessary lifestyle changes.	Promotes overall wellness and may reduce risk of recurrence. Note: Obesity in women has been found to be associated in a correlates with ischemic stroke.
Discuss the importance of a balanced diet low in cholesterol and sodium, if indicated. Discuss the role of vitamins and other Supplements.	Improves overall health and well-being and provides energy for life activities.
Refer and make aware of the importance of follow-up care by the rehabilitation team, e.g., physical therapists, occupational therapists, speech therapists, and occupational therapists.	Diligent work can eventually overcome or minimize remaining deficits.