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 Injury
The following are the common risk factors:
- Altered sensory reception, transmission, and/or integration
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.
Below are the common expected outcomes for stroke nursing care plan:
- Patient will interact appropriately with his or her environment and does not exhibit evidence of injury caused by sensory/perceptual deficit.
|Assess type and degree of hemisphere injury the patient exhibits.||which describe right and left hemisphere injuries.|
|Encourage patients with nondominant (right) hemisphere injury to slow down and check each step or task as it is completed.||Patients with nondominant (right) hemisphere injury also may have decreased pain sensation and pain sense and visual field deficit but typically are unconcerned or unaware of or deny deficits or lost abilities. They tend to be impulsive and too quick with movements. Typically, they have impaired judgment about what they can and cannot
do and often overestimate their abilities. These individuals are at risk for burns, bruises, cuts, and falls and may need to be restrained from attempting unsafe activities. They also are more likely to have
unilateral neglect than individuals with dominant (left) hemisphere injury.
|Remind patients who have a dominant (left) hemisphere injury to scan their environment.||These patients may lack or have decreased pain sensation and position sense and have visual field deficit on the right side of the body. They may need reminders to scan their environment but usually do not
exhibit unilateral neglect.
|Encourage making a conscious effort to scan the rest of the environment by turning head from side to side.||Patients may have visual field deficits in which they can physically see only a portion (usually left or right side) of the normal visual field (homonymous hemianopsia).|
|Give short, simple messages or questions and step-by-step directions. Keep conversation on a concrete level (e.g., say “water,” not “fluid”; “leg,” not “limb”).||These individuals may have poor abstract thinking skills. They tend to be slow, cautious, and disorganized when approaching an unfamiliar problem and benefit from frequent, accurate, and immediate feedback on performance. They may respond well to nonverbal
encouragement, such as a pat on the back.
|Have patients with apraxia return your demonstration of the task or see if they are able to be talked through a task or may be able to talk themselves through a task step-by-step.||Have patients with apraxia return your demonstration of the task or see if they are able to be talked through a task or may be able to talk themselves through a task step-by-step.|
|Intervene as follows for patients with nondominant (right) hemisphere injury:||Patients may have the following sensory perceptual alterations:|
|Keep the patient’s environment simple to reduce sensory overload and enable concentration on visual cues. Remove distracting stimuli.||Impaired ability to recognize objects by means of senses of hearing, vibration, or touch: These patients rely more on visual cues.|
|Assist patients with eating. Monitor the environment for safety hazards, and remove unsafe objects such as scissors from the bedside.||Difficulty recognizing and associating familiar objects: Patients may not know the purpose of silverware. These patients may not recognize dangerous or hazardous objects because they do not know the
purpose of the object or may not recognize subtle distinctions between objects (e.g., the difference between a fork and spoon may
become too subtle to detect).
|Teach the patient to concentrate on body parts. For example, by watching the swaying of hands or movement of the feet while walking. Using a mirror can also help them adjust.||Misconception of own body and body parts: These patients may not perceive their foot or arm as being a part of their body.|
|Provide these patients with a restraint or wheelchair belt for support.||Inability to orient self in space: They may not know if they are standing, sitting, or leaning.|
|Provide a structured, consistent environment. Mark outer aspects of the patient’s shoes or tag inside sleeve of a sweater or pair of pants with “L” and “R.”||Visual-spatial misconception: The patient may have trouble judging distance, size, position, rate of movement, form, and how parts relate to the whole. For example, the patient may underestimate distances and bump into doors or confuse inside and outside of an object, such as an article of clothing. These patients may lose their
place when reading or adding up numbers and therefore never complete the task.
|Direct the patient’s attention to a particular sound (e.g., playing different musical instruments and associating its sound to its name.)||Impaired ability to recognize, associate, or interpret sounds.|
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