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:
- Neuromuscular impairment, decreased strength and endurance, loss of muscle control/coordination
- Perceptual/cognitive impairment
The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Impaired ability to perform ADLs, e.g., inability to bring food from receptacle to mouth; inability to wash body part(s), regulate temperature of water; impaired ability to put on/take off clothing; difficulty completing toileting tasks
Common goals and expected outcomes:
- Patient will demonstrate techniques/lifestyle changes to meet self-care needs.
- Patient will perform self-care activities within level of own ability.
- Patient will identify personal/community resources that can provide assistance as needed.
Nursing Interventions and Rationales
Here are the nursing assessment and interventions for this cerebrovascular accident (stroke) nursing care plan.
|Assess abilities and level of deficit (0–4 scale) for performing ADLs.||Aids in planning for meeting individual needs.|
|Assess patient’s ability to communicate the need to void and/or ability to use urinal, bedpan. Take patient to the bathroom at periodic intervals for voiding if appropriate.||Patient may have neurogenic bladder, be inattentive, or be unable to communicate needs in acute recovery phase, but usually is able to regain independent control of this function as recovery progresses.|
|Identify previous bowel habits and reestablish normal regimen. Increase bulk in diet, encourage fluid intake, increased activity.||Assists in development of retraining program (independence) and aids in preventing constipation and impaction (long-term effects).|
|Avoid doing things for patient that patient can do for self, but provide assistance as necessary.||To maintain self-esteem and promote recovery, it is important for the patient to do as much as possible for self. These patients may become fearful and independent, although assistance is helpful in preventing frustration.|
|Be aware of impulsive actions suggestive of impaired judgment.||May indicate need for additional interventions and supervision to promote patient safety.|
|Maintain a supportive, firm attitude. Allow patient sufficient time to accomplish tasks. Don’t rush the patient.||Patients need empathy and to know caregivers will be consistent in their assistance.|
|Provide positive feedback for efforts and accomplishments.||Enhances sense of self-worth, promotes independence, and encourages patient to continue endeavors.|
|Create plan for visual deficits that are present: Place food and utensils on the tray related to patient’s unaffected side; Situate the bed so that patient’s unaffected side is facing the room with the affected side to the wall; Position furniture against wall/out of travel path.||Patient will be able to see to eat the food. Will be able to see when getting in/out of bed and observe anyone who comes into the room. Provides for safety when patient is able to move around the room, reducing risk of tripping/falling over furniture.|
|Provide self-help devices: extensions with hooks for picking things up from the floor, toilet risers, long-handled brushes, drinking straw, leg bag for catheter, shower chair. Encourage good grooming and makeup habits.||To enable the patient to manage for self, enhancing independence and self-esteem, reduce reliance on others for meeting own needs, and enables the patient to be more socially active.|
|Encourage SO to allow patient to do as much as possible for self.||Reestablishes sense of independence and fosters self-worth and enhances rehabilitation process. Note: This may be very difficult and frustrating for the caregiver, depending on degree of disability and time required for patient to complete activity.|
|Teach the patient to comb hair, dress, and wash.||To promote sense o f independence and self-esteem.|
|Refer patient to physical and occupational therapist.||Rehabilitation helps to relearn skills that are lost when part of the brain is damaged. It also teaches new ways of performing tasks to circumvent or compensate for any residual disabilities.|
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