Included in this guide are 12 nursing diagnosis for stroke (cerebrovascular accident) nursing care plans. Know about the nursing interventions for stroke, its assessment, goals, and related factors of each nursing diagnosis and care plan for stroke.
What is Cerebrovascular Accident (CVA) or Stroke?
Cerebrovascular accident (CVA), 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 stroke, 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
The major nursing care plan goals for patients with stroke depends on the phase of CVA the client is into. 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.
Listed below are 12 nursing diagnosis for stroke (cerebrovascular accident) nursing care plans:
- Ineffective Cerebral Tissue Perfusion
- Impaired Physical Mobility
- Impaired Verbal Communication
- Disturbed Sensory Perception
- Ineffective Coping
- Self-Care Deficit
- Risk for Impaired Swallowing
- Activity Intolerance
- Risk for Unilateral Neglect
- Deficient Knowledge
- Risk for Disuse Syndrome
- Risk for Injury
- Other Nursing Diagnosis
Common related factors for this nursing diagnosis:
- Lack of exposure; unfamiliarity with information resources
- Cognitive limitation, information misinterpretation, lack of recall
The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Request for information
- Statement of misconception
- Inaccurate follow-through of instructions
- Development of preventable complications
Common goals and expected outcomes:
- Patient will participate in learning process.
- Patient will verbalize understanding of condition/prognosis and potential complications.
- Patient will verbalize understanding of therapeutic regimen and rationale for actions.
- Patient will initiate necessary lifestyle changes.
Nursing Interventions and Rationales
Here are the nursing assessment and interventions for this stroke nursing care plan.
|Assess type and degree of sensory perceptual involvement.||This will affect the choice of teaching methods and content complexity of instruction.|
|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.|
|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.|
|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.|
|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.|
|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.|
References and Sources
The following are the references and recommended sources for stroke nursing care plans and nursing diagnosis including interesting resources to further your reading about the topic:
- Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care. Mosby. [Link]
- Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders Elsevier. [Link]
- Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Lippincott Williams & Wilkins. [Link]
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis. [Link]
- Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences. [Link]
- Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2017). Medical-surgical nursing: Assessment and management of clinical problems.
- Urden, L. D., Stacy, K. M., & Lough, M. E. (2006). Thelan’s critical care nursing: diagnosis and management (pp. 918-966). Maryland Heights, MO: Mosby.
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
Neurological Care Plans
Nursing care plans for related to nervous system disorders:
- Alzheimer's Disease | 13 Care Plans
- Brain Tumor | 3 Care Plans
- Cerebral Palsy | 7 Care Plans
- Cerebrovascular Accident | 8+ Care Plans
- Guillain-Barre Syndrome | 6 Care Plans
- Meningitis | 7 Care Plans
- Multiple Sclerosis | 9 Care Plans
- Parkinson's Disease | 9 Care Plans
- Seizure Disorder | 4 Care Plans
- Spinal Cord Injury | 12 Care Plans