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
Impaired Physical Mobility
Common related factors for this nursing diagnosis:
- Neuromuscular involvement: weakness, paresthesia; flaccid/hypotonic paralysis (initially); spastic paralysis
- Perceptual/cognitive impairment
The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength/control
Common goals and expected outcomes:
- Patient will maintain/increase strength and function of affected or compensatory body part.
- Patient will maintain optimal position of function as evidenced by absence of contractures, foot drop.
- Patient will demonstrate techniques/behaviors that enable resumption of activities.
- Patient will maintain skin integrity.
Nursing Interventions and Rationales
Here are the nursing assessment and interventions for this cerebrovascular accident nursing care plan.
|Assess extent of impairment initially and on a regular basis. Classify according to 0–4 scale.||Identifies strengths and deficiencies that may provide information regarding recovery. Assists in choice of interventions, because different techniques are used for flaccid and spastic paralysis.|
|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. Circulatory stimulation and padding help prevent skin breakdown and decubitus development.|
|Change positions at least every 2 hr (supine, side lying) and possibly more often if placed on affected side.||Reduces risk of tissue injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown.|
|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 and footdrop and facilitates use when 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 need for positional aids and/or splints during spastic paralysis:||Flexion contractures occur because flexor muscles are stronger than extensors.|
|Place pillow under axilla to abduct arm||Prevents adduction of shoulder and flexion of elbow.|
|Elevate arm and hand||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.|
|Begin active or 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 stimulation can predispose to rebleeding.|
|Assist patient with exercise and perform ROM exercises for both the affected and unaffected sides. Teach and encourage patient to use his unaffected side to exercise his affected side.||ROM exercise helps in reducing muscle stiffness and spasticity. It can also helps prevent contractures.|
|Assist patient to develop sitting balance by raising head of bed, assist to sit on edge of bed, having patient to use the strong arm to support body weight and move using the strong leg. Assist to develop standing balance by putting flat walking shoes, support patient’s lower back with hands while positioning own knees outside patient’s knees, assist in using parallel bars.||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 (by restoring vasomotor tone), promotes maintenance of extremities in a functional position and emptying of bladder, reducing risk of urinary stones and infections from stasis. Note: If stroke is not completed, activity increases risk of additional bleed.|
|Pad chair seat with foam or water-filled cushion, and assist patient to shift weight at frequent intervals.||To prevent pressure on the coccyx and skin breakdown.|
|Set goals with patient and SO for participation in activities and position changes.||Promotes sense of expectation of improvement, and provides some sense of control and independence.|
|Encourage patient to assist with movement and exercises using unaffected extremity to support and 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, as indicated.||Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown and 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.|
|Position the patient and align his extremities correctly. Use high-top sneakers to prevent foot drop and contracture and convoluted foam, flotation, or pulsating mattresses or sheepskin.||These are measures to prevent pressure ulcers.|
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