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
Disturbed Sensory Perception
- Disturbed Sensory Perception
- Disturbed Sensory Perception
Common related factors for this nursing diagnosis:
- Altered sensory reception, transmission, integration (neurological trauma or deficit)
- Psychological stress (narrowed perceptual fields caused by anxiety)
The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- 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
Common goals and expected outcomes:
- Patient will regain/maintain usual level of consciousness and perceptual functioning.
- Patient will acknowledge changes in ability and presence of residual involvement.
- Patient will demonstrate behaviors to compensate for/overcome deficits.
Nursing Interventions and Rationales
Here are the nursing assessment and interventions for this cerebrovascular accident (stroke) nursing care plan.
|Review pathology of individual condition.||Awareness on the type and areas of involvement aid in assessing specific deficit and planning of care.|
|Observe behavioral responses: crying, inappropriate affect, agitation, hostility, agitation, hallucination.||Individual responses are variable, but commonalities such as emotional lability, lowered frustration threshold, apathy, and impulsiveness may complicate care.|
|Evaluate for visual deficits. Note loss of visual field, changes in depth perception (horizontal and/or 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 and injury.|
|Assess sensory awareness: dull from sharp, hot from cold, position of body parts, joint sense.||Diminished sensory awareness and impairment of kinesthetic sense negatively affects balance and positioning and appropriateness of movement, which interferes with ambulation, increasing risk of trauma.|
|Note inattention to body parts, segments of environment, lack of recognition of familiar objects/persons.||Agnosia, the loss of comprehension of auditory, visual, or other sensations, may lead result to unilateral neglect, inability to recognize environmental cues, considerable self-care deficits, and disorientation or bizarre behavior.|
|Establish and maintain communication with the patient. Set up a simple method of communicating basic needs. Remember to phrase your questions so he’ll be able to answer using this system. Repeat yourself quietly and calmly and use gestures when necessary to help in understanding.||Note: even an unresponsive patient may be able to hear, so don’t say anything in his presence you wouldn’t want him to hear and remember.|
|Eliminate extraneous noise and stimuli as necessary.||Reduces anxiety and exaggerated emotional responses and confusion associated with sensory overload.|
|Speak in calm, comforting, 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 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.|
|Approach patient from visually intact side. Leave light on; position objects to take advantage of intact visual fields. Patch affected eye if indicated.||Helps the patient to recognize the presence of persons or objects and may help with depth perception problems. This also prevents patient from being startled. Patching the eye may decrease sensory confusion of double vision.|
|Stimulate sense of touch. Give patient objects to touch, and hold. Have patient practice touching walls 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.|
|Encourage patient to watch feet when appropriate and consciously position body parts. Make patient aware of all neglected body parts: 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.|
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