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
Risk for Disuse Syndrome
- Risk for Disuse Syndrome
The following are the common risk factors:
- Neuromuscular impairment with limited use of upper and/or lower limbs
Possibly evidenced by
- Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Common goals and expected outcomes:
- The patient and significant other will display methods that improve ambulating and transferring.
- The patient will not manifest evidence of shoulder subluxation or shoulder-hand syndrome.
Nursing Interventions and Rationale
Here are the nursing assessment and interventions for this stroke nursing care plans.
|Assess for subluxation of the shoulder such as severe pain and swelling, tingling sensation, inability to move the joint, altered
appearance of bony prominences.
|Shoulder subluxation happens when the muscles around the shoulder become weak resulting in the separation of the shoulder joint.|
|Instruct the patient to inspect his or her extremities first then check the position prior ambulating.||These are safety precautions to avoid falling. For an instance, alert the patient to make a conscious effort to raise and then extend the foot when ambulating.|
|Provide a pillow or lapboard to be used as a support in positioning the patient in the correct alignment. Encourage active/passive ROM to enhance muscle tone.||These interventions aids in maintaining the anatomic position.|
|Instruct the client with balance problems to adjust by leaning toward the stronger side as a means to ensure correct upright posture.||Stroke patients tends to lean heavily to their weak side.|
|Encourage the use of an arm sling.||The sling functions as a support and protection to the arm and shoulder while the client is standing or ambulating.|
|Avoid pulling the affected arm. Place a hand behind the scapula when moving the upper extremity instead of pulling from the arm; Utilize a lift sheet during bed repositioning. When the patient is sitting provide the arm with a firm support surface||These are interventions that help prevent subluxation and deformity. When in bed the shoulder should be placed a bit forward to counteract shoulder rotation. The affected arm should be placed in external rotation as the patient is lying on affected side.|
|Provide instructions on transfer techniques utilizing the stronger extremity to move the weaker extremity.||For example, to move the affected leg in bed or when changing from a lying to a sitting position, slide the unaffected foot under the
affected ankle to lift, support, and bring the affected leg along in the desired movement.
|Instruct the patient to use proper footwear. Avoid the use of slippers.||A well-fitting footwear helps improve balance. Using slippers may put the patient from risk from falls.|
|Provide light joint range of motion exercises and proper arm positioning to avoid shoulder-hand syndrome. Position the arm on the abdomen or rest it in a pillow when the patient is in bed. Do not place the arm under the body. Maintain the arm above heart level. Encourage repeated shoulder movement, and regular fist clenching and unclenching.||Shoulder-hand syndrome is a neurovascular condition characterized by pain, edema, and skin and muscle atrophy as a result of impairment of the circulatory pumping action of the upper extremity.|
|Instruct and apply the following transfer principles:
||These are methods to follow when moving patients with impaired physical mobility. These transfer principles emphasize using the stronger or unaffected side to help support patients for safe transfers to reduce the risk of falling.|
|If the client needs assistance from a health care staff, refrain the client pulling on or putting hands around the assistant’s neck as a means to support.||Staff members should utilize their own knees and feet to brace the feet and knees of weak clients.|
|Secure referral to physical therapy and occupational therapy if needed. Reinforce special mobilization techniques such as proprioceptive neuromuscular rehabilitation, neurodevelopmental treatment, motor relearning program, and constraint induced movement therapy per the client’s individualized rehabilitation program.||These techniques may vary from the general principles mentioned. For example, Bobath focuses on use of the affected side in mobility training so that patients try to bear weight on their affected side and move toward their affected side to relearn normal movement patterns and position. CI movement therapy involves restraining the
functioning arm to induce “rewiring of the brain,” thereby improving amount and quality of functional movement.
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.
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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