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:
- Situational crises, vulnerability, cognitive perceptual changes
The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Inappropriate use of defense mechanisms
- Inability to cope/difficulty asking for help
- Change in usual communication patterns
- Inability to meet basic needs/role expectations
- Difficulty problem solving
Common goals and expected outcomes:
- Patient will verbalize acceptance of self in situation.
- Patient will talk/communicate with SO about situation and changes that have occurred.
- Patient will verbalize awareness of own coping abilities.
- Patient will meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.
Nursing Interventions and Rationales
Here are the nursing assessment and interventions for this stroke nursing care plan.
|Assess extent of altered perception and related degree of disability. Determine Functional Independence Measure score.||Determination of individual factors aids in developing plan of care/choice of interventions and discharge expectations.|
|Identify meaning of the dysfunction and change to patient. Note ability to understand events, provide realistic appraisal of the situation.||Independence is highly valued in American culture but is not as significant in some cultures. Some patients accept and manage altered function effectively with little adjustment, whereas others may have considerable difficulty recognizing and adjust to deficits. In order to provide meaningful support and appropriate problem-solving, healthcare providers need to understand the meaning of the stroke/limitations to patient.|
|Determine outside stressors: family, work, future healthcare needs.||Helps identify specific needs, provides opportunity to offer information and begin problem-solving. Consideration of social factors, in addition to functional status, is important in determining appropriate discharge destination.|
|Identify previous methods of dealing with life problems. Determine presence of support systems.||Provides opportunity to use behaviors previously effective, build on past successes, and mobilize resources.|
|Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope, lethargy, withdrawal.||May indicate onset of depression (common after effect of stroke), which may require further evaluation and intervention.|
|Note whether patient refers to affected side as “it” or denies affected side and says it is “dead.”||Suggests rejection of body part and negative feelings about body image and abilities, indicating need for intervention and emotional support.|
|Provide psychological support and set realistic short-term goals. Involve the patient’s SO in plan of care when possible and explain his deficits and strengths.||To increase the patient’s sense of confidence and can help in compliance to therapeutic regimen.|
|Encourage patient to express feelings, including hostility or anger, denial, depression, sense of disconnectedness.||Demonstrates acceptance of patient in recognizing and beginning to deal with these feelings.|
|Acknowledge statement of feelings about betrayal of body; remain matter-of-fact about reality that patient can still use unaffected side and learn to control affected side. Use words (weak, affected, right-left) that incorporate that side as part of the whole body.||Helps patient see that the nurse accepts both sides as part of the whole individual. Allows patient to feel hopeful and begin to accept current situation.|
|Emphasize small gains either in recovery of function or independence.||Consolidates gains, helps reduce feelings of anger and helplessness, and conveys sense of progress.|
|Support behaviors and efforts such as increased interest/participation in rehabilitation activities.||Suggest possible adaptation to changes and understanding about own role in future lifestyle.|
|Refer for neuropsychological evaluation and/or counseling if indicated.||May facilitate adaptation to role changes that are necessary for a sense of feeling/being a productive person. Note: Depression is common in stroke survivors and may be a direct result of the brain damage and/or an emotional reaction to sudden-onset disability.|
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