Main Article: Cerebrovascular Accident (Stroke)
Cerebrovascular accident (stroke) refers to any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels or of the entire cerebrovascular system. 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.
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
Here are 8 nursing care plans about Cerebrovascular Accident (CVA, Stroke)
Ineffective Cerebral Tissue Perfusion
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
- 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
|Determine factors related to individual situation/cause for coma/decreased cerebral perfusion and potential for increased ICP.||Influences choice of interventions. Deterioration in neurological signs/symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity requiring patient be transferred to critical care 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.|
|Monitor/document 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/resolution of CNS damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA.|
|Monitor vital signs, i.e., note:Hypertension/hypotension, compare BP readings in both arms;Heart rate and rhythm; auscultate for murmurs;Respirations, noting patterns and rhythm, e.g., periods of apnea after hyperventilation, Cheyne-Stokes respiration.||Fluctuations in pressure may occur because of cerebral pressure/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.Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (e.g., stroke after MI or from valve dysfunction).Irregularities can suggest location of cerebral insult/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 brainstem is intact. Pupil size/equality is determined by balance between parasympathetic and sympathetic enervation. Response to light reflects combined function of the optic (II) and oculomotor (III) cranial nerves.|
|Document changes in vision, e.g., 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/degree of cerebral involvement and may indicate deterioration/increased ICP.|
|Position with head slightly elevated and in neutral position.||Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation/perfusion.|
|Maintain bedrest; provide quiet environment; restrict visitors/activities as indicated. Provide rest periods between care activities, limit duration of procedures.||Continual stimulation/activity can increase 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/cerebral injury, requiring further evaluation and intervention.|
|Administer supplemental oxygen as indicated.||Reduces hypoxemia, which can cause cerebral vasodilation and increase pressure/edema formation.|
|Administer medications as indicated:Alteplase (Activase), t-PA;Anticoagulants, e.g., warfarin sodium (Coumadin), low-molecular-weight heparin (Lovenox); antiplatelet agents, e.g., aspirin (ASA), dipyridamole (Persantine), ticlopidine (Ticlid); |
Antifibrolytics, e.g., aminocaproic acid (Amicar);
Peripheral vasodilators, e.g., cyclandelate (Cyclospasmol), papaverine (Pavabid), isoxsuprine (Vasodilan);
Steroids, e.g., dexamethasone (Decadron);
Neuroprotective agents, e.g., calcium channel blockers, excitatory amino acid inhibitors, gangliosides;
Phenytoin (Dilantin), phenobarbital;
|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.May be used to improve cerebral blood flow and prevent further clotting when embolus/thrombosis is the problem. Contraindicated in hypertensive patients because of increased risk of hemorrhage.Used with caution in hemorrhagic disorder to prevent lysis of formed clots and subsequent rebleeding.Preexisting/chronic hypertension requires cautious treatment because aggressive management increases the risk of extension of tissue damage. Transient hypertension often occurs during acute stroke and resolves often without therapeutic intervention.Used to improve collateral circulation or decrease vasospasm. |
Use is controversial in control of cerebral edema.
These agents are being researched as a means to protect the brain by interrupting the destructive cascade of biochemical events (e.g., influx of calcium into cells, release of excitatory neurotransmitters, buildup of lactic acid) to limit ischemic injury.
May be used to control seizures and/or for sedative action. Note: Phenobarbital enhances action of antiepileptics.
Prevents straining during bowel movement and corresponding increase of ICP.
|Prepare for surgery, as appropriate, e.g., endarterectomy, microvascular bypass, cerebral angioplasty.||May be necessary to resolve situation, reduce neurological symptoms/risk of recurrent stroke.|
|Monitor laboratory studies as indicated, e.g., prothrombin time (PT)/activated partial thromboplastin time (aPTT) time, Dilantin level.||Provides information about drug effectiveness/therapeutic level.|
Impaired Physical Mobility
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
- Maintain/increase strength and function of affected or compensatory body part.
- Maintain optimal position of function as evidenced by absence of contractures, footdrop.
- Demonstrate techniques/behaviors that enable resumption of activities.
- Maintain skin integrity.
|Assess functional ability/extent of impairment initially and on a regular basis. Classify according to 0–4 scale.||Identifies strengths/deficiencies and 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, sidelying) and possibly more often if placed on affected side.||Reduces risk of tissue ischemia/injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/decubitus.|
|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/footdrop and facilitates use when/if 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 use of/need for positional aids and/or splints during spastic paralysis:Place pillow under axilla to abduct arm;Elevate arm and hand;||Flexion contractures occur because flexor muscles are stronger than extensors.Prevents adduction of shoulder and flexion of elbow.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/ischemia. Circulatory stimulation and padding help prevent skin breakdown and decubitus development.|
|Begin active/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/imprudent stimulation can predispose to rebleeding.|
|Assist to develop sitting balance (e.g., raise head of bed; assist to sit on edge of bed, having patient use the strong arm to support body weight and strong leg to move affected leg; increase sitting time) and standing balance (e.g., put flat walking shoes on patient, support patient’s lower back with hands while positioning own knees outside patient’s knees, assist in using parallel bars/walkers).||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 (restores vasomotor tone), promotes maintenance of extremities in a functional position and emptying of bladder/kidneys, reducing risk of urinary stones and infections from stasis. Note: If stroke is not completed, activity increases risk of additional bleed/infarction.|
|Pad chair seat with foam or water-filled cushion, and assist patient to shift weight at frequent intervals.||Prevents/reduces pressure on the coccyx/skin breakdown.|
|Set goals with patient/SO for participation in activities/exercise and position changes.||Promotes sense of expectation of progress/improvement, and provides some sense of control/independence.|
|Encourage patient to assist with movement and exercises using unaffected extremity to support/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 (e.g., kinetic), as indicated.||Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown/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.|
Impaired Verbal Communication
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
- Indicate an understanding of the communication problems.
- Establish method of communication in which needs can be expressed.
- Use resources appropriately.
|Assess type/degree of dysfunction: e.g., patient does not seem to understand words or has trouble speaking or making self understood.Differentiate aphasia from dysarthria; |
Listen for errors in conversation and provide feedback;
Ask patient to follow simple commands (e.g., “Shut your eyes,” “Point to the door”); repeat simple words/ sentences;
Point to objects and ask patient to name them;
Have patient produce simple sounds, e.g., “Sh,” “Cat”.
Ask patient to write name and/or a short sentence. If unable to write, have patient read a short sentence.
|Helps determine area and degree of brain involvement and difficulty patient has with any or all steps of the communication process. Patient may have trouble understanding spoken words (receptive aphasia/damage to Wernicke’s speech area), speaking words correctly (expressive aphasia/damage to Broca’s speech areas), or may experience damage to both areas.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, e.g., inability to comprehend written/spoken words or to write, make signs, speak. A dysarthric person can understand, read, and write language but has difficulty forming/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. Feedback helps patient realize why caregivers are not understanding/responding appropriately and provides opportunity to clarify content/meaning.Tests for receptive aphasia. |
Tests for expressive aphasia; e.g., patient may recognize item but not be able to name it.
Identifies dysarthria, because motor components of speech (tongue, lip movement, breath control) can affect articulation and may/may not be accompanied by expressive aphasia.
Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia.
|Post notice at nurses’ station and patient’s room about speech impairment. Provide special call bell if necessary.||Allays anxiety related to inability to communicate and fear that needs will not be met promptly. Call bell that is activated by minimal pressure is useful when patient is unable to use regular call system.|
|Provide alternative methods of communication, e.g., writing or felt board, pictures. Provide visual clues gestures, pictures, “needs” list, demonstration).||Provides for communication of needs/desires based on individual situation/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. Use yes/no questions to begin with, progressing in complexity as patient responds.||Reduces confusion/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/idea association.|
|Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Talk without 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, e.g., garbled speech, obscenities.|
|Encourage SO/visitors to persist in efforts to communicate with patient, e.g., 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., job, family, hobbies.||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 with/refer to speech therapist.||Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits/therapy needs.|
Disturbed Sensory Perception
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
- 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.
|Review pathology of individual condition.||Awareness of type/area of involvement aids in assessing for/anticipating specific deficits and planning care.|
|Observe behavioral responses, e.g., hostility, crying, inappropriate affect, agitation, hallucination.||Individual responses are variable, but commonalities such as emotional lability, lowered frustration threshold, apathy, and impulsiveness may complicate care.|
|Eliminate extraneous noise/stimuli as necessary.||Reduces anxiety and exaggerated emotional responses/confusion associated with sensory overload.|
|Speak in calm, 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/validate 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/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/injury.|
|Approach patient from visually intact side. Leave light on; position objects to take advantage of intact visual fields. Patch affected eye if indicated.||Provides for recognition of the presence of persons/objects; may help with depth perception problems; prevents patient from being startled. Patching may decrease the sensory confusion of double vision.|
|Assess sensory awareness, e.g., differentiation of hot/cold, dull/sharp; position of body parts/muscle, joint sense.||Diminished sensory awareness and impairment of kinesthetic sense negatively affects balance/positioning and appropriateness of movement, which interferes with ambulation, increasing risk of trauma.|
|Stimulate sense of touch; e.g., give patient objects to touch, grasp. Have patient practice touching walls/other 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.||Presence of agnosia (loss of comprehension of auditory, visual, or other sensations, although sensory sphere is intact) may lead to/result in unilateral neglect, inability to recognize environmental cues/meaning of commonplace objects, 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, e.g., 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.|
Nursing Diagnosis: Ineffective Coping
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
- 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.
|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 loss/dysfunction/change to patient. Note ability to understand events, provide realistic appraisal of situation.||Independence/ability is highly valued in American society but is not as significant in some other cultures. Some patients accept and manage altered function effectively with little adjustment, whereas others have considerable difficulty recognizing and adjusting 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, e.g., family, work, social, future nursing/healthcare needs.||Helps identify specific needs, provides opportunity to offer information/support and begin problem-solving. Consideration of social factors, in addition to functional status, is important in determining appropriate discharge destination.|
|Encourage patient to express feelings, including hostility or anger, denial, depression, sense of disconnectedness.||Demonstrates acceptance of/assists 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/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 (e.g., 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/quality 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/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.|
Nursing Diagnosis: Self-Care Deficit
May be related to
- Neuromuscular impairment, decreased strength and endurance, loss of muscle control/coordination
- Perceptual/cognitive impairment
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
- 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.
|Assess abilities and level of deficit (0–4 scale) for performing ADLs.||Aids in anticipating/planning for meeting individual needs.|
|Avoid doing things for patient that patient can do for self, but provide assistance as necessary.||These patients may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for patient to do as much as possible for self to maintain self-esteem and promote recovery.|
|Be aware of impulsive behavior/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.||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, e.g.: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, e.g., button/zipper hook, knife-fork combinations, long-handled brushes, extensions for picking things up from floor; toilet riser, leg bag for catheter; shower chair. Assist and encourage good grooming and makeup habits.||Enables patient to manage for self, enhancing independence and self-esteem; reduces reliance on others for meeting own needs; and enables 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 SO/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 frequent/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).|
Risk for Impaired Swallowing
Nursing Diagnosis: Risk for Impaired Swallowing
Risk factors may include
- Neuromuscular/perceptual impairment
- Demonstrate feeding methods appropriate to individual situation with aspiration prevented.
- Maintain desired body weight.
|Review individual pathology/ability to swallow, noting extent of paralysis; clarity of speech; facial, tongue involvement; ability to protect airway/episodes of coughing or choking; presence of adventitious breath sounds; amount/character of oral secretions. Weigh periodically as indicated.||Nutritional interventions/choice of feeding route is determined by these factors.|
|Have suction equipment available at bedside, especially during early feeding efforts.||Timely intervention may limit amount/untoward effect of aspiration.|
|Promote effective swallowing, e.g.:Schedule activities/medications to provide a minimum of 30 min rest before eating;Provide pleasant environment free of distractions (e.g., TV);Assist patient with head control/support, and position based on specific dysfunction; |
Place patient in upright position during/after feeding as appropriate;
Provide oral care based on individual need prior to meal;
Season food with herbs, spices, lemon juice, etc. according to patient’s preference, within dietary restrictions;
Serve foods at customary temperature and water always chilled;
Stimulate lips to close or manually open mouth by light pressure on lips/under chin, if needed;
Place food of appropriate consistency in unaffected side of mouth;
Touch parts of the cheek with tongue blade/apply ice to weak tongue;
Feed slowly, allowing 30–45 min for meals;
Offer solid foods and liquids at different times;
Limit/avoid use of drinking straw for liquids;
Encourage SO to bring favorite foods.
|Promotes optimal muscle function, helps to limit fatigue.Promotes relaxation and allows patient to focus on task of eating/swallowing.Counteracts hyperextension, aiding in prevention of aspiration and enhancing ability to swallow. Optimal positioning can facilitate intake/reduce risk of aspiration, e.g., 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.Uses gravity to facilitate swallowing and reduces risk of aspiration. |
Patients with dry mouth require a moisturizing agent (e.g., alcohol-free mouthwash) before and after eating; patients with excess saliva will benefit from use of a drying agent (e.g., lemon or glycerin swabs) before meal and a moisturizing agent afterward.
Increases salivation, improving bolus formation and swallowing effort.
Lukewarm temperatures are less likely to stimulate salivation so foods/fluids should be served cold or warm as appropriate. Note:Water is the most difficult to swallow.
Aids in sensory retraining and promotes muscular control.
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/are sticky.
Can improve tongue movement and control (necessary for swallowing), and inhibits tongue protrusion.
Feeling rushed can increase stress/level of frustration, may increase risk of aspiration, and may result in patient’s terminating meal early.
Prevents patient from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after patient has finished eating foods.
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.
Provides familiar tastes and preferences. Stimulates feeding efforts and may enhance swallowing/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.||If swallowing efforts are not sufficient to meet fluid/nutrition needs, alternative methods of feeding must be pursued.|
|Encourage participation in exercise/activity 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.|
Nursing Diagnosis: Knowledge Deficit
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
- 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.
|Evaluate type/degree of sensory-perceptual involvement.||Deficits affect the choice of teaching methods and content/complexity of instruction.|
|Include SO/family in discussions and teaching.||These individuals will be providing support/care and have great impact on patient’s quality of life.|
|Discuss specific pathology and individual potentials.||Aids in establishing realistic expectations and promotes understanding of current situation and needs.|
|Identify signs/symptoms requiring further follow-up, e.g., changes/decline in visual, motor, sensory functions; alteration in mentation or behavioral responses; severe headache.||Prompt evaluation and intervention reduces risk of complications/further loss of function.|
|Review current restrictions/limitations and discuss planned/potential resumption of activities (including sexual relations).||Promotes understanding, provides hope for future, and creates expectation of resumption of more “normal” life.|
|Review/reinforce current therapeutic regimen, including use of medications to control hypertension, hypercholesterolemia, diabetes, as indicated; aspirin or similar-acting drugs, e.g., ticlopidine (Ticlid), warfarin sodium (Coumadin). Identify ways of continuing program after discharge.||Recommended activities, limitations, and medication/therapy needs are established on the basis of a coordinated interdisciplinary approach. Follow-through is essential to progression of recovery/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/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 lists/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 required/need to be planned for based on individual situation.|
|Refer to discharge planner/home care supervisor, visiting nurse.||Home environment may require evaluation and modifications to meet individual needs.|
|Suggest patient reduce/limit environmental stimuli, especially during cognitive activities.||Multiple/concomitant stimuli may aggravate confusion 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.|
|Refer to/reinforce importance of follow-up care by rehabilitation team, e.g., physical/occupational/speech/ vocational therapists.||Diligent work may eventually overcome/minimize residual deficits.|
Other Nursing Diagnoses
- Injury, risk for—general weakness, visual deficits, balancing difficulties, reduced large/small muscle or hand-eye coordination, cognitive impairment.
- Nutrition: imbalanced, 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.
- Home Maintenance, impaired—individual physical limitations, inadequate support systems, insufficient finances, unfamiliarity with neighborhood resources.
- Self-Esteem, situational low—cognitive/perceptual impairment, perceived loss of control in some aspect of life, loss of independent functioning.
- Caregiver Role Strain, risk for—severity of illness/deficits of care receiver, duration of caregiving required, complexity/ amount of caregiving task, caregiver isolation/lack of respite.